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Case of the Month - November 2012

Professor Andrew Whitelaw, Infection Control Society of Southern Africa

Case scenario 1:

A medical student was asked to clerk a patient with MDR-TB who was being admitted for a partial pneumonectomy. He had been on treatment with standard MDR therapy for 12 months with no resolution of symptoms, and was still smear positive 2 months prior to admission. On chest X-Ray he had severe disease in the right middle and upper lobes. Approximately one month later the medical student started complaining of non-specific symptoms of tiredness and lethargy, and occasional fevers. A chest X-Ray showed a left pleural effusion. The pleural effusion was tapped. Microscopy of the effusion showed no acid fast bacilli, however a GeneXpert MTB/Rif assay was performed which was positive for M. tuberculosis, resistant to rifampicin. A line probe assay was also performed on the effusion and this was negative. The GeneXpert was repeated and was negative. Culture of the pleural fluid was requested.

Case scenario 2:

A medical student was diagnosed with rifampicin susceptible pulmonary tuberculosis using the GeneXpert. Subsequent microscopy showed that he was smear-positive. He used to work in a study group with 5 other students, and these students were now concerned about their risk of acquiring TB. They wanted to know whether they should be tested, how they should be tested, and whether they should take prophylaxis.

Question 1: Was sinusitis an appropriate diagnosis in the first instance?

Continue to Answer 1