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///2015 Abstract Details
2015 Abstract Details2019-08-02T16:54:43-05:00

Case Report: Pulmonary and Laryngeal Tuberculosis in a 25 week Parturient

Abstract Number: S-28
Abstract Type: Case Report/Case Series

Jacqueline E Geier MD1 ; Barbara Orlando MD2

A 35 year old, Caucasian, parturient at 25 weeks gestation was admitted to our hospital with a 6 week history of odynophagia, severe GERD, and 11 pound weight loss. Her symptoms initially began as nasal congestion and cough which were treated by her primary physician empirically with azithromycin. Outpatient ENT and Gastroenterology consultants diagnosed her with laryngopharyngeal disease due to reflux and prescribed zantac with little improvement in symptomatology. Inpatient ENT evaluation revealed a swollen epiglottis and bilateral false vocal cords with small white plaques, pooling secretions, visible aspiration, normal and mobile true vocal cords, and normal mucosa. ENT and GI consultants recommended upper endoscopy for suspicion of esophageal mass vs. webs, as well as concern for fungal infection. The risks and benefits of the procedure and general anesthesia were discussed with the patient and her family and she agreed to the procedure with general anesthesia and intubation due to concern for aspiration with advanced pregnancy. The patient had a class II mallampati score and otherwise unremarkable airway exam. In light of the ENT/Anesthesia evaluations, a difficult airway was not anticipated, and general anesthesia was induced with propofol and succinylcholine with RSI technique. Direct Laryngoscopy was grade 4 on two attempts and revealed a normal appearing epiglottis with severe mucosal edema of the posterior oropharynx. Third attempt with the glidescope allowed improved visualization and revealed severe mucosal edema of the supraglottic structures preventing visualization of the vocal cords and intubation. The patient desaturated to the 70’s and was mask ventilated with cricoid pressure. The decision was made to abort the procedure and wake up the patient due to the severity of the supraglottic swelling and concern for worsening the edema with repeated manipulation. Saturations did not improve as quickly as expected, an LMA was placed to improve ventilation and saturations improved to low 90’s. R>L chest wall excursion was noted as well as rhonchi with decreased breath sounds over the left lung field. The patient emerged from anesthesia, was screened into the ICU for respiratory monitoring, and a portable chest xray was obtained. Chest Xray revealed left upper lobe cavitary lesion suspicious for TB. Subsequent AFB cultures and genotyping returned positive for Tuberculosis. Previously, the patient denied fever, night sweats, and cough, though her family stated that her cough did not seem to improve after initial treatment. She has not traveled to an endemic region recently, though visited Malaysia in 2009. This case highlights that typical constitutional symptoms such as fever and night sweats may not be present in the pregnant patient with TB. Additionally, though laryngeal TB is rare, the symptoms and signs are quite vague and the potential for a difficult airway should be suspected in patients with advanced infection.

SOAP 2015