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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 38-40

Multiple tuberculoma and choroid tubercles in a child with miliary tuberculosis


Department of Pediatrics, MGM Hospital and Medical College, Navi Mumbai, Maharashtra, India

Date of Submission12-Nov-2019
Date of Decision12-Dec-2019
Date of Acceptance03-Jan-2020
Date of Web Publication06-Nov-2020

Correspondence Address:
Dr. N Revati
Department of Pediatrics, MGM Hospital and Medical College, Kamothe, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpai.jpai_17_20

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  Abstract 


Miliary tuberculosis (TB) is a pathological name describing millet seed-sized (1–2 mm) granulomas in the various organs affected by tubercle bacilli. Miliary TB has a spectrum of manifestations that still perplex the most erudite and experienced clinicians and is a diagnostic and therapeutic challenge. Despite effective therapy being available, mortality from this disease has remained high. In children with miliary TB, chills, night sweats, hemoptysis, and productive cough have been reported less frequently, whereas peripheral lymphadenopathy and hepatosplenomegaly are more common compared with adults. Hereby, we present a case report of multiple tuberculoma and choroid tubercles in a child with miliary TB.

Keywords: Choroid tubercles, miliary tuberculosis, tuberculoma


How to cite this article:
Sivakami A, Shah H, Revati N. Multiple tuberculoma and choroid tubercles in a child with miliary tuberculosis. J Pediatr Assoc India 2020;9:38-40

How to cite this URL:
Sivakami A, Shah H, Revati N. Multiple tuberculoma and choroid tubercles in a child with miliary tuberculosis. J Pediatr Assoc India [serial online] 2020 [cited 2020 Nov 25];9:38-40. Available from: http://www.indjpai.com/text.asp?2020/9/1/38/300100




  Introduction Top


Tuberculosis (TB) is a leading cause of preventable morbidity and mortality worldwide. The disease primarily involves the lungs, and at times, distant blood-borne spread results in the development of extrapulmonary TB (EPTB).[1],[2] Miliary TB is a pathological name describing millet seed-sized (1–2 mm) granulomas in the various organs affected by tubercle bacilli.[3] Miliary TB has a spectrum of manifestations that still perplex the most erudite and experienced clinicians and are a diagnostic and therapeutic challenge. Despite effective therapy being available, mortality from this disease has remained high. The myriad clinical manifestations, atypical radiographic findings, and difficulties in establishing TB as the etiological diagnosis are the challenges in the diagnosis and treatment of miliary TB.[4] In children with miliary TB, chills, night sweats, hemoptysis, and productive cough have been reported less frequently, whereas peripheral lymphadenopathy and hepatosplenomegaly are more common, compared with adults. A higher proportion of children with miliary TB (20%–40%) suffer from TBM67-71 compared with adults.[2],[5] Hereby, we present a case report of multiple tuberculoma and choroid tubercles in a child with miliary TB.


  Case Report Top


A 12-year-old female patient reported to the hospital outpatient department with a complaint of fever for 15 days. The fever was associated with decreased appetite, lethargy, headache, and retro-orbital pain. She did not have any a family history of Koch's or Koch's contact. On examination, she was observed to have pallor, neck rigidity, and brisk reflexes. On fundus examination, bilateral choroid tubercles were noted [Figure 1].
Figure 1: Patient's fundus examination

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Chest X-ray showed bilateral rice grain shadows suggestive of miliary TB [Figure 2]. Computed tomography scan was performed to confirm the diagnosis of miliary TB. Magnetic resonance imaging of the brain was performed which showed multiple subcentimeter ring-enhancing lesion (>40) in the cerebrum, cerebellar peduncles, and brain stem [Figure 3]. CBNAAT sputum, MT, CBC, and erythrocyte sedimentation rate (ESR) were normal.
Figure 2: Chest X-ray of patient

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Figure 3: Patient's magnetic resonance imaging of the brain

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Treatment prescribed to patient

Child was given injection mannitol as antiedema measures and injection dexamethasone was as anti-inflammatory measures. According to the national guidelines, child was given CAT 1 – AKT (2 hZE + 4hE) antitubercular medicines.

Child was on regular follow-up: Intensive phase complete (uneventful) now on continuation phase.


  Discussion Top


Central nervous system TB is a serious form of TB due to the hematogenous spread of mycobacterium. Intracranial tuberculomas are the least common and rare form of EPTB. Miliary TB with choroid tubercles and multiple tuberculomas are extremely rare. Annamalai and Biswas reported a case of a solitary large active choroidal tuberculoma in one eye and multiple healed tubercles in the other. The patient was an immunocompetent girl with splenic and miliary TB and had a relatively asymptomatic systemic status. Aqueous humor analysis by the polymerase chain reaction (PCR) and real-time PCR was negative for the Mycobacterium tuberculosis genome. Based on the clinical history and investigations, treatment with four-drug regimen of anti-tubercular treatment with concomitant corticosteroids was started, and total healing of the lesion occurred in 3 months.[6],[7]

Shaaban reported a case of pediatric miliary TB in a 7-year-old female presented with fever associated with sweating, decreased appetite, and weight loss. Clinical examination showed hepatospenomegaly and pelviabdominal mass. Laboratory studies revealed anemia and elevated ESR for differential diagnosis. Malignancy was suspected, and a panel of radiological scans and histopathological study were done to investigate the mass and to search for other masses elsewhere. The bone marrow and the pelviabdominal mass biopsies were done, and showed normal bone marrow while the mass appeared to be TB granuloma. Tuberculin test, gastric lavage for Ziehl–Neelsen stain study for acid-fast bacilli, and PCR test for mycobacterium TB DNA in blood were negative. The ophthalmological screening before commencing anti-TB regimen revealed fundus with bilateral small, white subretinal opacities with the classical appearance of choroidal tubercles. The final diagnosis of miliary TB was made, and the patient subsequently started her anti-TB therapy in the chest hospital. Kumar et al. reported a case of bilateral multiple choroidal granulomas with systemic vasculitis-like features and disseminated TB in an immunocompetent patient without pulmonary involvement. A 26-year-old male Indian patient presented with bilateral blurred vision and systemic illness with vasculitis-like features. Examination revealed bilateral multiple choroidal granulomas and multisystem involvement without pulmonary involvement. Aqueous tap was positive for mycobacterium by PCR along with tissue biopsy leading to the diagnosis. There was a good systemic and ocular response to anti-tubercular therapy with the resolution of lesions. Their case emphasizes that, although uncommon, TB can involve multiple organs without pulmonary involvement and may mimic systemic vasculitis, it is not mandatory to have pulmonary findings for a confirmation of TB. Timely diagnosis with appropriate treatment can improve systemic and ocular disease.[8],[9]

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Declaration of patient consent

The authors certify that they had obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sachdeva D, Bishnoi I, Jagetia A, Rathore L, Agarwal A, Batra V,et al. Intraventricular tuberculoma in a child: A rare location. Pediatr Neurosurg 2017;52:93-7.  Back to cited text no. 1
    
2.
Sharma SK, Mohan A, Sharma A, Mitra DK. Miliary tuberculosis: New insights into an old disease. Lancet Infect Dis 2005;5:415-30.  Back to cited text no. 2
    
3.
Jabbour NM, Faris B, Trempe CL. A case of pulmonary tuberculosis presenting with a choroidal tuberculoma. Ophthalmology 1985;92:834-7.  Back to cited text no. 3
    
4.
Sahn SA, Neff TA. Miliary tuberculosis. Am J Med 1974;56:494-505.  Back to cited text no. 4
    
5.
Sharma SK, Mohan A. Miliary tuberculosis. In: Schlossberg D, editor. Tuberculosis and Nontuberculous Mycobacterial Infections. 6th ed. Washington: American Society for Microbiology Press; 2011. p. 415-35.  Back to cited text no. 5
    
6.
Hosoglu S, Geyik MF, Balik I, Aygen B, Erol S, Aygencel TG,et al. Predictors of outcome in patients with tuberculous meningitis. Int J Tuberc Lung Dis 2002;6:64-70.  Back to cited text no. 6
    
7.
Annamalai R, Biswas J. Bilateral choroidal tuberculoma in miliary tuberculosis Report of a case. J Ophthalmic Inflamm Infect. 2015;5:4.  Back to cited text no. 7
    
8.
Shaaban HA. Miliary TB with pelvic mass and choroidal tubercles in a child: Case report. Egypt Pediatr Assoc Gazette 2018;66:81-3.  Back to cited text no. 8
    
9.
Kumar N, Sudharshan S, Ganesh SK, Lingam G, Biswas J. Bilateral multiple choroidal granulomas and systemic vasculitis as presenting features of tuberculosis in an immunocompetent patient. J Ophthalmic Inflamm Infect 2016;6:40.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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