Tuberculosis
Patient Presentation:
D.S., a 48 year old man, presented to the ER with complaints of fever, night sweats, dull chest pain, and hemoptysis. He also reported a feeling of generalized weakness and decreased appetite. When asked about his medical history, he reported a history of end stage renal disease, kidney transplant 4 years ago, and hypertension. He currently is on immunosuppressant medications to prevent rejection of his transplanted kidney. His vital signs in the ER were BP 140/84, HR 103, RR 20, Temp 38.9, O2 sat 98% on room air. While in the ER, he continued to have a productive cough with bloody sputum. A sputum culture was obtained and sent to the lab. He was admitted to the hospital for further tests and monitoring.
Differential List:
Based on the clinical presentation of D.S., his symptoms could be related to syphilis, cytomegalovirus, bronchiectasis, a lung abscess, pericarditis, or pneumonia. Since he is immunosuppressed from being on his anti-rejection medications, he could also have been exposed to a bacterial infection that his immune system was unable to fight off. Further work up was needed in order to rule out the differential diagnoses.
Diagnosis:
A sputum culture had already been obtained and sent to the lab while D.S. was in the ER. The culture was positive for acid fast bacilli, and the lab was instructed to run further tests to determine the type of acid fast bacilli that were present. D.S. was placed on respiratory isolation as he was now being worked up for tuberculosis. A chest x-ray was done which showed lesions in the lungs. A CBC with differential, RPR, and QuantiFERON® gold test were drawn and sent to the lab. A PPD was placed (Mantoux test) on the left forearm and was to be read in 48 hours. The results of the CBC showed a WBC count of 13,000, indicating infection. RPR was negative. The QuantiFERON® gold test was positive, which is indicative of tuberculosis. The lab identified Mycobacterium tuberculosis as the acid fast bacilli present in the sputum. These findings confirmed that D.S. had tuberculosis.
Treatment:
D.S. was prescribed a treatment regimen which consisted of isoniazid, rifampin, ethambutol, and pyrazinamide. He was instructed that he would have to take these medications for 6-9 months. Due to his immunosuppressed state secondary to his kidney transplant medications, he would most likely have to take the medications for the full 9 months. He was told that he would no longer be contagious in a few weeks, but until then he had to continue airborne precautions, which include wearing a mask and careful hand washing. He was to return to his primary care physician for a follow up in 2 weeks.
Outcome:
D.S. returned to his follow up appointment and was feeling much better. He had been taking his medications properly and not missing any doses. His hemoptysis, chest pain, fever, and night sweats had resolved for the most part. He reported he still had a cough but he had no bloody sputum. The physician instructed him that although he felt much better, he had to continue to take the medications until the full course was complete. He was to return to the physician in one month to evaluate the effectiveness of his medications and treatment plan.