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[Case Report]

Case Report: Tuberculosis in a Young Baseball Player

Alicia Morgan-Cooper, MD; Mike Wasik, ATC; Jim Jernigan, MD; Edward G. McFarland, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 9 - SEPTEMBER 97


In Brief: This report of a 19-year-old pitcher with chest pain illustrates how an atypical presentation of pulmonary tuberculosis in an athlete can delay diagnosis. In addition to a history, physical examination, and chest radiographs, the tuberculin skin test is the key to diagnosis of this disease. Laboratory work includes blood tests, liver and renal function studies, analysis of aspirated fluids, and sputum cultures. Treatment generally consists of daily doses of isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin. Screening close contacts such as teammates is essential; prophylaxis using isoniazid must be initiated for those who test positive.

Through most of this century, tuberculosis declined because of improvements in hygiene and hospital care and the development of antituberculosis drugs. Until the early 120210s, tuberculosis was considered a minor, controllable public health problem (1,2). However, the incidence of the disease in the United States, including those who had tuberculosis infection as well as the active disease, increased by approximately 14% from 120215 to 1993 (3), largely because of the effects of homelessness, alcoholism, drug dependency, immigration from endemic areas, and the human immunodeficiency virus (HIV) epidemic (3,4). In addition, the incidence of multiple-drug-resistant Mycobacterium tuberculosis has increased and made treatment more difficult (1).

Given these developments, cases of tuberculosis among athletes are inevitable. As the following report shows, the initial presentation in an athlete can be misleading. The case report serves as the basis for a discussion of current concepts in the diagnosis, treatment, and prevention of tuberculosis in a sports team setting.

Case History

A 19-year-old, left-handed, male college pitcher presented to his athletic trainer with a 2-day history of right-sided chest pain. He first noticed the pain while lifting weights, and it was exacerbated by pitching. He described the pain as nonradiating and dull, near the level of ribs 8 through 10 at the right anterior axillary line.

He reported no recent respiratory infections, cough, shortness of breath, trauma, fever, chills, night sweats, or abdominal pain. He had no recent weight loss and no change in appetite. He did not smoke, but he used alcohol frequently. Chest radiographs taken after assessment by the team physician showed no abnormalities. The initial impression was a rib stress fracture or serratus anterior strain. He was treated conservatively with ice and anti-inflammatory medications.

After 5 days of treatment produced no improvement, a bone scan was ordered, but 24 hours later the patient developed a fever with temperatures up to 103°F. He was then seen by a family physician and was thought to have a viral illness and was given intravenous fluids and acetaminophen. The patient developed shortness of breath and his rib pain worsened over the next 24 hours, so he was admitted to the hospital for 3 days of evaluation.

In the hospital, repeat chest radiographs revealed a small pleural effusion (figure 1) but no other abnormalities. He was diagnosed as having bacterial pneumonia and was placed on intravenous ceftriaxone sodium supplemented with oral cefuroxime and erythromycin. A tuberculin skin test was performed since tuberculosis was part of the differential diagnosis. He continued to have pain in the anterolateral chest wall, low-grade fevers, and worsening dyspnea with green sputum production. Cefuroxime was changed to ofloxacin and given with erythromycin.

[FIGURE 1]

At a follow-up 7 days after discharge from the hospital, a repeat chest radiograph revealed a very large pleural effusion (figure 2). On physical examination at this time, the patient's breathing was labored. He had a temperature of 103°F, blood pressure of 120/70 mm Hg, heart rate of 110 beats per minute, and a respiratory rate of 24/min. His neck was supple with no throat erythema or tonsillar exudates. The cardiac exam was normal except for tachycardia. The respiratory examination revealed decreased breath sounds and dullness to percussion in the right lower lung fields only. The abdominal exam was normal, and there was no cervical or axillary lymphadenopathy. No rashes were present.

[FIGURE 2]

A complete blood count and liver and renal function studies were all within normal limits. A chest radiograph was also obtained. An HIV test was negative. Thoracentesis and biopsy revealed turbid pleural fluid with noncaseating granulomas. After the tuberculin skin test performed during his 3-day hospital stay revealed a 22-mm induration, tuberculosis was diagnosed. The patient reported no tuberculosis exposure.

Treatment. The patient was started on a combination of isoniazid and rifampin, and all his teammates were tested for tuberculosis. When two showed significant induration with no active symptoms, they were treated with isoniazid for prophylaxis, but no other precautions were taken.

Six weeks after the patient's initial presentation, a chest radiograph was taken. A comparison with the initial chest radiograph showed increased effusion. Ethambutol hydrochloride and pyrazinamide were added to the regimen after sensitivities became available. A thoracentesis was repeated to provide symptomatic relief. The patient's symptoms gradually resolved, and he returned to pitching 2 months after his initial presentation. He took medication for 6 months following diagnosis.

Diagnosis

A person suspected of having tuberculosis should be given a complete medical evaluation, including a medical history, physical examination, Mantoux tuberculin skin test (see "Reading the Mantoux Tuberculin Skin Test," below), chest radiograph, and bacteriologic examinations.

History and physical exam. The classic symptoms of tuberculosis are cough and chest pain. The persistent cough (usually lasting more than 3 weeks) is associated with mucopurulent sputum and, in some cases, hemoptysis (4). Systemic symptoms include fever, chills, night sweats, weight loss, and fatigue. It is important to question the patient about previous exposure to and infection with tuberculosis. If more information is needed, physicians can contact the local health department for records of a patient's previous tuberculosis treatment, since healthcare workers are required to report information on all persons with active tuberculosis to local public health authorities (5).

The physical exam may reveal cervical, axillary, or hilar lymphadenopathy. Decreased breath sounds, rales, and labored breathing may be present with active pulmonary tuberculosis. Vital signs are often altered, revealing tachycardia, tachypnea, and fever. Chest radiographs may show parenchymal infiltrates, unilateral pleural effusions, or granulomas.

Laboratory studies. Baseline blood tests, including a complete blood count, should be part of the laboratory studies for tuberculosis. Liver and renal function studies should also be ordered, since tuberculosis can involve the liver, kidneys, or gastrointestinal tract as well as the lungs; these studies may also rule out other illnesses, such as malignancies and hepatitis. Any effusion should be aspirated and examined for the high-protein, high-lactate dehydrogenase, and low-glucose levels that characterize tuberculosis.

Detection of acid-fast bacilli in sputum on stained smears examined microscopically may be an early clue to tuberculosis infection. A positive culture for M tuberculosis confirms the diagnosis of tuberculosis (3,4). However, since culture results are not available until 10 to 14 days after collection, a diagnosis is usually first made by clinical signs and symptoms and a skin test. Cultures should be done on all specimens whether or not the acid-fast bacilli smears are positive or negative. Follow-up sputum cultures should be performed monthly until there are three consecutive negative cultures (3,6).

Differential diagnosis. Because the patient in this case study was a pitcher and noticed the chest pain while lifting weights, the initial diagnostic considerations were a strained serratus muscle or rib stress fracture. However, when the patient failed to improve with ice and anti-inflammatory medications and had a rapid rise in temperature, other entities were considered.

Nontuberculous pneumonia usually causes pleuritic chest pain, high fever, dyspnea, and cough, as were evident in this patient. Neoplasm and pneumothorax were also possibilities. The patient's history of frequent alcohol use made gastrointestinal diseases such as liver abscess, pancreatitis, and hepatitis realistic possibilities. The positive tuberculin skin test, however, confirmed the diagnosis of tuberculosis.

Multiple-Drug Treatment

Adequate treatment of tuberculosis requires a minimum of 6 months of medication. Multiple drugs should be used to prevent the emergence of drug-resistant organisms. Our patient, treated in the early 1990s, was given isoniazid and rifampin; when drug susceptibilities were obtained, ethambutol and pyrazinamide were added.

The current recommendation (figure 3) is to start with a four-drug regimen that includes daily doses of isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin for 2 months. In areas where isoniazid resistance is low, ethambutol or streptomycin may not be necessary. If the organism identified is susceptible to isoniazid and rifampin, the pyrazinamide and ethambutol or streptomycin may be discontinued after 2 months, and isoniazid and rifampin are given for an additional 4 months (4,5,7). With such therapy, the symptoms of over 90% of patients will resolve and their monthly sputum cultures will become negative for three consecutive months (3).

[FIGURE 3]

Alternative regimens are needed for patients who require directly observed therapy because of lack of compliance (2,4). One such regimen consists of isoniazid, rifampin, pyrazinamide, and ethambutol given daily for 2 weeks and then twice weekly for 6 weeks; isoniazid and rifampin are then given twice weekly for 4 months or until sputum cultures are negative for 3 months (5). The same regimen is followed for AIDS patients except that treatment continues for at least 9 to 12 months (4,8).

Prevention in an Athletic Setting

Since tuberculosis is spread by airborne microbes, anyone in close respiratory contact with an infected person is exposed. Athletes are often in close contact with one another as well as with coaches, trainers, team physicians, and other healthcare providers, so when an athlete is diagnosed with tuberculosis, the health of many can be compromised.

If an athlete contracts tuberculosis, the clinician is responsible for reporting it to the local health department. Exposed individuals should be screened with the skin test and, if the test is positive, placed on a preventive therapy regimen to keep an infection from progressing into an active disease. Preventive measures are determined by a patient's risk of developing the active disease (see "Reading the Mantoux Tuberculin Skin Test," below) and the possibility of side effects from therapy (2). The current preventive regimen is 6 to 12 months of daily isoniazid. Six months of therapy is sufficient for most individuals, but 12 months is recommended for children and HIV-infected patients (4,9-13). Multiple-drug-resistant organisms are a growing problem, especially with the current AIDS epidemic. The management of these organisms depends on drug susceptibility, early detection, and aggressive, multiple-drug therapy. Technologies such as polymerase chain reaction testing and DNA sequence identification offer the possibility of more rapid diagnosis and identification of drug-resistant strains (6).

Along with receiving a treatment or preventive regimen, exposed players should be informed about tuberculosis prevention and transmission and counseled regarding the seriousness of the untreated disease. They should also be advised to cover their mouths when coughing and to stop drinking alcohol during therapy to decrease the chances of liver toxicity.

Tuberculosis is on the rise among the general public. Physicians need to be alert to its varied presentations so that early diagnosis, screening, and preventive and multiple-drug therapies can help stem the spread of this disease.

References

  1. Peloquin CA, Berning SE: Infection caused by Mycobacterium tuberculosis. Ann Pharmacother 1994;28(1):72-84
  2. Fox CW, George RB: Current concepts in the management and prevention of tuberculosis in adults. J La State Med Soc 1992;144(8):363-368
  3. US Department of Health and Human Services: Core Curriculum on Tuberculosis, ed 2. Atlanta, DHHS, Centers for Disease Control and Prevention, 1991
  4. Huebner RE, Castro KG: The changing face of tuberculosis. Annu Rev Med 1995;46:47-55
  5. McColloster P, Neff N: Outpatient management of tuberculosis. Am Fam Physician 1996;53(5):1579-1586
  6. Marshall BG, Shaw RJ: New technology in the diagnosis of tuberculosis. Br J Hosp Med 1996;55(8):491-494
  7. Barclay DM III, Richardson JP: Tuberculosis in the homeless. Arch Fam Med 1995;4(6):541-546
  8. Ferri FF: Practical Guide to the Care of the Medical Patient, ed 3. St Louis, Mosby-Year Book, Inc, 1995
  9. Sterling TR, Brehm WT, Frieden TR: Isoniazid preventive therapy in areas of high isoniazid resistance. Arch Intern Med 1995;155(15):1622-1628
  10. Connelly KK: Prevention and public health aspects of tuberculosis. Pediatr Ann 1993;22(10):605-608, 611
  11. McGowan JE: Nosocomial tuberculosis: new progress in control and prevention. Clin Infect Dis 1995;21(3):489-505
  12. Etkind SC: The role of the public health department in tuberculosis. Med Clin North Am 1993;77(6):1303-1313
  13. Blumberg HM, Watkins DL, Berschling JD, et al: Preventing the nosocomial transmission of tuberculosis. Ann Intern Med 1995;122(9):658-663


Reading the Mantoux Tuberculin Skin Test

A person who is suspected of having tuberculosis should be given the Mantoux tuberculin skin test, the preferred method of screening for tuberculosis. It identifies individuals at high risk for developing tuberculosis who could benefit from preventive therapy as well as those with active disease who need treatment (1). The skin test involves an intradermal injection of five tuberculin units of purified protein derivative on the forearm. The size of induration is read from 48 to 72 hours after administration (2,3).

The interpretation of the skin test varies with a patient's risk of developing tuberculosis. Those at highest risk are HIV-infected persons, intravenous drug users, and those with chest radiographs that suggest previous tuberculosis infection. A reaction of 5 mm or more is considered positive in these groups.

A second-tier risk group includes foreign-born persons from high-prevalence areas, persons in medically underserved, low-income populations, residents of correctional and nursing home facilities, and healthcare providers. Also included are those with medical conditions such as silicosis, diabetes mellitus, chronic malabsorption syndromes, low body weight (10% below ideal weight), and persons who are on corticosteroid therapy. For these patients, an induration of 10 mm or more is considered positive. A reaction greater than 15 mm is positive in people who do not have risk factors (3-5).

In patients with inconclusive skin tests, sensitivity can be increased by reexamining the skin test in 7 days; if results are still inconclusive, the tuberculin test should be repeated (1,6).

References

  1. US Department of Health and Human Services: Core curriculum on tuberculosis, ed 2. Atlanta, DHHS, Centers for Disease Control and Prevention, 1991
  2. McColloster P, Neff N: Outpatient management of tuberculosis. Am Fam Physician 1996;53(5):1579-1586
  3. American Academy of Pediatrics, Committee on Infectious Diseases: Screening for tuberculosis in infants and children. Pediatrics 1994;93(1):131-134
  4. Huebner RE, Castro KG: The changing face of tuberculosis. Annu Rev Med 1995;46:47-55
  5. Huebner RE, Schein MF: The tuberculin skin test. Clin Infect Dis 1993;17(6):968-975
  6. Ferri FF: Practical Guide to the Care of the Medical Patient, ed 3. St Louis, Mosby-Year Book, Inc, 1995


Dr Morgan-Cooper is a resident in pediatrics at Sinai Hospital in Baltimore. Mr Wasik is a team trainer at the University of Florida in Gainesville. Dr Jernigan practices internal medicine with McGuire Medical Group in Mechanicsville, Virginia. Dr McFarland is an assistant professor in the department of orthopedic surgery, section of sports medicine, at Johns Hopkins University in Baltimore. Address correspondence to Edward G. McFarland, MD, Johns Hopkins University, Dept of Orthopaedics, 2360 W Joppa Rd, Suite 205, Lutherville, MD 21093.


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