An otherwise well 11-year old girl presented with a 3-day history of chest pain and cough. The girl had been given clarithromycin 2 months earlier for cough and fever under the presumptive diagnosis of lower respiratory system infection. Chest X-ray revealed a cavitary lesion at the left lower lobe, and smaller lesions at the middle and upper lobes bilaterally (Fig. 1a). High resolution computed tomography (HRCT) confirmed the presence of multiple cavities which were located at the left upper lobe and at the superior segment of the collapsed left lower lobe, calcified subcarinal and hilar lymphnodes, and bilateral nodular non-cavitary parenchymal disease at the upper lobes (Fig. 1b and c). Mantoux tuberculin skin test showed an induration of 30 x 30 mm and interferon gamma release assay (IGRA, Quantiferon-TB, Cellestis) test was positive. No BCG vaccination was recorded and no BCG scar was evident. Sputum smear for acid fast bacilli stained positive, and PCR, culture of sputum and gastric aspirate all grew M. tuberculosis. Sensitivity to isoniazid, rifampin, streptomycin and ethambutol was shown by the BACTEC MGIT 960 SIRE test (Becton, Dickinson and Company, USA) and no mutation indicating resistance to antituberculous drugs was detected by Genotype MTBDR plus and MTBDRsl test (Hain, Germany) based on DNA-STRIP technology. Serology for HIV was negative and immunology work-up was normal. Isoniazid, rifampin, pyrazinamide and ethambutol were given for 2 months, followed by isoniazid and rifampin for 4 more months. Methylprednisolone was given for the first 3 weeks. Sputum staining was negative after 3 weeks of treatment. The girl had not attended school for the past 6 months for social reasons and was the second of three children of a family of Bulgarian origin. Positive family history or recent contact with tuberculosis was not reported. Following contact investigation, all family members were given chemoprophylaxis for positive tuberculin skin test and IGRA assay, but normal chest X-ray.
An 8-year old boy with B-cell acute lymphoblastic leukaemia, presented with fever, cough and respiratory distress while on maintenance chemotherapy. Chest radiographs suggested prominent hilums and a cavitary lesion at the left lower lung field (Fig. 2), while HRCT showed enlargement of paratracheal, hilar and mediastinal lymphnodes, consolidation at the lingula containing a small cavity and multiple pulmonary nodular lesions at the superior segment of the left lower lobe, the lateral segment of the right middle lobe and the posterior segment of the right lower lobe. There was no evidence of significant tracheal compression. Mantoux tuberculin skin test was negative, whereas IGRA test was positive. Gastric lavage grew M. tuberculosis which was susceptible to all drugs. The boy was successfully treated with isoniazid, rifampin, pyrazinamide and ethambutol for a total of 18 months (for isoniazid and rifampin) and methylprednisolone for 8 weeks. Outcome was uneventful over a 4-year follow-up period. CD4:CD8 ratio was 0.3 and remained low for a long period. The child originated from Albania and occasionally made visits to relatives there. He was not vaccinated with BCG. The source of infection was not identified, despite an investigation which included family and contacts as well as school mates and staff (34 individuals). A school teacher had recently received chemoprophylaxis, but did not have cavitary lesions. All children at school had already received BCG according to the Greek national immunisation programme. Chemoprophylaxis was given to three of them who presented with positive Mantoux test and positive IGRA assay, normal chest x-ray and normal first-line investigation results.