CRA13 ENTEROBACTER CLOACAE PNEUMONIA OBSCURING THE DIAGNOSIS OF PULMONARY TUBERCULOSIS WITH DIFFUSE ALVEOLAR HAEMORRHAGE

Zulkifli.S1
Hospital Pakar Sultanah Fatimah, Muar

Introduction

Hemoptysis is a common presentation in pulmonary tuberculosis however diffuse alveolar haemorrhage in Pulmonary Tuberculosis is rarely reported. Here we report a case of Pulmonary tuberculosis presented as diffuse alveolar haemorrhage which was obscured by enterobacter cloacae pneumonia.  

Case Report

A 62-year-old Malaysian male with a history of CRHD on Warfarin for 10 years, ischemic heart disease, and previous hyperthyroidism presented with hemoptysis, cough, fever, and shortness of breath. He requires high concentration of oxygen up till VM60% with his Chest Xray shows bilateral pulmonary patchy infiltrates. Initial sputum AFB was negative and his sputum culture came back as Enterobacter cloacae (AmpC Producer) strain. He was initially started with Intravenous Cefepime, however his condition did not improve despite the targeted intravenous antibiotic. His initial INR upon arrival was 1.3, with PT 14.6 and APTT 33. His warfarin was subsequently withheld in view of hemoptysis. 

He subsequently underwent CTA and CECT Thorax on 22/12/23 with findings of diffuse ground glass opacities with crazy paving appearance likely to represent diffuse pulmonary haemorrhage with possible superimposed infection. He was then referred to Pulmonologist for bronchoscopy however he was not stable enough to be transferred to the referral hospital.

Sputum TB GenXpert was sent and the MTB complex was detected. He was subsequently started with an Anti-tuberculous drug. He subsequently was able to wean down oxygen concentration and was able to discharge home. 

Conclusion

This case highlights the importance of maintaining a high index of suspicion for pulmonary TB in the setting of DAH, even with negative sputum AFB results. Additionally, it underscores the need to consider concurrent infections, such as Enterobacter cloacae pneumonia, which can complicate the clinical presentation and delay the initiation of appropriate treatment.