Yesterday Dr Tyler Wells shared an exciting case of a 25 year old female from Hawaii who had flown to Portland for her rheumatology clinic appointment with a complaint of upper back pain who had a history of Behcet’s disease, previously briefly on immunosuppressant medications.
We began with a differential for upper back pain in the setting of Behcet’s with questionable immune status and clarified that in addition to common MSK etiologies once must, rather uniquely, consider both infectious causes and also vascular (arterial and venous).
As a result of the thoughtful Dr Wells’ information gathering, we were able to learn that the patient brought with her a CD-rom of a recent CT chest scan that revealed a LUL cavitary lesion! Dum dum dum…..
The differential you ask? Try a C.A.V.I.T.Y!
- C- CANCER: primary (ex. Squamous cell carcinoma), metastasis
- A- AUTOIMMUNE (GPA, Rheum nodules)
- V- VASCULAR (pulmonary infarct)
- I- INFECTION (TB, bacterial abscess, septic emboli, cocci, actinomycosis, nocardiosis, crypto)
- T-TRAUMA (pneumoatoceles)
- Y-YOUTH/CONGENITAL (bronchogenic cyst)
Long story short, that mass got biopsied and she was also found to have a positive Quantifuron gold. TB!
Interestingly, we are still not quite sure what her risk factors were: ?3 months of Etanercept several years ago, travel to Indonesia in 2017?
Perhaps the most novel learning point from this case, however, was thinking about the question: “OH MY GOSH, SHOULD SHE HAVE BEEN ON THAT PLANE?!”
The WHO Guidelines for Tuberculosis and Air Travel comment more on established cases of TB versus suspected, however, it does seem like for flights <8 data-preserve-html-node="true" hours the concern for risk of transmission is lower. That said, if you are involved in a cases of confirmed TB in an airline passenger, here are the guidelines for the health care provider.