7/M, A case of late-diagnosed Mycobacteria tuberculosis due to combined infection with Mycoplasma pneumoniae / fever(onset: 6 days ago), intermittent right chest pain (onset: 20 days ago)
Chief
complaint
or Title
A case of late-diagnosed Mycobacteria tuberculosis due to combined infection with Mycoplasma pneumoniae / fever(onset: 6 days ago), intermittent right chest pain (onset: 20 days ago)
Department of Pediatrics, Ajou University School of Medicine
* History
Date of Admission; 2001.2.10 Present illness; A 7 year-old previously healthy boy was admitted to our hospital via emergency room because of fever and intermittent right chest pain. Because of fever and chest pain he took a chest radiograph in a private clinic. The chest radiograph revealed pleural effusion, and he was transferred to out hospital for the diagnosis and management. Past history : He was born by NSVD at IUP 40 wks and birth weight was 3.60kg. He completed vaccines as routine vaccination schedule including BCG. Family history : He was born as a second baby of two siblings. There were no medical histories of cardiovascular, autoimmune, or pulmonary disease in his family.
* R.O.S.& P/Ex
Review of system : general malaise(-), chronic fatigue(-), weight loss(-), fever/chilling(+/-), respiratory distress on walking(+), right chest pain(+), cough/sputum/rhinorrhea(±/-/-), nausea/vomiting/diarrhea(-/-/-) Physical examination : Vital sign : blood pressure: 100/60mmHg, pulse rate: 98/min, respiratory rate: 22/min, body temperature: 36.8?. He was alert and not so ill looking. No chest retraction was found, but breath sound was decreased without rale or wheezing on right lung field. There was no digital clubbing nor cyanosis
* Lab
1) Hematologic values
first hospital day
third hospital day
eight hospital day
discharge day
10days after discharge
15months after discharge
hemoglobin(g/dL)
11.0
10.4
9.9
11.6
11.3
11.9
white-cell count(/mm3)
7,700
5,300
5,400
8,600
6,800
11,290
band forms
neutrophils
60.9%
48.1%
60.7%
71.0%
41.1%
63.8%
lymphocytes
24.7%
38.8%
26.1%
23.9%
43.4%
29.7%
monocytes
13.2%
11.2%
10.7%
4.6%
10.5%
3.5%
platelet count(/mm3)
334x103
333x103
438x103
659x103
384x103
395x103
ESR(mm/hr>
64
63
100
48
42
22
CRP(mg/dL)
5.0
7.3
11.7
<0.4
2) Biochemical findings AST 32 U/L, ALT 15 U/L, Ca 9.4 mg/dL, P 4.2 mg/dL, BUN 12.4mg/dL, Cr 0.5 mg/dL, LDH 329 U/L, total protein 7.0 g/dL, albumin 3.9 g/dL, Na 136 mmol/L, K 3.8 mmol/L, Cl 100 mmol/L
3) Mycoplasma antibody titer On admission : =1:1280 12th hospital day : 1:640 6 weeks after intial examination : 1:320 15 months after initial examination : 1:640
4) Mantoux tuberculin skin test on admission : negative 12 month after discharge : 20 mm of induration
5) pleural fluid evaluation
1st hospital day
3rd hospital day
appearance
yellow and hazy
reddish and cloudy
pH
7.299
7.326
S.G.
>1.040
1.035
protein(mg/dL)
5600
4700
PF : serum ratio
0.8
0.77
g1ucose(mg/dL)
95
101
LDH (U/L)
1200
750
PF : serum ratio
3.65
2.54
ADA (U/L)
143.8
108.1
red-cell count(/uL)
5250
3360
white-cell count(/uL)
7250
210
neutrophils
38%
6%
lymphocytes
49%
89%
monocytes
13%
3%
atypical lymphocytes
2%
Gram stain: (-) (first hospital day) ? (-) (third hospital day) bacterial culture : no growth (first hospital day) ? no growth (third hospital day) AFB stain: (-) (first hospital day) ? (-) (third hospital day) Culture for M. tuberculosis complex * no growth after 8 wks (specimen from first hospital day) * Mycobacterium tuberculosis complex 10 CFU/medium (specimen from third hospital day, but we could not confirm this till 1 year after the result because the patient did not visit hospital for 1 year)
* Clinical Course
On the 1st hospital day, body temperature was over 38?. Initially he was treated with intravenous antibiotics (ampicillin/sulbactam, ceftriaxone), oral antibiotics (roxithromycin). The chest radiographs showed massive pleural effusion in the right lung and collapse of right middle lobe (Fig.1). Diagnostic thoracentesis was done and the data from pleural fluid examination was described as above. A closed chest tube thoracostomy was performed which yielded large amount of yellowish and hazy fluid. On the 5th hospital day, the closed chest tube was removed because there was no drainage of pleural fluid collection. Mycoplasmal antibody titer was =1:1280, which was positive. The patient gradually recovered with oral roxithromycin without progression of pleural fluid collection. On the 10th hospital day, fever subsided. On the 12th hospital day, the intravenous dexamethasone was started because the chest radiographs showed remained pleural effusion and adhesive pleural thickening and the chest ultrasonogram revealed complicated pleural effusion which had adhesive irregular pleural surface. On 7th hospital day, the chest radiograph showed the remarkable improvement of pleural effusion and nearly clear lung. He was discharged with roxithromycin at the 18th hospital day(Fig. 2).
After discharge, the pleural thickening was remained, but the patient stop to visit hospital for a ling time without confirm the complete resolution of the chest radiograph. During 12 month after discharge, he has experienced 2 episodes of skin infection on the right chest wall, but the lesions were healed spontaneously. On the day of visit with 3rd skin infection, we found the skin lesion was related with previous chest tube insertion and on the same day we could confirm the positive culture data from the specimen yield on 3rd hospital day. And the follow up chest radiograph showed residual pleural thickening and newly developed parenchymal consolidation on the pleural side of right mid-lung field(Fig.3). At the time he took the Mantoux tuberculin skin test again. The test conversed to positive while the first test had shown negative on the admission (12 month ago). According to the previous culture result( Mycobacterium tuberculosis complex (10 CFU/medium, isolated from his pleural fluid which was yielded at 3rd hospital day, 12 month ago), oral anti-TB therapy was started. After 12 months' chemotherapy (2 months of INH, RIF, PZA/10 month with INH and RIF), the chest radiograph showed marked improvement and the skin lesion was healed completely after 2 month of anti-TB medication.
* If you click the image you able to see original
image
Figure 1. Initial chest radiographs
Figure 1. Initial chest radiographs
Figure 2. Chest radiographs on discharge
Figure 3. Chest radiograph at12month after discharge(no anti-TB medication)
Figure 4. Chest radiograph after 10 months of anti-TB medication
Discussion Discussion points for differential diagnosis of pleural effusion due to M. tuberculosis and M. pneumoniae in this case.
Question 1. Can we suspect M. tuberculosis infection in this case from clinical manifestation and initial laboratory findings ?
Family history of tuberculosis : no Clinical manifestation : non specific PPD skin test : negative Chest radiograph : unilateral massive pleural effusion with shifting Mycoplasmal antibody : 1:1280 on admission day PCR for M. tuberculosis : not done Pleural fluid examination :
case patient
reference patient
appearance
yellow and hazy
yellow and hazy
pH
7.299
7.139
S.G.
>1.040
>1.040
protein (mg/dL)
5600
5400
PF : serum ratio
0.8
0.77
g1ucose (mg/dL)
95
26
LDH (U/L)
1200
848
PF : serum ratio
3.65
3.39
ADA (U/L)
143.8
133.9
red-cell count(/uL)
5250
2950
white-cell count(/uL)
7250
2240
neutrophils
38%
3
lymphocytes
49%
80
monocytes
13%
14
atypical lymphocytes
3
Question 2. Are there any specific clinical manifestations which are favorable to the diagnosis of Mycobacterium tuberculosis ?
Chronically ill looking : no Weight loss : no More severe respiratory symptoms : not specific Long lasting fever : no
Question 3. Are there any clues in personal or familial histories ?
BCG vaccination : done Family history of pulmonary tuberculosis : no History of immunodeficiency : no Poor socioeconomic state : yes
Question 4. Is there any special finding of chest X-ray ?
Unilateral pleural effusion with shifting : non specific for any kinds of pleural effusion Incomplete resolution of chest X-ray : it may suspect that antibiotic therapy is not proper in this case, however, many cases of mycoplasmal pneumonia would show radiological abnormalities more than 4 weeks after initial proper management.
Question 5. Are there any solid parameters for initial diagnosis of Mycobacterium tuberculosis before culture proof ?
It is not always clear, however, several clinical and laboratory tests could be the indicative parameters which suggest Mycobacterium tuberculosis infection :
1. Family history of tuberculosis. 2. Contact history with tuberculosis patient. 3. Positive skin test for PPD. 4. Clinical symptoms and radiographic findings resist on going antibiotic therapy. 5. Positive result of PCR for Mycobacterium tuberculosis. 6. Positive AFB staining from pleural fluid or biopsy specimen. 7. Typical features of pleural fluid examination 8. Positive culture for Mycobacterium tuberculsosis (however, the confirmation of result needs more than 4-6 weeks after inoculation)
Cf. Comparison of initial pleural fluid examination in 4 cases of culture-proven tuberculosis combined with mycoplsmal infection diagnosed by anti-mycoplasmal antibody titer.
case
sex/age
FHx
mycoplasmal Ab
ADA
WBC
neut
lym
mono
LDH
UKS
M, 15
-
1:160
53.2
320
50
45
5
1786
SWD
M, 4
+
1:640
133.9
2240
3
80
14
848
PJM
M, 6
-
1:1280
143.8
7250
38
49
13
1200
PJW
M, 14
+
1:640
74.6
210
6
89
3
790
Question 6. Is there any problem with the delayed initial anti-TB medication ?
Question 7. Dose a mycoplasmal infection decrease host cellular immunity and could it possible that coincidental mycoplasmal infection induce the reactivation of tuberculosis, or increase the susceptibility to mycobacterial infection ?
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