CT Case 093
A 57-year-old woman presented to the emergency department with fevers, cough and night sweats and recent weight loss. She arrived in Australia from Philippines 5 days previously.
In the ED she had significant respiratory distress requiring high flow oxygen and subsequent intubation and ventilation as her respiratory failure progressed.
Notable pathology includes WCC 26 and lactate 10.
Her CXR is shown below
Describe and interpret the CXR
There is bilateral extensive pulmonary consolidation. There is almost complete opacification of left upper zone with central lucencies which are suggestive of cavitations.
This CXR appearance with upper lobe involvement and possible cavitations raised suspicion for Tuberculosis.
A CT chest, abdomen and pelvis was performed.
Describe and interpret the CT scans
There is diffuse bilateral consolidation more prominent in the upper lobes.
There is left upper lobe cavitation.
Bilaterally there are pleural effusions.
There is marked hepatomegaly with a small amount of ascites.
There is diffuse wall thickening in the small and large bowel.
Clinical Pearls
She received treatment for severe community acquired pneumonia and presumed TB with Isoniazid, Pyrazinamide, Rifampicin and Ethambutol as well as Ceftriaxone and Azithromycin.
She was transferred to ICU for management of her multiorgan failure and severe sepsis.
She had +ve AFB in her sputum which fortunately was treatment sensitive and after 6 weeks of therapy she was AFB negative. However, given the extent of her disease it was recommended she have 9 months of treatment with dual therapy, isoniazid and rifampicin.
TB is caused by Mycobacterium tuberculosis, and very rarely by Mycobacterium bovis. In Australia it is a notifiable disease. Transmission occurs via inhalation of infectious aerosols, two-thirds of cases in Australia are pulmonary TB. Tuberculosis can manifest in any organ, with the more common locations being kidneys, spine (Pott’s disease) and the brain.
Australia has a low incidence of TB with 85-95% cases in patients born overseas, commonly in SE Asia as in this patient. Standard 4 dose therapy is commenced then once the strain is confirmed as fully drug-sensitive ethambutol can be omitted as in this case. Implications for managing such cases include airborne precautions and nursing in a negative pressure room to avoid HCW transmission.
References
- Tuberculosis (TB). Health.Gov.Au
- Brims F. CXR Case 046. LITFL
- Gibbs M. Adult CXR Cases 025. LITFL
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Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
