Our patient is a 56-year-old man with medical history significant for common variable immune deficiency on biweekly intravenous immunoglobulin therapy who presented initially to Henry Ford Hospital for evaluation for fecal transplantation for Clostridium difficile diarrhea refractory to medical management. The patient underwent his first fecal transplant with transient improvement, but his diarrhea recurred and he subsequently failed 3 further fecal transplants. He was finally initiated on long-term oral vancomycin with symptom resolution.
His hospital course was complicated by increasing oxygen requirements from a baseline of 2 L/min at home to 6 L/min. Lung auscultation revealed diffuse rhonchi and decreased breath sounds on the right side. He was afebrile and had increasing low to normal white blood cell counts in the prior 3 days (2.6-6.0 x 109/L). Chest X-ray showed diffuse consolidation throughout the right lung consistent with pneumonia (Figure 1), and he was started on intravenous antibiotics for treatment of hospital-acquired pneumonia.
Three days after initiating therapy, the patient still remained short of breath and hypoxic. Computed tomography scan of the chest was obtained, which showed consolidation within the right lung apex with areas of central lucency suggesting cavitation (Figure 2).
Serial sputum samples were positive for acid-fast bacilli, and NAAT (Enhanced Amplified Mycobacterium tuberculosis Direct Test, Gen-Probe, San Diego, CA) run by the state of Michigan, identified M. tuberculosis complex ribosomal RNA, providing the diagnosis of tuberculosis. The patient was started on isoniazid, ethambutol, pyrazinamide, and rifampin while awaiting results of cultures.
A second non-NAAT test (AccuProbe, Hologic, Marlborough, MA) was run and came back negative for tuberculosis. Two weeks later, high performance liquid chromatography showed a pattern consistent with M. celatum, and the 4-drug regimen was changed to ethambutol, azithromycin, and moxifloxacin. Final cultures confirmed the result.