Pneumonia with positive tuberculin test
Dr Ira Shah
Medical Sciences Department, Pediatric Oncall
Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056.
Clinical Problem :
A 2 year old girl presented with fever, cough and cold since 4 days. There was no refusal of feeds, loss of appetite. She had received 6 months of antituberculous therapy 1 year back in view of Pulmonary TB in mother and a positive Mantoux test of 10 x 10 mm. The child had received all routine vaccines including BCG. Diet and milestones were normal. On examination, she was well nourished {weight = 12 kg, 50th centile` height = 80 cm} and had crepitations in right inframammary region. Other systemic examination was normal. Investigations showed right parahilar haziness on Chest X-Ray and hemoglobin of 10.4 gm, dl with WBC count of 10,400, cumm {50 percent polymorphs and 50 percent lymphocytes} with ESR of 30 mm at end of 1 hour. She was treated with IV Amoxycillin, Clavulanic acid antibiotic for 5 days but fever persisted. A repeat Mantoux test was 15 x 15 mm. A repeat WBC count showed 9,400, cumm {30 percent polymorphs and 70 percent lymphocytes}.
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Should this child be treated with Antituberculous therapy_?
Discussion :
This child has presented with acute onset of fever with lower respiratory tract infection as well as rhinitis. Rhinitis in tuberculosis {TB} is unusual and is usually unilateral. Also TB in the lungs presents with low grade chronic fever and chronic cough. Though this child had a positive Mantoux test it does not suggest active tuberculosis. The child also had a positive Mantoux test 1 year ago and was treated for latent TB at that time adequately. A positive mantoux currently could suggest past TB infection, positivity due to previous BCG vaccination or even infection due to atypical mycobacteria. Thus, one cannot interpret mantoux test in this child.
If the child had aggravation of TB this time, then the child should have had failure to thrive, loss of appetite and primary progressive TB which was absent. Thus, in this child, active TB seems unlikely. The pneumonia could be due to viral, bacterial or even atypical organism. Since the child seems to have crepitations unilaterally with lymphocytic predominance and normal WBC count, an atypical organism seems to be the cause. As a result amoxicillin-clavulanic acid may not show a response. Here a macrolide group of antibiotic may be useful. This child was treated with Azithromycin for 5 days following which fever, cough and Chest X-Ray normalized.
Thus, there is no need for antituberculous therapy in this child.
E-published: September 2011 Vol 8 Issue 9 Art No. 61
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