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doi:10.1111/jpc.12906
INSTRUCTIVE CASE
A warning about tuberculosis John Whitehall,1 Julia Sgarlata,2 Matthew Edwards,2 Geoffery Bent2 and Catherine Allgood2 1
Paediatrics, University of Western Sydney, 2Paediatrics, Campbelltown Hospital, Sydney, New South Wales, Australia
Introduction Tuberculosis (TB) is uncommon in Australian children, but its rate is increasing. Diagnosis can be difficult, especially in infants. With parental permission, we present an infant born in Sydney to Pacific Islanders to emphasise the contagiousness, difficulty in early diagnosis and possibility of rapid decline. In New Zealand, Pacific peoples are known to have a high rate of TB.1
Clinical Record The alert, well-grown 5-month-old infant was brought by her mother to an emergency department near her home in Sydney’s western suburbs because of mild coughing for 2 weeks. She was afebrile, not ‘sick’, had been eating well and had not lost weight. Two months previously a cousin of the mother had visited from New Zealand, holding the child in her arms and napping in the same room on three occasions. The cousin had a productive cough and was later diagnosed with TB. Examination of the child revealed normal oximetry, minimal respiratory distress, decreased breath sounds on the right, and hepatosplenomegaly. Hb was 108 g/L, white cell count 15.8 × 109 /L and C-reactive protein 36 mg/L. Chest X-ray (CXR) revealed unexpected pathology: massive right-sided consolidation, mediastinal adenopathy and widespread nodular opacities (Fig. 1). Pneumonia was diagnosed and antibiotics were commenced but malignancy was considered. Next day, temperature rose to 39.3 C, respiratory distress increased and the nodules in the CXR were reappraised as miliary TB. Ultrasonography confirmed hepatomegaly with multiple hypo-echoic foci (to 1 cm) and uncomplicated splenomegaly. The child was referred to a tertiary centre where acid fast bacilli (1–5/hpf) were detected in gastric aspirate smears, and Mycobacterium tuberculosis was confirmed by PCR. Interferon gamma release assay was positive. Microscopy of centrifuged cerebrospinal fluid obtained by lumbar puncture (LP) revealed nine white cells/hpf (one polymorph, three mononuclear and Key Points 1 Tuberculosis (TB) may be contracted after minimal exposure. 2 Initial signs of disease may be subtle. 3 Decline may be rapid, especially with unsuspected meningitis. Correspondence: Prof. John Whitehall, Paediatrics, University of Western Sydney, Locked Bag 1797 Penrith South DC, Sydney, NSW 1797, Australia. Fax: 02 46 20 3891; email: [email protected] Conflict of interest: There are no conflicts of interest. Accepted for publication 9 March 2015.
five degenerate cells) but normal levels of protein and glucose. No acid-fast bacilli were detected, and polymerase chain reaction was negative. Blood HIV screen was negative. Therapy with rifampicin, isoniazid, ethambutol and pyrazinamide was commenced. Two days later, she became drowsy and confused, tachycardic and tachypnoeic. A computed tomography scan of brain showed multiple tuberculomata, meningeal enhancement and mild dilatation of the ventricles. Raised intracranial pressure was diagnosed and intravenous steroids were given urgently. Fortunately, she recovered quickly and was discharged to outpatient care in
doi:10.1111/jpc.12906
INSTRUCTIVE CASE
A warning about tuberculosis John Whitehall,1 Julia Sgarlata,2 Matthew Edwards,2 Geoffery Bent2 and Catherine Allgood2 1
Paediatrics, University of Western Sydney, 2Paediatrics, Campbelltown Hospital, Sydney, New South Wales, Australia
Introduction Tuberculosis (TB) is uncommon in Australian children, but its rate is increasing. Diagnosis can be difficult, especially in infants. With parental permission, we present an infant born in Sydney to Pacific Islanders to emphasise the contagiousness, difficulty in early diagnosis and possibility of rapid decline. In New Zealand, Pacific peoples are known to have a high rate of TB.1
Clinical Record The alert, well-grown 5-month-old infant was brought by her mother to an emergency department near her home in Sydney’s western suburbs because of mild coughing for 2 weeks. She was afebrile, not ‘sick’, had been eating well and had not lost weight. Two months previously a cousin of the mother had visited from New Zealand, holding the child in her arms and napping in the same room on three occasions. The cousin had a productive cough and was later diagnosed with TB. Examination of the child revealed normal oximetry, minimal respiratory distress, decreased breath sounds on the right, and hepatosplenomegaly. Hb was 108 g/L, white cell count 15.8 × 109 /L and C-reactive protein 36 mg/L. Chest X-ray (CXR) revealed unexpected pathology: massive right-sided consolidation, mediastinal adenopathy and widespread nodular opacities (Fig. 1). Pneumonia was diagnosed and antibiotics were commenced but malignancy was considered. Next day, temperature rose to 39.3 C, respiratory distress increased and the nodules in the CXR were reappraised as miliary TB. Ultrasonography confirmed hepatomegaly with multiple hypo-echoic foci (to 1 cm) and uncomplicated splenomegaly. The child was referred to a tertiary centre where acid fast bacilli (1–5/hpf) were detected in gastric aspirate smears, and Mycobacterium tuberculosis was confirmed by PCR. Interferon gamma release assay was positive. Microscopy of centrifuged cerebrospinal fluid obtained by lumbar puncture (LP) revealed nine white cells/hpf (one polymorph, three mononuclear and Key Points 1 Tuberculosis (TB) may be contracted after minimal exposure. 2 Initial signs of disease may be subtle. 3 Decline may be rapid, especially with unsuspected meningitis. Correspondence: Prof. John Whitehall, Paediatrics, University of Western Sydney, Locked Bag 1797 Penrith South DC, Sydney, NSW 1797, Australia. Fax: 02 46 20 3891; email: [email protected] Conflict of interest: There are no conflicts of interest. Accepted for publication 9 March 2015.
five degenerate cells) but normal levels of protein and glucose. No acid-fast bacilli were detected, and polymerase chain reaction was negative. Blood HIV screen was negative. Therapy with rifampicin, isoniazid, ethambutol and pyrazinamide was commenced. Two days later, she became drowsy and confused, tachycardic and tachypnoeic. A computed tomography scan of brain showed multiple tuberculomata, meningeal enhancement and mild dilatation of the ventricles. Raised intracranial pressure was diagnosed and intravenous steroids were given urgently. Fortunately, she recovered quickly and was discharged to outpatient care in
