Our patient is a 67-year-old male with a past medical history significant for
hypertension and
hyperlipidemia came to a hospital with
hemoptysis. He was also having
cough and
shortness of breath for the last 1 month. He said that his
hemoptysis was about 1 cup per day mixed with yellowish sputum. He noticed around 20 pounds of
weight loss in the last 1 month. He also complained of night sweats but had no
fever. He had no history of travel outside the USA. He has never been incarcerated before, but he endorsed that his son has been to Jail before and he visited him twice a year in patient's home. But he also said that his son has never been diagnosed with TB. He smoked 1.5 packs per day for the last 50 years and quit smoking 2 months ago. His medication include
hydrochlorothiazide, lisinopril,
gabapentin,
aspirin and
trazodone. On examination, vital signs were within the normal range except a hearty rate of 106 beats/minute. He had slightly pale conjunctiva, non-icteric sclera and had wet tongue and buccal mucosa. There was decreased air entry with crepitations in the right side of the posterior chest but no wheezes or
rales. No peripheral
lymphadenopathy, no peripheral
edema or sign of fluid collection in the abdomen. Chest x ray showed multiple cavitary lesion in the right upper lobe area. CT scan of the chest with
PE protocol showed pulmonary venous partial
thrombosis in the right upper lobe. Multiple cavitary lesions with hilar and mediastinal
lymphadenopathy. There are also smaller nodular lesions in the left chest too. Small right
pleural effusion with multiple calcified granulomata in the left upper lobe. QuantiFERON
gold test was found to be positive. Sputum AFB smear was found to be strongly positive and it is sensitive to
rifampin. Echocardiography showed no valvular lesions with preserved ejection fraction (>65%) and normal right ventricular size and normal right ventricular systolic pressure. Liver
enzymes and renal function tests were found within the normal limit. HIV test was negative. Patient was started with intensive phase anti-
tuberculosis treatment with
rifampin,
isoniazid,
ethambutol,
pyrazinamide with
vitamin B6. He was also started with anticoagulation with
heparin and
warfarin considering the
tuberculosis being the cause of the pulmonary vein
thrombosis. Patient was also given supportive treatment and he made a gradual improvement and was discharged with anti-
tuberculosis treatment and
warfarin. Patient needed to be placed on a higher dose of
warfarin as it was difficult to keep him therapeutic with lower doses. He was also advised to follow with
infectious disease and anticoagulation clinic. Patient was found to have a significant increase in liver
enzymes and
bilirubin on follow up and the anti-TB medications were stopped to be restarted one by one with a follow up of his liver
enzymes and liver function tests. He was also continued with
warfarin.