Article Type : Opinion Article
Authors : Karaagac AT
Keywords : Anaemia
Two
male infants, 5/12 and 9/12 years old, with Down syndrome, congenital heart
anomalies, and recurrent pulmonary infections were referred to our hospital for
cardiac surgery. The 5-month-old infant was 3500gr and 57cm (both <3rd
percentile). On physical examination (PE) he had pallor, fever, bilateral
sibilant rales, crackles, and the signs of congestive heart failure. His
transthoracic echocardiography revealed atrioventricular septal defect,
pulmonary hypertension, and fibrinous pericardial effusion. Laboratory findings
were normal except for moderately elevated acute phase reactants with mild
anaemia. Chest roentgenogram showed bilateral multifocal consolidations.
Clinical and radiological findings didn’t improve despite 3 weeks of large
spectrum antibiotic treatment. There was no bacterial growth in the sputum
cultures. His tuberculin skin test was negative, and the quantiferon test
result was “indeterminate”. The gastric lavage specimens were subjected to
smear evaluation for acid-fast bacilli (AFB) and culture for mycobacteria using
established methods. Computerized thora tomography (thorax CT) showed bilateral
diffused ground-glass appearance and reticulonodular shadowing. Therefore, a
bronchoscopy was performed by the paediatric pulmonologist. Since the cardiac
surgery of our patient was an emergency, Isoniazid-Rifampicin therapy (10
mg/kg/day) was initiated as soon as the broncho alveolar lavage (BAL) sample
was obtained. The therapy was changed to a 4-drug anti-TBC regimen after
constricti pericardium was detected during the cardiac operation, which was
approved by pathology. BAL polymerized chain reaction (PCR) test result was
positive for Mycobacterium tuberculosis. Unfortunately, the patient died on the
24th postoperative day. As a result of the family screening, his mother was
identified as the source of infection. The second case, a 9-month-old infant,
was 5300 gr and 63cm (both < 3rd percentile). He had been hospitalized 3
times for repeating pulmonary infections. On PE, he had pallor, cutis marmoratus,
bilateral crepitations, and the signs of congestive heart failure. His
transthoracic echocardiography demonstrated ventricular and atrial septal
defects, mitral and tricuspid regurgitation. Laboratory values were normal
except for slightly increased acute phase reactants with mild anaemia. His
chest roentgenogram showed bilateral paracardiac consolidations and atelectasis
in the right lung. Findings didn’t improve despite 3 weeks of large spectrum
antibiotic treatment. There was no bacterial growth in the sputum cultures.
Torax CT showed consolidations with air bronchograms in the upper posteromedial
part of the right lung, atelectatic regions in the upper and lower
posteromedial zones of the left lung. Therefore, a bronchoscopy was performed.
BAL sample PCR and acid-fast bacilli tests were negative. He was operated on
and discharged from the hospital on the 10th postoperative day. Tuberculosis
bacilli were produced in his BAL Lowenstein-Jensen culture on the 45th day.
Treatment was initiated following the drug sensitivity test. His parents were
also screened for TBC. Pulmonary tuberculosis is still an important cause of
morbidity and mortality in children. It was reported that there are more than
1?million new cases of childhood TB annually. Delayed diagnosis is associated
with more advanced disease and worse treatment outcomes [1-3]. On the other
hand, diagnosis of TBC is challenging due to difficulties in gathering
respiratory samples from the infant age group, absence of gold-standard
diagnostic tests, and a wide spectrum of disease symptoms that overlap with
pneumonia, malnutrition, immune deficiencies, and congenital heart
anomaly-related congestive heart failure [4-6]. As a conclusion, TBC should be
investigated in children with recurrent and/or resistant pulmonary infections.
It is important to remember that malnutrition or congestive heart failure
symptoms may mimic and/or mask the symptoms of tuberculosis in children with
congenital heart diseases.