47 y/o female who is a resident of Yemen emigrated to USA 3 years ago presents with progressive dyspnea on exertion and also clubbing noted on physicial exam. Patient does not speak English , hence the history was obtained from her husband who has accompanied her to the clinic today. Six months ago she developed a nonproductive cough. She denies any hemoptysis. No weight loss. She states that she has been exposed to her sister-in-law who had TB. Patient denies any night sweats or weight loss. She had a PPD placed and it was 20 mm. ALso, she had a CT scan of the chest done which showed extensive abnormal areas of groundglass in a diffuse and symmetric pattern, and less prominent, septal lines most prominent at the bases.Patient denies any nausea, vomiting,diarrhea, constipation, abdominal pain, chest pain at this time.Patient denies any weight loss, fevers, or chills.
She was put on 4 drug TB regimen and then 3 sputums were induced which were all negative (and cultures all negative for 63 days). That's when I see her - 3 months after the regimen was started. To ME, she denies any dyspnea except waking up at night gasping for breath once or twice a week or two. She does have a non-productive cough. When I saw her she has itching and redness on the back of the hands. Her repeat CT again shows diffuse ground glass pattern. No opacities or lesions or infiltrates. No adenopathy. An ANA screen was was "positive", but titers not done.
So now I am stuck with someone of 4 drugs without evidence of active TB and with itching that is likely from one of the drugs. I am about to bronch her for the ground glass. Any comments/thoughts? How would you approach this case?
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I think you have a patient from an endemic area with a positive PPD but 3 negative induced sputums, a clinical picture that is not typical for active TB, and radiographs that are 1) not typical for TB and 2) have not improved with several months of appropriate treatment for active TB.
So, I think that the treatment of TB can be scaled back to appropriate treatment for latent TBI, and that you should more aggresively persue an etiology of the ground glass. I agree with starting with a bronch, and suspect a surgical biopsy will be necessary.
In the olden days when Cx media for TB were slower and there was no PCR, one of the ways of diagnosing the disease in someone with a compatible clinical syndrome was response to adequate therapy. It is hard to judge whether she has had a good response: dyspnea may be better, language barrier, not many symptoms at baseline...
I agree with JCH that you need to entertain other diagnoses but I would continue the TB therapy until you have had a chance to do the bronch.
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