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Wednesday, December 11, 2013
Consolidation in the Lungs
I had an attack of Tuberculosis (caseating mediastinal lymphadenopathy)in Feb 2001. I took treatment for a year and a CT scan on March 02 showed complete resolution of the disease. Since then, I have been having Upper Respiratory track infections frequently but all X rays have been clear. About a couple of weeks back, I started feeling very lethargic and about a week back I started developing low grade fever (only in the night) which continued for 3 days. There was no weight loss and very less cough. I went to a physician who suggested a X ray. The X ray revealed a fibro infiltrative opacity in the right upper zone and a bulky left helum. However, my physician asked for a CT scan. the CT scan report revealed a Patch of Consolidation in the lung window with underlying fibrosis in the right upper lobe posterior segment. Also, minimal plueral thickening was noted in the pleura liningthe right posterior segment of upper lobe and left apicoposterior segment of upper lobe. There was no evidence of any lymphadenopathy. My physician suspects pneumonia. Could this be a recurrence of TB.
The most important part of assessing whether or not you have recurrent tuberculosis is whether you initially had tuberculosis. There are other diseases besides tuberculosis that cause caseating mediastinal lymphadenopathy, and in the absence of stains or cultures showing the organism, alternative processes must be considered.
The Centers for Disease Control recommend attempting to confirm the diagnosis of tuberculosis prior to instituting therapy. This can be done one of two ways:
1) Laboratory criteria: Isolation of M. tuberculosis from a clinical specimen (i.e. sputum) Or, when a culture has not been or cannot be obtained, demonstration of acid-fast bacilli in a clinical specimen
2) For cases that lack laboratory confirmation, ALL elements of the clinical case definition must be met: a) A positive tuberculin skin test b) Signs and symptoms compatible with tuberculosis, such as abnormal, unstable (worsening or improving) chest radiograph or clinical evidence of disease c) Treatment with two or more antituberculous medications, and d) A completed diagnostic evaluation
The fact that the lymphadenopathy cleared with treatment is reassuring, but not sufficient to make the diagnosis of tuberculosis.
It also would be helpful to know what medications you took for one year. The standard treatment for active tuberculosis is for 4-, 6-, or 9-months depending on the drug regimen. In the case of the 9-month regimen, generally the treatment is Isoniazid and Rifampin for nine months with ethambutol or streptomycin for the first 2 months if INH resistance rate is not documented to be less than 4%.
To document resistance, sputum smear and cultures should be obtained monthly or at least following 2, 4, and 6 months of treatment. While a chest xray is important at the conclusion of therapy it is not as helpful (or as essential) as sputum examination.
In summary, this could be a recurrence of Tb if Tb was never documented to have cleared by sputum exams. However, an alternative diagnosis to Tb must be considered if the appropriate diagnostic criteria were not present prior to initiation of therapy.
J Daryl Thornton, MD, MPH
Assistant Professor of Medicine
School of Medicine
Case Western Reserve University