RESUMO
Background: Pulmonary aspergillosis (PA) is common among patients with tuberculosis (TB). With both infections presenting with similar clinical and radiologic features, diagnosis of PA is often made too late or missed completely due to lack of clinical suspicion and poor diagnostic laboratory capacity for mycotic infections prevalent in our settings. We present a case of preventable mortality caused by delayed diagnosis and treatment of PA in a patient with pulmonary TB (PTB). Case presentation: A 13-year-old female was diagnosed and treated for PTB, having received anti-TB regimen for 8 months in a mission hospital from where she was referred due to worsening cough, chest pain and progressive breathlessness. The patient was re-assessed and investigated, with GeneXpert detecting Mycobacterium tuberculosis, susceptible to rifampicin. Diagnosis of pulmonary tuberculosis complicated by right pneumothorax was made indicating an emergency thoracotomy and chest tube insertion and continuation of the first line anti-TB regimen. At about 2 weeks into admission, patients had features of superimposed acute bacterial sepsis with fever becoming high grade, marked neutrophilia with toxic granulation and elevated sepsis biomarker, and this necessitated empiric antibiotic treatment with parenteral meropenem and vancomycin. However, the patient only had mild clinical improvement following which there was progressively worsening respiratory symptoms and massive haemoptysis. Result of sputum fungal study was available on admission day 20 and revealed a growth of Aspergillus flavus. Treatment with intravenous voriconazole was however commenced rather late when the fungal respiratory disease could no longer be remedied. The patient died on admission day 23. Conclusion: Diagnosis of PA in patients with background TB is often made too late to guarantee timely and effective antifungal treatment with negative consequences on patients' outcomes. Improving clinical and laboratory capacities is essential to reducing mortality from PA in healthcare facilities.
Assuntos
Humanos , Tuberculose , Diagnóstico , Aspergilose Pulmonar , Mycobacterium tuberculosis , VoriconazolRESUMO
The emergence of resistant strains of mycobacterium tuberculosis (TB) to antituberculous drugs has compounded the management of the chronic infection. More than 90% of rifampicin (RIF)-resistant isolates are also isoniazid resistant; hence, rifampicin resistance (RR) is a surrogate marker for multidrug resistant TB (MDR-TB). Although there are limited reports of pediatric RR/MDR-TB in Nigeria, there had not been similar report in our hospital until now. A 2-year-old girl was admitted with 2-month history of fever, cough with dyspnea, and progressive weight loss. There was no known contact with adult who had chronic cough; the toddler and her parents have not been treated for TB in the past. Her chest X-ray showed nodular opacities, while gastric washout for GeneXpert MTB/RIF confirmed RIF-resistant TB. The parents declined screening for TB despite counseling. The patient was subsequently referred to a specialized center for the management of drug-resistant TB, but the parents failed to go for the treatment. Young children are at risk of developing TB disease and MDR/RR-TB, which is more complex to manage than drug-susceptible TB due to longer treatment duration, increased toxicity, as well as poor parental compliance to the demand of treatment.
