394 Tüberküloz ve Toraks Dergisi 2005; 53(4): 394-396
Recurrent pneumothorax at an infant with miliary tuberculosis
M. Ayşin TAŞAR1, İlknur BOSTANCI2, Sinan ASLAN1, Resul YILMAZ1, Yıldız DALLAR1
1Ankara Eğitim ve Araştırma Hastanesi, Pediatri Bölümü,
2Ankara Eğitim ve Araştırma Hastanesi, Pediatrik Allerji ve Astım Bölümü, Ankara.
ÖZET
Miliyer tüberkülozlu bir süt çocuğunda tekrarlayan pnömotoraks
Miliyer tüberküloz (Tbc) için üç aydır anti-Tbc tedavi alan yedi aylık kız hasta, akut gelişen dispne ve siyanöz şikayeti ile hastaneye başvurdu. Akciğer grafisinde sağ akciğerde pnömotoraks saptandı. Kapalı su altı tüp drenajı uygulandı. Hasta düzeldikten sonra taburcu edildi. Bir hafta sonra aynı şikayetler ile aynı hemitoraksta pnömotoraks için tekrar hospitalize edildi. Tekrar aynı tedavi uygulandı. Anti-Tbc tedavi 12. ayın sonunda kesildi. Miliyer Tbc’nin yaşamı tehdit edici nadir bir komplikasyonu pnömotorakstır. Sadece tanı anında veya tedavi başladıktan kısa süre sonra değil tedavi boyunca ileriki aylarda da görülebilir. Bu hastayı miliyer Tbc tedavisi sırasında pnömotoraks gelişen ilk süt çocuğu olduğu için sunmak istedik.
Anahtar Kelimeler: Miliyer tüberküloz, pnömotoraks, süt çocuğu.
SUMMARY
Recurrent pneumothorax at an infant with miliary tuberculosis
Tasar MA, Bostanci I, Aslan S, Yilmaz R, Dallar Y
Department of Pediatrics, Ankara Education and Research Hospital, Ankara, Turkey.
A seven-month-old girl with miliary tuberculosis (Tbc) admitted to hospital due to development of acute dyspnoea and cya- nosis at the end of third month of anti-Tbc therapy. Pneumothorax was evident at right lung with the chest radiography. A chest tube placed under water seal was applied. The patient healed up and then discharged. One week later, the patient admitted to hospital again, with same complaints due to pneumothorax at the same hemithorax. Same treatment was app- lied to the patient. Anti-Tbc therapy was stopped at the end of 12thmonth. Although, pneumothorax is a rare life-threate- ning complication of miliary Tbc, it’s not seen only on admission or soon after beginning of the therapy, but it can be seen several months later during treatment. We want to report this case. That is the first case in which pneumothorax developed during therapy of an infant with miliary Tbc.
Key Words: Miliary tuberculosis, pneumothorax, infant.
Yazışma Adresi (Address for Correspondence):
Dr. M. Ayşin TAŞAR, Ankara Eğitim ve Araştırma Hastanesi, Pediatri Bölümü, Cebeci, ANKARA - TURKEY
Tuberculosis (Tbc) is still an important health problem in developing countries covering Turkey.
Pneumothorax, which is a clinical complication of Tbc, is more common among adolescents and adults, not in infants (1,2). Therefore, we reported this seven-month-old girl with miliary Tbc, who has developed spontaneous pneumothorax two times with in a week interval, while being treated with a four-drug regimen for three months.
CASE REPORT
A four-month-old girl admitted to hospital with pro- ductive cough, fever and vomiting lasting for a we- ek. She had no pneumonia history and there was no Tbc in her family history. One dose of Bacille Calmette-Guérin (BCG) vaccine was administered.
Physical examination: Her body weight was 4150 g (3 p), height 60 cm (50 p), head circum- ference 36 cm (< 3 p), pulse rate 160/min, res- piratory rate 60/min. Both hemithorax were par- ticipating respiration equally. There were crepi- tations at lung basal. Liver and spleen were pal- pable 5 cm at midclavicular line.
Laboratory evaluation showed haemoglobin 9.2 g/dL, total leukocyte count 28.000/mm3, platelet 454.000/mm3. In blood smear, there were 68%
polymorphonuclear leukocyte, 18% lymphocyte, band forms 14%, toxic granulations was positive.
Mantoux test was negative. Acidoresistant bacille in fasting gastric fluid were (+++) positive. At pos- teroanterior chest film, miliary infiltrations were observed bilaterally (Figure 1). In thorax compu- terized tomography, there were multiple lympha- denopathies in the anterior mediastenum perivas- cularly and right paratracheal region (the largest one was 2 cm in diameter); and there were mic- ronodular densities all over the pulmonary area (Figure 2). These findings were consisting with miliary Tbc. Liver was detected as 106 mm and grade II parenchyma echogenity in abdominal ult- rasonography. Lumber puncture findings were as follows. Leucocytes 29/mm3, chloride 118 mmol/L, protein 296 mg/L, glucose 53 mg/mL at the same time serum glucose was 82 mg/mL.
Microorganism was not detected in native materi- al and cerebrospinal fluid culture was negative for bacterial pathogens.
With these findings the patient was diagnosed as miliary Tbc and she was treated with a four-drug
regiment including streptomycin, morphozynami- de, rifampicin and isoniazid. Ethambutol was substituted morphozynamide due to elevated se- rum liver enzyme levels on the 10thday. Family history was negative for Tbc, but Tbc screening revealed that her father was acidoresistant bacille positive and had cavitary Tbc lesion, so that iso- niazid prophylaxis was given to his five children.
Although, appropriate therapy has been given and controls were had been properly, after three months the case had admitted with acute dysp- nea and cyanosis. On physical examination ge- neral condition was bad, and she had peroral cya- nosis. On thorax examination respiratory sounds were not heard by auscultation. Chest film sho- wed pneumothorax on right lung. A chest tube was applied. On the seventh day of treatment, pneumothorax was cured and patient was disc- harged. After one week she again admitted hos- pital with acute dyspnoea and her chest film reve- aled pneumothorax at the same hemithorax. Sa- me therapy was given to patient and according to clinical and radiographical findings, the patient discharged in seventh day of her hospitalisation and her treatment had continued for 12 months.
DISCUSSION
Pneumothorax is a well-known complication of cavitary Tbc and it is rare but a recognizable complication of miliary Tbc in adults (1-4). Mili- ary Tbc is a common form of Tbc among infants and children, but it is not seen commonly toget- her with pneumothorax (4-7). Up to now, 18 ca- ses miliary Tbc complicated with pneumothorax
Taşar MA, Bostancı İ, Aslan S, Yılmaz R, Dallar Y.
Tüberküloz ve Toraks Dergisi 2005; 53(4): 394-396 395
Figure 1. Miliary infiltrations observed bilaterally at posteroanterior chestgraphy of the patient.
Recurrent pneumothorax at an infant with miliary tuberculosis
Tüberküloz ve Toraks Dergisi 2005; 53(4): 394-396 were reported in English literature. Only six of them were younger than 17 years old and only two infant cases were reported (4-7). The youn- gest one was 21 days old who died 6 hours later on admission (5). Four cases were unilateral and the others were bilateral. All bilateral cases had recurred. In our case pneumothorax occur- red two times at the same hemithorax.
A miliary Tbc series including 22 cases was re- ported from Turkey and there were no pneumot- horax complicating acute miliary Tbc (8).
Mechanism of pneumothorax in miliary Tbc is not clear. In the cases, at which initially develo- ped pneumomediastenum, air leakage through mediastinal pleura is thought to be the cause of pneumothorax (1). But this explanation does not cover the cases that have only pneumotho- rax as our case. The considered mechanism is rupture of subpleural miliary nodules into ple- ural space secondary to necrosis or caseificati- on, or rupture of bullous lesion developed near miliary tubercules (5-7).
In any Tbc suspicion, familial Tbc screening must be done. Infectivity of infants is very low and infection spreads via close contact with adults. In this case, family screening reveals that her father is the origin.
All cases reported in literature have miliary Tbc together with pneumothorax on admission. In our case, pneumothorax developed at the third month of treatment. Although pneumothorax is
a rare complication, it should be remembered in patients with miliary Tbc. It can be seen both in early and late periods of treatment. So in any acute dyspnea episode during treatment period we have to suspect of pneumothorax and family members and caregivers should be warned abo- ut this complication.
REFERENCES
1. Diaz Rojas F, Cordova Gutierrez H, Aguirre Gas H. Spon- taneous pneumothorax associated to active pulmonary tuberculosis. Prensa Med Mex 1978; 43: 282-6.
2. Narang RK, Kumar S, Gupta A. Pneumothorax and pne- umomediastinum complicating acute miliary tuberculo- sis. Tubercle 1977; 58: 79-82.
3. Mert A, Bilir M, Akman C, et al. Spontaneous pneumot- horax: A rare complication of miliary tuberculosis. Ann Thorac Cardiovasc Surg 2001; 7: 45-8.
4. Peiken AS, Lamberta F, Seriff NS. Bilateral pneumothora- ces: A rare complication of miliary tuberculosis. Am Rev Respir Dis 1974; 110: 512-7.
5. Sharma A, Kumar S, Rattan KN. Pneumothorax compli- cating acute miliary tuberculosis in children. Trop Doct 2000; 30: 111-2.
6. Sharma A, Kumar P. Miliary tuberculosis with bilateral pneumothorax: A rare complication. Indian J Chest Alli- ed Sci 2002; 44: 125-7.
7. Wammanda RD, Ameh EA, Ali FU. Bilateral pneumotho- rax complicating miliary tuberculosis in children: Case report and review of the literature. Ann Trop Paediatr 2003; 23: 149-52.
8. Gurkan F, Bosnak M, Dikici B, et al. Miliary tuberculosis in children: A clinical review. Scand J Infect Dis 1998;
30: 359-62.
396
Figure 2. Thorax computerized tomography of the patient.
