Case Reports in Infectious Diseases

Case Reports in Infectious Diseases / 2019 / Article

Case Report | Open Access

Volume 2019 |Article ID 9068516 | 3 pages |

Mycobacterium tuberculosis-Associated Necrotizing Pneumonia With Adjunctive Corticosteroid Therapy

Academic Editor: Tomoyuki Shibata
Received05 Jan 2019
Accepted16 Jun 2019
Published01 Jul 2019


Necrotizing pneumonia induced by Mycobacterium tuberculosis is a rare but severe condition. It is difficult to distinguish between M. tuberculosis-associated and bacterial necrotizing pneumonia. The optimal treatment for this condition is controversial. Here, we report a case of M. tuberculosis-associated necrotizing pneumonia treated with the adjunctive corticosteroid and the antituberculosis drugs.

1. Introduction

Necrotizing pneumonia is a rare but severe condition of lung parenchymal destruction commonly caused by bacterial pathogens. Necrotizing pneumonia induced by M. tuberculosis was reported in children recently [1], and several published cases with M. tuberculosis pulmonary gangrene had been reported in adults before [2]. However, optimal therapeutic strategy for this condition is still controversial [3]. Here, we report an interesting case with M. tuberculosis-associated necrotizing pneumonia treated successfully with initiation of corticosteroid followed by antituberculosis drugs.

2. Case Report

A 44-year-old male patient was hospitalized because of progressive dyspnea, cough, and fever during one month. His past medical history was unremarkable. He appeared initially with mild fever, dry cough, and night sweating but untreated. After two weeks, he felt shortness of breath and coughed up yellow sputum. He had been admitted in the general hospital where he had undertaken the first bronchoscopy which revealed the negative results of bronchoalveolar lavage (BAL) for both acid-fast bacillus (AFB) smear and M. tuberculosis polymerase chain reaction (PCR). He had been diagnosed with community-acquired pneumonia but not improvement after a 10-day course of antibiotic therapy and was transferred to our tertiary hospital.

On admission, he was alert, with body temperature 37°C, pulse rate of 84 beats/min, respiratory rate of 28 breaths/min, and blood pressure of 120/80 mmHg. He was supplied with oxygen via bag-valve mask at 10 L/min, and the result of arterial blood gas showed pH 7.38, PaO2 70 mmHg, PaCO2 32.7 mmHg, and 19.4 mmol/L. Physical examination revealed dullness on percussion, fine crackles, and decreasing breath sound at the right lower lung field. Cell blood count with white blood cells 8.84 G/L (77.5% neutrophil and 13.3% lymphocyte) and hematocrit 38.2%, C-reactive protein level 78.4 mg/L, and mildly elevated liver transaminase level were recorded. The rapid testing for human immunodeficiency virus was negative. Chest X-ray showed consolidation in the right lower hemithorax, and the first contrast-enhanced chest computed tomography (CT) revealed small necrotizing cavities in this consolidation area (Figure 1(a)). With aforementioned information, we suspected differential diagnoses as follows: necrotizing pneumonia with particular pathogens (high-virulence bacteria, tuberculosis, or fungal infection) or noninfectious diseases (autoimmune disease, malignancy, or vascular disease). The antinuclear antibodies test was negative and the histopathological result of transthoracic lung biopsy showed an inflammatory process. He was treated with the combination of broad-spectrum antibiotics (meropenem, ciprofloxacin, and vancomycin) during four days but he still had fever. The adjunctive therapy with corticosteroid (40 mg methylprednisolone intravenous once daily) was commenced, and his condition improved spectacularly (defervescence, breath normally without oxygen) but the fever reoccurred on the fourteenth day after hospitalization. The second chest CT undertaken showed a significant regression of the consolidation (Figure 1(b)). The second bronchoscopy showed the positive BAL results for AFB smear and M. tuberculosis PCR. The treatment with a six-month antituberculosis regimen resolved his condition completely on follow-up.

3. Discussion

In our case, diagnosis of necrotizing pneumonia associated with M. tuberculosis was based on the consistent chest CT (lung parenchymal consolidation with lack of perfusion, microabscesses) and the positive BAL result for M. tuberculosis. The destruction of pulmonary parenchyma induced by M. tuberculosis usually develops from months to years in most cases. Nonetheless, there are a few cases (necrotizing pneumonia and pulmonary gangrene) in which this destruction may progress rapidly causing severe respiratory failure. The pathogenic mechanism can be explained by the intensive tuberculous inflammation causing the widespread vascular thrombosis and arteritis [2]. With this atypical manifestation of pulmonary tuberculosis, it is difficult to discriminate between M. tuberculosis-associated and bacterial necrotizing pneumonia [1]. According to the best of our knowledge, this is the first reported case of M. tuberculosis-associated necrotizing pneumonia in adults.

The adjunctive therapy of corticosteroid showed significantly improving outcomes of patients with not only severe community-acquired pneumonia [4] but also advanced pulmonary tuberculosis [5, 6]. Therefore, the corticosteroid treatment could be useful in management of M. tuberculosis-associated necrotizing pneumonia. Although the corticosteroid was initiated without antituberculosis drugs, the clinical and radiological tests showed significant improvement in our case. This can be through the beneficial effects of corticosteroid in reducing the intensive tuberculous inflammation. Moreover, the adjunctive therapy with corticosteroid should be considered in managing bacterial necrotizing pneumonia. However, using corticosteroids in these cases should be researched more before arriving at a definite conclusion.

Conflicts of Interest

No potential conflicts of interest relevant to this article were reported.


  1. C. Jacobs, P. Goussard, and R. P. Gie, “Mycobacterium tuberculosis, a cause of necrotising pneumonia in childhood: a case series,” International Journal of Tuberculosis and Lung Disease, vol. 22, no. 6, pp. 614–616, 2018. View at: Publisher Site | Google Scholar
  2. F. A. Khan, M. Rehman, P. Marcus, and V. Azueta, “Pulmonary gangrene occurring as a complication of pulmonary tuberculosis,” Chest, vol. 77, no. 1, pp. 76–80, 1980. View at: Publisher Site | Google Scholar
  3. N. Chatha, D. Fortin, and K. J. Bosma, “Management of necrotizing pneumonia and pulmonary gangrene: a case series and review of the literature,” Canadian Respiratory Journal, vol. 21, no. 4, pp. 239–245, 2014. View at: Publisher Site | Google Scholar
  4. W.-F. Wu, Q. Fang, and G.-J. He, “Efficacy of corticosteroid treatment for severe community-acquired pneumonia: a meta-analysis,” American Journal of Emergency Medicine, vol. 36, no. 2, pp. 179–184, 2018. View at: Publisher Site | Google Scholar
  5. R. A. Smego and N. Ahmed, “A systematic review of the adjunctive use of systemic corticosteroids for pulmonary tuberculosis,” International Journal of Tuberculosis and Lung Disease (IJTLD), vol. 7, pp. 208–213, 2003. View at: Google Scholar
  6. J. Y. Yang, M. Han, Y. Koh et al., “Effects of corticosteroids on critically Ill pulmonary tuberculosis patients with acute respiratory failure: a propensity analysis of mortality,” Clinical Infectious Diseases, vol. 63, no. 11, pp. 1449–1455, 2016. View at: Publisher Site | Google Scholar

Copyright © 2019 Ho Lam Nguyen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

More related articles

761 Views | 279 Downloads | 0 Citations
 PDF  Download Citation  Citation
 Download other formatsMore
 Order printed copiesOrder

Related articles

We are committed to sharing findings related to COVID-19 as quickly and safely as possible. Any author submitting a COVID-19 paper should notify us at to ensure their research is fast-tracked and made available on a preprint server as soon as possible. We will be providing unlimited waivers of publication charges for accepted articles related to COVID-19. Sign up here as a reviewer to help fast-track new submissions.