A 15 year old girl presented with exertional SOB for last 1 month which exacerbated for last 2 days. At OPD she was grade 4 Dyspneic with resting desaturation with cyanosis and following cxr. the patient had repeated sputum for AFB which were found to be negative. ELISA for HIV 1&2 was negative. the patient had dramatic response in improvement of SOB with pulsed methylprednisolone but deteriorated again after discontinuation. ABG was suggestive of PaO2/FiO2 less than 200 with increased D(A-a)O2. Patient partly denied mechanical ventilatory support.. as long as pt was on IV methylpred she remained stable but deteriorated just within 24 hr of its discontinuation. TLC normal, CRP raised, serum ANA negative, serum RA factor slightly raised. What may be the possibilities?
c-ANCA was negative, TLC - 12200 with 5% eosinophil, renal function was within normal limit
consider the possibility of Disseminated Kochs with secondary ARDS
It might very well fit interstitial lung disease. A HRCT and lung biopsy would help in confirmation. Treatment is using immunomodulators.
My vote would go for an ILD as well. Like Mr.Chandrasekaran has correctly suggested - an HRCT Thorax and BAL would help greatly.
Interestingly- have you considered the possibility of pulmonary lymphoma?
Since HIV was negative- a case of histoplasmosis would not be likely- but all the same lets see what the lymphatics look like on the HRCT.
Do keep us updated Arnab
Hrct suugestive of military pattern--fits with progressive primary disease(disseminated ) kochs
3 earlier sputum samples under RNTCP were negative. After HRCT scan we planned to have sputum for AFB repeated as a routine procedure before FOB and surprisingly it came as scanty 11 and 3+ on two samples under fluorescent microscopy. ATD was started...pt improved but but again after 7 days high grade fever appeared but no dyspnea...all the workups for fever came as negative along with genexpert report showing rifampicin sensitivity...what may be the reason and wat will be our next step???
u need to give steroids as AKT may cause paradoxical reaction if used alone. use oral steroids for 2 + 4 weeks
she will respond
Check indian pediatrics...number of article supporting this information
A very nice case indeed- kudos to your team for helping this child.
thank you sir...actually one chest speciualist of our team also had DCH who just gave the idea....is it now a routine protocol of doing gastric lavage to diagnose tb in childhood? @indrajit suresh sir
The case was discussed nicely with complete work up. Keep up the good work Arnab.
For suspected pulmonary Kochs - Yes- Gastric Lavage (early morning fasting) is routinely done for children below 5 years (as they cannot expectorate) . The yield is variable- but it is quite helpful. The main problem encountered is the NGT insertion which is quite problematic in young children- and more often than not- the child will struggle, cry, gag and vomit, so the performance of the same procedure on 3 successive days is quite traumatic.
For older children, hypertonic saline nebulization (early morning fasting) helps in a good sputum sample collection.
Sadly though because of the stigma attached to TB- compliance with treatment is quite poor in children, and their feeding pattern is also thrown out of gear.
@chandrasekaran Venkatesh - thank u sir
@Indrajit Suresh - I think 2 samples are now enough rather than going for 3 consecutive days
good - anyway keep posting new challenging cases - stimulates the grey cells a lot :-)
yes regarding the sampling - if the yield is good- 2 samplings are adequate , however our bosses always insisted on 3 - and it ended up being the headache of ours (the then post graduates) to coax the parents and the child for the procedure.
How often do you perform gastric lavages?
many a times we get the referred cases from pediatric medicine department and we often did this procedure but in most of d cases we are able to perform it once and in few cases we did it twice. The procedure is so painful that their parents most of the cases did not give consent for procedures to be repeated. Till now in 4 cases we were able to demonstrate on AFB on early morning gastric aspirate done only once.
A nice case highlighting importance of conviction along with open minded approach. In India one has to be doubly sure in excluding TB. I believe Prof Supriya Sarkar is there to guide you Arnab.
Yes sir prof s sarkar is my guide...and i m really lucky to have him as my guide...sir how do u know professor s sarkar?
When he was RMO in CNMC way back in 1997-98, I was his house staff. Convey my regards to him.
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