The Gorgas Courses in Clinical Tropical Medicine

Selected Cases Seen by 2007 Course Participants

History:  52 year old male who presented with a 4 month history of fever, night sweats, dyspnea, dry cough and a 25 kg weight loss.  He also reports increasing hoarseness and increasing pain on swallowing.  Initial sputum examination for acid-fast bacilli was negative, but 1 month prior to admission he presented at a hospital in another city and was diagnosed with sputum positive TB [chest X-ray shown in Image A] and begun on standard 4-drug therapy with which he was adherent.  At the time of admission he reports continued progression of his symptoms and weight loss.

Epidemiology:  Patient is a farmer from Quillabamba in the jungle regions of Cusco Department.  Non-smoker, non-drinker, no previous TB history.  Was treated with an unknown quantity of antimony 15 years ago for a cutaneous leishmania ulcer on his chest wall.

Physical Examination:  Afebrile.  Normal vital signs.  2 cm non-tender right cervical lymph node.  Direct laryngoscopy disclosed a granulomatous appearing lesion on the true vocal cords.  Examination of the chest disclosed no evidence of pleural effusion or consolidation.  There were bronchial breath sounds bilaterally but worse at the right base.  No hepatosplenomegaly.  Skin:  quiescent psoriasis most marked on the legs, scar of previous leishmanial ulcer.

Laboratory Examination:  Hematocrit 35.  WBC 16.7 with 70 neutrophils, 4 bands, 3 eosinophils, 21 lymphs.  LFTs normal.  BUN, creatinine normal.  HIV negative.  HTLV-1 negative.  3 induced sputum samples for acid fast bacilli and PAS staining negative.  Chest X-ray soon after admission and after over 1 month of anti-TB medication is shown in Image B.  Vocal cord biopsy was positive for Leishmania but as this did not explain the progressive pulmonary disease, a lymph node biopsy was performed.

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