Paediatric progressive primary tuberculosis.

A previously healthy 13-year-old Japanese girl with a BCG vaccination history and no tuberculosis (TB) exposure history presented to the hospital with mild dyspnea for 1 month and fever for 5 days. Computed tomography showed consolidation with a pleural effusion, obstructed left main bronchus with an air bronchogram, and traction bronchiectasis of the left upper lobe (Fig. 1A, B). No improvement was observed with ampicillin. Computed tomography on day 23 showed a new granular shadow in the right upper lobe (Fig. 1C). Despite a negative interferon-gamma release assay (IGRA) result, the sputum on day 55 was positive for acid-fast bacilli on a ZiehlNeelsen stain and Mycobacterium tuberculosis on polymerase chain reaction. A fourdrug antituberculous regimen was initiated and she recovered rapidly. TB exposure history, positive tuberculin skin test or IGRA, and typical imaging findings are the triad for primary TB diagnosis (Perez-Velez and Marais, 2012; Lewinsohn et al., 2017; Ahmed et al., 2020). In pediatric primary TB, consolidation may be present and can be misdiagnosed as bacterial pneumonia; however, massive consolidation is rare (GriffithRichards et al., 2007). Primary pulmonary TB should be considered in children with lung consolidation that is unresponsive to antibiotics, despite negative IGRA and TB exposure history.

A previously healthy 13-year-old Japanese girl with a BCG vaccination history and no tuberculosis (TB) exposure history presented to the hospital with a 1-month history of mild dyspnoea and fever for 5 days. Computed tomography (CT) showed consolidation with a pleural effusion, obstruction of the left main bronchus with an air bronchogram, and traction bronchiectasis of the left upper lobe (Fig. 1A, B). No improvement was observed with ampicillin. CT on day 23 showed a new granular shadow in the right upper lobe (Fig. 1C). Despite a negative interferon-gamma release assay (IGRA) result, the sputum on day 55 was positive for acid-fast bacilli on a Ziehl-Neelsen stain and positive for Mycobacterium tuberculosis on polymerase chain reaction. A four-drug antituberculous regimen was initiated and she recovered rapidly.

Fig. 1

Paediatric progressive primary tuberculosis in a 13-year-old girl, with obstruction of the left main bronchus and bronchiectasis (A, B) Chest computed tomography showing consolidation with a pleural effusion and obstruction of the left main bronchus (arrow, A), and an air bronchogram in the left lung. (C) Follow-up chest computed tomography showing a new granular shadow in the right upper lobe (arrow).

In developed countries, a history of TB exposure, positive tuberculin skin test or IGRA, and typical imaging findings are the triad for diagnosing primary TB [1], [2], [3]. In paediatric primary TB, consolidation may be present and can be misdiagnosed as bacterial pneumonia; however, massive consolidation as seen in this case, is rare [4]. Primary pulmonary TB should be considered in children with lung consolidation that does not respond to antibiotics, even if the IGRA and TB exposure history are negative.

Consent to publish: The patient and her parents provided written informed consent to the publication of the case description.

Ethics approval: Ethics approval is not required for case studies at our institution.

Funding: None.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.