A 65-year-old immunocompetent man presented to the respiratory clinic with recurrent chronic productive cough and gradual loss of weight for 2 years. He denied any fever, haemoptysis, urinary symptoms, or contact to any patients with pulmonary tuberculosis. His initial vital signs were unremarkable (blood pressure = 130/70 mmHg, pulse rate = 76 beats per minute, oxygen saturation = 98% at room air, and temperature = 36.5 C). At the first encounter, he was underweight with a BMI of 17 kg/m2. On examination, there was reduced air entry in the left upper lung. The abdomen was soft and nontender. His sputum sample was sent for tuberculosis workup; however, the results were negative. Routine blood investigations including full blood count and urine profile were within normal limits. The inflammatory makers were not elevated with a white cell count of 11 g/dL. His past medical history included benign prostatic hyperplasia and remote history of healed scrotal abscess.
The initial chest radiograph revealed fibrotic lung changes in the upper zones, more so on the left than the right. Subsequently, a contrast-enhanced computed tomography (CT) of the thorax with high-resolution CT reconstruction was performed and showed extensive scarring in both apical regions, again more so on the left. In addition, there were nonconfluent clusters of micronodules (Figure 1) in the right lung with a few smaller regions of tree-in-bud nodularity. There was no significant mediastinal or hilar lymphadenopathy. In the upper part of the abdomen included in the CT, there were also incidental findings of the partial duplex system of the left kidney with mild-to-moderate hydronephrosis in the lower moiety with proximal hydroureter (Figure 2). To further investigate this urinary finding, a multiphasic renal CT scan was then performed and did not reveal any calculus, suspicious ureteric mass or external compression from lymphadenopathy. The culture of his urine sample grew mycobacterium tuberculosis (MTB) complex, and he was diagnosed with active genitourinary and pulmonary tuberculosis. He was commenced on antituberculous medication (Akurit-4). His symptoms improved, and he started to gain weight. A repeated CT scan at 4 months revealed significant improvement of the aforementioned clusters of micronodules, tree-in-bud changes, and left hydronephrosis. Given the positive urine culture for tuberculosis with concurrent respiratory and constitutional symptoms, and improvement of the lung changes and respiratory symptoms following antituberculous treatment, the above-described nonconfluent clusters of micronodules were likely to represent active pulmonary tuberculosis.