I have come across difficulties in dealing a case of an infant. Would you kindly give your valuable opinion?
A 7 month old infant presented to me with high grade fever with chill rigor for 1.5 months. Before presenting to us he has been seen and evaluated by many pediatricians. He had cough. He had received all the vaccines up to his age. Total count was elevated with neutrophilic predominance. His Chest X-ray revealed a large cavity in the left upper zone with a few infiltrations in the right lung. Sputum culture failed to reveal any organism. Sputum for AFB smear was negative so also the BACTEC culture. HRCT scan revealed a large cavity in the left upper zone. The infant had received many intravenous antibiotics including complete staph coverage with no clinical improvement. In this situation how will you approach to the case? Is TB yet a possibility though cavity is very rare in TB infancy? Will a course of ATD be helpful for the infant? What should be the next diagnostic work-up?
it can still be tuberculosis. What about history of contact and BCG immunisation status? was his mantoux positive?. Has he recieved appropriate anti staphylococcal and anti Klebsiella antibiotics for appropriate duration? Does he have previous xray which were normal? It can help to rule out congenital lung cyst which has become infected.
I hope, we have ruled out immunodeficiency (secondary and / or primary).
Previous 'courses of antibiotics' needs to be discussed in more detail. As bacterial lung abscess, would require longer duration of antibiotics (upto 6 weeks), and clinical improvement can take long time.
Diagnostic work up of TB may include contact tracing, gastric aspirate for AFB, FNA or biopsy of lymph nodes (if present) etc.
Lung tap may be reserved for a later diagnostic work up, as it has got some complications.
Also it is important to take a detailed family history, along with assessing the growth of the child. Growth would help you assess the chronicity of illness.
Yes we also think that way.....TB is still a strong possibility......but cavitation in neonate due to tuberculosis is rare though few case reports are there in the literature. The infant received 14 days course of vancomycin followed by another two weeks of linezolid without any symptomatic improvement before presenting to us. Blood culture before the start of antibiotics didnt reveal any microorganism. He didnt have any contact history with known TB case. He did receive BCG vaccination as per schedule
one more info we are still continuing linezolid therapy and it is on the 4th week now and investigation going on. Recently we aspirate morning gastric sample and sent it for AFB smear and BACTEC culture and waiting for the results to come
The chest xray looks like a diaphragmatic hernia. Might be a late presentation. The diaphragm on the left side is not cleary seen. I suggest you get the x ray reported. Also try placing a nasogastric tube and repeat the xray. Sometimes air in the stomach or intestines which are lying in the pleural cavity may be mistaken for pneumatocoels or cavity.
How did you elicit a history of chills in a 7 month infant? Also does the infant have any failure to thrive , what is his current weight? Has there been good weight gain? Is the infant immunosupressed? Is there HIV? It appears to be a lung abscess which could occur as a complication of pneumonia or a pneumatocoele which could occur with any pneumonia especially Staphylococcal pneumonia and which could last for a few months to a year. A good radiologist should be able to tell you whether it is lung abscess or pneumatocoele.
It would be interesting to know what finally happened to this peculiar case. Would there be any updates?
it was a cavity not pneumatocele or something else. We did gastric lavage with pediatric ryle's tube and immediately send it for AFB smear and BACTEC culture. One thing you can't ignore a diagnosis of tuberculosis where though cavitary pulmonary tuberculosis is extremely rare in childhood. Being pulmonologist we were eager to exclude tb. Fluortesecent microscopic exmination of smear prepared from gastric aspirate showed AFB positive as scanty 11 as per new grading of sputum positivity under fluoresect microscope in RNTCP. We started ATD for this patient immediately and subsequently the BACTEC culture report showed growth of M. tb and follow up chest x-ray after 4 months of ATD showed almost complete radiological resolution as well as symptomatic improvement.
infant cavitary tb is an extremely rare entity though few support we got from the existing literature and in fact it is not so uncommon what we think. There are case series, articles on this in the literature. But in most of those cases they failed to demonstrate tubercle bacilli rather they diagnosed it on the basis of contact tracing, respones to treatment by ATD. But we demonstrated tubercle bacilli and one should know morning gastric aspirate is an usefull tool for pediatric age group who cannot expectorate properly.
Thank you.
very interesting arnab- indeed a peculiar case. Good that you were able to treat the child well.
In this 7 month old child with fever and large cavity in left upper zone, Tb may be possibility but less likely. Congenital malformations (CCAM, CLE, cystic lesions) with secondary infections are more likely.
Other causes may be necrotising peumonia.
Additional investigations may help in confirming diagnosis and include: bronchoscopy and bronchoalveolar lavage for bacteria, fungus and AFB. CT scan if not already done.
If unusual organism is identified, may further investigate for underlying immune deficiency
Yes Sir, we have investigated the child so also the pediatrician. Staphylococcal pneumonia was a strong possibility. Tuberculosis with a cavity in this age group is a least possibility. But the most pathetic thing is that when we have sent this case report to journal for possible publications they denied it as it is a common case and nothing new to it. So can anyone mention here some journals where we can send it for publications???
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