Miliary tuberculosis in a young child – a case report
Liliana Pinho1, Sara Oliveira1, Josefina Serino2, Teresa Febra3, Sandra Ramos1, Conceição Silva1, Maria José Dinis1
1Paediatrics,
3Centro
Centro Hospitalar Póvoa de Varzim/Vila do Conde; 2Ophthalmology, Hospital Pedro Hispano, Matosinhos;
de Diagnóstico Pneumológico, Póvoa de Varzim/Vila do Conde – Portugal
INTRODUCTION
Tuberculosis represents a public health problem. During 2011, a total of 41 cases of tuberculosis in children were notified in Portugal, with 17
of them less than 5 years old. Young age and HIV infection are the most important risk factors for severe or disseminated disease.
CASE REPORT
Previously healthy 3-year-old girl
Normal physical
examination
Normal WBC
↑CRP (22mg/dL)
Urinalysis:
leucocytes+bacteria

Oral cefuroxime
(40 mg/kg/day)
Normal physical examination
and urinalysis

Symptomatic treatment
Urine culture:
Escherichia coli

Oral amoxicillinclavulanate
(sub-therapeutic dose)
Antibiotic
intolerance
Pale skin, high fever (40⁰C),
hepatomegaly
Laboratory findings: mild anemia,
↑CRP (21mg/dL),↑transaminases
(AST 245U/L, ALT 143U/L), nitrites
and bacteria in urinalysis…

Intravenous cefuroxime
Urine culture confirmed
UTI by E. coli
Laboratory reevaluation:
Normal WBC, CRP 13
mg/dL, ESR 16 mm/hr,
AST 132U/L, ALT 93U/L
Chest X-ray (figure 1)
Diarrhea
Anorexia
Dysuria
Abdominal pain
Fever
Day 1
Day 2
Day 4
Day 13
Emergency Service
Emergency Service
Emergency Service
Day 19
Day 23
Hospital admisson
Negative tuberculin skin test
Isolation of Mycobacterium tuberculosis in gastric
aspirate, cerebrospinal fluid and urine
Persistent fever and anorexia, despite
antibiotic treatment for UTI
Hepatomegaly with hepatitis
(streptomycin-resistant)
(negative viral serology)
Pulmonary infiltrate with a miliary pattern
Miliary tuberculosis?
• Normal cerebral MRI
• Ophthalmological examination: tuberculous posterior
Figure 1. Chest X-ray
uveitis (figure 2)
Therapy with rifampicin, isoniazid and pyrazinamide associated with prednisolone
Significant clinical improvement after two weeks of treatment
Total treatment consisted of prednisolone (1 month), rifampicin, isoniazid and pyrazinamide (2 months),
followed by rifampicin and isoniazid (10 months)
HIV infection and main primary immunodeficiencies were excluded
Figure 2. Choroidal tuberculomas
COMMENTS
Even in the era of advanced medical technology, tuberculosis is still a diagnostic challenge, especially when the presentation is atypical and
extra-pulmonary. Beyond that, in this case, superinfection by other bacteria somewhat delayed recognition of the underlying tuberculosis.
A high index of suspicion by the physician is required as prompt institution of adequate treatment is decisive for final outcome.
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