DOI: 10.1097/01.pec.0000278392.94634.4e
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PMID: 17572524
Issn Print: 0749-5161
Publication Date: 2007/06/01
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Excerpt
The child was otherwise well, with no reported cough, fever, diarrhea, vomiting, weight loss, or anorexia. She had been born in Germany to immigrant Somali parents and had arrived in the United Kingdom via Scandinavia, a route common for the United Kingdom Somali population. She had never visited her parents' country of birth and was fully immunized according to protocol in her native Germany but had not received a Bacillus Calmette-Guerin (BCG) vaccination.
On physical examination, she was a quiet, but healthy, and thriving child of 5 years, her weight measuring just greater than the 50th centile for age. She was not clubbed, and apart from small palpable cervical nodes, there was no sign of peripheral lymphadenopathy. She had normal recorded vital signs, and examination results of the cardiovascular, respiratory, and abdominal systems were normal. No BCG vaccination scar was present. Examination of her musculoskeletal system demonstrated marked swelling of the proximal phalanx of her left index finger (Fig. 1).
The swelling was warm to the touch, only very slightly tender, and resulted in limitation of movement at the metacarpophalangeal and proximal interphalangeal joints. There was no associated regional lymphadenopathy. Plain radiographs of the finger demonstrated marked soft tissue swelling and periosteal reaction around the proximal phalanx, consistent with pyogenic or tuberculous osteomyelitis (Fig. 2).
With tuberculosis (TB) in the differential diagnosis, a plain chest radiograph was performed (Fig. 3), which demonstrated left upper lobe consolidation.
The radiological findings were highly suggestive of tuberculous infection, and a tuberculin test was performed in the ED. Blood work in the ED showed a hemoglobin level of 10 mg/dL, white blood cell count of 6.8 × 109/L (neutrophils 4.8, no bands), normal platelets, an erythrocyte sedimentation rate of 60 mm/h, and a C-reactive protein of 55 mg/L. Sickle cell screen results were negative, and there was no growth on venous blood culture. The girl was referred to the general pediatric team with a requested consult to the plastic (hand) surgeons, and she was commenced on antibacterial therapy. Bone biopsy and washout were performed on the day after admission, the histopathology report of which indicated areas of bone necrosis, some caseous, with evidence of bone remodeling and new bone growth. There were no properly formed granulomata, and acid-fast bacilli were not seen. This tissue sample was positive for growth of Mycobacterium tuberculosis 7 weeks after culture was set up.
Forty-eight hours after admission, the girl's tuberculin test result was strongly positive, with a 25-mm-diameter palpable area of induration around the injection site. She was then commenced on antituberculous therapy (oral rifampicin, isoniazid, pyrazinamide). She was discharged home on day 4 after admission on her oral antituberculous drugs and a finishing course of oral antibiotics. At review 6 weeks later, a follow-up radiograph of the finger demonstrated further destruction of the proximal phalanx with ongoing periosteal reaction (Fig. 4).
Results of the girl's mother and 3 siblings were all negative on screening for TB. She continues on antituberculous therapy but has subsequently moved out of the region.
