A 4-Month-Old Infant with Cough and Fever Case Challenge

Case Challenge
A 4-Month-Old Infant
with Cough and Fever
Fatih Firinci, MD; Funda Özgürler, MD; Mustafa Dogan, MD; Ilker Devrim, MD;
Tekin Nacaroglu, MD; Ali Kocyigit, MD; and Emin Mete, MD
Fatih Firinci, MD, is Assistant Professor, Department of Pediatric Allergy and Immunology,
Pamukkale University Medical Faculty. Funda
Özgürler, MD, is a Research Assistant, Pamukkale
University Medical Faculty, Department of Pediatrics. Mustafa Doğan, MD, is Assistant Professor,
Department of Pediatric Cardiology, Pamukkale
University Medical Faculty. İlker Devrim, MD, is
Associate Professor, Department of Pediatric Infectious Disease, Dr. Behcet Uz Children’s Training and Research Hospital. Tekin Nacaroglu, MD,
is from the Department of Pediatric Allergy and
Immunology, Dr. Behcet Uz Children’s Training
and Research Hospital. Ali Koçyiğit, MD, is Assistant Professor, Department of Radiology, Pamukkale University Medical Faculty. Emin Mete, MD,
is Associate Professor, Department of Pediatric
Allergy and Immunology, Pamukkale University
Medical Faculty.
Address correspondence to: Fatih Firinci, MD,
Pamukkale University Medical Faculty, Departments of Pediatrics, 20500 Denizli, Turkey; email:
healthy. There was no history of vomiting or seizure.
At admission, his temperature was
39°C and he was in respiratory distress. Breath sounds were decreased
in his right hemithorax. He was in the
third percentile for his weight and the
tenth percentile for his length. Chest
radiograph showed that his right lung
was totally infiltrative, and there was a
cavitary lesion in the right upper lobe
(Figure 1). Ultrasound was performed
to exclude the possibility of pleural effusion, and no effusion was detected.
His white blood cell count was 28,100
mm3, hemoglobin level was 10.6 g/dL,
platelet count was 660,000 mm3, and Creactive protein was 2.3 mg/dL. Liver
and renal function tests were normal.
Treatment with intravenous (IV) teicoplanin and meropenem was started. For
respiratory distress, he was given IV
methylprednisolone, nebulized salbutamol, and ipratropium bromide. His respiratory distress was resolved, but there
was not marked response to treatment.
His thorax computerized tomography
(CT) showed consolidation in the right
upper lobe with cavitation and air bronchogram (Figure 2). Gastric aspirates
were negative for Mycobacterium tuberculosis. His tuberculin skin test was also
negative, but mycobacterium PCR was
positive. Due to the positive PCR test for
tuberculosis, chest radiographs for his
parents were also evaluated. The child’s
mother’s test was negative, but a cavitary
lesion was detected on his father’s chest
radiograph. Bronchoalveolar lavage results showed acid-fast bacilli positivity.
Sputum culture was done, and antituberculosis treatment was started for his father. The patient’s tuberculosis treatment
is still ongoing.
Images courtesy of Fatih Firinci, MD.
4-month-old boy was referred
to our clinic with a diagnosis
of pneumonia. When he was
2 months old, he was treated for pulmonary infection for 20 days. A few
days after being discharged, he was
referred to our clinic with the symptoms of cough, fever, and respiratory
distress. His natal and prenatal history were unremarkable. His one sibling had died due to pneumonia at the
age of 1 month, but his parents were
Figure 1. Chest radiograph of patient with cavitation on the right upper lobe.
For diagnosis, see page 140
doi: 10.3928/00904481-20140325-05
Editor’s note: Each month, this department features a discussion of an unusual diagnosis in areas including genetics, radiology, or dermatology. A description and images
are presented, followed by the diagnosis and an explanation of how the diagnosis was
determined. As always, your comments are welcome via email at [email protected]
Healio.com/Pediatrics | 139
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Disclosure: The authors have no relevant financial relationships disclose.
Case Challenge:
Figure 2. Lung computed tomography scan shows right upper lobe (A) consolidation area with air
bronchogram (B).
Primary Cavitating Tuberculosis
Tuberculosis is still one of the most
important diseases causing mortality
and morbidity in developing countries.1
According to the World Health Organization, at least half a million children
become ill with tuberculosis each year
and up to 70,000 children die because
of tuberculosis every year.2 Children
can present with tuberculosis at any age,
but the most common age is between
1 and 4 years. Because of non-specific
symptoms and difficulty in establishing
a definitive diagnosis, it may be difficult
to diagnose tuberculosis in infants and
children.1 Tuberculous cavities are usually seen in adults as a result of post-primary pulmonary tuberculosis; however,
primary infection with cavitation is rare
among children2 and seen mostly in Africa and India.3
In primary tuberculosis, the most
common symptom is cough, unlike our
case contact with adult pulmonary tuberculosis. Although consolidation in a chest
radiogram is the most common finding;
CT scan is more useful for diagnosis of
parenchymal lesions and tuberculosis
One of the manifestations of progressive primary tuberculosis lung lesion is the
occurrence of necrosis and liquefaction of
the caseous material within the primary
140 | Healio.com/Pediatrics
challenges/children/en. Accessed on September 6, 2013.
3.Yang W, Jianjun D, Siyan D. Primary cavitating tuberculosis in a 2-month-old infant. Pediatr Infect Dis J. 2012;31(10):1097-1099.
4.Van Hest R, De Vries G, Morbano G. Cavitating tuberculosis in an infant: case report
and literature review. Pediatr Infect Dis
J. 2004;23(7):667-670.
5. Arikan-Ayyildiz Z, Uzuner N, Cakmakçi H. Pulmonary tuberculosis in infants under one year of
age. Turk J Pediatr. 2011;53(3):250-254.
6.Maniar BM. Cavitating pulmonary tuberculosis below age of 2 years. Indian Pediatr.
focus. This material may discharge into
a bronchus resulting in a cavity, which is
defined as primary cavitating tuberculosis.5
Right lung involvement is more common,
as was seen in our case.3,5 Prognosis for
primary cavitating tuberculosis is typically
very poor. Furthermore, it has been reported that mortality is higher as the patient’s
age decreases. Mortality in Turkey was
70.6% in children younger than 6 months
and 41.9% in those aged 7 to 12 months.5
Mortality was higher at lower ages because
of miliary tuberculosis and because tuberculosis meningitisis is more common in
that age group. In our case, miliary tuberculosis was not seen in chest radiogram,
and the patient’s cerebrospinal fluid examination was normal.
Primary cavitating tuberculosis is
rarely seen in children younger than 12
months. At the time of this writing, our
patient, who had presented with ongoing
fever and cough for 3 weeks, had not yet
resolved his symptoms with anti-tuberculous therapy.
Although rare, primary tuberculosis
should be kept in mind as a potential
diagnosis for infants who are unresponsive to pneumonia treatment. Due to
diagnostic difficulties and nonspecific
symptoms in children, more studies may
be needed as compared to adults.
1.Schneider E, Castro KG. Tuberculosis trends
in the United States, 1992-2001. Tuberculosis
(Edinb) 2003; 83: 21-29.
2. Tuberculosis (TB). World Health Organization
website. Available at: http://www.who.int/tb/