Question of the Week

Question :

Posted On : 19 Dec 2004

A 4 year 4 month old child:
Child had neonatal pustulosis- treated with antibiotics.
Child had inguinal hernia and emergency surgery was performed at 7 months of age.
1 yr of age, child had BCG adenitis, MT plus VE, LN BIOPSY REVEALED LANGHANS GIANT CELL. CHILD WAS GIVEN FIRST COURSE OF AKT FOR 6 MONTHS,

Child was apparently ok for the next 7 months. 2 yrs 4 months of age, child had loose motions, fever, not gainig weight but was thriving well. His barium meal follow through was done which revealed ileal narrowing and diagnosed to have abdominal tuberculosis and was again started on AKT for 9 months. Child started gaining weight and was thriving well for apparently next 6-7 months.

2yr 9 months child had radiologically proven pneumonia with hilar lymphadenopathy and he was given a course of antibiotics for the same ,chest lesion resolved.

3 yr 2 months- persistent high grade fever. He was treated for enteric and malaria.

3 years 9months he CAME WITH PERSISTENT FEVER, XRAY CHEST REVEALED WIDENED MEDIASTINUM,CT CHEST REVEALED MEDIASTINAL LN, PARENCHYMAL LUNG LESION OVER LEFT LUNG BASE, EXTENDING UPTO PLEURA, WITH PLEURAL EFFUSION.MULTIPLE SMALL PARAAORTIC LN plus . MT -VE, CHILD WAS GIVEN A COURSE OF AKT {THIRD TIME 2 SEHRZ plus 1EHRZ plus 6 HR} WHICH CHILD is still taking. GAINED WT AROUND 1 KG. BAL WAS DONE - NO AFB, PCR -VE.

4 years, PRESENTED WITH PERSISTENT IRRITATION OR URETHRA, NO HEMATURIA BUT FREQUENCY plus USG - KUB REVEALED A THICKENED POST WALL OF BLADDER, CYSTOSCOPIC BIOPSY WAS DONE WHICH DID NOT SHOW ANY GRANULOMA, BUT DID REVEAL CHRONIC INFLAMMATION WITH MULTI LAYERING, POLYPOIDAL LESION. AFB-VE, PCR- VE, CHILD WAS CONTINUED ON AKT.

4 years 2 months- AGAIN HAD PERSISTENT FEVER 2 MONTHS LATER, WHICH SUBSIDED WITH ANTI PYRETICS.

4 years 4 months - AGAIN CAME TO US WITH HIGH GRADE FEVER, COUGH, OCC. LOOSE MOTIONS, HEAPTSPLENOMEGALY plus , NO VISIBLE LN NODES. CT CHEST,ABDOMEN REVEALED THE SIZE OF LN HAD GONE DOWN SIGNIFICANTLY, FRESH LESION ON THE RT. LUNG BASE, NO ABDOMINAL LNODES.

ALL HIS ROUTINE INVESTIGATIONS WERE NORMAL ALL THE TIME EXCEPT ESR WHICH WAS 30 TO 50 DURING ALL EPISODES AND Hb WAS AROUND 9-10. CULTURE NEVER GREW ANY ORGANISM. THIS TIME CONSIDERING A PROBABILITY OF DRUG FEVER ALL MEDICINES WERE STOPPED, BUT FEVER STILL PERSISTED. MY IMPRESSION WAS A CHRONIC INTERCURRENT INFECTION , INFLAMMATION INVOLVING RETICULOENDOTHELIAL SYSTEM WITHOUT EVIDENCE OF HYPERSPLENISM, WITH INVOLVEMENT OF LUNG PARENCHYMA AND GI TRACT.

D,D COMES TO TB, PRIMARY IMMUNE DEFICIENCY TO BE RULED OUT. HIV -VE. WHAT IS UR OPINION?

Expert Answer :

No expert answer available.

Answer Discussion :

Norma Eby

TBD

20 years ago

pramod

drug resistance

20 years ago

pramod madhukar kulk

Recurrent tuberculosis could be due to repeated exposure to untreated family contact or resistent tuberculosis.
Non T cell immunodeficiency needs to be ruled out.

20 years ago

pediatriconcall

What one would be interested in knowing is the lymph node biopsy report done earlier. Did it show only Giant cells or were they "caseating" granulomas. In bsence of caseation, one would like to consider, conditions such as SARCOIDOSIS, HISTIOCYTOSIS apart from immunodeficiency and tuberculosis.
It would be ideal to repeat a lymph node biopsy and do the following:
Histopathology by a good pathologist
Culture for AFB by bactec
Routine culture and microscopy

A lymph node biopsy would go a long way to determine the cause. Also in the meatime, workup for immunodeficiency.

20 years ago

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