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Mediastinal mass in an infant: A rare presentation of extrapulmonary tuberculosis
R Radhika1, M S Tullu, O Shamla
1Department of Pediatrics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, Maharashtra, India.
Insights
Mediastinal tuberculosis is a rare cause of masses in children, often linked to immunodeficiency. This case highlights a pre-extensively drug-resistant tuberculosis infection in an infant, leading to a fatal outcome despite treatment.
Area of Science:
- Pediatrics
- Infectious Diseases
- Pulmonology
Background:
- Mediastinal tuberculosis is an uncommon cause of mediastinal masses in pediatric populations.
- Limited data exists on the prevalence, clinical presentation, and outcomes of mediastinal tuberculosis in children.
- Immunodeficiency may be associated with mediastinal tuberculosis, but it can also occur in immunocompetent children.
Purpose of the Study:
- To report a rare case of pre-extensively drug-resistant (pre-XDR) tuberculosis presenting as a mediastinal abscess in a young infant.
- To highlight the diagnostic challenges and treatment complexities of pediatric mediastinal tuberculosis.
- To underscore the potential complications and poor prognosis associated with severe pediatric tuberculosis.
Main Methods:
- Case report of a 4.5-month-old infant with respiratory distress and a mediastinal abscess.
- Diagnostic workup included chest radiography, computed tomography (CT) scan, and GeneXpert testing of abscess aspirate.
- Treatment involved a modified antitubercular regimen for pre-extensively drug-resistant tuberculosis and supportive care in the pediatric intensive care unit (PICU).
Main Results:
- GeneXpert confirmed Mycobacterium tuberculosis in the abscess aspirate, identified as pre-extensively drug-resistant (pre-XDR) tuberculosis.
- The infant required mechanical ventilation for 15 days and showed initial clinical and radiological improvement.
- Despite treatment, the patient developed linezolid-induced lactic acidosis, measles, and ultimately succumbed to measles-related pneumonia.
Conclusions:
- Mediastinal tuberculosis, even in pre-XDR forms, presents a significant diagnostic and therapeutic challenge in infants.
- Aggressive management and close monitoring for treatment complications are crucial in pediatric tuberculosis cases.
- This case underscores the critical need for increased awareness and research into pediatric mediastinal tuberculosis and its outcomes.
Abstract:
Tuberculosis as cause of mediastinal mass, is rare in children, and may be seen in immunodeficiencies. Data on the prevalence of mediastinal tuberculosis and on its clinical spectrum and outcome is lacking in children. A 4.5-month-old boy presented with fever and cough since 7 days and increased respiratory activity. He had respiratory distress with hypoxia. Examination revealed decreased breath sounds on the right lung with tracheal shift to the left. Chest radiograph showed homogenous opacity in the right upper zone, with heterogenous opacity in the right middle and lower zones and tracheal shift to left. Computed tomography scan confirmed the presence of mediastinal abscess. Human immunodeficiency virus status of patient's mother and primary immunodeficiency workup of the child were negative. In view of clinical deterioration and non-responsiveness to 10 days of intravenous antibiotics, tuberculosis workup was done. GeneXpert of the abscess aspirate showed Mycobacterium tuberculosis (rifampicin resistant). Patient was labeled as pre-XDR tuberculosis based on the line probe assay. Antitubercular regimen was modified accordingly (linezolid, amikacin, cycloserine, clofazimine, and ethionamide). The child required invasive mechanical ventilation in pediatric intensive care unit (PICU) for 15 days. The patient showed clinical and radiological improvement and was discharged after 6 weeks of inpatient stay. However, the patient was readmitted 16 days later with linezolid-induced lactic acidosis, developed measles, and succumbed to measles complication (pneumonia).
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