A 34-year-old woman in Portugal without recognized immunocompromise developed acute fulminant pulmonary tuberculosis complicated by acute respiratory distress syndrome. Following respiratory failure refractory to mechanical ventilation and prone positioning, clinicians successfully managed the patient using veno-venous extracorporeal membrane oxygenation rescue therapy.
In Plain English: The Clinical Takeaway
- Severe Presentation: Tuberculosis can occasionally strike rapidly, mimicking ordinary bacterial pneumonia and causing severe lung failure even in healthy adults.
- Rescue Oxygenation: Extracorporeal membrane oxygenation acts as an artificial lung, pumping blood outside the body to oxygenate it when conventional mechanical ventilators fail.
- Diagnostic Vigilance: Clinicians must consider tuberculosis in unexplained severe respiratory failure, especially when standard antibiotics fail to resolve symptoms.
Emergency Department Presentation and Initial Misdiagnosis
The patient presented to the emergency department with a 10-day history of persistent dry cough, anorexia, high fever reaching 40.3°C, and pleuritic precordial chest pain. Blood work revealed an elevated C-reactive protein level of 27.8 mg/dL and a procalcitonin level of 0.96 ng/mL. Arterial blood gas analysis documented hypoxemia and respiratory alkalosis under oxygen therapy.
Initial diagnostic evaluations, including urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila, fourth-generation HIV serology, and a comprehensive respiratory panel, returned negative results. Presuming a bilateral bacterial pneumonia based on chest radiography showing airspace consolidation, physicians initiated empiric antimicrobial therapy with intravenous amoxicillin/clavulanic acid and azithromycin.
Intensive Care Escalation and Tuberculosis Diagnosis
Respiratory deterioration necessitated transfer to the intensive care unit two days after admission, where thoracic computed tomography confirmed marked bilateral peribronchovascular interstitial thickening and basal pulmonary consolidation. After fulfilling criteria for acute respiratory distress syndrome, the patient underwent orotracheal intubation with neuromuscular blockade and prone positioning sessions.
Polymerase chain reaction testing of repeat bronchoalveolar lavage fluid ultimately confirmed the presence of Mycobacterium tuberculosis complex.
| Clinical Parameter | Admission Value | Reference Range |
|---|---|---|
| Hemoglobin | 13.2 g/dL | 12.0-15.0 g/dL |
| C-reactive protein | 27.8 mg/dL | <0.5 mg/dL |
Veno-Venous Extracorporeal Membrane Oxygenation Rescue
Transferred to an isolation intensive care unit nine days later, the patient experienced further respiratory decline with a PaO₂/FiO₂ ratio below 150 and mixed acidosis. Mechanical ventilation mechanics documented a restrictive pattern with a plateau pressure of 26 cmH₂O and static compliance of 29 mL/cmH₂O. Faced with refractory respiratory failure, the medical team transferred the patient to a specialized center for femoro-femoral veno-venous extracorporeal membrane oxygenation cannulation.
Under extracorporeal support and lung-protective ventilation, the patient stabilized and successfully underwent extubation seven days after cannulation. Decannulation occurred four days later following a successful spontaneous flow trial. She was subsequently discharged.
Contraindications & When to Consult a Doctor
Persistent high fevers, worsening shortness of breath, or a chronic cough unresponsive to standard outpatient antibiotics warrant immediate emergency medical evaluation and diagnostic screening.
Global Epidemiological Context and Public Health Impact
Tuberculosis remains a major global health challenge responsible for an estimated 10 million new cases and over 1 million deaths worldwide in 2024. According to the WHO incidence category, Portugal and Brazil both belong to category 4, representing 10% of the global disease burden, with an incidence of 10-49 cases per 100,000 people. This case underscores the diagnostic complexities of fulminant presentations in non-immunocompromised hosts and demonstrates the life-saving potential of extracorporeal support in specialized centers.
