Clinician's Corner

The Editorial Board encourages all readers to submit an interesting case to the “Clinician's Corner”. The case presentation should not exceed 200 words and should give the reader enough information to suspect the diagnosis without making it obvious. The discussion should not exceed 600 words and should be followed by a couple of ‘clinical pearls’. A maximum of two references may be included, if helpful. The submitted cases will undergo peer review and revision at the discretion of the editors. Priority is given to cases illustrating an approach to common problems or important clinical clues to less common diagnoses that should not be missed. The Editorial Board hopes that this provides an opportunity for trainees and paediatricians practising outside of the teaching hospitals to share their clinical experiences and to publish in Paediatrics & Child Health. If you have a case to submit, contact Dr Friedman by e-mail at the address at the bottom of the page. A 14-month-old boy was seen because of a persistent pneumonia for two months. Two months before admission he had a flu-like illness characterized by fever and cough. The chest radiograph showed bronchial wall thickening and sub-segmental atelectasis in the right middle lobe. He was treated with a 10-day course of amoxicillin-clavulinic acid. Following this, he continued to cough but he was afebrile and continued to thrive. Eight weeks later, follow-up postero-anterior (Figure 1A) and lateral chest radiographs (Figure 1B), done because of persistent coughing, showed consolidation in the right middle lobe with mediastinal lymphadenopathy. Postero-anterior (A) and lateral (B) chest radiographs showing consolidation in the right middle lobe with mediastinal lymphadenopathy He was born in Canada. He had not travelled and there were no pets at home. His father was Canadian and white, and his mother had lived in Canada for 15 years but had been born in the Philippines. Both were healthy. Further history revealed that eight months earlier his maternal grandmother had moved to Canada from the Philippines to care for him while his parents worked. She had been unwell for two months with symptoms consisting of shortness of breath and was currently admitted to hospital for a ‘pneumonia’. Diagnostic tests were performed that revealed the cause of his persistent pneumonia. A tuberculin skin test showed 14 mm of induration. All three gastric aspirates grew Mycobacterium tuberculosis sensitive to first line drugs. A computed tomography scan performed because of persistent wheeze demonstrated extensive cavitating mediastinal lymphadenopathy requiring steroid therapy. He was treated for nine months with isoniazid, pyrazinamide and rifampin, with gradual resolution of the consolidation and dystrophic calcification of some paratracheal lymph nodes. Both parents had positive tuberculin tests but were free of disease. The grandmother had bronchial washings that grew M tuberculosis with the same susceptibility pattern. This case highlights several important points for the clinician. First, a good history is essential in the diagnosis of pneumonia. Although the rate of tuberculosis (TB) in Canadian-born individuals is much lower than in foreign-born people, the risk factors (immigration from a high risk country, human immunodeficiency virus [HIV] infection, drug use, history of incarcerations, homelessness, travel to high risk areas) should be sought in cases of persistent pneumonia. Children exposed to adults in any of the high risk groups are at an increased risk of infection. The major route of transmission of TB is respiratory, via small infectious droplet nuclei of 1 to 5 μm in diameter that can remain suspended in air for hours. Infection rates of household contacts is estimated to be 21% to 23% because prolonged, rather than casual, contact is required. This rate increases if the index case has active cavitary disease because cavitary lesions are usually loaded with bacilli and easily become airborne with any coughing effort. The repeated close contact of the grandmother with this child would certainly have been a factor in this case. Once infected, children younger than four years of age are at high risk for developing disease compared with adults. The reasons why younger children are more likely to develop disease are probably related to the immaturity of the cellular immune system and its relative decreased ability to handle a new infection. In this case the parents had not developed disease. When young children are infected, the most common clinical symptoms are cough (80%), fever (64%), loss of appetite (43%) and localized wheezing (38%), or they may be asymptomatic. The inflammatory response in the lung parenchyma and the enlargement of the hilar/paratracheal nodes comprise the typical ‘primary complex’ lesion seen in newly infected children. The initial chest radiographs in this case did not include a lateral film, which may have revealed early hilar or paratracheal lymphadenopathy, an important finding that coupled with the history of a household contact, could potentially have led to an earlier diagnosis. Children with primary disease rarely produce sputum. Even if obtained, the sputum has a low number of organisms, which usually results in negative sputum smears. Aspiration of early morning gastric fluid that represents aspirated night-time pulmonary secretions or bronchoalveolar lavage (BAL) fluid, are the most sensitive means of obtaining specimens for culture. Finally, the host inflammatory response associated with treatment of the disease was the likely mechanism for the progressive cavitation and enlargement of the mediastinal lymph nodes seen in this patient. This process was responsible for bronchial compression resulting in localized wheezing. The use of corticosteroids in this clinical setting may be of temporary benefit to alleviate symptoms. Consider TB as a cause of unresolved pneumonia, especially if close contacts have risk factors for TB. Household contacts are the most likely source of infection in children with primary TB. Lateral chest radiographs are important in children in whom you suspect TB to visualize hilar and mediastinal lymph nodes. Early morning gastric aspirates or BAL are usually required in children to obtain specimens with a reasonable yield for culture. Cultures should always be attempted before treatment because of the possibility of drug-resistant TB. Lymphadenopathy can progress with treatment.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.