Critical Care: Student/Resident Case Report Poster - Critical Care III |

Is It TB Causing Your Patient's Distress? FREE TO VIEW

Justin Seashore, MD; Jessica Gupta, MD; Peter Spiro, MD
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Ichan School of Medicine at Mount Sinai, Elmhurst, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):425A. doi:10.1016/j.chest.2016.08.438
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care III

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute Respiratory Distress Syndrome (ARDS) is a life threatening medical condition faced in intensive care units, it is due to inflammation in the lungs which is commonly due to sepsis. Pulmonary tuberculosis as a cause of ARDS is a rare etiology which is not traditionally a differential for intensivists in the United States.

CASE PRESENTATION: 60 year old Filipino male with history of hypertension, alcohol abuse, 20pack-year smoker, presented with sudden onset of substernal chest pain, fevers, productive cough and shortness of breath. Denied nausea, vomiting, constipation, diarrhea, recent travel, weight loss, leg swelling/pain, orthopnea, and hemoptysis. Chest X-Ray showed diffusely patchy infiltrates throughout the left lung, right lower lobe and interstitial alveolar infiltrates in the right upper lung field. Patient’s condition worsened and was intubated in the setting of ARDS. Mechanical ventilation with protective ventilation was started. Community appropriate broad spectrum antibiotics were given along with oseltamivir for influenza. Despite broadening of antibiotics the patient had no significant improvement, frequent fevers with max temperatures reaching greater than 103 Fahrenheit. At Day 10 due to no significant improvement, sputum was sent for acid fast bacili, which returned positive, RIPE therapy was initiated at this time. The cultures eventually grew mono-resistant mycobacterium tuberculosis. On day 17 steroids were started to reduce the inflammation that potentially hindered weaning, he was successfully extubated on day 20.

DISCUSSION: While ARDS is not uncommon, cases in setting of active pulmonary tuberculosis in a non-immunocompromised individual especially in the United States are rare. In studies outside of the US have average delay to diagnosis and treatment varies from 15 days up to 30 days (1). These delays increase the high mortality rate related to such patient populations which can be up to 90% (2). Use of corticosteroids in ARDS as well as pulmonary tuberculosis remains controversial, and a Cochrane report notes clinical improvement in TB the evidence is limited to low powered studies(3). This combined treatment process seemed beneficial in our patient.

CONCLUSIONS: Our case demonstrates the importance of intensivists including pulmonary tuberculosis as a differential diagnosis when managing patients in ARDS, especially in our growing global patient population.

Reference #1: Lee PL, patient mortality of active pulmonary tuberculosis requiring mechanical ventilation. Eur Respir J. 2003 Jul;22(1):141-7

Reference #2: Befort P, Clinical review of eight patients with ARDS due to pulmonary tuberculosis. Scand J Infect Dis. 2012 March

Reference #3: Critchley JA, Adjunctive steroid therapy for managing pulmonary tuberculosis. Cochrane Database Syst Rev. 2014 Nov 12

DISCLOSURE: The following authors have nothing to disclose: Justin Seashore, Jessica Gupta, Peter Spiro

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