CRP2 GIANT BULLAE: THE AFTERMATH OF PULMONARY TUBERCULOSIS

Huey Ying Sui, Siew Choo Su
Hospital Tengku Ampuan Rahimah, Klang, Malaysia

Introduction: 

Tuberculosis, a common infection in the developing countries, has pulmonary (parenchymal, airway, vascular, mediastinal and pleural lesions) and extrapulmonary sequelae. We report a girl with extensive airway and parenchymal lesions as a sequelae of late diagnosis of pulmonary tuberculosis (PTB).

Case report: 

We report a 12-year-old Sabahan-girl with chronic productive cough, fever, chills, rigors and night sweats for 8 months, loss of appetite/weight and reduced effort tolerance. She was hypoxaemic, cachexic and tachypnoiec. She was diagnosed with smear positive PTB (sputum AFB 1+, sputum MTB culture was positive, sensitive to first line anti-TB) and commenced on anti-TB (Isoniazid, Rifampicin, Pyrizinamide, Ethambutol). She had a prolonged hospitalisation with persistent fever and required prolonged supplemental oxygen. After 3 months of hospitalisation, she was discharged on home oxygen. A CECT thorax after 1 month on anti-TB showed diffuse bronchiectatic changes with bullae at subpleural region and reticulonodular changes peripherally. After 6 months of anti-TB (2 months intensive phase, 4 months maintenance phase), she reported an improvement in symptoms. However, she remained hypoxaemic (SpO2 91%) with diffuse coarse crackles. 

A repeat CECT thorax after 9 months on anti-TB showed multiple large lung bullae (largest in the left upper lobe). Her family opted for conservative management instead of surgical intervention. 

She presented 15 months later with 2 weeks history of left-sided-pleuritic chest-pain and reduced effort tolerance. Her CXRs showed enlarging left bulla over the left upper lobe with mediastinal shift to the right. Her repeat PTB work up was negative. 

She underwent left thoracotomy and bullectomy on day 27 of admission and treated as reactivation/reinfection of PTB with recommencement on anti-TB for 6 months (2 months intensive phase, 4 months maintenance phase). After 1 month of anti-TB, her symptoms completely resolved.

Conclusion:

PTB remains a common lung infection with significant morbidity and mortality in developing countries. Early diagnosis and treatment of PTB is important to reduce long term sequelae and complications of thoracic tuberculosis affecting the lung parenchyma, and airways, as demonstrated in our patient.