CASE HISTORY AND DISCUSSION
A male in his 60’s was seen in the pulmonary medicine outpatient clinic.
He is a former smoker who was diagnosed with sputum positive pulmonary
tuberculosis 4 years ago and was initiated on anti-tuberculous drugs,
which he took for six months and was declared to be cured at the end of
treatment. He was also diagnosed with Type 2 diabetes mellitus and has
been on oral hypoglycemic agents. For the last 3 years, he has been
having streaky hemoptysis for which he was prescribed short courses of
tranexamic acid with transient improvement.
He presented to our clinic with two episodes of large volume hemoptysis
which occurred about 10 days prior to his visit. He also reported a 12kg
weight loss in the last 3 months. His physical examination was
unremarkable. Routine laboratory investigations revealed leukocytosis of
14,400/m3, elevated glycated hemoglobin of 12.2% and mild anemia
(10.4g/dL) with normal platelet counts, normal serum creatinine level
and normal blood coagulation indices. Sputum Xpert TB PCR did not detect
Mycobacterium tuberculosis.
Imaging revealed a thick walled fibrocavitatory lesion with surrounding
consolidation in the posterior segment of the right upper lobe with the
posterior segment bronchus leading into the cavity. Nodular
consolidation was also noted in the left upper lobe (Figure 1). There
were no hypertrophied bronchial arteries seen in the imaging study.
Bronchoscopy with bronchoalveolar lavage was planned to exclude
reinfection or reactivation of tuberculosis or other bacterial or fungal
infection. Bronchoscopy was done using a 5.8mm adult bronchoscope which
revealed an essentially normal tracheobronchial tree up to the level of
the lobar bronchi. A 3.8mm paediatric bronchoscope was navigated through
the right upper lobe posterior segment bronchus into one of its
subsegments which led into a cave-like structure which extends to the
apical segment of the right upper lobe. (Figure 2, Video 1).
Bronchoalveolar lavage samples were taken from the posterior segment of
the right upper lobe, and bacterial cultures grew Klebsiella pneumoniae.
Fungal cultures were negative. Mycobacterium tuberculosis was not
detected from Xpert TB PCR and Mycobacterial growth indicator tube
(MGIT) culture did not grow any Mycobacterium species.
Studies have shown that up to 91% of patients successfully treated for
tuberculosis develop some form of parenchymal or pleural sequelae. (1)
This underlines the importance of early diagnosis and treatment of
post-TB sequelae in order to prevent complications.
Hemoptysis is a common symptom of post-TB infections. Important
etiologies to consider in the evaluation of patients with respiratory
symptoms after TB treatment include fungi (particularly Aspergillus
spp.), non-tuberculous mycobacteria, and other bacteria. (2)
Between 20-50% of patients with cavitary TB have persistent cavities
after completion of anti-TB treatment. (3) Cavities can be thin- or
thick-walled, and may or may not contain fungal balls. (2)
The healing response following cavitary TB is incomplete and results in
fibrotic scarring which can lead to open or closed healing. Open healing
poses a significant risk for opportunistic infections and a combination
of high humidity, warm temperatures, immune sheltering, and lack of
innate defenses provide an opportunity for secondary colonization with
bacteria or fungi. (3)