MY PEDIATRIC CASE

By Dr.Sally Zeinatie















This case was followed by me during internship in the pediatric ward.His CVS went unnoticed till discharge date,while filling the discharge summary I noticed CVS was unexamined,to find later the congenital anomalies he had.Suspecion of T.B was put forward by me to my seniors but unfortunately Mantoux mislead everyone.Still I felt T.B is there somewhere in a hidden form,and suggested CT chest.I noticed the kyphosis which lead me to suggest CT Spine,which then lead to the suggestion of MRI Spine.With the help of these investigations my diagnosis was confirmed.It is a very interesting case,therefore liked sharing it with you.


9 YRS OLD
PAKISTANI
Admitted on 07/05/06

Known case of DOWN’S SYNDROME

Mild to moderate grade fever,
Associated with sweating
At night time ONLY
Accompanied with weight loss
For one month

Negative history:
No Hx of URTI,
No change of bowel habits,
No urinary symptoms,
No Joint pain,
No skin rash,
NO HX OF RECENT TRAVEL TO PAKISTAN

Past Medical:
K/C of DOWN’S SYNDROME
Past Surgical:
Not significant
Medications:
Not on any medications
Family Hx:
No one in the family has down’s syndrome,T.B, or malignancies
Birth Hx:
Normal vaginal delivery,
Preterm at 7 months,
Developmental Hx:
Speech delay,
Cannot say anything.
Diet Hx:
Normal solid diet
Immunization up to date

O/E:
Pale
Not in respiratory distress
Well hydrated
Afebrile
Multiple post cervical lymphadenopathy
BP:120/85
Pulse:77/min

Chest:decreased air entry on right side,right mid zone.
CVS:S1+S2+early diastolic murmur with fixed splitting of S2
CNS:intact,alert,no meningeal signs
Abdomen:soft,non tender,hepatomegaly 2cm below costal margin.
ENT:normal

D/D:
TUBERCULOSIS
MALIGNANCY
BRUCELLA
EBV
AUTOIMMUNE

INVESTIGATIONS:
CBC:
Hb 10.7
WBC 16
Platelets 550
Neutrophils 65
Glucose 4.9
CRP 161
ESR 72
U/E Normal
LFT Normal
Mantoux test negative
Brucella negative
EBV IGM negative
ANA negative
Mycoplasma negative
Urine culture :No growth
Blood film Normal

On 09/05/06 ECHO was done
Small PDA with left to right shunt
Possible ASD secundum
Bicuspid Aortic valve with raphae
Mild mitral valve prolapse
Good LV function

Was discharged on 09/05/06
With the impression of
Pneumonia
Was given KLACID 150mg BD

Was seen in clinic on 16/05/06
Repeated CBC:
Hb 10.4
WBC 12.4
ESR 58
CRP 125
Mantoux test Negative

Was seen in clinic on 27/05/06
C/O: Running low grade fever on&off
CBC:
Hb 11.1
WBC 18.8
ESR 42
CRP 129

Was admitted:
to repeat
CBC,ESR,CRP,U/E,LFT,
Blood culture,brucella,
ECHO to R/O endocarditis,
Mantoux test
Readmitted on 27/05/06

D/D:
TB
Malignancy
Endocarditis

3 Blood culture taken at spike of fever at 10pm
Showed NO growth

CBC:
Hb 10.6
WBC 21.2
PCV 501
Glucose 4.4
U/E Normal
CRP 161
ESR 55
Urine culture:NO growth

ECHO done on 28/05/06
No vegetations seen in LV,mitral valve,or aortic valves
Normal pulmonary valves
No pericardial effusion
Normal LV function
Normal aortic arch
Conclusion: NO evidence of endocarditis

Repeat
Mantoux test
CT chest
To consider
Bone marrow examination & culture

CXR
Showed pulmonary infiltration with cavity formation.



CT Chest
Multiple bilateral confluent opacities are seen extending in both the upper lobes &right lobe,
Showing air bronchogram as well as reticulonodular infiltrates.
No hilar or mediastinal lymphadenopathies,
No pleural masses or collections are seen.




D8+D9 vertebral body partial collapse.




CT SPINE



Kyphus deformity at D8+D9 with destruction of opposing articular surface




Opposing subarticular osteosclerosis



Soft tissue,
pravertebral collection
with marginal calcification
is seen abutting D8+D9 vertebrae



Conclusion
D8+D9 vertebrae collapse
Discal destruction
With paravertebral collection
Multiple bilateral pulmonary opacities
Suggestive of long standing infectious spondolytis
Probably of Tuberculous etiology with Pulmonary T.B




MRI of DORSO-LUMBAR SPINE
Spondylodistal erosive process is seen involving D8 & D9 & intervening disc space.
D9 vertebra showed anterior wedging.
Vertebral body, its posterior neural arches are seen to be involved.
D8 & D9 disc space is almost obliterated.



Pre & paraspinal multinoculated cystic component is seen.
Anterior epidural intraspinal component is also noted mildly impressing on the cord at this level.
Another enhancing component is seen posterior epidurally opposite D7 down to D9 levels not causing any cord compression.



Conclusion
Spondylo-discal inflammatory erosive process of D8 & D9 & its intervening disc with pre & para & intraspinal cystic component.



The picture is most likely representing POTT’S disease

DIAGNOSIS:
PULMONARY TUBERCULOSIS
WITH POTT’S DISEASE

ON 07/06/06 MANTOUX TEST REPEATED WAS POSITIVE upto 20mm

STARTED & DISCHARGED ON:
STREPTOMYCIN 500mg OD
ISONIAZIDE 200mg OD
RIFAMPICIN 300mg OD
PYRAZINAMIDE 500mg OD
MULTIVITAMIN 5ml OD

POTT’S DISEASE

Pott's disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints.
More precisely it is called tuberculous spondyloarthropathy and the original name was formed after Percivall Pott (1714-1788), a London surgeon.
It is most commonly localized in the thoracic portion of the spine. The fictional (hunch back of notre dame) had a gibbous deformity
humpback
that is thought to have been caused by tuberculosis

SIGNS & SYMPTOMS
back pain
fever
night sweating
anorexia
weight loss
Spinal mass, sometimes associated with numbness, tingling or muscle weakness
of the legs

DIAGNOSIS
blood tests - elevated blood sedimentation rate
tuberculin skin test
radiographs of the spine
bone scan
CT of the spine
bone biopsy

LATE COMPLICATIONS
Vertebral collapse resulting in kyphosis
Spinal cord compression
sinus formation
paraplegia
(so called Pott's paraplegia)

MANAGEMENT

non-operative - antituberculous drugs
analgesics
immobilization of the spine region
Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine

PREVENTION
Controlling the spread of tuberculosis infection can prevent tuberculous spondylitis and arthritis.
Patients who have a positive PPD test (but not active tuberculosis) may decrease their risk by properly taking medicines to prevent tuberculosis.
To effectively treat tuberculosis, it is crucial that patients take their medications exactly as prescribed.