A 53-year-old male with a history of alcohol abuse, anxiety and insomnia presented to an outpatient clinic for his annual physical examination. He smoked half a pack of cigarettes a day for 25 years. Currently he drinks beer 2-3 times per week, but heavy liquor more frequently in the past. He denied illicit drug use and high-risk sexual activities. He was active and independent with activities of daily living. During the visit, the patient was complaining of coughing in the morning, bringing up small amounts of sputum, and of dyspnea upon exertion for some time. The patient was afebrile, and had blood pressure of 125/80 mmHg, heart rate 60 bpm. Physical exam did not have any rhonchi or wheezes. All other systems were negative. His white blood cell count was 6700/muL with 52% neutrophils, 33% lymphocytes. A chest x-ray was ordered and revealed a questionable ill-defined medial right upper lobe infiltrate, which could be related to pneumonia. However, no sputum was collected for further evaluation. There were no pleural effusions or pneumothorax. Subsequently, a computed tomography (CT) scan without contrast of the chest showed right upper and lower lobe tree-in-bud micro-nodularity in a peri-bronchovascular distribution. There were associated larger nodular opacities in the right upper lobe measuring up to 2.0 x 1.2 cm at the right apex. The patient was prescribed Levaquin for seven days, and the QuantiFERON-TB Gold test was ordered. The patient was advised to have a follow-up visit after one month. At that time, the patient felt much better and had minimal cough. However, his pulmonary function showed mild chronic obstructive defect without significant bronchodilator reversibility. The repeat CT scan of the chest showed multiple nodules in the right upper and lower lobes, especially in the azygos lobe. All these nodules were associated with a branching micronodular pattern (Fig. 1). In addition, the patient's QuantiFERON-TB Gold test was positive. The bronchoscopy was performed and showed a normal appearing endobronchial anatomy. The right lower lobe had normal findings. Attention of the scope was focused to the apex of the right lung. Multiple transbronchial lung biopsies were taken from the azygos lobe as well as the atypical subsegment of the right upper lobe. Microbiological studies revealed Mycobacterium tuberculosis in both the bronchoalveolar lavage and lung biopsy specimens. Tissue specimens were also sent for histopathology showing necrotizing granulomatous inflammation. The patient started on ethambutol, rifampin, pyrazinamide and isoniazid with vitamin B6 supplementation for two months, followed by rifampin and isoniazid with vitamin B6 for six months. Patient had been asymptomatic and no side effects so far at a follow-up visit a couple of months later.
A computed tomography (CT) scan of the chest showing multiple nodules, including in the azygous lobe, right upper lobe, and right lower lobe, with associated micronodular patterns.