A50-54 Relapsing Tuberculosis and Aspergillosis in a Patient With Silicosis: A Case Report

Abstract Introduction Patients with silicosis are at increased risk of pulmonary infections. Although routine screening for tuberculosis (TB) is recommended, there are no specific, evidence-based guidelines to prevent TB relapse or reinfection in this population. We report a case of relapsing TB with concomitant pulmonary aspergillosis in a patient with silicosis. Case Presentation A 66-year-old man presented to the emergency department with a 1-day history of dyspnea, productive cough, and hemoptysis. Hours before arrival he developed chest pain, diaphoresis, and fatigue. His medical history included chronic obstructive pulmonary disease (COPD), silicosis, malnutrition, right-ventricular dilated cardiomyopathy, and three episodes of TB within the previous three years. He was receiving treatment for relapsing pulmonary aspergillosis (voriconazole started three months before admission) and for TB (a second-line regimen due to the interaction between rifampin and voriconazole). On admission he was afebrile and hemodynamically stable; however, his oxygen saturation did not surpass 70% despite supplemental oxygen. Physical examination revealed rhonchi over the right apex and base. Initial work-up showed metabolic alkalosis, leukocytosis with neutrophilia, and microcytic hypochromic anemia. Chest computed tomography revealed extensive architectural distortion with parenchymal destruction, bronchiectasis, volume loss, and complex cavitary lesions in the upper lobes. The remaining parenchyma showed marked interstitial involvement with a reticulomicronodular pattern and some foci of alveolar consolidation. The differential diagnoses were exacerbated COPD or a new pulmonary infection. The patient was managed with broad-spectrum antibiotics, bronchodilators and high flow nasal cannula, but on hospital day 7, he developed hypoxemic respiratory failure (PaO2/FiO2 109 mmHg) and was admitted to the intensive care unit. Given progressive pulmonary disease and a poor prognosis, goals of care were revised to limit life-sustaining interventions. He was transferred to the general ward, where his condition continued to deteriorate, with worsening dyspnea and a new pleural effusion. He died two months after admission. Discussion The risk of developing TB is higher in patients with silicosis than in the general population and is associated with higher rates of relapse and drug-resistant disease. Management is challenging due to drug interactions, coinfections, and silicosis-related comorbidities (e.g., pulmonary hypertension, heart failure, COPD), which affect both regimen selection and treatment duration. Regular and exhaustive follow-ups including symptom review, microbiological testing for TB and other pathogens, and imaging, with bronchoalveolar lavage in selected cases should be prioritized in patients with silicosis. Early detection of TB relapse or reinfection limits further parenchymal injury, and reduce hospitalizations and mortality. This abstract is funded by: None