Smear Negative Tuberculosis in an 85-Year-Old Female Presenting with Body Weight Loss: A Case Report

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1 [Case 臺灣老誌 Report] Smear Negative TB in an 85-Year-Old Female 第 7 卷第 3 期 Smear Negative Tuberculosis in an 85-Year-Old Female Presenting with Body Weight Loss: A Case Report Chang-Hung Chen 1, Horng-Ming Yeh 2 Abstract This 85-year-old female had been independent and healthy came to our geriatric clinic on Jan. 28, 2012, due to body weight loss, poor appetite, dysphagia and general weakness during the past one to two months. Mild dyspnea without fever and sputum developed just a day before visiting the clinic. Chest X-ray revealed diffuse interstitial infiltrations with areas of consolidation in the lobes of both lungs. With an initial clinical suspicion of tuberculosis (TB), three sets of sputum acid-fast stains were done, but with negative results, the sputum TB culture results were still pending. Progressive dyspnea and fever developed on Feb. 1, and the patient was admitted to the intensive care unit due to bilateral pneumonia complicated with acute respiratory failure. Ceftriaxone and solucortef were given with ventilator support. Her condition improved after supportive treatment and she was transferred to the general ward on Feb. 13. The positive TB culture results were announced on Feb 23, and anti-tb regimen with ethambutal, isoniazid, and rifamycin was given. Abnormal liver function unfortunately developed days after initiation treatment. Elderly persons are less likely to have classic symptoms of TB, such as fever, night sweats, and hemoptysis than the young. Early identification of TB in patients with a negative sputum smear is even more difficult. This case highlights the need for a high index of suspicion of TB in elders with atypical presentations such as unintentional body weight loss. 200

2 Vol.7 No.3 陳長宏等 Taiwan Geriatr Gerontol (Taiwan Geriatr Gerontol 2012; 7(3): ) Key words: tuberculosis, elder, smear-negative, weight loss 1 Department of Chest Medicine; 2 Department of Geriatrics, Tainan Municipal Hospital, Taiwan Correspondence to: Horng-Ming Yeh No. 670, Chung Der Road, Tainan 701, Taiwan (Tainan Municipal Hospital) Tel: (886) yehwu@ms31.hinet.net 201

3 臺灣老誌 Smear Negative TB in an 85-Year-Old Female 第 7 卷第 3 期 Introduction Older adults are uniquely susceptible hosts for tuberculosis (TB). Compared to young adults, older adults are less likely to have the classic symptoms of TB, such as fever, night sweats and hemoptysis [1]. Early identification of TB in patients with a negative sputum smear is even more difficult. Clinicians must face the dilemma of prescribing empirical treatment or waiting for the final culture results weeks later. We herein report a case of smear negative TB in a previously healthy 85-yearold female, who presented with dysphagia and body weight loss. Later on, the patient progressed to respiratory failure and recovered after supportive treatment. The accurate diagnosis was established after the TB culture result was obtained three weeks later. Case Report This 85-year-old female had been independent and healthy. She received a total abdominal hysterectomy and bilateral salpingo-oophorectomy in 2006 due to mucinous cystadenoma, and underwent open reduction and internal fixation in Oct due to a left distal radio-ulnar comminuted fracture. She has no known history of TB contact, no steroid use, and no recent quinolone use. She came to our geriatric clinic on Jan. 28, 2012, due to body weight loss, poor appetite, dysphagia, and general weakness during the past one or two months. She was afebrile with mild dyspnea but no chronic cough. Physical examination revealed her body weight was only 36 kg, body height cm, blood pressure 128/59 mmhg, pulse rate 99/min, respiratory rate 22/min, and body temperature 36.5 C. Crackles were audible in both pulmonary bases. Chest X-ray revealed a diffuse reticular-nodular pattern with areas of consolidation mostly in both lower lung fields, and obvious progression was noted compared with the previous film (Fig. 1). Chest CT scan showed diffuse interstitial infiltrations with areas of consolidation in both lungs (Fig. 2). Progressive dyspnea and fever up to 38.4 C developed on Feb. 1, endotracheal intubation was performed, and she was admitted to intensive care unit due to acute respiratory failure. The differential diagnosis included pulmonary TB and lymphagitis carcinomatosis. Panendoscopy was performed to rule out underlying gastric malignancy, and showed gastric ulcer only. Tumor markers, including AFP, CEA, and CA199 were negative. The CA125 value was 64.2 U/ml (<35), and the gynecological sonogram and pelvic exam were negative. 202

4 Vol.7 No.3 陳長宏等 Taiwan Geriatr Gerontol a. Oct. 20, 2011 b. Jan. 28, 2012 Fig. 1 Chest X-ray revealed a diffuse reticular nodular pattern with areas of consolidation in both lower lung fields; obvious progression was noted. Feb. 4, 2012 Fig. 2 Diffuse interstitial infiltrations with areas of consolidation in the lobes of both lungs. Due to an initial clinical suspicion of TB, three sets of sputum acid-fast stains were done soon after intubation, but yielded negative results, the sputum TB culture 203

5 臺灣老誌 Smear Negative TB in an 85-Year-Old Female 第 7 卷第 3 期 results were still pending. Positive laboratory tests included WBC 15501/ul, and segments 82%. Ceftriaxone and solucortef were then given with ventilator support. Blood culture, sputum culture, and urine culture were all negative. Her condition improved and she was transferred to the general ward on Feb. 13 after successful weaning. A positive TB culture was identified on Feb 23, sputum culture grew mycobacterium tuberculosis complex and the drug susceptibility test showed no resistance to first-line drugs. Anti-TB treatment with ethambutol, isoniazid, and rifamycin was given on the same day. The anti-tb drugs were stopped unfortunately, due to abnormal liver function (Table 1). Isoniazid 200 mg qd was given then, after liver function tests returned to normal. At this writing, the patient was receiving isoniazid, and rifamycin under regular outpatient follow-up. Table 1 Abnormal liver function developed after anti-tb regimen was initiated 26-Feb 1-Mar 5-Mar 9-Mar AST (GOT) (10-35) U/L ALT (GPT) (0-40) U/L Total bilirubin ( ) mg/dl Discussion In developed countries, TB is essentially a disease of the old and very old of the indigenous population [2]. Elderly peoples are uniquely susceptible hosts for TB. Immune senescence, poor nutrition, and comorbidities contribute to the risk of mycobacterium tuberculosis reactivation in the elderly [3]. Nearly all TB in the elderly represents reactivation of infection that was acquired much earlier in life, suggesting that reduced host defenses that previously contained the infection have assumed a major role in clinical disease. Older adults are less likely than younger adults to have the classic symptoms of TB, including fever, night sweats, or hemoptysis, but they are more likely to present with nonspecific symptoms, such as the body weight loss and poor appetite of this patient. Unintentional weight loss in the elderly may reflect undiagnosed illness. The most commonly identified causes in the differential diagnosis are cancer, gastrointestinal disorders, and depression [4]. Consumption, or extreme body weight loss, was usually linked to TB in the 19 th century 204

6 Vol.7 No.3 陳長宏等 Taiwan Geriatr Gerontol [5]. Local and international consensus data focus on cough as the main symptom to look for. However, weight loss was still found to be a presenting symptom in 45% of patients diagnosed with TB in a population-based US study, which indicates that the classic symptoms of chronic cough and fever are insensitive predictors of TB [6]. Pulmonary TB in elderly adults is often mistaken for community-acquired pneumonia [7]. Radiographic changes in elders with pulmonary TB are less likely to be upper lobe and cavitary than in younger adults [8]; the picture of diffuse interstitial infiltrations with consolidation in this patient was treated as community-acquired pneumonia first. The diagnosis of mycobacterial infection is traditionally a two-stage process requiring weeks for completion. For diagnosis of pulmonary infection, patients are initially triaged into isolation if needed based on the results of acid-fast smears of sputum collected at the time of admission and on the next three consecutive mornings [9]. More rapid and appropriate treatment can lead to fewer ultimate complications and hospitalization in patients who have the disease, and avoidance of unnecessary treatment and isolation of those who do not have TB. Early identification of TB in patients with a negative sputum smear is difficult. With a initial clinical suspicion of TB, three sets of sputum acid-fast stains were done for this patient, but with negative results, the sputum TB culture results were still pending at the time. The failure to quickly recognize and treat affected patients leads to increased mortality, secondary resistance, and ongoing transmission [10,11]. Studies using molecular linkage estimated that in 13-20% of patients with TB, the disease was transmitted by patients with smear-negative TB [12,13]. New tools based on nucleic acid amplification for TB diagnosis have been developed in the past few years. Guidelines have been updated to suggest that nucleic acid amplification tests be performed on at least one respiratory specimen from all patients with suspected TB for rapid diagnostics [14]. Treatment of TB does not vary by age, but the toxicities of anti-tb therapy may be more prevalent in those at an advanced age, and drug interactions are common [15]. Taiwan is considered a country with a moderate TB prevalence, with an incidence rate of 62 per 100,000 in 2008 [16]. It is therefore important to maintain a high index of suspicion with every person-- not only those who are immunocompromised. This case highlights the need for a high index of suspicion of TB in elderly persons with atypical presentations such as unintentional body weight loss. Weight loss is still a presenting symptom in many patients diagnosed with TB, while the classic symptoms of chronic cough and fever are 205

7 臺灣老誌 Smear Negative TB in an 85-Year-Old Female 第 7 卷第 3 期 insensitive predictors. References 1. Zevallos M, Justman JE: Tuberculosis in the elderly. Clin Geriatr Med 2003; 19: Janssens JP, Zellweger JP: Clinical epidemiology and treatment of tuberculosis in elderly patients. Schweiz Med Wochenschr 1999; 129: Meyer KC: The role of immunity and inflammation in lung senescence and susceptibility to infection in the elderly. Semin Respir Crit Care Med 2010; 31: Reife CM: Involuntary weight loss. Med Clin North Am 1995; 79: Sontag S: Illness as Metaphor. New York, Vintage Books, Miller LG, Asch SM, Yu EI, et al: A population-based survey of tuberculosis symptoms: how atypical are atypical presentations? Clin Infect Dis 2000; 30: Htwe TH, Mushtaq A, Robinson SB, Rosher RB, Khardori N: Infection in the elderly. Infect Dis Clin North Am 2007; 21: Morris CDW: The radiography, haematology and bronchoscopy of pulmonary tuberculosis in the aged. Quart J Med 1989; 71: Huebner RER, Good C, Tokars JI: Current practices in mycobacteriology: results of a survey of state public health laboratories. J Clin Microbiol 1993; 31: Farmer P, Bayona J, Becerra M, et al: The dilemma of MDR-TB in the global era. Int J Tuberc Lung Dis 1998; 2: Van Rie A, Enarson D: XDR tuberculosis: an indicator of publichealth negligence. Lancet 2006; 368: Behr MA, Warren SA, Salamon H, et al: Transmission of mycobacterium tuberculosis from patients smearnegative for acid-fast bacilli. Lancet 1999; 353: Tostmann A, Kik SV, Kalisvaart NA, et al: Tuberculosis transmission by patients with smear-negative pulmonary tuberculosis in a large cohort in the Netherlands. Clin Infect Dis 2008; 47: Centers for Disease Control and Prevention. Updated guidelines for the use of nucleic acid amplification tests in the diagnosis of tuberculosis. MMWR Morb Mortal Wkly Rep 2009; 58: CR Marion and KP High: Tuberculosis in older adults. In: T.T. Yoshikawa and D.C. Norman (eds.), Infectious Disease in the Aging: A Clin Handbook. Totowa: Humana press, 2009: 行政院衛生署疾病管制局 : 台灣結核病 206

8 Vol.7 No.3 陳長宏等 Taiwan Geriatr Gerontol 防治年報 2009 from gov.tw/public/data/ pdf [July 31, 2012 accessed] 207

9 病例報告 一位 85 歲女性因體重減輕求診後發現痰液檢查陰性肺結核 : 個案報告 陳長宏 1 葉宏明 2 摘要 一位 85 歲原本健康獨立的女性, 因為一個多月來體重減輕 食慾差 虛弱於民國 101 年 1 月 28 日來診, 來診前一日覺得氣促但無發燒 胸部 X 光顯示兩側肺野彌漫性間質浸潤併實質病變 在疑似肺結核感染的診斷下, 留取三套痰液結核菌抗酸性染色及培養, 但初步痰液抗酸性染色結果為陰性 病患因發燒及氣促逐漸嚴重以肺炎合併急性呼吸衰竭的診斷於 2 月 1 日轉入加護病房接受呼吸器 抗生素 類固醇等治療 病患接受上述治療後好轉於 2 月 13 日轉回普通病房繼續治療 2 月 23 日接獲肺結核細菌培養陽性報告即給予抗結核藥物, 但用藥數天後因出現肝功能異常而停藥 老年人罹患肺結核時比較不會有發燒 夜汗 咳血等典型症狀, 在痰液檢查陰性病患早期診斷出肺結核更加困難 老年人接受肺結核治療較易出現副作用, 臨床醫師需在依經驗決定治療或等待結核菌培養報告中作出困難的抉擇 ( 臺灣老年醫學暨老年學雜誌 2012;7(3): ) 關鍵詞 : 結核 老年人 痰液抹片檢查陰性 體重減輕 1 台南市立醫院胸腔內科 2 老年科通訊作者 : 葉宏明通訊處 : 台南市 701 東區崇德路 670 號 ( 台南市立醫院 ) 電話 :(886) yehwu@ms31.hinet.net 208