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A 4-year-old Thai boy with RUL consolidation (Page 1/2)
Prepared by...
Kakanang Jantarapagdee, M.D.
Sudawan Siriaksorn, M.D.
Thirasak  Borisuthibandit, M.D.
Muthita Trakultivakorn, M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University
A 4-year-old Thai boy Address: Lampang province.

Referred from Lampang General Hospital, Lampang, Thailand
Chief compliant: Chronic cough for 5 months
Present illness:
> Five months prior to this admission, he developed non-productive cough without fever, dyspnea, and other symptoms. The coughing spell was mild and did not disturb his activities. His mother gave him only an anti-tussive medication.
> One week prior to this admission, the coughing symptom still persisted. His mother brought him to Lampang General Hospital where he was admitted. The chest x-ray disclosed a RUL consolidation. He was given ceftriaxone and roxithromycin for 3 days and then switched to oral antibiotics for 1 week without any improvement. He was then referred for further investigation and management.
Past history:
> At 5 months old, he has had prolonged fever with left axillary lymphadenitis and hepatomegaly. A tuberculin skin test was positive (induration 20 mm indiameter). The histologic finding of the biopsied lymph node was consistent with Mycobacterium infection. His chest x-ray was normal. He was diagnosed as a probable disseminated M. bovis infection from BCG vaccination. He was given anti-mycobacterial therapy for 9 months.
> Later, he experienced 1 episode of bacterial pneumonia, 1 episode of fistula in ano, and several episodes of cervical lymphadenitis and skin abscesses.
Family History:
> No history of consanguineous marriage, (Figure 1) or history of recurrent infection and unexplained death in his family.
 
Physical examination:
GA: A boy, active, no dysmorphic feature, normal weight gain and development
V/S: T 36.8 oC, BP 110/60 mmHg, PR 114/min, RR 34/min, SaO2 96 % (room air)
HEENT: Mild pale conjunctiva, no icteric sclera, no injected pharynx, tonsils were not enlarged, tympanic membranes were normal in appearance.
Lymph node: Bilateral cervical and inguinal lymph nodes were palpable (0.5 cm in diameter), while axillary and epitrocheal lymph node were not palpable.
Chest: Trachea in midline, no retraction
Lung: Decreased breath sound, dullness on percussion, and increased vocal and tactile fremitus over the RUL area
Heart: Regular rhythm, normal S1 and S2, no murmur
Abdomen: Soft, not tender, liver was just palpable with the liver span of 9 cm. Spleen was palpable 1 cm below the LCM.
Extrimities and Skin: No edema, no clubbing finger. The BCG scar was noted on left deltoid area.
Problem list:
  1. Chronic cough with RUL consolidation
2. Anemia
3. History of recurrent infection
Investigatons:
>
 CBC:
  Hb 9.5 g/dl, Hct 33.1%, Platelets 609,000 /mm3
  WBC 14,000 cell/mm3 (N 40% Eo 7% Baso 1% Lym 46% Mono 6%)
  Absolute lymphocyte count was 6440 cell/mm3
  Absolute neutrophil count was 5600 cell/mm3
>
 PBS: hypochromic 2+ microcytic 2+
>
 Reticulocyte count: 4.2% (corrected value 2.8%)
>
 SI/TIBC: 24/310 mcg/dl (iron saturation 7%)
>
 Stool exam for parasite: Negative
>

Stool occult blood: Negative

>
 Tuberculin skin test: Induration of 18 mm in diameter at 48 and 72 hr.
>
 CXR:Figure 2
 
Figure 2
Chest x-ray revealed the RUL consolidation
>
 Gastric washing for AFB: Negative for 3 days
>
 Gastric washing culture for bacteria: Negative
>
 Serum galactomannan: Negative
>
 Chest CT scan: Figure 3: Chest CT scan demonstrated consolidation of apical and posterior segments of RUL, posterior part of anterior segment of RUL, superior segment of RLL and medial and posterior aspect of right hemithorax. There were few lymph nodes at the pre- and paratracheal, pre- and subcarinal regions. The largest was 1.1 cm in short axis at the paratracheal group. Prominence of the splenic size without focal lesion was noted. The included liver and both kidneys appeared normal.
 
   
>
 BAL fluid exam: Negative for gram stain, AFB, and modified AFB, but numerous pseudohyphae with few yeasts, morphologically consistent with Candida spp. were found in Wright’s stain. (Figure 4)
 
  Figure 4: Wright’s stain of BAL fluid demonstrated numerous pseudohyphae with few yeasts, morphologically consistent with Candida spp. (arrow)
   
>
 BAL fluid culture for bacteria: 10 4 – 10 5 g -streptococci, and a -streptococci
>
 BAL fluid culture for fungus:Candida spp.
>
 BAL fluid cytology: Numerous reactive pneumocytes, ciliated columnar cells, macrophages and lymphocytes within bacteria-rich background. Numerous pseudohyphae with few yeasts, morphologically consistent with Candida spp. were also observed. Neither granulomatous inflammation nor malignancy was seen.
>
 Anti-HIV antibody: Negative with 2 testing methods
>
 Serum immunoglobulin: IgG 2426 g/dl, IgA 209 g/dl, IgM 267 g/dl, IgE 45 IU/ml
>
 Nitroblue tetrazolium (NBT) test:
 
   
>
 Dihydrorhodamine-123 (DHR-123) assay: Figure 5
 
  Figure 5: (A) His DHR-123 assay shown modest DHR shift with broad-based histogram. (B) DHR-123 assay of his mother shown bimodal histogram. (C) DHR-123 assay of normal individual shown normal shift histogram.
   
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