A 43-year-old Italian woman, a non-smoker, was referred to another clinic where she was treated by a pulmonologist for fever, cough and left chest pain. The chest X-ray (Fig. 1) showed a moderate left pleural effusion; she reported no comorbidity.
She underwent neither blood tests nor thoracentesis, as the pulmonologist did not consider these as being necessary for such a small effusion. She started treatment with 500 mg levofloxacin bis in die per os for 2 weeks.
After 2 weeks a chest X-ray showed improvement in the left pleural effusion; she had no fever (it had disappeared after 3 days of treatment), but chest pain persisted.
Two months later the patient was well, without fever, albeit with very slight thoracic pain during deep inspiration; a chest X-ray showed no parenchymal lesions, but only an occlusion of the left costophrenic sinus. CT scan was normal at that time.
At this stage, the patient asked us to intervene because she was not satisfied with her treatment by the other doctor; we decided to follow the patient up at our clinic with no other treatments or examinations since she was well and because of the complete resolution shown by the chest X-ray picture.
One month later, she presented with a swelling of her right wrist without fever (Fig. 2). An MRI scan showed a typical picture of tenosynovitis (Fig. 3). Rheumatic tests (C Reactive Protein, Rheumatoid factor, Antinuclear Antibodies, Cyclic Citrullinated Peptide) were completely negative and the patient was treated with Nonsteroidal Anti-Inflammatory Drugs.
Three months later she presented high fever (39 ) and cough without sputum; chest X-ray showed ill defined nodular opacities in the upper lobes and no pleural effusion (Fig. 4).
CT scan showed both speculated nodules and branching focal centrilobular opacities consistent with the so called tree-in-bud pattern in the upper lobes (Fig. 5). Laboratory tests, including HIV test, were negative.
A diagnostic fibre optic bronchoscopy was performed. There were no secretions in the tracheobronchial tree. A bronchoalveolar lavage (BAL) was performed in the upper left lobe. The BAL was stained with Kinyoun and auramin stain and tuberculosis nucleic acid amplification test (TB-NAAT) were also performed: all these results were negative. Culture on both solid (Lowenstein Jensen, bioMerieux, Marcy l'Etoile, France) and liquid (Bactec MGIT semi-automated system - Becton Dickinson, Italy) media was positive for M. tuberculosis.
In conclusion, the patient's clinical picture can be summarized as follows: at the beginning left pleural effusion, 2 months later right wrist tenosynovitis and, after another 3 months, pulmonary tuberculosis.
We treated her with rifampicin (600 mg), isoniazid (300 mg), pyrazinamide (500 mg x 2) and ethambutol (500 mg x 3) for 2 months followed by rifampicin and isoniazid for 4 months, resulting in the complete resolution of the pulmonary and wrist involvement.