Shirleen Loloyan, MD

The referring community hospital is concerned that the girl may have tuberculosis (TB) but is unable to complete the workup because of lack of bronchoscopy service. Transfer for further workup, including bronchoscopy, is requested. 

The mother reports that her daughter has had no fevers, sweats, weight loss, nasal congestion, rash, joint pain or swelling, shortness of breath, visual changes, or emesis. She does not have a history suspicious for aspiration. She does not have a chronic cough or a history of recurrent respiratory, sinus, or ear infections. She also does not have a history of prolonged bleeding or easy bruising. 

You review her past medical history, which is notable for mild reactive airways disease with viral illnesses and appendicitis at 6 years, but is otherwise negative. She was born full term without complications. Her travel history consists of a trip to East Asia when she was 5 years old, but she has not traveled since. There are no known sick contacts. 

Her family history reveals that her father has asthma for which he is taking fluticasone propionate. The family history is otherwise negative for other respiratory illnesses, including cystic fibrosis, recurrent sinopulmonary infections, or hematologic or autoimmune diseases. There are no known family members with TB or who have tested positive for purified protein derivative (PPD); however, her parents come from Southeast Asia, where TB is endemic. 

Physical examination reveals that her weight and height are normal for her age. She is speaking in full sentences and seems very cheerful. She has a temperature of 37°C; heart rate, 111 beats per minute; respiratory rate, 20 breaths per minute; blood pressure, 111/62 mm Hg; and oxygen saturation, 100% on room air. Her exam is notable for minimal wheezes at the right lung base, but she is breathing comfortably without distress. 

Her cardiac exam reveals a regular rate and rhythm without gallops or murmurs. She does not have nasal drainage or polyps. Her throat is clear without tonsillar hypertrophy, bleeding, or exudates. She does have a few carious molars but no missing teeth. She does not have digital clubbing or extremity bruising. She also does not have any skin rashes, decreased joint mobility, or joint pain or swelling. Her abdomen is soft without any masses or hepatosplenomegaly. Her neurologic exam is normal as well. 

You review the laboratory results sent by the referring community hospital.  

The complete blood count (CBC) is reassuring, with a white blood cell count of 8, hemoglobin of 12.7 g/dL, hematocrit of 37%, and platelet count of 355 K/µL. The white blood cell count differential is 49% neutrophils, 41% lymphocytes, 7% monocytes, and 2.6% eosinophils. Blood urea nitrogen is 4 mg/dL, and creatinine is 0.35 mg/dL, both normal. C-reactive protein is also normal at <0.2 mg/dL. 

Rheumatologic labs, including negative antinuclear antibodies, perinuclear antineutrophil cytoplasmic antibodies, cytoplasmic antineutrophil cytoplasmic antibodies, and antiglomerular basement membrane antibody, and C3 and C4 are normal. 

Infectious workup has thus far been negative, including 3 gastric aspirates negative for acid-fast bacilli, PPD without any induration at 48 and 72 hours, and sputum bacterial culture without growth of respiratory pathogens. Coccidioides IgG and IgM are also negative. Stool occult blood was negative. Her CXR and chest CT readings report a right middle lobe infiltrate but no adenopathy. 

You decide to repeat the CBC, which remains essentially the same. You decide to check a coagulation profile, which is normal, revealing a partial thromboplastin time of 27, prothrombin time of 11.3, and international normalized ratio of 1.1. Urinalysis is also normal without blood, protein, nitrites, or leukocytes.  

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