Background: A 33 year old HIV-negative Gambian, who hadn’t left the UK for 7 years, presents with haemoptysis, 6 month cough, sweats, and weight loss. He completed standard treatment for presumed pulmonary TB in Banjul (2006), with a completely normal CXR (2015). He was normotensive, with low grade fever, Hb 110, normal clotting, mild neutropenia, CRP 11, ESR 88, with bilateral cavitating lesions in upper lobes, calcified cavity in the left apex, and tree-on bud appearance throughout left lung, suggestive of active TB. He acutely deteriorated with projectile haemoptysis, leading to haemodynamic compromise requiring tranexamic acid and embolisation of bronchial arteries.

Investigations: IGRA negative. CD4 634 (44%). The ϒ-IFN axis was tested, excluding a complete defect in the IL12-signalling-pathway. Bronchial-alveolar-lavage smear and PCR negative for MTB. Serial induced-sputa however, cultured and identified M.Kansasii, a Non-Tuberculous-Mycobacterium (NTM) on Whole-Genome-Sequencing.

Management: In absence of any radiological structural lung disease, with apparent immune-competence, the source of acquisition remains elusive. Empirical treatment included Ethambutol/Rifampicin/Isoniazid/Moxifloxacin/Clarithromycin and intravenous Amikacin for 6 weeks, to cover for reinfection/relapse with resistant-MTB, as well as NTB. Rifamycin, which is the critical component for treatment success, had to be stopped due to transminitis after 1 month. We rationalised to a multi-drug regime containing ≥3 active agents as an effective course, based on analogy of patients with rifampin-resistance. This led to normalisation of ESR and 2.2kg weight gain, plus radiological resolution 8 months into treatment. He continues to receive a minimum of twelve months after culture-conversion.

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