Case 5: A 32-Year-Old with Chronic Cough - Opportunistic Infections: Treatment

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Case 5: A 32-Year-Old with Chronic Cough and Suspected Tuberculosis

Authors: Susan M. Graham, MD MPH
Masahiro Narita, MD

Case last updated: December 9, 2005

A 32-year-old man presents with fatigue and occasional chest pain. He notes an intermittent cough productive of scanty, yellowish phlegm for the past 4 weeks and has lost approximately 10 pounds. He immigrated from Vietnam 3 years ago and has no regular source of medical care. A chest radiograph reveals a patchy right upper lobe infiltrate (Figure 1). A diagnosis of tuberculosis (TB) is suspected. Further work-up shows a tuberculin skin test with 6 mm of induration, and three sputum smears negative for acid-fast bacilli (AFB). The patient agrees to HIV testing and is found to be HIV-infected.

Which one of the following statements is most likely TRUE?

	If a nucleic acid amplification test on sputum is positive for Mycobacterium tuberculosis, sputum culture is not required.
	If the pleural effusion is tapped, there is greater than 80% likelihood that a Ziehl-Neelsen stain of pleural fluid will show AFB.
	The patient’s small tuberculin skin test reaction is probably due to prior BCG vaccination, and an alternative diagnosis should be sought.
	Therapy for TB should be initiated while the diagnostic work-up continues.
	The patient’s CD4 cell count is almost certainly less than 100 cells/mm3.

Figure 1