Drug-resistant Disseminated Tuberculosis in Children : A Case Report

Abstract

Drug-resistant Disseminated Tuberculosis in Children : A  Case Report

Uraiwan          Tarunotai                      MD*

Manutham      Manavathongchai      MD*

*Department of Pediatrics, BMA Medical College and Vajira Hospital

A 12-year-old Thai girl had low grade fever for 2 months. During the second month, the developed dry cough, redness of cheeks, alopecia and weigh loss.  The initial diagnosis was fever of unknown origin (FUO). The laboratory finding revealed E.  coli bacteremia without underlying immunologic disorder.  She was treated with ceftazidime and amikacin till the culture turned negative.  She did not improve, still had fever and headache. Further investigations were performed such as chest radiograph, ultrasound of abdomen, CT scan of brain, bronchoalveloar lavage for AFB stain/culture and CSE AFB stain/ culture/PCR.  The results showed that she developed enterococcal meningitis and disseminated TB (military TB with TB meningitis and splenic abscess). She was treated with vancomycin and DOTS regimen (INH, rifampicin, pyrazinamide and ethambutol) with dexamethasone and lumbar puncture for releasing the brain pressure.  She still had fever and headache and 2 months later the BAL culture showed M. tuberculosis which resisted to INH, streptomycin, ethambutol, azithromycin and clarithromycin.  So, the treatment failure dued to drug resistance.  All medications were changed to the sensitive drugs rifampicin, pyrazinamide, ofloxacin and kanamycin.  She still had intermittent fever during the next 3 weeks, so ethionamide and PAS were added for 3 months then continued only 4-drug regimen rifampicin, pyrazinamide, ofloxacin and ethionamide till 12 months.  She got better and the weight gained from 25 kg to 40 kg.

Key word: tuberculosis, drug resistance, children, fever of unknown origin

Vajira Med J 2003 ; 47 : 57 - 62