Clinical case of the month. A 20-year-old man with cough of two months duration.

A 20-year-old man with no significant past medical history presented to the emergency department complaining of cough for two months. The cough, productive of greenyellow sputum, had gradually worsened over the two months prior to presentation. He also complained of subjective fevers, night sweats, fatigue, and a 15-pound weight loss over this period. The patient denied any history of hemoptysis, recent sick contacts, or prior incarcerations. The remainder of the patient’s review of systems was negative. The patient had no significant surgical or family history. He denied smoking, alcohol use, and illicit drug use. The patient worked as a parking valet and was not taking any prescription medications. On physical examination, the patient’s vital signs were all within the normal range and included a respiratory rate of 18/min and a systemic arterial oxygen saturation of 100% breathing air. Lung examination revealed only decreased breath sounds in both upper lung zones. The remainder of the patient’s physical exam was normal. Plain radiograph of the chest demostrated bilateral upper lobe infiltrates with cavitary lesions (Figure 1). Upon admission, the patient was placed in respiratory isolation and started on rifampin, isoniazid, pyrazinamide, ethambutol, and pyridoxine daily for empiric treatment of pulmonary tuberculosis. A non-contrast computed tomogram (CT) of the chest also showed extensive upper lobe disease with areas of bronchiectasis, consolidation, lobular nodules, and cavitation (Figure 2). Sputum stains revealed acid fast bacilli (AFB), and sputum cultures grew Mycobacterium tuberculosis. After four days of hospitalization