A70-02 Pulmonary Deception: A Case of Atypical Tuberculosis Presenting as Multifocal Pneumonia

Abstract Introduction Tuberculosis (TB) is a chronic airborne granulomatous infection caused by Mycobacterium tuberculosis, ranging from latent infection to destructive active disease, most often pulmonary. TB on imaging most commonly demonstrates upper-lobe cavitary consolidation with tree-in-bud nodularity. Primary or disseminated disease may show adenopathy or miliary nodules, and atypical patterns include multifocal, lower-lobe, or diffuse ground-glass opacities. Globally, the burden is highest in sub-Saharan Africa and parts of Asia, where crowding, limited access to care, and impaired immune function converge. We describe a case of pulmonary TB in a patient from Cameroon with no other identifiable risk factors who presented with acute hypoxemic respiratory failure and multifocal opacities mimicking atypical pneumonia, ultimately confirmed by microbiologic testing after a diagnostic delay. Case A 32-year-old man with no significant history presented with two weeks of productive cough, fever, and chills. He was 92% on room air, placed on 2 L nasal cannula. Labs showed WBC 3.11. Rapid viral panel, blood cultures, and HIV were negative. MSSA nasal swab positive. He was born in Cameroon and moved to the US in 2021. He had recently traveled internationally (Ivory coast, Tanzania, Peru). He denied prior TB testing or known exposure, homelessness, or incarceration. Chest Computed Tomography showed bilateral diffuse ground-glass opacities, centrilobular consolidation, and dense right middle lobe consolidation [Figure 1]. He was treated as multifocal bacterial pneumonia with ceftriaxone/azithromycin but did not improve. Pulmonology was consulted, and bronchoscopy was performed. Bronchoalveolar lavage (BAL) was lymphocyte predominant and AFB positive. Infectious disease was consulted. Mycobacterium tuberculosis PCR on BAL was positive. He started rifampin, isoniazid, pyrazinamide and ethambutol regimen, was weaned off oxygen, and followed up outpatient. Discussion Multifocal TB is observed both in immunocompetent and in those with compromised immune systems. Although TB remains a major global health concern, its presentation as multifocal pneumonia is uncommon and poses significant diagnostic challenges. A detailed social history—the patient’s country of origin, recent travel, and potential exposure risks—is essential for identifying those at increased risk and guiding early diagnosis. This case emphasizes the importance of maintaining a high index of suspicion for TB particularly in patients who fail to respond to standard antibiotic therapy. Lastly, collaboration between pulmonology and ID specialists was crucial in confirming the diagnosis and providing comprehensive management of the illness. This case highlights the importance of clinicians to keep suspicion for TB infection even when traditional imaging and risk factors are not present. This abstract is funded by: None