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Disseminated Tuberculosis on an Otherwise Healthy Pediatric Patient FREE TO VIEW

Lilian Pereira, DO; Erica Cavalcante, DO; Bernadete Silva, DO; Waldonio Vieira, DO; Roseana Sovano, DO
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Santa Casa de Misericordia do Pará Brazil, Ananindeua, Brazil

Chest. 2015;148(4_MeetingAbstracts):172A. doi:10.1378/chest.2260628
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SESSION TITLE: Tuberculosis Global Case Reports

SESSION TYPE: Global Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Disseminated tuberculosis (TB) can involve several organs and clinically presents itself with multiple signs and symptoms. Pulmonary infection is generally the primary focus. The development of TB disease depends on inherent immunologic status of the host. Miliary disease and tubercular (TB) meningitis are the earliest and most deadly complications of primary TB. Genitourinary TB (GU TB) is the second most common form of extrapulmonary disease after peripheral lymphadenopathy. Despite it comprises 20% of nonpulmonary TB form, it is still misdiagnosed.

CASE PRESENTATION: We report a case of an otherwise healthy, 11-year-old boy with disseminated tuberculosis who exhibited a wide spectrum of extrapulmonary involvement. He had nonspecific symptoms such as fever, weight loss (10 kg), fatigue, malaise, asthenia, anorexia, headache, and recurrent urinary infections for 4 months. Thereafter, a painful swelling appeared in his left scrotum and treated as a nonspecific abscess with drainage and antibiotics before admission at the tertiary hospital. His physical examination showed an extremely thin boy, palpable masses on left hypochondrium and flank, and a painful and erythematous scrotal mass ipsilateral. Urine analysis revealed hematuria and sterile pyuria but the urine was positive for acid-fast bacilli (AFB) on the third sample. Cerebrospinal fluid (CSF) yielded normal results.Bronchoalveolar lavage (BAL) smear produced a negative response for AFB. . Tuberculin Skin Test (TST) was anergic. There were no associated systemic disorders and HIV infection was not detected. A Chest Computed Tomography (CT) scan displayed well-defined randomly distributed nodules. Head CT scan showed hypoattenuating lesions on white matter. On a contrast, enhanced abdominal CT scans revealed intraluminal calcifications in the left kidney, hydronephrosis degree V, and a heterogeneous mass adjacent to left testis. A treatment with standard fixed-dose-combination tablets containing 4 drugs (RHZE) was initiated during the intensive care phase (2 months), R 150/H75/Z400/E275and 2 drugs (RH) during the continued treatment (7 months) and an oral corticosteroid (prednisone at a dose of 1mg/kg/day for 4 weeks). The patient showed marked recovery after initiation of anti-TB therapy and the scrotal mass had gradually subsided.

DISCUSSION: Miliary tuberculosis (TB) is the widespread dissemination of Mycobacterium tuberculosis via hematogenous spread. It is estimated that it accounts for approximately less than 2% of all cases of TB in immunocompetent patients. In addition, miliary TB may mimic many diseases. GU TB comprises approximately 15-20% of extrapulmonary cases of TB in some developing countries, which is roughly twice that in developed areas. It is very uncommon in children. Persistent sterile pyuria and hematuria are the most classical findings in GU TB. In the case of epididymal TB, pain swelling, heaviness or mass lesion in the scrotum are the common presenting complaints, as observed in our case. Serial early-morning urine cultures (at least 3) for acid-fast bacilli (AFB) are still considered the criterion standard for evidence of active tubercular (TB) disease with a sensitivity of 65% and a specificity of 100%. Although microbiologic staining has a low sensitivity, our case presented AFB positive in the urine smear. Nonspecific clinical presentations may mimic other pathologic lesions. In this case, the patient was initially treated for the scrotal mass as a nonspecific abscess with drainage and usual antibiotics. Therefore, a high index of clinical suspicion for TB on a severely debilitated patient allowed prompting initiation of empirical therapy anti-TB.

CONCLUSIONS: Tuberculosis (TB) is the most common cause of infection-related death worldwide. Therefore, a high index of clinical suspicion is important to obtain an early diagnosis and to ensure improved clinical outcomes. Early empirical treatment for possible but not yet definitive miliary TB increases the likelihood of survival and should never be withheld while test results are pending.

Reference #1: Manual de Recomendações para o controle da tuberculose no Brasil. Ministério da saúde, 2010.

Reference #2: Wise GJ, Marella VK. Genitourinary manifestation of tuberculosis.Urol Clin North Am 2003, 30:111-121

Reference #3: Klaus-Dieter Lessnau: Miliary Tuberculosis. Updated: Sep 13, 2013 http://emedicine.medscape.com/article/221777-overview#aw2aab6b2 (accessed in March 22, 2015)

DISCLOSURE: The following authors have nothing to disclose: Lilian Pereira, Erica Cavalcante, Bernadete Silva, Waldonio Vieira, Roseana Sovano

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