Dr.Subbulakshmi P S, Dr.Jayakumar.C, Dr. Praveena N Bhaskaran,AIMS, Kochi
Five month old ex-preterm twenty eight weeks presented with ear discharge and swelling behind the right ear for ten days with a fever for five days duration. She was admitted and started on IV Antibiotics in a near hospital
Growth parameters were less than third centile (failure to thrive+). The child was developmentally normal and Immunizations were up-to date according to NIS. No history of viral upper respiratory tract infection
No family h/o TB, immunodeficiencies.
Except fever other vitals were normal
PICCLE normal
Right ear showed tender, fluctuant swelling with redness in the right ear.No focal Neurological deficits
Other systems were within normal limits.
DIFFERENTIALS:
● Primary infections of mastoid,otitis externa/media
● Immunodeficiencies
● Dental/Tonsillar abscess
● Trauma
● Genetic susceptibity to infections
● Suppuration of mastoid lymphnodes
Investigations: CXR done was normal.
CSF Analysis done were normal.
HRCT showed coalascent otomastoiditis with bezold’s abscess.
Incision and drainage for right subperiosteal abscess was done and biopsy from the abscess tissue suggested chronic granulomatous inflammation with necrosis with AFB, suggesting MTB. Gene Xpert and AFB stain reported positive for MTB.
Histopathology-Microphotogram shows a chronic granulomatous inflammation with caseous necrosis (white arrow) and multinucleated giant cells (black arrow)
BERA done was normal.
The ba was initiated on 4 drug ATT . Later she developed worsening of the swelling which was drained surgically. She then developed drug related liver injury after starting ATT following which all drugs were withdrawn and reintroduced (without pyrazinamide) as per protocol
Following which the liver functions remained normal.Primary tuberculous infection of the middle ear is an extremely rare entity in immunocompetent individuals.
Therefore, NBT-DHR and Flow cytometry was done on suspicion of immunodeficiency and was reported to be normal.
Genetic Testing-. Mendelian susceptibility to mycobacterial diseases was suspected and advised genetic testing but deferred due unaffordability.
Treatment for Tuberculosis in Children:
DISCUSSION: The diagnosis of primary MTB infection explained the poor response to common antibiotics and the subclinical presentation. The presence of such CT findings along with an indolent course of the disease should shift the suspicion toward rare causes, specifically MTB. Primary tuberculous otomastoiditis is rare. A chronic and indolent presentation of otitis media with poor response to conventional antibiotics should raise the suspicion of rare and unusual etiologies like MTB. A high index of clinical suspicion is required to narrow down the DDs to establish early diagnosis and initiate the appropriate treatment to prevent serious complications such as labrynthitis, meningitis, facial nerve palsy.