LOOK BEFORE YOU LEAP: A REPORT OF A MISSED DIAGNOSIS

ABSTRACT

SESSION TITLE Rare Pulmonary Infections SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/18/2022 0135 pm - 0235 pm INTRODUCTION: Tuberculosis (TB) rates in the USA are currently at the lowest in history. During 2010-17, only 5175 TB cases occurred in children in the USA. Even in Hidalgo County on the Texas-Mexico border there were only 36 cases of TB among all age groups in 2020. CASE PRESENTATION An asymptomatic 3-year-old male presented to the PICU with a positive PPD and an infiltrate in the right lower lobe on chest x-ray. Once three morning gastric aspirates were obtained child was started on a 4 drug regimen recommended by the health department, and sent to the pulmonology clinic for further care awaiting identification and sensitivity of an organism. Child was born at 35 weeks gestation, spent 8 days in NICU for unclear reasons requiring intubation and oxygen. Upon review of patient history and chest x-ray, diagnosis of TB became less likely. This was further confirmed by gastric aspirate revealing no organisms and negative QuantiFERON Gold. CT with oral and IV contrast revealed a right-sided congenital diaphragmatic hernia (CDH) in the foramen of Morgagni. Patient received definitive outpatient surgery in October 2021. At 3-month follow-up there were no surgical complaints and patient reported increased exercise tolerance. DISCUSSION: TB is very rare in the US, even in the Rio Grande Valley where the proportion of cases are higher. This child received 42 doses of TB treatment after a positive PPD and consolidation on chest x-ray. However, x-ray did not clearly indicate TB infection and in fact was suspicious for bowel in the chest cavity. This case clearly indicates the need for careful examination of radiographs and ordering more tests such as the QuantiFERON Gold as needed before jumping to what may seem to be the obvious conclusion. Even though CDH are uncommon and Morgagni hernias are rare making up only 2-3% of CDH, a closer look at the case was warranted. This child's misdiagnosis led to more than simply unnecessary medical treatment, it also led to social stigma for the family that culminated in the father being terminated from his job. This child's surgical repair was delayed due to missed diagnosis of Morgagni hernia in NICU, PICU, and health department and delayed ordering of confirmatory TB tests. Furthermore, patient was referred to surgery in March 2020 but was delayed by 19 months due to COVID-19. The pandemic was also the stimulus for the outpatient nature of the complicated surgery. It is unclear why patient's PPD was positive. It is of note that mother's PPD was also positive due to contact with active TB years prior to child's birth. One hypothesis is this may have caused positive PPD in child and is a future question to pursue. CONCLUSIONS: We want to emphasize to look before you leap and investigate before you treat. There was harm to the child and family done by treating aggressively that could have been prevented and an opportunity to help the child that was delayed. Reference #1 Cowger TL, Wortham JM, Burton DC. Epidemiology of tuberculosis among children and adolescents in the USA, 2007–17 An Analysis of National Surveillance Data. The Lancet Public Health. 2019;4(10). doi10.1016/s2468-2667(19)30134-3 Reference #2 Leeuwen L, Fitzgerald DA. Congenital diaphragmatic hernia. Journal of Paediatrics and Child Health. 2014;50(9)667-673. doi10.1111/jpc.12508 Reference #3 Mohamed M, Al-Hillan A, Shah J, Zurkovsky E, Asif A, Hossain M. Symptomatic congenital Morgagni hernia presenting as a chest pain A case report. Journal of Medical Case Reports. 2020;14(1). doi10.1186/s13256-019-2336-9 DISCLOSURES No relevant relationships by Isha Mittal No relevant relationships by Barbara Stewart