Dysphonia as the Great Masquerader: A Case of Tuberculosis

Abstract Introduction: Tuberculosis (TB) is a communicable disease with active and latent phases. In the United States, up to 13 million people have latent infections with 5-10% of individuals developing active infection. Testing is imperative to identify such cases. Case: A 71-year-old woman with squamous cell carcinoma of the lung status post chemotherapy and radiation and sarcoidosis on chronic steroids was admitted for evaluation of a several month history of progressive hoarseness and supraglottic edema. Prior vocal cord biopsies showed ulcerated keratosis with granulomatous inflammation and reactive atypica. GMS stains were negative, and there was no evidence of malignancy. Repeat laryngoscopy showed scattered white lesions throughout the larynx and an enlarged epiglottis. Due to suspicion for laryngeal candidiasis, Fluconazole was started. CT chest showed bilateral lung nodules and right upper lobe airspace disease thought to represent post-treatment changes. On day four of admission, the patient experienced several episodes of hemoptysis. Sputum culture grew Staphylococcus aureus, and patient was started on Vancomycin. The next day, the patient experienced recurrent hemoptysis and subsequent PEA arrest. Multiple rounds of ACLS were unsuccessful, and the patient died. Autopsy showed Mycobacteria tuberculosis PCR positivity from the right upper lobe, necrotic pulmonary nodules with necrotizing granulomas with acid-fast bacilli, acid fast bacilli involving the epiglottis and larynx, diffuse pulmonary hemorrhage, and sarcoidosis with non-necrotizing granulomas involving lymph nodes, small bowel, spleen, liver, and bone marrow. Discussion: The presence of hoarseness, airway edema, and lung nodules in a patient with a history of malignancy and sarcoidosis on immunosuppressive therapy presented a complex diagnostic challenge. Concomitant sarcoidosis and tuberculosis is extremely rare, and TB was suspected to be a complication of prolonged steroid use in this patient. Laryngeal tuberculosis accounts for less than one percent of all tuberculosis cases, and patients can present with dysphonia, dysphagia or cough due to involvement of the vocal cords. Given the association between laryngeal tuberculosis and pulmonary involvement, evaluation for pulmonary tuberculosis is crucial. Patients with laryngeal and pulmonary tuberculosis are at increased risk of severe, potentially life-threatening airway compromise due to involvement of both upper and lower airways. Multidisciplinary collaboration with Otolaryngology and Infectious Diseases is essential for accurate diagnosis and management to prevent patient morbidity and mortality, as well as transmission of infection.