The Lung puzzle - unraveling the enigma of recurrent respiratory infections
Medical history-
A 56-year-old homemaker from Hyderabad presented with a complex medical history spanning over a decade.
Her medical journey began in 2009 when she was diagnosed with pulmonary tuberculosis (TB) and treated with anti-tubercular therapy (ATT) for 6 months
Initial Diagnosis and Treatment (2009)
In 2009, the patient developed symptoms of daily cough with sputum, low-grade evening rise of temperature, and weight loss for 20 days. Her sputum tested positive for Acid-Fast Bacilli (AFB), and a chest X-ray (CXR) showed features of pulmonary Koch's. She was diagnosed with pulmonary TB and started on ATT, which she took for 6 months. Following treatment, her sputum converted to negative, and she remained asymptomatic for the next 10 years.
Relapse and Re-Treatment (2018)
In 2018, at the age of 50, the patient experienced a relapse of symptoms, including cough, fever, and weight loss. Her sputum tested positive for AFB and Cartridge-Based Nucleic Acid Amplification Test (CBNAAT). She was diagnosed with drug-sensitive TB and started on ATT again for 6 months. Following treatment, her symptoms improved, and her sputum converted to negative.
Road Traffic Accident and Respiratory Complications (2023)
In October 2023, the patient was involved in a road traffic accident, resulting in:
- A fracture of the head of the humerus
- Right radial nerve injury, leading to wrist drop
During a subsequent surgical procedure, complications arose when the patient was positioned in the left lateral decubitus position:
- Desaturation (twice)
- Wheezing
- Shortness of breath
The procedure was aborted, and the patient was referred for pulmonology consultation.
Pulmonology Consultation and Investigations
A High-Resolution Computed Tomography (HRCT) chest scan revealed:
- Few old tuberculosis (TB) changes
- ? Active
However:
- Sputum test results were negative
- Interferon-Gamma Release Assay (IGRA) results were negative
- No features of pulmonary TB were present
The procedure was subsequently performed under general anesthesia. Initially, the patient was asymptomatic and followed up for a few months before being lost to follow-up.
Bronchoscopy and Non-Tuberculous Mycobacteria (NTM) Diagnosis
Pre-Travel Health Check-Up and Subsequent Findings (April 2024)
As part of her routine pre-travel health check-up in April 2024, the patient underwent a chest X-ray, which revealed:
- Left lung collapse
To determine the underlying cause, the patient's sputum and routine screening tests were conducted, but all results were negative. A staged bronchoscopy was performed, involving:
- Cryoablation
- Balloon bronchoplasty
Pus collected during the procedure was sent for cultures, and PCR results showed:
- Non-Tuberculous Mycobacteria (NTM)
- Speciation could not be determined
Initial Management and Second Opinion-
The patient was initially managed with antibiotics and supportive medications. However, due to increasing symptoms post-bronchoscopy, sought a second opinion at another hospital.
A CT scan was performed, revealing:
- Few infiltrates on her right lung (?spillage)
Initially, the patient continued on her medications, including:
- Injection amikacin (750 mg IV) on alternate days for 2 months
- Tablet rifampicin (600 mg OD)
- Tablet clarithromycin (500 mg BD)
- Tablet ethambutol (1000 mg OD)
The patient showed initial symptomatic improvement.
August 2024 - symptoms aggravated and was given cephalosporin oral for 2weeks
Worsening Symptoms and Peripheral Neuropathy
Exacerbation of Symptoms and Hospitalization (November 2024)
In November 2024, the patient presented with:
- Cough
- Shortness of breath (SOB)
- Reduced appetite
- Weight loss for 10 days, prompting hospitalization.
Investigations and Findings-
Routine investigations and screening tests were negative. However, a repeated High-Resolution Computed Tomography (HRCT) chest scan revealed:
- New patchy consolidations
- Nodular parenchymal opacities in the right lung
The patient was initially started on Polymyxin B for 2 days but developed:
- Tingling
- Numbness of lower limbs
- Ataxia
A neurology opinion was sought, and peripheral neuropathy was suspected. Nerve Conduction Studies (NCS) showed near-normal results.
Revised Treatment Plan-
The patient was then treated with a combination of:
- Aztreonam
- Ceftazidime + Avibactam for 2 weeks.
Readmission and Video Bronchoscopy (2025)
On January 31, 2025, the patient was readmitted with similar complaints that had persisted for 10 days. The following diagnostic procedures were performed:
- Video bronchoscopy
- Endobronchial Ultrasound (EBUS) Transbronchial Needle Aspiration (TBNA) on February 4, 2025
Diagnostic Findings
The EBUS Fine Needle Aspiration Cytology (FNAC) report revealed:
- Reactive lymphadenitis (stations 7 and 4R)
- No evidence of granuloma or neoplasia
All other reports were negative, but Non-Tuberculous Mycobacteria (NTM) was isolated on PCR in March.
Microbiological Reports and Treatment
The patient received drug sensitivity and culture reports, which showed:
- Mycobacterium abscessus was isolated
- Sensitivity to amikacin, linezolid, tigecycline, and clarithromycin
Consequently, the patient was started on all these antibiotics from March 11, 2025, and continues on this treatment regimen to date.
Current Clinical Status
The patient's current state is characterized by:
- Significant weight loss: 52 kg to 42 kg over 8 months
- Persistent symptoms:
- Intermittent, low-grade fever
- Easy fatiguability
- Shortness of breath (Grade 3)
- Hoarseness of voice
- Painful oral ulcerations with inflamed tongue, leading to reduced oral food intake
- Appetite: slightly improved
Past Medical History
- No known history of:
- Diabetes Mellitus (DM)
- Hypertension (HTN)
- Asthma
- Coronary Artery Disease (CAD)
- Epilepsy
Family History
- No relevant family history
Immunization History
- Yearly influenza vaccination
- 5-yearly pneumococcal vaccination
Personal History
- Diet: Vegetarian
- Appetite: Reduced
- Bowel and bladder habits: Regular
- Sleep pattern: Slightly reduced
Concerns and Questions
1. Duration of antibiotic consumption:The patient has been on antibiotics for an extended period, which increases the risk of antibiotic resistance, side effects, and interactions.
2. Potential side effects: The patient is at risk of developing side effects from her medications, such as nephrotoxicity, ototoxicity, and peripheral neuropathy.
3. Alternative management options: Considering the patient's persistent symptoms and reduced quality of life, it is essential to explore alternative management options, including surgical interventions or other medical therapies.
4. Improving quality of life:The patient's significant weight loss, persistent symptoms, and reduced appetite have severely impacted her quality of life. It is crucial to address these issues and develop a plan to improve her overall well-being.The patient is at risk of developing side effects from her medications, such as nephrotoxicity, ototoxicity, and peripheral neuropathy.
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