The 2nd patient is a boy of 2 years and 1 month old, who was referred by the local health center to rule out neoplastic process for presenting a lytic lesion in the epiphysis of left distal femur. His vaccination scheme was completed except the 3rd dose of rotavirus vaccine. The BCG immunization antecedent was recorded at birth, in July 2015. He had a history of low extremity trauma due to a fall from the bed of approximately 50 cm that provoked contusion in the left lower limb with increase in volume, limitation of gait and pain predominantly at the level of the left knee.
He was 1st admitted in the Emergency Service of National Institute of Pediatrics (INP- Spanish acronym) in regular general conditions but with an increased volume of the medial anterior face of the left knee, manifesting pain of mild intensity on flexion extension of the knee, claudication of gait (walking impai,rment) and pain on bipedal. On admission, reported 12 g/dL of hemoglobin, 37.9% of hematocrit, 6.6 (103/mm3) of leucocytes, 2.5 (103/mm3) of neutrophils, 3 (103/mm3) of lymphocytes, and 465 (103/mm3) of platelets. He was subjected to oncological evaluation by the Service of Oncology who ruled out neoplastic processes based on incompatible radiological data. Probable infectious osteomyelitis was suspected and in view of that, empirical treatment based on 200 mg/kg/day of dicloxacillin was started. The patient was later sent to the ward of Pediatric infectious Diseases to continue his treatment procedure. The X-ray of the left low limb depicted a large lytic lesion, compromising the internal condyle of the distal epiphysis of the left femur, with conserved cortical edges in the border of the lesion (Fig. 4). The MRI showed data suggestive of chronic osteomyelitis; hence, bone surgery and curettage were performed and subsequently, graft placement with bioactive bone was undertaken. During the trans-surgical scan, bone tissue biopsy was obtained which reported chronic granulomatous arthritis with caseous necrosis, histopathological data suggestive of M tuberculosis. The staining and polymerase chain reaction of the positive sample for M tuberculosis are reported. On suspecting osteitis secondary to Tuberculosis, it was decided to start a comprehensive approach or procedure based on the following: lumbar radiography without apparent alterations; lung radiography with the presence of 2 bilateral radiopaque lesions in pulmonary hila, suggestive of calcified nodule without another apparent alteration of the pulmonary parenchyma (Fig. 5); the parent's radiographies were normal; high resolution computed tomography (CT) of lung of the patient with report of left perihilar ganglionic growth of 13 to 8 mm and presence of a 2 mm nodular lesion on the left lower lobe at the basal level, suggestive of calcified granuloma. Antituberculous treatment based on isoniazid, 10 mg/kg/day; rifampicin, 15 mg/kg/day; pyrazinamide, 25 mg/kg/day and ethambutol, 27 mg/kg/day was started. When M bovis was typified, clarithromycin at 15 mg/kg/day was added in the treatment scheme. Presently, the evolution of the patient is favorable. He is still subjected to procedures to rule out primary immunodeficiency with report of nitroblue tetrazolium negative for chronic granulomatous disease.
High resolution computed tomography (CT) of left parahilar ganglionic growth of 13 to 8 mm and the presence of a 2 mm nodular lesion located in the left lower lobe at the basal level suggestive of calcified granuloma. CT = computed tomography.