Interventional Pulmonology/Critical Care Attending Swedish Hospital, United States
Introduction: Endobronchial ultrasound-guided biopsy is the gold standard diagnostic procedure in cases of lung malignancy but is not commonly utilized in the tuberculosis (TB) population. In patients with no obvious risk factors, pulmonary TB may be misdiagnosed as a pneumonia or malignancy. Here, we present a case of a patient with persistent fevers of an unknown origin (FUO), failing antibiotic therapy and with initial negative microbiological results and using EBUS guided biopsy to diagnose TB.
Description: A 59 year-old female had initial complaints of intermittent right sided chest pain, described as “scratchy” and precipitated by a cough. Symptoms continued to progress, developing fevers along with a worsening cough. After one month from initial symptom onset, she went to her primary care physician. Initial chest x-ray was unremarkable, but due to symptom progression she was prescribed oral antibiotics. Despite this treatment, fevers continued prompting the patient to go to the emergency department. Chest x-ray at this time showed a new right apical infiltrate. The patient was admitted to the ICU and treated with intravenous antibiotics. Once the fever trend improved, she was discharged on oral antibiotics. Unfortunately, immediately after discharge, the fevers returned, and the patient again was hospitalized. Additional imaging with CT showed a paratracheal mass, concerning for malignancy and given the patient’s history of polycythemia vera, raising concern for extramedullary hematopoiesis. Interventional pulmonology was consulted and bronchoscopy with endobronchial ultrasound guided biopsy was performed. Cytology showed no evidence of malignant cells, however acid-fast bacilli cultures resulted in a diagnosis of tuberculosis. The patient started on appropriate antimicrobial therapy with subsequent resolution of fever and cough.
Discussion: Tuberculosis can oftentimes have similar presentations to other lung pathologies, such as pneumonia or malignancy. TB may go undiagnosed in patients with no obvious risk factors or if smear and cultures are negative. EBUS guided biopsy can provide significant diagnostic benefit in patients with FUO if initial microbiological results are negative, along with being able to identify multi-drug resistant TB strains.
