When Antitubercular Therapy Isn't Enough: A Case Report of Persistent Cavitary Tuberculosis and the Role of Surgery

Abstract INTRODUCTION: Mycobacterium tuberculosis bacilli can persist even after antitubercular therapy, especially in patients with cavitary disease. This residual bacillary load in the cavities poses a risk of not only relapse and disease recurrence but may also cause extensive architectural distortion and further sequelae, as was seen in our patient. In such cases, the appropriate route of treatment can be complicated. The ] case highlights the importance of considering extensive surgical management in certain cases, to improve outcomes and quality of life. CASE REPORT: A 58-year-old female presented with cough with yellowish expectoration, associated with 3-4 episodes of blood-tinged sputum daily since 10 days, breathlessness (grade 2 MMRC), vomiting and loss of appetite for 1.5 months. On examination, she was afebrile, with a pulse rate of 118 bpm, respiratory rate 24/minute, blood pressure 110/70 mmHg and saturation 90% on room air. She was on anti-tubercular therapy (ATT) with Isoniazid, Rifampicin, Pyrazinamide and Ethambutol), but was non-compliant with treatment. Patient was started on 2L of oxygen via nasal prongs. Complete blood hemogram was normal, but she had deranged liver enzymes. History and treatment is summarised in the given timeline (PTB: pulmonary TB; CBNAAT (Cartridge-based nuclein acid amplification test; MTB: mycobacterium tuberculosis; MGIT: Mycobacterium growth indicator tube; LFT: Liver function tests) Owing to LFT derangement, ATT was withheld. Repeat HRCT thorax showed multiple thick-walled air-fluid densities in the left upper hemithorax, inseparable from the residual left upper lobe parenchyma, communicating with the anterior and posterior bronchial segments of the left upper lobe. During admission, she also demonstrated signs of irritability, low mood, and loss of interest and was subsequently diagnosed with major depressive disorder, and was started on tablets Escitalopram 5mg and Clonazepam 0.25 mg. Individual ATT was re-introduced once liver enzymes were within normal limits. Second curative surgery was considered, but deferred due to patient's unwillingness and psychological distress. CONCLUSION: In the presence of severe architectural distortion of lung and positive tissue biopsy for tuberculosis, medical therapy alone may not be sufficient, and agressive surgical resection may be required to minimize the recurrence of symptoms, as well as to protect the remaining normal lungs from spillover infections. A delay in adequate surgical management has a direct impact on the patient's quality of life and increases risk of mortality from worsening disease.