A five-year-old developmentally normal boy was hospitalized with fever on and off for more than three months. Fever was found to be high-grade and was associated with painless and clear discharge from both ears. There had been discharge offrank pus from his right ear with pain and impaired hearing in the week before hospitalization. He had received both oral and topical medications (comprising fluoroquinolones and aminoglycosides) for his ailment from several practitioners without any respite to his symptoms. He had been immunized appropriately.
On examination, he was found to be febrile, toxic, and undernourished with wasting. His submandibular, cervical, and axillary lymphnodes were found to be significantly enlarged bilaterally. His left upper deep cervical lymph nodes were found to be matted. There were multiple healed perforations in both tympanic membranes with granulation tissue, furuncle, and pus discharge from his right ear. The pus was swabbed and sent for microbiological examination. A fine needle aspiration cytology of the left upper deep cervical node revealed caseating granulomas suggestive of tuberculosis. A chest X-ray which was obtained showed miliary mottling [Figure 1]. Tuberculin test elicited no response, and HIV I and II ELISA were also found to be negative. The history had to be reviewed again for possible contact with a known tuberculosis case but was found to be negative.
As the child was toxic with high-grade fever and chills, a complete blood count was ordered which showed neutrophilic leukocytosis. The ear swab culture grew S.aureus and smear for acid-fast bacillus (AFB) and culture was reported to be negative (probably because the child had been on aminoglycoside ear drops for variable periods before presentation). The child was treated with appropriate antistaphylococcal antibiotic based on culture and sensitivity of the organism. In view of the chronic symptoms, chronic and painless clear aural discharge initially and miliary mottling on chest X-ray, a diagnosis of miliary tuberculosis with otitis media was made and antitubercular therapy (ATT) had to be added to his treatment. With the above treatment, fever and earache subsided, and pus discharge reduced from his right ear. However, he continued to have clear discharge from both ears for which he required frequent toileting. He was discharged after two weeks of hospitalization on ATT. On follow-up at four weeks, he continued to be afebrile, gained weight, his ear discharge reduced considerably, and his lymph nodes regressed in size. Hearing assessment was not done as he reported a subjective improvement in hearing.