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INTRODUCTION: Spina Ventosa is a rare condition that is easy to misdiagnose as other diseases. We present a case of late-diagnosed Spina Ventosa, which had not only the osteoarticular tuberculosis symptoms but also some severe symptoms, including pleural effusion, ascites, and anemia. By intensive treatment, our patient recovered completely. CASE REPORT: A 7-year-old boy was admitted with complaints of painless swelling of metacarpals, metatarsals, and phalanges of his hands and feet and a discharging sinus of the left toe. There was no family or past history of tuberculosis. His immunizations were up to date. General examination revealed that the child had pallor and was emaciated. No lymphadenopathy was detected. Investigations revealed hemoglobin: 74 g/l, and erythrocyte sedimentation rate (ESR) was 42 mm/hour. QuantiFERON-TB test was positive. The radiograph showed irregular swelling with sclerosis of the underlying bones. The right-hand x-ray showed cortical destruction, sclerosis, and cystic expansion or right second metacarpal. Chest x-ray indicated pleural effusion. Histopathological examination of specimen from the foot and lung and abdomen fluid confirmed tuberculosis. The child was treated with the first-line tuberculosis treatment regimen (Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide) for two months, followed by Isoniazid, Rifampicin, and Pyrazinamide for a further four months. His lesions disappeared after six weeks of intensive treatment. CONCLUSION: A delay in diagnosis and treatment of tuberculosis can lead to systemic manifestations in multiple organs. Despite the delay in diagnosis, this child had a good outcome due to being treated promptly and adequately after the presentation.
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BACKGROUND: Drug resistant typhoid fever is a major clinical problem globally. Many of the first line antibiotics, including the older generation fluoroquinolones, ciprofloxacin and ofloxacin, are failing. OBJECTIVES: We performed a randomised controlled trial to compare the efficacy and safety of gatifloxacin (10 mg/kg/day) versus azithromycin (20 mg/kg/day) as a once daily oral dose for 7 days for the treatment of uncomplicated typhoid fever in children and adults in Vietnam. METHODS: An open-label multi-centre randomised trial with pre-specified per protocol analysis and intention to treat analysis was conducted. The primary outcome was fever clearance time, the secondary outcome was overall treatment failure (clinical or microbiological failure, development of typhoid fever-related complications, relapse or faecal carriage of S. typhi). PRINCIPAL FINDINGS: We enrolled 358 children and adults with suspected typhoid fever. There was no death in the study. 287 patients had blood culture confirmed typhoid fever, 145 patients received gatifloxacin and 142 patients received azithromycin. The median FCT was 106 hours in both treatment arms (95% Confidence Interval [CI]; 94-118 hours for gatifloxacin versus 88-112 hours for azithromycin), (logrank test p = 0.984, HR [95% CI] = 1.0 [0.80-1.26]). Overall treatment failure occurred in 13/145 (9%) patients in the gatifloxacin group and 13/140 (9.3%) patients in the azithromycin group, (logrank test p = 0.854, HR [95% CI] = 0.93 [0.43-2.0]). 96% (254/263) of the Salmonella enterica serovar Typhi isolates were resistant to nalidixic acid and 58% (153/263) were multidrug resistant. CONCLUSIONS: Both antibiotics showed an excellent efficacy and safety profile. Both gatifloxacin and azithromycin can be recommended for the treatment of typhoid fever particularly in regions with high rates of multidrug and nalidixic acid resistance. The cost of a 7-day treatment course of gatifloxacin is approximately one third of the cost of azithromycin in Vietnam. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN67946944.
