TB or Not TB

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Presentation Description

A case illustration showing how this uncommon Paediatric condition can present with features suggestive of Tuberculosis

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Presentation Transcript

TB or Not TB:

TB or Not TB Dr S Sen SpR North Western Deanery Dr F Child Consultant Respiratory Paediatrician RMCH

To be or not to be:

To be or not to be

Objectives:

Objectives Case Presentation Discussion Take home message

Case:

Case AS 12 years Asian Boy Presents in Sept 2008 Back after 3 weeks holiday in Pakistan Fever,Cough,Headache & Abdominal Pain Marked weight loss,myalgia & constipation

History:

History Previously fit and well No contact with TB but cousin recently treated for typhoid Middle of 3 children-All fit and well Immunizations up to date with BCG scar present

Clinical Examination:

Clinical Examination Febrile Pale but not jaundiced Cervical lymphadenopathy No hepatosplenomegaly

Investigations:

Investigations FBC including film & MP,U&Es,LFTs,Bone profile,CRP,ESR,culture Urine & Stool cultures Viral serology & PCRs Autoimmune screen Immunoglobulins,Lymphocyte subsets and Function

Investigations( Contd):

Investigations( Contd) Quantiferon and Mantoux Test negative Toxoplasma,Yersinia,Brucella,Bartonella serology negative Hepatitis and HIV screen negative

Imaging:

Imaging Chest X Ray

Ultrasound Abdomen:

Ultrasound Abdomen

USS Report:

USS Report Normal appearances of Liver, Gall bladder, Spleen & Pancreas Both kidneys contain multiple cysts. No hydronephrosis Right lower abdomen area with mass like appearance produced by lymph nodes matted together Overall dimensions 4.6 x 2.5 x 2.1 cms with the largest lymph node 3.1 x 1.3 cm

CT Scan Abdomen:

CT Scan Abdomen

CT scan report:

CT scan report Multiple simple cysts in both kidneys Right iliac fossa showed 3.4x 2.4 lymph node mass. Some nodes showed characteristic low density consistent with tuberculous infection Unfortunately due to their position and encasement of vessels they were not amenable to Percutaneous FNA or Biopsy

Open biopsy:

Open biopsy Histopathology report

Diagnosis:

Diagnosis Presumed diagnosis of Abdominal Tuberculosis Started on quadruple antitubercular therapy with Rifampicin,Pyrazinamide,Isoniazid and Ethanbutol

Progress:

Progress Seen in OPD 3 weeks later Still febrile with spikes of fever above 38 three times a day Loss of appetite & weakness Weight gain of 200gms Right supraclavicular lymphadenopathy Facial Rash

Admission:

Admission Admitted to ward for observation of Fever pattern, dietary assessment and further investigations Seen by Rheumatologist Possibility of autoimmune disease raised Battery of tests arranged Results all negative

Histopathology:

Histopathology Further histopathology report received confirming the diagnosis of Kikuchi’s disease

Kikuchi’s disease:

Kikuchi’s disease Kikuchi disease (KD) was reported for the first time in 1972 in Japan by Kikuchi and by Fujimoto and his colleagues. KD is an idiopathic, self-limited necrotizing lymphadenitis.

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