Case Presentation: A 70-year-old Vietnamese gentleman without a significant past medical history was admitted to the hospital after a mechanical fall. Apart from facial pain related to the fall, the patient did not report any other symptoms. He was afebrile and hemodynamically stable. His physical examination was unremarkable. During his trauma evaluation, bilateral apical pulmonary nodules were incidentally noted. A follow up CT Chest not only confirmed these pulmonary nodules measuring 6 to 12 mm but also revealed a left lower lobe cavitary lesion. The patient did not have any shortness of breath, cough, fevers, night sweats or weight loss prior to and during this hospitalization; of note, the patient worked as a medical technician for multiple decades after emigrating and recently moved into an apartment with multiple roommates. Ultimately, Mycobacterium Tuberculosis grew in two acid fast bacilli sputum cultures. A third sputum culture grew acid fast bacilli with speciation pending. Additionally, serum mycobacterium tuberculosis PCR was detectable. He was discharged on direct observation therapy with rifampin, isoniazid, pyrazinamide, ethambutol, and pyridoxine.
Discussion: While TB is more commonly diagnosed in developing countries, it remains prevalent in the United States though may present in unique ways. Interestingly, this patient has had multiple negative purified protein derivative (PPD) skin tests since immigrating to the United States 30 years ago. While this patient was immunocompetent, he had TB exposure as a as a medical technician. It should be remembered that common symptoms including fevers, night sweats, and cough are often absent in the elderly. Including TB in the differential for elderly patients with pulmonary lesions or lymphadenopathy who lack classic symptoms can allow for the prompt diagnosis of and treatment of active pulmonary TB.
Conclusions: In 2017, there were 1.3 million tuberculosis (TB) related deaths worldwide and an incidence of 9,105 reported cases. While the incidence continues to decrease, TB remains a major public health challenge given the limited availability of antimicrobial regimens in the setting of increasing multi-drug resistant strains. Therefore, recognizing and accurately diagnosing asymptomatic patients with active pulmonary TB allows for prompt treatment and prevention of disease transmission. Specific populations such as the elderly and the immunosuppressed may have atypical presentations that can delay diagnosis, ultimately placing large segments of the community at-risk.