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📋 Case Presentation: Post-Tuberculosis Sequelae

MD Final Practical Examination

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🔵 CASE VIGNETTE

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🔵 HISTORY OF PRESENTING ILLNESS

• Progressive exertional dyspnea for 6 months, now present at rest (MMRC Grade 3–4)
• Recurrent hemoptysis — small to moderate amounts of bright red blood
• Chronic productive cough with mucopurulent sputum
• Fatigue, weight loss, and evening rise of temperature for 3 months
• Bilateral leg swelling (ankle edema) for 1 month

• Treated for pulmonary tuberculosis 10 years ago — completed a full 6-month DOTS regimen (2HRZE/4HR); declared cured
• Has had recurrent chest infections since then
• No history of diabetes, HIV, or immunosuppression

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🔵 GENERAL PHYSICAL EXAMINATION

Clubbing + central cyanosis + raised JVP + bilateral edema = COR PULMONALE — a classical post-TB sequela

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🔵 RESPIRATORY SYSTEM EXAMINATION

Inspection

• Barrel-shaped chest (hyperinflation)
• Use of accessory muscles
• Trachea deviated to the left
• Left hemithorax — decreased movement
• Prominent intercostal spaces on right

Palpation

• Trachea: shifted LEFT (fibrosis/collapse of left upper lobe)
• Apex beat: shifted (mediastinal displacement)
• Tactile vocal fremitus: increased left upper zone, decreased left lower zone

Percussion

• Left upper zone: dull (fibrosis/consolidation)
• Left lower zone: stony dull (pleural effusion/thickening)
• Right upper zone: hyperresonant (compensatory emphysema)

Auscultation

• Left upper zone: bronchial breathing + coarse crackles
• Left lower zone: absent breath sounds (pleural thickening)
• Right side: rhonchi (obstructive component)
• Amphoric breathing over cavitary region

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🔵 CARDIOVASCULAR EXAMINATION

• Loud P2 (pulmonary hypertension)
• Right ventricular heave (parasternal)
• TR murmur at tricuspid area

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🔵 DIFFERENTIAL DIAGNOSIS

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🔵 INVESTIGATIONS

Sputum Examination

• AFB smear × 3 (morning) — to rule out recurrence/reactivation
• Sputum culture (LJ medium / MGIT) — gold standard for active TB
• Drug sensitivity testing (DST) — if positive
• Sputum for fungal culture + KOH — for Aspergillus
• Sputum cytology — to rule out malignancy

Blood Investigations

Imaging

• Upper lobe fibrosis and volume loss
• Tracheal/mediastinal shift toward the affected side
• Pleural thickening / calcification
• Cavitary lesions (with or without Monod sign = fungal ball)
• Bronchiectatic changes
• Elevated diaphragm on affected side

• Gold standard to assess:
  • Extent of bronchiectasis (cylindrical/varicose/saccular)
  • Fibrotic bands and traction changes
  • Cavitary lesions with fungal ball (hyperdense rounded mass)
  • Pleural thickening/calcification
  • Emphysematous bullae

• Right ventricular hypertrophy
• Raised RVSP (pulmonary hypertension)
• TR jet velocity > 3.4 m/s

• Mixed (restrictive + obstructive) pattern
• Reduced FEV1, FVC, FEV1/FVC
• Reduced DLCO (destroyed parenchyma)

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🔵 DIAGNOSIS

Post-Tuberculosis Sequelae manifesting as:

1. Destroyed Left Lung (fibrosis + bronchiectasis)
2. Chronic Cavitary Pulmonary Aspergillosis (aspergilloma in residual cavity)
3. Cor Pulmonale (secondary to chronic hypoxic pulmonary hypertension)
4. Chronic Respiratory Failure (Type II)

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🔵 PATHOPHYSIOLOGY (For Viva)

TB infection
     ↓
Granuloma formation → Caseous necrosis → Cavity formation
     ↓
Healing with FIBROSIS → Volume loss → Traction bronchiectasis
     ↓
Residual cavity → Colonized by Aspergillus fumigatus → Aspergilloma
     ↓
Chronic hypoxia → Pulmonary vasoconstriction → Pulmonary hypertension
     ↓
RV hypertrophy → Cor pulmonale → Right heart failure

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🔵 MANAGEMENT

A. General Measures

• Oxygen therapy (controlled, 24–28% via Venturi mask — caution in Type II RF)
• Nutritional rehabilitation (high-protein diet)
• Pulmonary rehabilitation
• Smoking cessation

B. Specific Medical Treatment

C. Surgical Options

• Surgical resection of aspergilloma — considered if:
  • Massive hemoptysis unresponsive to medical/radiological treatment
  • Adequate lung reserve exists
  • Single localized lesion

  Note: Surgery is risky due to adherent pleura and poor lung reserve (Harrison's, p. 5145)

• Bronchial artery embolization (BAE) — preferred non-surgical option for massive hemoptysis
• Lung transplantation — in end-stage destroyed lung (rare, selected cases)

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🔵 COMPLICATIONS OF POST-TB SEQUELAE

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🔵 PROGNOSIS

• Depends on extent of lung destruction, presence of aspergilloma, and cor pulmonale
• 5-year mortality in cor pulmonale + Type II RF is high (~50%)
• Early antifungal therapy (itraconazole ≥6 months) stabilizes/improves 60–75% of aspergilloma cases
• Regular follow-up with PFTs, CXR, and echo every 6 months

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🔵 VIVA / EXAMINER QUESTIONS TO PREPARE

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🔵 SUMMARY STATEMENT (For Exam Closing)

"This is a case of a 52-year-old male with a known history of treated pulmonary tuberculosis, now presenting with progressive dyspnea, hemoptysis, and features of right heart failure. Clinical and investigative findings are consistent with post-TB sequelae in the form of a destroyed left lung with chronic cavitary pulmonary aspergillosis, complicated by type II respiratory failure and cor pulmonale. Management includes controlled oxygen therapy, oral itraconazole for aspergilloma, diuretics for cor pulmonale, and consideration of bronchial artery embolization if massive hemoptysis occurs."

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