Tuberculosis contact study: An unexpected finding

Jiménez Muñoz, Beatriz; Rovira Marcelino, Gemma; de la Figuera von Wichmann, Mariano.

Sardenya Primary Care Center, Barcelona, Spain.

Case description

46 years old male, from Nepal, living in Spain last 10 years.

Cholecystectomy in 1998

No chronic drugs

Married, two healthy children Testicular tuberculosis diagnosed and treated

in Nepal in 1995.

No drugs allergies No toxic habits

Working as a cook. Now he has his own family restaurant.

Case description

• He came to our primary care center, referred from the hospital, for a Tuberculosis contact study: his brother was diagnosed of smear-positive Tuberculosis, they work together daily.

• He has no respiratory symptoms, fever, sweating or other. No recent trips abroad.

• Not vaccinated against Tuberculosis.

• Physical examination:

Only minimal bibasal rales on lung auscultation.

Aditional test

PPD is applied, pending result. We demand chest Rx.

The patient came back in 72 hours: PPD: Negative. We check the image test.

• CRP 7,4 mg/L, DHL 380 UI/L.

• Blood TB Quantiferon: Negative.

• Urinary antigens for Legionella and Pneumococo: Negative.

• Antigens for: influenza A/B, parainfluenza, SRV, CMV, adenovirus: Negative.

• HIV, HCV, HBV: Negative.

• Tumor markers: Negative.

Pulmonar CT:Nodular pulmonary involvement, predominantly in upper lobes. Mediastinal and hiliar bilateral involvement.

Aditional test

[ ]With these findings, we decided to refer the patient to respiratory service for further testing

Bronchoscopy: No endobronchial gross lesions.

BAL: No Gram. KB y TB-CRP: Negative. Sputum culture: Negative.

5% hemosiderophages, 45% macrophages, 5% eosinophils, 15% PMN leukocytes, 30% lymphocytes (lymphocytes T 87,00%: CD4 74,00%, CD8 13,00%).

Transbronchial biopsy: Non-caseating granulomas.

With all these results, the main diagnosis is granulomatous disease.

Aditional test

Blood test: ACE: Elevated. ANCA, C3-C4, cryoglobulines, RF: Negative.

PET-CT: Supra and infra-diaphragmatic nodal involvement. Pulmonary, splenic, hepatic, renal and bone nodular involvement. Dilated ventricular chambers.

Echocardiogram: Dilated left ventricle with apical aneurysm without thrombus. LVEF 39%. Diastolic dysfunction. Moderate MI.

Finally...

The patient was diagnosed with Sarcoidosis, with lung, liver, spleen, kidney, heart, bone and adenopathic involvement.

We started treatment with high-dose prednisone and we referred the patient to rheumatology and cardiology for further controls.

Conclusions

We shouldn´t forget the importance of chest radiography as a quick, cheap and accessible method for the diagnosis of many diseases, even if the findings do not point to our primary suspected diagnosis.

As primary care physicians, we are a vital link in screening for multiple diseases. Our fast-acting, with progressive and consistent application of additional tests can make a clear difference in the prognosis of our patients.

Thank you!, ¡Gracias!