CRA30 TRIPLE THE TROUBLES: A TYPICAL CASE OF LUNG CANCER WITH ATYPICAL CIRCUMSTANCES

Hui Mei Lim, Wan Yi Leong, Abd Ghani, NA, Umadevi A.Muthukumaru, Irfhan Hyder Ali, Fong Wan Lee
Respiratory Department, Hospital Pulau Pinang, Pulau Pinang, Malaysia

Introduction
Tuberculosis represents a significant health issue and presents several diagnostic challenges, particularly in individuals with a history of tuberculosis infection. Sputum microscopy is the simplest and most cost-effective method; however, it has limited sensitivity. The GeneXpert MTB/RIF assay enables rapid detection of Mycobacterium tuberculosis. GeneXpert MTB/RIF may produce false positive results as it can detect both viable and non-viable MTB DNA.

Case Report
A 71-year-old ex-smoker presented with persistent cough and dyspnea, despite having completed treatment for pulmonary TB two years prior. He had comorbidities including hypertension, diabetes mellitus, dyslipidemia, and hepatitis B liver disease. He was undergoing therapy for an acute exacerbation of COPD and a CTPA thorax performed to evaluate for pulmonary embolism.  Bronchoscopy with endobronchial biopsy was conducted following CT scan which revealed of squamous cell carcinoma with P40 positive and histomorphological evidence of fungal components suggestive of Aspergillus Fulmigatus. The bronchoalveolar lavage sample tested GeneXpert MTB positive with low detection, no rifampicin resistance. The patient commenced therapy for relapsed pulmonary TB and pulmonary aspergillosis, which consisted of EHRZ and voriconazole. Regrettably, he did not survive the experience. Retrospectively, the bronchoalveolar lavage for mycobacterium culture yielded no growth.

Discussion
This case highlighted that reliance solely on GeneXpert/RIF assays for the diagnosis of tuberculosis is insufficient.  Complete clinical assessment and radiographical evidence should be considered to establish an accurate diagnosis, particularly in patients with a history of infection and low detection levels.  It is important to consider the potential for cross-contamination during bronchoscopic procedures.