Article Text

  1. A. Sorrentino,
  2. S. Hollingsworth,
  3. M. D. Railey
  1. Birmingham, AL., 1Helsinki University Hospital


Background After a decline in the number of cases of tuberculosis seen in the United States a few decades ago, we are once again seeing it on the rise for various reasons, including increased rates of drug use, immigration, and HIV. As more cases present, there are also more atypical presentations of this disease. For this reason, our index of suspicion should be higher to ensure earlier detection.

Case Report 1 16-year-old female with 6 days of pleuritic, nonradiating chest pain. Denies fever, vomiting, or diarrhea. She is 3 months postpartum, on Depo-Provera, and takes no other medications. Review of systems is positive for mild shortness of breath and right calf pain and swelling. She is afebrile, mildly tachycardic (102), but not tachypneic or hypoxic. Significant labs include a hematocrit of 29, ECG with sinus tachycardia, CXR will ill-defined RUL opacity, and elevated D-dimer (1037). With the concern for possible pulmonary embolus, lower extremity Doppler studies are performed and are negative for clot. Helical chest CT reveals mediastinal adenopathy with RUL obstructive pneumonitis consistent with compressive nodal mass. Further workup reveals a PPD + 22.5 mm. She was discharged with the diagnosis of pulmonary tuberculosis on three-drug directly observed therapy.

Case Report 2 16-year-old female with acute onset of fever/malaise. She also complains of mild headache, intermittent nausea and vomiting, and upper respiratory symptoms, along with subjective weight loss over the preceding 2 weeks. On presentation, she is febrile to 102°F, tachycardic to 131, not tachypneic or hypoxic. Her labs reveal a normal CBC except for mild anemia (33), urinalysis significant for both hematuria and proteinuria, and her CXR has bilateral interstitial infiltrates. As part of her workup for potential pulmonary-renal syndromes and immunodeficiencies, she has a PPD placed that is + 15 mm. CT of the chest, abdomen, and pelvis reveals renal involvement. She was discharged with the diagnosis of miliary tuberculosis. Her CXR showed complete resolution of findings after 3 months of four-drug therapy.

Discussion Both of these patients presented to our emergency department with some symptoms of tuberculosis but also had findings consistent with other disease processes. As we are seeing an increase in the incidence of tuberculosis in our communities, we should consider it earlier in our differential diagnosis. This could affect not only the outcome of the patient but also have a public health impact.

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