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Tuberculosis

Could `vague nodular opacities` be TB?

10/01/2007

Question:

I am a 32-year-old female. For the last month, I have had a bad upper/lower respiratory tract infection. My doctor could hear "rattles, wheezing, etc." in my lungs, and I have been having a hard time breathing. My doctor put my on Levaquin and gave me a Rocephin shot and inhalers. I did better for a few days, then I relapsed. They sent me for a chest x-ray at this point, which came back as being "fairy normaly." Still, I continued to have problems, was put on Omnicef, and finally went back on Thursday. My lungs sounded so bad, my doctor sent me for a stat CT scan. I also got another shot of Rocephin. The nurse called me shortly after and said it was fine. Then, the next day (yesterday), my doctor called me, sounding fairly upset, and said the radiologist had called her back with the following conclusions:

"There are very vague nodular opacities within the superior segment of the right lower lobe. There is also a questionable vague left lower lob opacity. No focal consolodation is indentified. The trachea and mainstem bronchi appear clear. There are a few small (less than 5mm) calcified left hiliar lymph nodes. The visualized portions of the liver and spleen appear normal (the liver is mildy distorted by respiratory artifact)" Impressions: 1. Findings comatible with prior exposure to granulomatous disease. 2. There are vague opacities within the superior segment of the right lower lobe and possibly within the left lower lobe as well. These are non-specific. These subtle opacities could be re-evaluated with a follow-up unenhanced CT examination in three months time if clinically appropriate in order to document resolution and exclude possibility of progressing pathology."

When I was 2, I tested positive for TB and did INH therapy for a year (my grandfather was a Baton Death March survivor and had TB...all of the 12 grandkids ended up testing positive). I had years of chest x-rays that were negative (and my recent one was "normal" too. This was my first CAT scan. So, could these be scars from my old TB scare? My mom says I never had active TB, but obviously I guess I did if there are scars? Could this be indicative of a new bout of TB? Or maybe I just have a resistant pneumonia (explaining why it gets better for a few days after the rocephin shot?), and the other stuff has been there my whole life? I asked my doctor to take a sputum sample on Thursday to tests for pathogens, and we are waiting on the results. So, I`m not having any additional treatment done this weekend. I have 3 little girls, so I am really freaked out about them getting near me. I am getting a referral to a lung specialist next week. Should I get a TB skin test? My mom always told me not to have another one done because it would be dangerous for me, but that doesn`t seem to make sense. Should I get my daughters and hubby tested? What are your overall impressions? I actually don`t feel too bad, just coughing a little, and I had my last Rocephin shot 2 days ago. Should I get a lung biopsy or something? Thank you SO much for your help!!!

Answer:

If you had a positive TB skin test when you were 2 years old, there is no need to repeat a TB skin test now, because you already know that you had a TB infection, and placing a new one wouldn't provide any information you don't already know, other than that you have been infected with TB. It sounds as if you took a year of INH preventative treatment when you were 2, which was intended to decrease the chances that you would have reactivation TB in the future, but this treatment is not 100% effective.

It sounds like you have been asked to cough up some sputum samples for acid-fast bacteria (AFB), and for other cultures and laboratory tests that will help determine whether you have reactivation pulmonary TB or some other infectious cause of cough that hasn't improved with therapy. Your doctors should be able to tell you the results of the sputum smears for AFB within a day or two of when they are collected, but even if the smears are negative, you could still have reactivation pulmonary TB, so they may want to send a sputum sample for a TB nucleic acid amplification test, also. Mycobacterium tuberculosis is a slow-growing bacteria, so the laboratory holds the sputum AFB cultures for 6 to 8 weeks.

It wouldn't hurt your daughters or husband to go ahead and get TB skin tests applied and read now. Even if their TB skin tests come back negative, if it turns out that you do have pulmonary TB, your pediatrician may want to give preventative therapy to your daughters, especially if any are less than 5 years of age or immunocompromised, until results of repeat TB skin testing about 10 - 12 weeks after you start therapy. It sounds as if you and your doctors are going to work together to find out what is making you sick and get you on the right treatment help you feel better.

Best of luck to you and your family.

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Response by:

Lisa A Haglund, MD Lisa A Haglund, MD
Associate Professor of Clinical Medicine
College of Medicine
University of Cincinnati