A Complex Case of Recurrent Pulmonary Tuberculosis, Pulmonary Aspergillosis and Systemic Multiorgan Failure
Ms Olivia Turpin 1, Dr Aekta Sharma 2, Dr Kathryn Le Grice 2, Dr Ajikumar Kavidasan *2
Correspondence to: Dr Ajikumar Kavidasan, Croydon University Hospital.
Copyright
© 2026 Dr Ajikumar Kavidasan. 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.
Received: 17 July 2026
Published: 01 August 2026
DOI: https://doi.org/10.5281/zenodo.21713968
Background
Tuberculosis (TB) remains a major global health problem, although recurrent disease is relatively uncommon in low-incidence countries (World Health Organization [WHO], 2024). Recurrence may occur through relapse of the original infection or reinfection with a new strain and is most frequently associated with multidrug-resistant tuberculosis, treatment failure, immunosuppression and structural lung disease (Vega et al., 2024).
Chronic pulmonary aspergillosis (CPA) is an important long-term complication of pulmonary TB. Residual cavitary lesions provide an environment for colonisation by Aspergillus species, resulting in chronic infection or aspergilloma formation (Denning et al., 2011). It is estimated that TB accounts for the majority of CPA cases worldwide (Denning et al., 2011). Distinguishing active TB from chronic pulmonary aspergillosis is frequently challenging because symptoms and radiological appearances overlap considerably (Denning et al., 2016).
Reports describing recurrent tuberculosis occurring decades after previous treatment in combination with chronic pulmonary aspergillosis and critical illness remain rare.
Case Presentation
A 52-year-old male presented with a two-week history of worsening pleuritic chest pain and a chronic productive cough.
This patient was treated for pulmonary TB in 1994 whilst living abroad and 1996 whilst living in the UK. We had limited information regarding his first treatment; however, his second treatment was as per standard protocol for fully sensitive TB((World Health Organization [WHO], 2024). Two years following this treatment, an aspergilloma was identified and he was commenced on itraconazole
Initial chest radiography demonstrated extensive bilateral cavitary lung abnormalities(figure1). In view of his previous pulmonary tuberculosis and chronic pulmonary aspergillosis, recurrent active tuberculosis, progression of chronic fungal disease and secondary bacterial infection were all considered.
Standard anti-tuberculous therapy (ATT)was commenced following microbiological confirmation of recurrent pulmonary tuberculosis in accordance with international treatment guidance (WHO, 2024). Antifungal therapy for chronic pulmonary aspergillosis was started and monitored throughout admission.
The patient developed progressive hypoxaemic respiratory failure requiring intensive care admission, invasive mechanical ventilation and subsequent tracheostomy. His admission was complicated by severe ARDS, septic shock requiring vasopressor support and acute kidney injury requiring renal replacement therapy.
Antimicrobial therapy was escalated according to microbiological findings and specialist microbiology advice. Following identification of subtherapeutic rifampicin concentrations, anti-tuberculous therapy was optimised. Therapeutic drug monitoring is increasingly recognised as a useful adjunct in selected patients with severe tuberculosis or delayed clinical response, particularly in critically ill patients where altered pharmacokinetics may reduce drug exposure (Alsultan & Peloquin, 2014).
Investigations
Computed tomography (CT) of the thorax demonstrated extensive bilateral cavitary destruction with a pulmonary mycetoma within a pre-existing cavity (figure 2). Bronchoalveolar lavage isolated Klebsiella pneumoniae, while subsequent respiratory cultures grew Stenotrophomonas maltophilia.
Serial thoracic imaging demonstrated persistent bilateral cavitary disease with mediastinal lymphadenopathy, splenic infarcts and a persistent pulmonary mycetoma. Although fungal cultures remained negative, previously positive Aspergillus serology, characteristic radiological appearances and established chronic pulmonary aspergillosis supported continuation of antifungal treatment.
Differential Diagnosis
The principal differential diagnoses included recurrent pulmonary tuberculosis, progression of chronic pulmonary aspergillosis and secondary bacterial pneumonia. The coexistence of all three disease processes contributed to clinical deterioration and complicated interpretation of both clinical and radiological findings.
Outcome and Follow-up
Despite an initially poor prognosis, the patient demonstrated gradual clinical and radiological improvement over subsequent weeks (figure 3). Vasopressor support was discontinued, renal function recovered sufficiently to allow cessation of renal replacement therapy, and he was successfully weaned from mechanical ventilation following tracheostomy decannulation.
He was transferred to the respiratory ward for multidisciplinary rehabilitation and completion of anti-tuberculous and antifungal therapy. He was subsequently discharged home with long-term oxygen therapy and ongoing follow-up with specialist tuberculosis services.
Discussion
Recurrent pulmonary tuberculosis is uncommon in low-incidence settings, particularly after two previously completed treatment courses (Vega et al., 2021). Recurrence may represent relapse of the original infection or reinfection with a new strain, although differentiation requires molecular typing (Vega et al., 2024). The prolonged interval between episodes in this case favours reinfection, although this could not be confirmed.
Previous pulmonary tuberculosis is the strongest recognised risk factor for chronic pulmonary aspergillosis. Residual cavitary disease provides a favourable environment for Aspergillus colonisation, and patients frequently present with symptoms that overlap considerably with active tuberculosis (Denning et al., 2011; Denning et al., 2016). This diagnostic uncertainty may delay recognition of recurrent tuberculosis or progression of fungal disease and highlights the importance of comprehensive microbiological investigation.
ARDS is an uncommon but severe complication of pulmonary tuberculosis and is associated with high mortality (Sharma et al., 2016). Our patient required prolonged invasive mechanical ventilation, tracheostomy and renal replacement therapy before ultimately recovering. This favourable outcome demonstrates that recovery is possible despite severe tuberculosis-related critical illness when prompt anti-tuberculous therapy, optimisation of antimicrobial treatment and multidisciplinary intensive care are maintained.
This case highlights the importance of considering recurrent tuberculosis even decades after apparent successful treatment, recognising co-existing chronic pulmonary aspergillosis in patients with progressive cavitary lung disease, and maintaining a multidisciplinary approach in severe tuberculosis complicated by critical illness.
Learning Points
References