Cavitating Pulmonary Tuberculosis in a 3-year-old Child: A Case Report

Pushpa Kini¹ https://orcid.org/0000-0001-6186-0336, Manjunath Laxminarayana² https://orcid.org/0009-0008-6770-085X, Soham Bhunia³

^1–3Department of Pediatrics, Kasturba Medical College, Manipal, Karnataka, India

Corresponding Author: Manjunath Laxminarayana, Department of Pediatrics, Kasturba Medical College, Manipal, Karnataka, India, Phone: +91 9535280485, e-mail: l.manjunath@manipal.edu

Received: 12 April 2024; Accepted: 12 November 2024; Published on: 17 February 2025

ABSTRACT

Cavitating pulmonary tuberculosis (PTB) frequently occurs in adults and is uncommon in children. We report a case of a 3-year-old female child who presented with complaints of fever, cough, and poor weight gain. Clinical findings and chest X-ray were suggestive of right lower lobe pneumonia. The patient was treated with IV antibiotics, responded well, and was discharged.

She presented with a recurrence of fever and weight loss. High-resolution computerized tomography of the thorax revealed cavitation in the posterior-basal segment of the right lower lobe of the lung. She was treated with antitubercular therapy (ATT) and responded well to the treatment.

Keywords: Antitubercular therapy, Case report, Cavitating lesion, Pulmonary tuberculosis

How to cite this article: Kini P, Laxminarayana M, Bhunia S. Cavitating Pulmonary Tuberculosis in a 3-year-old Child: A Case Report. Indian J Respir Care 2024;13(4):253–255.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.

INTRODUCTION

Pulmonary tuberculosis (PTB) is caused by Mycobacterium tuberculosis (MTB); children acquire the infection by being near those affected. In 2022, tuberculosis (TB) ranked as the second leading cause of death globally after coronavirus disease 2019 (COVID-19), with 7.5 million newly diagnosed TB cases. Of those affected, 55% were men, 33% were women, and 12% were children (aged 0–14). India has the highest percentage of cases (27%) among the top eight countries, where two-thirds of the global cases were reported.¹ Diagnosis of PTB in a child having clinical symptoms but with negative microbiological testing is challenging. Therefore, having a high index of suspicion for TB and prompt antitubercular therapy (ATT) will reduce morbidity and mortality. This case report presents the pretreatment clinical course, course of hospitalization, response to ATT, and follow-up.

CASE DESCRIPTION

A 3-year-old female child presented with complaints of poor weight gain and loss of appetite, along with fever and cough for 8 days. There was a high-spiking fever (4–5 spikes/day), intermittent with chills and rigors. The cough was wet type and progressive, accompanied by posttussive vomiting.

Examination revealed a height of 90 cm and a weight of 11.58 kg, both <3rd percentile. Development was appropriate for age. A Bacillus Calmette-Guérin (BCG) scar was present, and there was no family history of TB.

She was febrile at admission (102°F). Respiratory system examination revealed a respiratory rate of 38 CPM, normal vesicular breath sounds with reduced air entry, and coarse crepitations heard at the right infrascapular, infra-axillary, and inframammary areas.

Baseline investigations reported raised inflammatory markers: C-reactive protein (CRP) (97.84 mg/L) and erythrocyte sedimentation rate (ESR) (38 mm/hour). Complete blood count indicated iron deficiency anemia. Consolidation was evident in the right lower zone on the chest X-ray, leading to a diagnosis of right lower lobe pneumonia (Fig. 1). She was treated with IV antibiotics (ceftriaxone and gentamicin), and inflammatory markers repeated after the completion of the antibiotic course were normal. She was discharged after being afebrile for 5 days on IV antibiotics.

Fig. 1: Right homogeneous opacity in the lower zone of the right lung (indicated by arrows)

There was a recurrence of high-grade fever and cough within 1 week of discharge from the hospital. A chest X-ray revealed a solitary round cavitary area in the right lower zone of the lung (Fig. 2). Further evaluation was conducted as the high-spiking fever persisted while on IV antibiotics. Microbiological testing for PTB (fasting gastric aspirate and GeneXpert for acid-fast bacilli) was negative, and the tuberculin test showed no induration at 48 hours. There was no contact with an active case of PTB. High-resolution computerized tomography (HRCT) of the thorax revealed a well-defined thin-walled fibro-cavity with a few thin incomplete septations measuring approximately 2.8 × 3.5 × 2.5 cm, along with adjacent areas of fibro-atelectasis and ground-glass attenuation in the posterior-basal segment of the right lower lobe (Fig. 3). Cavitating lesions postbacterial pneumonia due to common organisms are rare, leading to the consideration of PTB. Subsequently, the patient was treated with ATT. The initial intensive phase lasted 2 months and included HRZE (isoniazid, rifampicin, pyrazinamide, and ethambutol), intramuscular streptomycin (once per day for 30 days), and ciprofloxacin. After completing the intensive phase, pyrazinamide was discontinued, and the continuation phase included HR (isoniazid, rifampicin) for 10 months, ethambutol (intensive phase: 2 months, continuation phase: 4 months), and ciprofloxacin (intensive phase: 2 months, continuation phase: 2 months). Ethambutol and ciprofloxacin were stopped as planned, and the patient is currently in the 6th month of therapy with HR (isoniazid and rifampicin) being continued. Drug compliance has been satisfactory. Strict compliance with medications was emphasized, with monthly follow-up visits for general physical assessment, weight checks, and monitoring of liver function tests (LFT). At her 6th-month follow-up, a repeat chest X-ray revealed no evidence of cavitation (Fig. 4). The clinical response was adequate, with symptom resolution and a weight gain of 315 gm/month over the past 6 months. Dietary modifications were discussed, and education on adherence to medications until treatment completion and the importance of follow-up visits was provided.

Fig. 2: A solitary round cavitary area in the lower zone of the right lung (indicated by arrows)

Fig. 3: HRCT thorax (coronal section) showing a well-defined thin-walled fibrocavity with a few thin incomplete septations within, measuring approximately 2.8 × 3.5 × 2.5 cm, with adjacent areas of fibro-atelectasis and ground-glass attenuation in the posterior-basal segment of the right lower lobe of the lung

Fig. 4: Resolution of cavitation in the lower zone of the right lung

DISCUSSION

PTB includes intrathoracic lymphadenopathy and parenchymal disease. In children, tubercular infection presents as a ”primary complex,” which includes the Ghon focus and hilar lymphadenopathy. In younger children, TB can progress rapidly, leading to tissue destruction and cavity formation, known as progressive primary TB.² Nonproductive cough, low fever, and weight loss are the most common clinical features of PTB in young children.³

Like adults, children are also prone to develop adult-type postprimary TB with the distribution of cavities in the upper lobe and apices of the lower lobes of the lung, which is rare in prepubescent children.⁴^,⁵ The incidence of cavitation on lung radiographs is between 5 and 16%, frequently missed on plain radiographs alone. Hence, a CT chest should be performed to demonstrate cavitation.⁵

In the present case report, HRCT of the thorax revealed a cavity in the right lower lobe of the lung.

Tubercular bacilli are paucibacillary in younger children, and because they cannot expectorate, it is challenging for microbiological diagnosis.⁶^,⁷ Since smear microscopy has lower sensitivity, negative results do not rule out TB.⁸ In this case report, the gastric aspirates for MTB and tuberculin test were negative. A clinical diagnosis of PTB was made, and ATT [intensive phase (2 months), continuation phase (10 months)] was started since the fever was remitting and HRCT of the thorax revealed a cavity. Injection streptomycin was added in the intensive phase, as the drug is bactericidal and has good penetration in the cavity. Since ATT medications need to be continued for a long duration and with the possibility of adverse effects, poor compliance could be the cause of treatment failure; hence, compliance with the medications is better when injections are part of the treatment schedule. Children with cavitary lesions require regular follow-up and nutritional support. If reactivation occurs, ATT must be restarted after complete reevaluation. After starting ATT, the response was evident with resolution of symptoms, satisfactory weight gain at follow-up, and radiological clearance of imaging.

CONCLUSION

PTB in a child is a clinical challenge as microbiological tests are often not positive. In this case report, the HRCT thorax showing the cavitating lesion was considered tubercular in nature due to weight loss, persistent high fever and cough, with microbiological tests being negative. The patient responded to ATT with resolving symptoms, radiological clearance of the cavity, and weight gain at follow-up.

Clinical Significance

Clinical symptoms, along with supporting evidence and response, were sufficient in this case report for managing cavitary PTB with negative microbiological testing.

ORCID

Pushpa Kini https://orcid.org/0000-0001-6186-0336

Manjunath Laxminarayana https://orcid.org/0009-0008-6770-085X

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