Dr. Theresa Raju,Dr. C Jayakumar,Dr Praveena ,Dr Navya George
Sixteen year old boy suffering from Myelin oligo dendrocyte glycoprotein antibody associated disease (MOGAD ) on Mycophenolate Mofetil since one year presented with high grade intermittent fever ,rigors and sweating of 1 month do f h.History of weight loss about 3kg in 1 month.
At 15 years of age,he had paraesthesia over his left thigh radiating to the left leg and ankle and difficulty in getting up from squatting position and climbing stairs.MRI was suggestive of transverse myelitis and optic neuritis.MOG antibodies were positive and he was and was pulsed with IV Methylprednisolone followed gradual tapering over 3 months.At 16 years of age he had blurring of vision in left eye followed vomiting,weakness and numbness of left limb.This boy had history of fever with headache 4 days prior to the onset of these symptoms.He was evaluated and diagnosed with relapsing MOGAD-area postrema syndrome.This time also IV methyl pred was given and discharged with Azathioprine and tapering doses of oral steroids..
During the first week of current symptoms,he was evaluated and found to have Leucopenia and Azathioprine was stopped following which his counts improved.
But fever persisted and WBC was again dropping hence oral steroids was restarted along with Mycophenolate Mofetil considering MOGAD relapse.
Labs showed TC 3300,elevated CRP
.PUO work up
Salmonella antibodies,Brucella IgM,EBV IgM,CMV IgM and dengue were negative Chest xray and echo was normal.USG Abdomen showed hepatomegaly.ANA IFA had a mixed pattern(fine speckled and cytoplasmic).Complements were normal
Gene Xpert done from sputum sample detected MTB but there was no Rifamipicin resistance.
Quantiferon TB gold was negative.The child was started on ATT with serial monitoring of LFT .CSF analysis was done and was moderately positive for serum MOG IgG antibody.Retina examination revealed multiple small yellow round lesions outside arcade ,?multifocal choroiditis and ?choroid tubercle.Fundus fluorescinangiograohy (FFA) done showed multiple focal choroiditis and choroidal tubercles.Oral steroids and ATT were continued and MMF was stopped.In view of leucopenia with ANC of 453 and persisted fever spikes Bone marrow biopsy marrow biopsy revealed cellular marrow showing trilineage maturation and granulomatous inflammation.AFB stains and bone marrow culture were negative.Due to persistent fever spikes he was started on Naproxen after which fever spikes reduced but leucopenia persisted.In view of persistent leucopenia with ANC<400 he was started on Inj Filgrastin after which counts improved(TC:9000,N:83.5%,L:7% In view of perisisting fever and leucopenia,PET CT was done which revealed multiple tiny b/l lung nodules mainly in the upper lobe-?sarcodiosis/TB and abnormal FDG avidity in bilateral salivary galnds and multifocal lymph node.Hence a diagnosis of diiseminated TB was made with findings of sputum positivity,choroid tubercles and bone marrow granuloma.
Repeat labs before discharge showed TC of 4250,N:37%,L:48% and CRP of 5.He remained afebrile for more 1 month after discharge,the counts were showing improving trends with TC of 6600,N/L:63/32%,PLT of 3 lakhs.
He was managed with Fixed Drug Combinations of anti TB drugs as per NTEP program .
Take home message:It is very prudent to look meticulously for Tuberculosis as apart of PUO work up esp if the child is immune suppressed