[Multifocal tuberculosis in children: diagnostic traps]

ABSTRACT

Tuberculosis is a bacterial infection that occurs in endemic forms. This disease is still present in Morocco despite vaccination of 100%. Children, whether are immunocompetent or not are contaminated by positive adults-smear. The symptoms are often not too specific, which explains the severe forms. The authors report a case of multifocal tuberculosis. It concerns a year-old five-and-a-half- girl admitted for chronic iron deficiency anemia. The child has been followed-up for 5 months by iron deficiency anemia that unimproved the condition. No previous history of repeated infection, no tuberculosis contamination. The story of her disease began in April 2011 showing asthenia. Iron deficiency anemia required a treatment but without clinical or biological improvement after 5 months of treatment. One month prior to admission abdominal pain appeared, persistent fever and cough; all unimproved by the multiple prescribed outpatient antibiotic treatments. On admission, the child was pale, febrile at 38.5 with failure to thrive and signs of malnutrition; the abdomen was distended with HPSM. Pleuropulmonary examination showed discrete crackles [rales]. The lymph nodes are free. Apart from this long-term fever check-up showed microcytic hypochromic anemia [7.4g/l] and a biological inflammatory syndrome. According to physiological check-up, the research of BK in sputum X3 was negative, Tuberculin Skin Test [TST] and quantiferon test were negative. Abdominal ultrasound found a thickening of the colonic wall, with multiple infra-centimetric lymphadenopathies, a layer of intraperitoneal effusion, evoking thus lymphoma. The echocardiography showed an intra-pericardial effusion of non-compressive average size. Thoracic-abdominal-pelvic scan showed multiple nodules and micro-nodules of bronchiolar type and multiple necrotic mesenteric lymph nodes above and below the meso-colon, and a thickening of the ascending and transverse colons suggesting evolutive pulmonary and abdominal tuberculosis. Mini-laparotomy revealed an agglutination of loops and the presence of whitish granulations at the caecal region, with mesenteric lymph nodes. The anatomical-pathological study of the biopsies revealed peritoneal ileal appendicular the caecal region, with mesenteric lymph nodes. The anatomical-pathological study of the biopsies revealed peritoneal ileal appendicular caseo-follicular tuberculosis, with tuberculous lymphadenitis. The little girl has been put under antibuercular treatment following the severe multifocal tuberculosis scheme with a clear clinical and radiological improvement since D15 of treatment. Through this illustrative case, the authors stress the need to consider an iron deficiency anemia that is refractory to replacement therapy as a potential symptom of TB infection