NECROTIZING PNEUMONIA WITH HYDROPNEUMOTHORAX CAUSED BY MYCOBACTERIUM TUBERCULOSIS WITH IN A HEALTHY YOUNG WOMAN

ABSTRACT

CASE Patient is a 21-year-old Guatemalan female with no significant past medical history was hospitalized with worsening productive cough for the last 4 weeks, with greenish sputum associated with pleuritic chest pain, shortness of breath and low appetite. Patient denies any fever, night sweating, weight loss. She states that she came from Guatemala around 3 years ago. Denies any nausea, vomiting, diarrhea, abdominal pain, falls or injuries. She works in the poultry industry. No sick contact. No recent travel. She denies any family members with similar symptoms. No reported history of TB in the family. On admission, she was alert, vitals were stable except for mild tachycardia, and was saturating well on room air. Physical examination revealed dullness on percussion, diffuse crackles, and decreasing breath sound bilaterally. Cell blood count with white blood cells 8.6G/L (72.4% neutrophil and 15% lymphocyte) and hemoglobin ad hematocrit 10.5/34.7 and mildly elevated liver transaminase level were recorded. Chest X-ray showed, Severe bilateral basilar pneumonitis worse on left. Moderate-sized left pleural effusion and the first contrast-enhanced chest computed tomography (CT)revealed severe multifocal necrotizing pneumonia with bilateral pleural effusions. The left pleural effusion raised the question of a loculated infected pleural effusion, and she also developed small apical hydropneumothorax. Patient was started on broadspectrum antibiotic coverage as well as pigtail placement on the left for drainage of pleural effusion. Fungal serologies, QuantiFERON gold assay, pleural fluid studies and sputum series for AFB stain were sent. COVID PCR negative. Cryptococcal negative. HIV negative. Sputum culture showing gram- negative rods Serratia marcescens and positive acid-fast bacilli for mycobacterium tuberculosis, pleural fluid is strongly exudative and sputum AFB smear showed positive PCR for Mycobacterium tuberculosis complex. She started on Rifampin, INH, Pyrazinamide and Ethambutol. IMPACT/DISCUSSION: Necrotizing pneumonia is a serious complication of community acquired Pneumonia, it's a rare but severe condition of lung parenchyma destruction commonly caused by bacterial pathogens. Necrotizing Pneumonia with M.tuberculosis have been reported in children and several cases of pulmonary gangrene in adults but very few cases of necrotizing pneumonia have been reported.The destruction of pulmonary parenchyma induced by M. tuberculosis usually develops from months to years but there are a few cases (necrotizing pneumonia and pulmonary gangrene) in which this destruction may progress rapidly causing severe respiratory failure. The pathogenic mechanism can be explained by the intensive tuberculous inflammation causing the widespread vascular thrombosis and arteritis. CONCLUSION: Our case report highlights the rarity of Mycobacterium tuberculosis causing necrotizing pneumonia and physicians should be aware of this rare presentation which develops rapidly causing severe respiratory failure.