A 54-year-old woman with a history of hypertension presented with a worsening headache and a left hemisensory defect. A CT scan of her head without contrast showed a right parietal hemorrhage with spreading edema; the masslike effect caused shifting of the midline to the contralateral side. The patient gradually became comatose and required intubation for airway protection. Intravenous corticosteroids were administered to decrease the effect of the lobar hemorrhage. Fever developed 3 days after admission.
A chest film showed the endotracheal tube satisfactorily positioned and an infiltrate in the right upper lobe. Antibiotic therapy was begun for management of probable aspiration pneumonia. The patient remained febrile, and acute respiratory distress syndrome (ARDS) developed. The chest film seen here shows diffuse infiltrates. Tracheal aspirate revealed acid-fast bacilli. Antituberculous medications were initiated, but the patient died 2 weeks later.
Despite the availability of effective antituberculous agents, tuberculous pneumonia may still cause ARDS; this condition requires mechanical ventilation and carries a high mortality rate.1 Dr Samer Alkhuja of Greenwich, Conn, notes that underlying primary tuberculosis is more prone to become reactivated in a patient receiving immunosuppressive therapy, such as corticosteroids. In such a patient, persisting fever and worsening of pulmonary infiltrates as seen on a chest film should suggest this entity and direct an appropriate diagnostic effort and therapy.
1. Penner C, Robers D, Kuminoto D, et al. Tuberculosis as a primary cause of respiratory failure requiring mechanical ventilation. Am J Respir Care Med. 1995;151:867-872.