Unsuspected tuberculosis in COPD and use of levofloxacin: diagnostic challenges

A 92-year-old female ex-smoker with chronic obstructive pulmonary disease (COPD) GOLD III, was admitted because of communitarian pneumonia in November 2013. She had been using inhaled corticosteroids and bronchodilators and presented five exacerbations of COPD due to pneumonia in the same year, with hospitalizations in March and September. The patient underwent the routine protocol for exacerbated COPD, and bacilloscopy for tuberculosis (TB) was negative. On admission, she had intense dyspnea and a productive cough that improved by administration of levofloxacin. Tests with Ziehll-Neelsen staining in bronchopulmonary secretions resulted negative. Notwithstanding, during actual admission, the culture in Lowenstein-Jensen medium seeded in September was found positive for M. tuberculosis susceptible to isoniazid, rifampin, streptomycin, and ethambutol. Therefore, the patient underwent the standard regimen for tuberculosis. Except in September, when she used piperacillin-tazobactam, all previous exacerbations of COPD were treated with levofloxacin. This effective drug against M. tuberculosis can hinder its growth in culture. The use of levofloxacin in unsuspected TB may constitute an additional diagnostic challenge, and risk of late diagnosis is increased in patients with COPD in use of inhaled corticosteroids. Case studies may contribute to increase the suspicion index about TB associated with COPD.