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A 3-month-old male with persistent cough, abnormal chest radiograph and positive PPD
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A 3-month-old male was worked up for a persistent cough with an abnormal chest radiograph (Figure 1) and a positive purified protein derivative, with the diagnosis of pulmonary TB of the right upper lobe with positive cultures from two gastric aspirate samples and the bronchoalveolar lavage obtained with bronchoscopy (Figure 2).
He was initially treated with the recommended daily four-drug regimen (pyrazinamide, rifampin, isoniazid and ethambutol), pending culture and sensitivity results. The source of exposure appeared to be his grandmother, who is his primary caregiver and was diagnosed a few weeks earlier, but sensitivities of her isolate were not yet available. His grandmother is receiving direct observed therapy from the health department. The child’s organism (and the grandmother’s) was soon found to be pan-sensitive, and the ethambutol was discontinued.
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Figure 1: The patient was worked up for a
persistent cough with an abnormal chest radiograph. |
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Figure 2: Evidence of pulmonary TB of the
right upper lobe. |
The patient had a good initial clinical response, and his chest radiograph 1 month into therapy was somewhat improved (Figure 3). However, on routine follow-up after 2 months of therapy, he was found to still have a persistent, course rhonchi and wheezes on the right side, and three-drug therapy was continued. A chest radiograph at that time revealed worsening right upper lobe infiltrate, and he underwent a CT scan (Figure 4) showing consolidation, adenopathy and some calcification. Another bronchoscopy was done, as shown in Figure 5. All stains on the bronchoalveolar lavage (BAL) were negative for bacteria, fungi and acid-fast bacilli organisms, and cultures are pending.
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Figure 3: The patient’s chest radiograph
1 month into therapy was somewhat improved. |
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Figure 4: After 2 months, a chest radiograph
revealed worsening right upper lobe infiltrate and he underwent a CT scan.
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What’s Your Diagnosis?
- Bronchial abscess
- Fungus ball
- Foreign body
- Endobronchial tuberculosis
Figure 5 shows a right mainstem bronchus lesion consistent with endobronchial tuberculosis (answer D) in a patient known to have pulmonary TB. There are five mechanisms of developing endobronchial TB: 1) direct extension from adjacent parenchymal disease; 2) implantation from infected sputum; 3) hematogenous spread; 4) lymphatic drainage from parenchymal disease; and 5) compression and erosion of lymph node into the bronchus (the most likely mechanism in this patient).
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Figure 5: Right mainstream bronchus
lesion. |
This uncommon complication seems to occur more in adults, but is not rare in children. The treatment is the same anti-TB chemotherapy regimen as above, plus steroids (1-2 mg/kg/day of prednisone) are recommended by most experts to decrease the swelling and stenosis that often results. Whether it was needed or not, because of this complication, the patient was left on three-drug therapy for an extra 2 months (4 months total), and eventually completed 6 months of anti-TB therapy (rifampin and isoniazid) and 6 weeks of steroid therapy with a 3-week taper with good results (Figure 6). On the recommendation of the pulmonologist, the baby had a third bronchoscopy that was normal, with negative studies at the end of treatment.
The second BAL never grew TB, but with previously confirmed pulmonary disease, it left no doubt as to the cause of the lesion. For the same reason, fungal and secondary bacterial infection was ruled out with the bronchoscopy. Lastly, a foreign body in a baby this young is unusual, and again should have been identified by bronchoscopy.
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Figure 6: After anti-TB therapy and steroid
therapy with a 3-week taper, good results were produced. |
Acknowledgement: Thanks to John Saito, MD, former pediatric pulmonologist at Scott & White, for providing assistance with this case and the bronchoscopy pictures.
Columnist comments
Active TB should probably always be co-managed with the primary provider, a pulmonologist (if pulmonary in location) and an infectious diseases specialist familiar with the treatment of TB, as treatment recommendations can be fairly complicated. I don’t see enough TB to consider myself an expert. So while various textbooks and the current Red Book have excellent chapters on the diagnosis and management of TB, most of us non-experts on the treatment of TB, especially when it is an unusual case, rely on the personal advise of real experts such as Jeffrey Starke, MD, at Baylor College of Medicine in Houston for guidance, and who always seems very happy to help.
James H. Brien, DO, is Vice Chair for Education at The Children’s Hospital at Scott and White and is the Associate Professor of Pediatrics at Texas A&M University, College of Medicine, Temple, Texas. email: jhbrien@aol.com.
Disclosure: Dr. Brien reports no relevant financial disclosures.