DR.MOHAMMED IRFAN SHEIKHalmost 4 years ago

Drug-Resistant Miliary Tuberculosis in a Child

A previously healthy 8-year-old girl presented to the hospital with a 3-month history of dry cough and persistent fevers. A chest radiograph (Panel A) and a subsequent contrast-enhanced computed tomographic (CT) scan (Panel B) showed a diffuse, miliary (i.e., millet seed–like) pattern of uniformly sized, small nodules throughout both lungs. The soft-tissue window (not shown) revealed necrotic-appearing mediastinal lymph nodes. A tuberculin skin test and an interferon-γ release assay were positive, and a sputum acid-fast bacilli smear was negative. Cultures were obtained from multiple sources, including sputum, bronchoalveolar lavage, and cerebrospinal fluid. During the wait for the culture results, empirical first-line treatment for tuberculosis was initiated; however, the patient’s condition did not improve after 2 months of therapy. Because the cultures remained negative, a lung biopsy was performed with video-assisted thoracoscopy; a hematoxylin and eosin stain of the biopsy specimen showed caseous necrosis, and an acid-fast stain was positive for bacilli (Panel C, arrows). Drug-resistant tuberculosis was suspected. Because the results of tests to confirm drug resistance can take weeks to return, treatment was empirically changed to a regimen that is standard for drug-resistant tuberculosis in the region. The patient’s temperature returned to normal within 2 weeks after initiation of this treatment regimen, and repeat CT images at 2 months showed improvement. When the results of the drug-resistance tests were returned, isoniazid-resistant tuberculosis was confirmed.