Diagnostic Dilemma

Is it TB_?

A 5½ years old girl presented with cough, cold and tachypnea for a month along with loss of appetite for which child had been started on 4 drug anti tuberculous therapy {ATT} by her physician. There was TB in grandfather 2 years ago. She was immunized appropriately for her age. Her Chest X-Ray had right paracardiac haziness. Mantoux test was negative. On presentation, her weight was 13 kg and height was 107 cm, respiratory rate was 38, min with no distress and she had bilateral crepitations with generalized lymphadenopathy, pallor and hepatomegaly. Other systems were normal. Her repeat Chest X-Ray showed bilateral reticulonodular shadows in both mid-zones. Hemoglobin was 11.2 gm, dl, WBC count of 12,800, cumm {79 percent polymorphs, 17 percent lymphocytes}, ESR of 110 mm at end of 1 hour, HIV ELISA was negative. Sputum for acid fast bacillus {AFB} on smear was negative. She was continued on ATT {2 months HRZE and then HR} but cough persisted. She continued to have bilateral crepts. Other conditions for chronic lung disease were considered. Her Echocardiography was normal. Serum ACE levels were elevated {64 U, L {Normal = 8 to 52 U, L}}, repeat ESR was 19 mm at end of 1 hour, serum calcium was normal {8.9 mg, dl}. CT chest was done that showed mild bronchiectasis of both lower lobes of lungs with peribronchial thickening. Her serum immunoglobulins showed elevated serum IgE {1364 mg, dl {Normal = 10 to 180 mg, dl}} elevated IgG {1740 mg, dl {Normal = 640–1420 mg, dl}}, normal IgA {186 mg, dl} and elevated IgM {214 mg, dl {Normal = 40–180 mg, dl}}. Her sweat chlorides were 34 mmol, L and CD19 was 19 percent and CD20 was 20 percent.

What is the diagnosis in this child_? Does the child have TB_? Why does she have bronchiectasis_?
Expert Opinion :
Though the ACE levels were elevated, the CT chest has not shown any lymphnodes. Thus would we still consider sarcoidosis_?

Regarding mycoplasma, is it seen with chronic lung disease
Answer Discussion :
manish alexander
cystic fibrosis
13 years ago
ahmed Ragab
yes she is tb
13 years ago

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