A Case of Pulmonary Tuberculosis Presenting as Multiple Nodular Opacities on a Chest X-Ray
A 30-year-old man presented to the emergency with complaints of fever with chills since 15 days along with progressive dyspnea, cough and sputum since five days. On examination the patient had bilateral diffuse ronchii with extensive coarse crepitations, was dyspenic and tachypnic. He had an SpO2 = 64% without oxygen, blood pressure (BP) = 130/70 mm of Hg, pulse = 110 bpm, temperature-102°F. He was admitted to the intensive care unit and was put on oxygen support using a face mask at a rate of 2–6 liters per min. The patient was empirically placed on piperacillin-tazobactam combination, moximycin and was nebulized with salbutamol. The investigations sent included a chest X-ray, electrocardiography, ultrasound abdomen, sputum examination, urine examination, blood cultures, liver function and renal function tests. A bedside two dimentional trans-thoracic echocardiography was normal. All the blood examination reports were normal and the cultures were sterile. The sputum examination revealed the presence of acid-fast bacilli. The chest X-ray showed bilateral multinodular opacities involving the middle and lower zones with nodules varying in size from 1–3 cm []. The ultrasound abdomen showed hepatomegaly 14 cm below the right costal margin, splenomegaly 9 cm. Based on the chest X-ray a differential diagnosis was made which included lymphoma, benign tumors, septic emboli, inflammatory granulomas (tuberculosis, nocardiosis, fungal infection) or non-infectious granulomas (sarcoidosis, rheumatoid nodules, Wegener's granulomatosis). The patient was initiated on anti-tuberculosis treatment which included rifampicin, isoniazid, pyrazinamide, ethambutol and streptomycin. Symptomatic improvement in the clinical status of the patient was noticed after seven days as the dyspnea and tachypnea were relieved, he was afebrile and he maintained saturation above 95% without oxygen support. The patient was discharged after 20 days on anti-tuberculosis therapy.