Lung cavities in an infant: Could it be only tuberculosis?
T Arun Babu1, CGD Kumar2,
1 Department of Pediatrics, Indira Gandhi Medical College and Research Institute, Pondicherry, India
2 Department of Pediatrics, Institute of Child Health, Egmore, Chennai, Tamil Nadu, India
T Arun Babu
Department of Pediatrics, Indira Gandhi Medical College and Research Institute, Pondicherry
|How to cite this article:|
Babu T A, Kumar C. Lung cavities in an infant: Could it be only tuberculosis?.J Postgrad Med 2013;59:160-161
|How to cite this URL:|
Babu T A, Kumar C. Lung cavities in an infant: Could it be only tuberculosis?. J Postgrad Med [serial online] 2013 [cited 2020 Aug 5 ];59:160-161
Available from: http://www.jpgmonline.com/text.asp?2013/59/2/160/113813
We read the case report titled 'Lung cavities in an infant: Could it be tuberculosis?' authored by Save et al., with interest.  We would like to raise few points regarding the case.
The infant had presented with acute onset of respiratory symptoms and chest X-ray revealing cavities with background consolidation. Common acute respiratory infections causing pneumonia with cavities like Staphylococcus aureus, gram negative bacteria, pneumococcus, and anaerobes should have been considered and ruled out in this case.  Even a suspicion of tuberculosis should not preclude authors from considering and ruling out common bacterial causes. It was surprising to note that there was no mention of blood culture or any antibiotics in this report. Withholding antibiotics in an acute respiratory infection due to suspicion of tuberculosis is unjustifiable because tuberculosis was never confirmed at that time. The child could have easily worsened if it was bacterial pneumonia. No information regarding the acute management like oxygen therapy, saturation, intravenous fluids have been discussed.
Clinical examination has revealed marked hepatosplenomegaly, but the Ultrasonography and computed tomography (CT) scan of abdomen was normal. How was that possible? Moreover, hepatosplenomegaly in the presence of tuberculous lung cavities should raise strong suspicion of disseminated tuberculosis, in which case, liver biopsy and cerebrospinal fluid analysis should have been done.  Wall thickness of lung cavities measured by CT scan, could have been an important factor supporting tuberculous etiology.  Hemogram, Erythrocyte Sedimentation Rate (ESR), and bronchoalveolar lavage for acid fast bacilli (AFB) would have given weightage to the diagnosis.
When the diagnosis was confirmed based on the response to empirical therapy, the other differential diagnosis considered should have been mentioned to make the discussion complete. Even to diagnose tuberculosis retrospectively, the workup looks grossly incomplete. Authors suggest that weight gain of 1 kg as response to therapy which the child would have gained even otherwise. Child has appropriate weight for age and the birth weight would give more information regarding the pattern of normal weight gain. Since antituberculosis treatment (ATT) was started empirically, a complete follow up is required before coming to any conclusion within 1 month of starting therapy. Follow up becomes mandatory in this child for assessing clinical, bacteriological, and radiological clearance and to monitor development of bronchiectasis, which is commonly seen in these patients. 
The reason for recurrence in the mother, whether she was asymptomatic during antenatal period in spite of multiple lung cavities and whether the possibility of multidrug resistance had been ruled out, remains unclear.
Authors have taken effort to present this as a classical case of cavitary tuberculosis in an infant. As readers, we are interested to know the problems faced while arriving at the diagnosis and other differential diagnosis considered.
|1||Save S, Doshi H, Somale A. Lung cavities in an infant: Could it be tuberculosis? J Postgrad Med 2012;58:213-4.|
|2||Ryu JH, Swensen SJ. Cystic and cavitary lung diseases: Focal and diffuse. Mayo Clin Proc 2003;78:744-52.|
|3||Working Group on Tuberculosis, Indian Academy of Pediatrics (IAP). Consensus statement on childhood tuberculosis. Indian Pediatr 2010;47:41-55.|
|4||Vijayasekaran D, Selvakumar P, Balachandran A, Elizabeth J, Subramanyam L, Somu N. Pulmonary cavitatory tuberculosis in children. Indian Pediatr 1994;31:1075-8.|