Pandemic Influenza (H1N1) and Mycobacterium tuberculosis Co-infection
A previously healthy 47-year-old man was referred to the emergency department (ED) on December, 2009 for dyspnea and documentation of pneumonic consolidation in chest X-rays from another primary care clinic. He complained of two weeks of cough, sputum, and rhinorrhea. Dyspnea upon exertion had developed since the day before he visited the ED. Laboratory findings were as follows: WBC, 8,260/mm3; neutrophils, 80.2%; lymphocytes, 1,050/mm3 (11.7%); and CRP, 79.6 mg/L. His chest X-ray image revealed heterogenous ground glass opacities in bilateral lung fields. For further evaluation of the pulmonary lesions, a chest CT was performed, and multisegmental involvement of centrilobular nodules with a tree-in-bud appearance and multiple small cavitary lesions were observed, suggesting active pulmonary tuberculosis. In addition, RT-PCR for pH1N1 via nasopharyngeal swab was positive, and a serum glucose test registered 404 mg/dL. Admission was recommended for proper management of pH1N1 and active pulmonary tuberculosis as well as previously unknown diabetes mellitus. However, the patient refused admission and was discharged with medications such as oseltamivir, isoniazid, rifampin, ethambutol, and pyrazinamide. An AFB smear reported to be 4+ next day, and improvement of symptoms and pulmonary consolidation in chest X-ray were observed upon out-patient department follow-up visit after 5 days. Later, growth of MTB was confirmed in respiratory specimens. It took about 6 months for the lung lesions of heterogenous ground glass opacities and consolidations to nearly resolve.