SESSION TYPE: Infectious Disease Cases III
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Primary TB in infants is uncommon, but has high risk of dissemination. Diagnosis can be complicated by symptoms mimicking upper respiratory infection (URI), especially when TB risk factors are not elicited. Delayed diagnosis can be critical if multi-drug resistant M. tuberculosis (MDR-TB) is present.
CASE PRESENTATION: A three month old female twin presented with a three days of URI symptoms and dyspnea without fever. Her twin and three year old sister had similar symptoms. Physical exam was only significant for nasal congestion and mild retractions. CXR, followed by chest CT, showed left hilar and mediastinal adenopathy, consistent with primary tuberculosis. Parents denied foreign birth/travel and TB contacts, but later reported a visiting maternal aunt from Peru with cough for a week. Tuberculin skin test (TST) measured 5-10 mm of induration. Gastric AFB smear was positive and Mycobacterium tuberculosis confirmed by DNA probe. The maternal aunt was diagnosed with cavitary TB. The patient was started on rifampin, isoniazid, pyrazinamide, and ethambutol and discharged after obtaining three negative AFB smears. After a month, CXR showed decreased but persistent adenopathy and cultures confirmed MDR-TB. Her treatment was changed to pyrazinamide, ethambutol, levofloxacin, and amikacin, and she is doing well. Her siblings were thoroughly evaluated for MDR-TB and have no signs of infection.
DISCUSSION: MDR-TB are species resistant to isoniazid and rifampin. Only 1.2% of 2010 CDC reported TB was MDR-TB. Treatment is problematic since four second-line drugs, including a fluoroquinolone and an aminoglycoside, must be used. Treatment response in children requires monitoring weight, appetite, and associated symptoms for at least 2 years. Frequent radiologic evaluations and serial AFB smears and cultures are also essential. Immunocompetent children less than 4 years old require chemoprophylaxis after MDR-TB exposure, regardless of their TST results. If the TST remains negative 8-10 weeks after exposure, prophylaxis may be discontinued, if there is no ongoing exposure.
CONCLUSIONS: Although recognition and diagnosis of TB is challenging for pediatricians, an infant with risk factors for exposure should raise clinical suspicion for TB. Further experience is necessary to determine optimal antimicrobials, effective doses, and duration of therapy for pediatric MDR-TB that will maximize bactericidal effects and minimize adverse outcomes.
1) Al-Dabbagh, M., et al. Drug-resistant tuberculosis: pediatric guidelines. Pediatric Infectious Disease Journal 30: 501-5. 2011.
2) Guidelines for the Management of Drug-resistant tuberculosis, World Health Organization.
3) Drobac, P.C. et al. Community-based therapy for children with multi-drug resistant tuberculosis. Pediatrics 117: 2022-9. 2006.
DISCLOSURE: The following authors have nothing to disclose: Giselle Barraza, Angela Jimenez, Theresa Fiorito, Christina Valsamis, Melodi Pirzada, Teerath Tanpitukpongse, Andrew Mastanduono, Leonard Krilov, Paul Lee
No Product/Research Disclosure InformationWinthrop University Hospital, Mineola, NY