Diagnostic Dilemma


A 4 years old boy presented with cough and breathlessness for one month. His Chest X-Ray showed multiple nodular lesions in lung and CT chest showed extensive bilateral patchy consolidation with nodular infiltrates and mediastinal adenopathy suggestive of TB. Mantoux test and HIV ELISA were negative. His gastric lavage did not show any acid fast bacilli (AFB). He was started on antituberculous therapy (ATT) consisting of Isoniazid, Rifampicin, Pyrazinamide, Ethambutol. He was a patient with cerebral palsy and epilepsy and was also on nitrazepam, sodium valproate, Topiramate for his seizures. His ATT course was completed after 1 year and Chest X-Ray was normal. Three months later he again presented with cough and Chest X-Ray showed fibrocavitatory TB in right lower zone. He was started on category 2 of ATT. His sputum smear for AFB was negative and TB culture after 6 weeks did not grow any organism. After 3 months, his Chest X-Ray showed miliary lesions. Parents were counseled regarding bronchoalveolar lavage but refused.

What should be the treatment now?
Expert Opinion :
The patient was started on 2nd line ATT consisting of Amikacin, Ofloxacin, Ethionamide, clofazamine and PAS and 6 months later Chest X-Ray is normal. Amikacin was stopped after 6 months and he is currently on Ofloxacin, PAS, clofazamine and Ethionamide.
Answer Discussion :
Consider Multi drug resistant Tuberculosis. Quarantine
6 years ago
Sourav Maiti
BAL is strongly suggested with GeneXpert for Mycobacterium tuberculosis and rifampicin resistance but also perform Gram stain and culture for Nocardia. If good quality sputum can be induced, go for it. Send the sample for PCR for TB and also work up for Nocardia.
6 years ago

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