Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai, India.

Clinical Problem :
A 13 years old boy with Down’s syndrome presented with intermittent evening rise of temperature for past 2 months associated with productive cough. He had lost 4 kg weight in the same time and had loss of appetite. He had received a 9 month antituberculous treatment {ATT} at 7 months of age and again a one month ATT at 10 years of age for pericardial effusion. There was no contact with tuberculosis patient. He was immunized till date. He had delayed milestones and was currently studying in 1st grade and could take care of himself. On examination, his weight was 36 kg, height was 135.5 cm. He had pallor, clubbing, mongloid features and insignificant cervical lymphadenopathy with hypotonia and hepatomegaly. Other systems were normal. Investigations showed hemoglobin of 9.2 gm, dl, white cell count of 13,000, cumm {78 percent polymorphs, 19 percent lymphocytes}, ESR of 105 mm at end of 1 hour. Mantoux test was negative and sputum for acid fast bacillus {AFB} was positive for AFB bacillus. Chest X-Ray showed miliary mottling. Patient was started on category II ATT regime and TB culture sensitivity after 6 weeks showed sensitivity to all antituberculous drugs. After 3 months of ATT, sputum for AFB was negative and ATT was stopped after 1 year of therapy. Child had gained 10 kg in one of treatment.

Question :
How common is presence of acid fast bacilli in the sputum smear of a miliary TB_?

Expert Opinion :
In adults with suspected tuberculosis, the sputum smear is a helpful test. For a positive acid-fast bacilli sputum test, at least 5,000 to 10,000 bacilli, millimeter of specimen are required. {1} Mycobacterium tuberculosis culture needs 10-100 microorganisms. {2} Patients with miliary tuberculosis usually do not have cavities. Therefore, they present a very low concentration of bacilli when compared to those with cavitatory TB. {3} Thus, though chances of getting a bacteriological confirmation in miliary TB is high with a culture, presence of acid fast bacilli on a sputum smear in children with miliary TB is rare. In immunocompromised patients, the bacterial load is high and chances of getting a positive AFB on smear in miliary TB is high. {4} Our patient had Down’s syndrome which leads to poor immune response and thus he seems to have had a positive AFB.

1. World Health Organization. Global Tuberculosis Control: Surveillance, Planning, Financing. WHO Report` 2002. Available at website: ww.who.int, gtb, publications, globrep01, otherpernnex4Amer.xls. Accessed April 3, 2003.
2. Dunlap NE, Bass J, Fujiwara P, et al. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. {online series} Am J Respir Crit Care 2000`161:137695. Available at website: ww.cdc ,gov, nchstp, tb, pubs, 1376.pdf. Accessed April 3, 2003
3. Fernandes SR, Homa MN, Igarashi A, Salles AL, Jaloretto AP, Freitas MS, et al. Miliary tuberculosis with positive acid-fast bacilli in a pediatric patient. Sao Paulo Med J. 2003`121{3}:125-7.
4. Swaminathan S, Padmapriyadarsini C, Ponnuraja C, Sumathi C H, Rajasekaran S, Amerandran V A, Reddy M, Deivanayagam C N. Miliary tuberculosis in human immunodeficiency virus infected patients not on antiretroviral therapy: Clinical profile and response to shortcourse chemotherapy. J Postgrad Med 2007`53:228-31

Correct Answers :  yes 70%
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