Respiratory Failure Secondary to Tuberculosis
Patient presentation:
R.S. was a 62 year old male. His medical history included hypertension, gout, and renal insufficiency. The patient presented ambulatory to the emergency department with his wife who reported that the two of them had just returned to the United States from South Africa one-week prior. The patient was placed in a surgical mask and placed in respiratory isolation, while staff donned N95 masks. The patient’s symptoms included two days of SOB, cough, intermittent fevers, and pain in the chest. The patient was lethargic, hot to the touch, and diaphoretic. A set of vital signs was obtained and his blood pressure was 98/53, his heart rate was 140 beats per minute, respiratory rate was 32 breaths per minute, temperature was 39.2 degrees Celsius, and his O2 saturation was 89% on room air.
The physical exam showed that R.S. was tachycardic, tachypnic with labored breathing, extremely anxious and confused. His lung sounds had rhonchi bilaterally, the ECG showed sinus tachycardia, and his pedal and femoral pulses were weak and thready. Initial blood work included two sets of blood cultures. An arterial blood gas, complete blood count, BMP, PT/INR, and a sputum culture were obtained. Additionally, three large bore IVs were placed. The physician ordered a stat chest x-ray and two liters of normal saline to be hung on a pressure bag.
Lab values:
WBC 20.6; INR 1.5; HCO3- 24; H/H 9.4/35; pH 7.22; Lactate 12; Platelets 135,000; Ionized Ca++ 0.90; PT/PTT – 14/44; K+ 5.0 ABG: pH 7.25, PaCO2 60, PaO2 69, HCO3- 26
Differential List:
Tuberculosis, pneumonia, septic shock
Treatment:
The patient was emergently intubated and placed on a ventilator (ventilator settings: Rate-16, FiO2-100%, tidal volume 500ml, and 5 of PEEP) for respiratory failure/ acute respiratory acidosis. The physician ordered antibiotics (moxifloxacin, vancomycin), and started a central line in the patient’s femoral vein. Fluids were not enough to keep the patient’s blood pressure above 80/40, so a vasopressor norepinephrine bitartrate was added at 10mcg/min, boosting blood pressure to 98/70. Oxygen levels stabilized keeping oxygen saturations above 92%.
Outcome:
The patient was transferred to the Intensive Care Unit (ICU) where fluid and antibiotic management was maintained. The sputum culture results came back positive for Mycobacterium tuberculosis. The antibiotic regimen was changed to anti tuberculosis (TB) medications including rifampicin, isoniazid, pyrazinamide and ethambutol. The patient eventually recovered and was discharged from the hospital after a prolonged hospital stay. The patient was sent home with a 12-month course of anti TB medications to take to stave off recurrent infection.