Disseminated tuberculosis with paradoxical miliary tuberculomas of brain in a child with rickets
A 5-year-old marasmic male child was referred to our institute for multiple lymphadenopathy. His mother in the same household had pulmonary tuberculosis. On admission, the child had no history of cough, dyspnea or night sweats. However, he was lethargic and unable to stand or sit without support. His general examination was quite remarkable for the evidence of severe protein energy malnutrition (PEM) and rickets. He had marked pallor, generalized xerosis, crusted lesions with boil on the lower back, and hyperpigmented friction dermatosis on buttocks. His crawling movement was further complicated by valgus deformity of legs due to nutritional rickets. Cervical [] and groin examination showed multiple matted lymph nodes forming a large cervical and inguinal lymphadenopathy. His ocular examination revealed nebular keratopathy in both eyes. His initial evaluation at the previous institute did not reveal any malignancy as a possible etiology for large cervical and inguinal lymphadenopathy. His detailed clinical neurological evaluation did not reveal any positive findings. Hematological investigation revealed severe anemia (Hemoglobin - 7.3 gm/dl), leukocytosis (Total Leukocytes Count - 15,700/mm3; 84% neutrophils, 12% lymphocytes, 3% monocytes, and 1% eosinophils), and mild thrombocytopenia (87,000/mm3). Biochemical investigation for rickets showed hypocalcemia (serum calcium - 6.31 mg/dl), normal phosphate (serum phosphate - 4 mg/dl), higher alkaline phosphate - 310, and low Serum 25 (OH) D - 8 ng/ml. He was seronegative for human immunodeficiency virus (HIV) on Enzyme-Linked Immunosorbent Assay (ELISA) test; Mantoux test was also negative. The chest X-ray revealed miliary Koch's infiltration with a widening of the costochondral junction of the ribs due to rickets in the bony thorax []. Abdominal and thoracic ultrasound revealed mild hepatomegaly, mild splenomegaly, and enlarged mesenteric, inguinal, peripancreatic, celiac axis, periportal, and bilateral iliac lymph nodes. Corroborative radiological evaluation for rickets (X-ray both knee and wrist joint) showed metaphyseal widening with splaying and fraying of epiphysis and changes related to osteoporosis, and pencil line thinning of the epiphyseal cortex, suggesting rickets []. Fine needle aspiration cytology of cervical lymph node showed features of tuberculous lymphadenitis with the presence of acid-fast bacilli.\nAntituberculosis therapy including Streptomycin injection (according to CAT-1 of the National Tuberculosis Control Program) and oral steroids were started. Cytology report confirmed the Koch's etiology. Severe PEM and vitamin deficiency were aggressively managed in the hospital with supervised high protein diet and oral therapeutic supplementation of Vitamin A and Vitamin D with calcium. During 2 weeks of observation in the pediatric ward, the child recovered gradually and was discharged home with oral medicines. Within 3 weeks of discharge, the patient presented again to the pediatric intensive care unit with generalized tonic-clonic convulsions. There was no focal neurological sign on examination. The computed tomography (CT) scan of brain revealed multiple small tuberculomas in the brain parenchyma scattered like millets in the cerebral hemispheres, bilateral cerebellum, and brain stem []. Few of them were conglomerate in the left cerebellum, right parietal region, and pons with periventricular hypodensity. Anticonvulsant therapy was started and Streptomycin and steroid were added to the chemotherapy. Afterward, the child was symptom free.