Grand Rounds

A 3 and a half years old girl with recurrent pneumothorax

Medical Sciences Department, Pediatric Oncall, Mumbai, India

Clinical Problem :
A 3½ years old girl presented with fever and cough since 15 days, breathlessness since 10 days and altered sensorium since 1 day. She was treated for the same with intravenous antibiotics but had no improvement. There was no history of TB contact and she was immunized till date. On examination, she was lethargic, had respiratory distress {respiratory rate = 50, min} and tachycardia {heart rate = 140, min} with subcostal and intercostals retractions. There was pallor and enlarged tonsils with absent BCG scar. On respiratory system examination, she had crepitations on right infra-axillary region. CNS examination was normal. She had hepatomegaly. Other examination findings were normal. Investigations showed miliary mottling on Chest X-Ray, hypoxia on arterial blood gas analysis and negative Mantoux test. She was treated with IV antibiotics and antituberculous therapy {ATT}. Bronchoalveolar lavage grew Klebsiella. On 4th day of treatment, she developed right sided pneumothorax for which intercostals drainage {ICD} was put. Subsequently she developed multiple spontaneous pneumothorax bilaterally for which multiple ICDs were done over a period of next 75 days. She also required negative suction with ICD in view of incomplete lung expansion. After 82 days of presentation, ICD was removed and child was stabilized. She was continued on ATT.

What is the cause of recurrent pneumothorax in this child _?

Discussion :
This child has miliary mottling on Chest Xray which is suggestive of Tuberculosis in this child. Though BAL grew Klebsiella, it is quite unlikely that Klebsiella should have a miliary picture on the Xray. Now miliary TB on healing leads to fibrosis of the lungs. This makes the lung less compliant and more prone to rupture and leading to pneumothorax. Corticosteroids have a tendency to suppress the normal fibrotic reaction around the tuberculous lesion and thus prevent the lung from getting fibrosed. Thus, it is recommended that all children with miliary Tb should received steroids along with the ATT with ATT taking care of the TB and steroids preventing the fibrosis.

E-published: April 2010, Vol 7 Issue 4 Art No. 24

Correct Answers :  yes 100%
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