CP 2 - Pulmonary tuberculosis presenting as pyopneumothorax in a correctional facility: A case reportooked domain

Vilochani DC, Jayasekera PK, Piyasiri DLB, Solangaarachchi SASN, Umayangana MWT  , National Hospital Galle

Abstract

Introduction

Pulmonary tuberculosis (PTB), which is endemic in Sri Lanka, commonly presents with chronic cough and haemoptysis in the background of constitutional symptoms. We report a case of PTB presented as bilateral pneumonia complicated by pyopneumothorax.

 Case report

A 41-year-old-man with diabetes mellitus, who had defaulted on treatment for diabetes due to imprisonment for nearly two years, was brought to the emergency treatment unit after being found unconscious. On admission, he had a high fever and dyspnoea. Chest X-ray revealed bilateral pneumonia with right pneumothorax, necessitating an intercostal drain tube (ICT).

Investigations showed leucocytosis (WBC 15.2 ×10 9/L) with neutrophils 89%, and CRP 210mg/L with ESR 95mm/h. The ICT drain was purulent, confirming the diagnosis of pyopneumothorax. Repeated routine pus cultures from ICT were negative. Sputum culture grew a sensitive heavy growth of mucoid coliform, but the patient deteriorated despite meropenem. CT scan of the chest demonstrated bilateral cavitary consolidations. Glycaemic state was controlled with treatments and HIV was negative. Further history revealed that he had been imprisoned with an inmate for months, who was later diagnosed with PTB. He had a history of chronic cough with occasional haemoptysis for two months. Supporting this history, pleural fluid analysis showed +1 acid-fast bacilli (AFB), and GeneXpert detected a low level of Mycobacterium tuberculosis without rifampicin resistance. Subsequent sputum AFB testing was also positive. The Mantoux test was negative.

He was commenced on the standard anti-tuberculosis regimen and observed inward for clinical improvement. His biochemical markers were improved and he was later discharged with follow-up at the chest clinic.

Discussion

Sri Lanka, being a low-burden country for Tuberculosis, remains the second leading infectious disease according to the WHO. The burden is higher in correctional facilities compared to the general public, though the published data is lacking. This case highlights the importance of screening and isolation practices in correctional facilities, which prevent further dissemination and complications due to delayed diagnosis. A high index of suspicion is needed for patients presenting with severe respiratory infections, particularly when there is an exposure history.