Pandemic Influenza (H1N1) and Mycobacterium tuberculosis Co-infection
A previously healthy 20-year-old woman was admitted on December, 2009 because of abdominal pain, fever and 10 kg of weight loss during the previous two months. The physical examination upon admission revealed a high body temperature (39.3℃). Laboratory findings were as follows: white blood cells (WBC), 4,110/mm3; neutrophils, 76.4%; lymphocytes, 480/mm3 (11.7%); hemoglobin, 10.2 g/dL; C-reactive protein (CRP), 34.9 mg/L; and erythrocyte sedimentation rate, 62 mm/hr, and a stool occult blood test was positive. A chest X-ray showed granular opacity in the bilateral apical area. Repetitive sputum acid fast bacilli (AFB) fluorescent smear studies were negative. A computed tomographic (CT) scan of the abdomen and pelvis revealed diffuse swelling of the liver, gallbladder, distal small bowel and ascending colon. Considering the influenza pandemic period and opacities in the chest X-ray, a reverse transcriptase polymerase chain reaction (RT-PCR) for pH1N1 via nasopharyngeal swab specimen was performed, and pH1N1 infection was confirmed on hospital day (HOD) 2. The conventional dose of oral oseltamivir (75 mg b.i.d.) was prescribed to the patient. On the same day, the patient complained of hematochezia, and then sigmoidoscopic evaluation revealed several polypous and aphthous lesions on the cecum and rectum with erythema, edema, granularity and telangiectasia, while pathologic evaluation of the biopsy specimen revealed acute colitis. Fever and respiratory symptom improved after three days of treatment with oseltamivir, but hematochezia had been continued, and after 5 afebrile days, fever started to spike again with higher degree up to 39.7℃. An interferon-gamma releasing assay (QuantiFERONTB Gold; Cellestis Ltd., Carnegie, Australia) was positive, and the pathology result of colonoscopy done for further evaluation of hematochezia revealed a chronic granulomatous inflammation consistent with intestinal tuberculosis, and a Ziehl-Neelsen stain revealed acid-fast bacilli. On the next day of pathology report, a MTB complex-specific PCR of sputum revealed positive results, and the administration of isoniazid, rifampin, ethambutol and pyrazinamide was initiated (HOD 16). Symptoms of fever, abdominal pain and hematochezia gradually improved within 5 days of treatment with anti-tuberculosis mediation, and the growth of MTB was confirmed in the sputum specimens after three weeks of collection.