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An 87-year-old widower, who was living alone in a studio apartment of a senior housing
development, complained of a cough productive of scant amounts of grayish sputum for several
weeks. He had no fevers, sweats, or other constitutional symptoms. On physical examination, he
appeared vigorous and was not coughing. Temperature was 98 ◦F. Auscultation of the lungs
revealed scattered rhonchi, which cleared on coughing. He was a nonsmoker and denied a history
of lung disease or exposure to tuberculosis.
Chest X-ray was done and an infiltrate was seen. Sputum culture was sent and a 10-day course of
clarithromycin was instituted. The cultures were negative and the patient went about his normal
business. Six months later, he reappeared at the doctor’s office complaining of persistent
coughing, again without constitutional symptoms. Physical examination was unchanged and the
infiltrate was again demonstrated on chest X-ray. The patient now revealed that, “after thinking
about it,” he remembered that 70 years before his college roommate had been forced to leave
school because of “consumption.”
Except for excision of a melanoma 2 years ago, and a remote history of duodenal ulcer, the
patient has been otherwise well. He was widowed over 1 year before the onset of his cough, but
has been socially active and in relatively good spirits.
The patient’s chest X-ray showing an infiltrate in the lingula.

Tasks:
1. What further tests are required?
Task 1 (3.0) cytologic and microbiologic evaluation for bacteria, fungi, and
acid-fast bacillus (AFB).
Although the patient does not have constitutional symptoms or weight loss, and is a
nonsmoker, a lung malignancy should also be considered, as lung cancer increases with age,
cancer and other serious comorbidities increase risk of TB, and this patient has a history of
melanoma.

Flexible bronchoscopy,
chest computed tomography scan – to assist in ruling out carcinoma.
skin testing to diagnose TB is controversial,
tuberculina.
Skin test positivity wanes with time after exposure to Mycobacterium tuberculosis, as the
population of memory CD4 T cells declines.
. Elderly patients undergoing skin testing whose initial test is negative should be retested
after 2–3 weeks.
this patient, the smear obtained from expectorated sputum was positive for AFB.

2. Of what diagnostic significance is the chest X-ray?

Task 2 (3.0). The patient’s isolated lingular infiltrate is a “classic” finding in primary TB.
majority of elderly with TB have reactivation disease, in which the lingular infiltrate
would be seen as an extension of upper lobe disease.
However, primary as well as postprimary pulmonary TB may present without these
classic radiographic features, especially in the elderly,
who are less likely to have cavitary or apical lesions and more likely to have mid and
basal zone lesions
These findings are similar to those seen in patients with profoundly decreased cell-
mediated immunity, such as patients with HIV infection.
3. What risk factors have contributed to the patient’s problem?
Task 3 (2.0) Among all ethnic groups and both sexes, TB is much more common in the
elderly population as a whole than in younger age groups .
Chronic cough that age alone is an independent risk factor for TB. This age-associated
risk might be related to comorbidities impacting on immunologic function, such as
diabetes, chronic obstructive pulmonary disease, cardiovascular disease, renal
insufficiency, cancer, or even gastrectomy,

Our patient has a history of melanoma excision, and it would be important to consider
recurrent tumor,
The issue of emotional stress has been raised as a precipitant of a variety of diseases. In
late life, stress often comes as a result of losses, such as death of a spouse or loss of
employment.
There is evidence that the hypothalamic–pituitary– adrenal axis and the sympathetic
nervous system play a role in the depression of T-helper cells, which are important in
controlling infection.
Bereavement has been associated with excess mortality from a number of diseases,
including TB, alcoholism, heart disease, and others. Men are at greater risk of mortality
following loss and bereavement than are women.
4. What preventive measure should be implemented within the patient’s housing complex?
Task 4 (2.0) Regardless of whether the patient had primary or postprimary disease, interviews,
skin testing, and chest X-rays of the patient’s contacts should be conducted. If TB skin testing
had been required of new residents and employees in the housing complex, retesting at this time
would facilitate discovery of the index case if the patient had primary TB, and would identify his
contacts at risk for primary disease if he had reactivation TB.

Final score: