Abstract Introduction Tuberculosis (TB) is caused by Mycobacterium tuberculosis, which remains one of the most prevalent infectious diseases globally. Although classic insidious presentations of TB are marked by weight loss, night sweats, and a persistent cough, acute TB may manifest with nonspecific symptoms mimicking other illnesses. Atypical fulminant manifestations can be challenging in non-endemic regions or non-immunocompromised hosts. The following case describes a 44-year-old male with a history of Actinomycetoma who was admitted to ICU for acute respiratory distress syndrome (ARDS). Case A 44-year-old male with a history of Actinomycetoma infection in the foot treated with itraconazole, presented with shortness of breath and cough. Upon examination, he was found to be tachypneic and tachycardic, and critically desaturating on room air. A CT scan of the chest (Figure 1) revealed extensive and diffuse consolidations, with characteristic centrilobular and “tree-in-bud” opacities, along with a 2. 9 cm right lower lobe nodule that was suspicious for a mycetoma or fungus ball. Patient was started on broad-spectrum antibiotics. The patient was initially admitted to ICU for respiratory failure. He was found to have pancytopenia, notably thrombocytopenia as low as 5x10³/microliter, which required multiple units of transfused platelets. The patient was intubated due to continued decline, and had a bronchoscopy, which revealed TB; antibiotics were then adjusted accordingly and prone positioning was utilized. Patient was eventually extubated and transitioned to BiPAP, followed by High Flow Nasal Cannula. Due to continued pancytopenia, the patient had a bone marrow biopsy that revealed no immunophenotypic abnormalities, confirming that the pancytopenia was likely in the setting of infection. The patient’s respiratory status ultimately improved, and the patient was discharged with follow up to hematology/oncology, pulmonology, and infectious disease. Discussion This patient presented with critical, acute respiratory failure requiring intubation, which contrasts sharply with the usual subacute or chronic course of pulmonary tuberculosis. His illness involved profound systemic toxicity, specifically marked by severe thrombocytopenia, which is rarely the dominating feature of localized TB. The chest imaging showed diffuse consolidations and “tree-in-bud” opacities—patterns more suggestive of widespread systemic disease—rather than the characteristic, localized cavitary lesions of typical pulmonary TB. Furthermore, this case is notable for the dramatic clinical progression and the convergence of two severe, rare infections: Actinomycetoma and acute active TB. This case highlights the critical necessity of considering rare and atypical disease presentations and maintaining a broad treatment approach when managing patients with such diagnostically challenging and severe systemic illness. This abstract is funded by: None
Sculthorpe et al. (Fri,) studied this question.