October 2015

Title: A Little Liver and a Big TB problem
David P Moore - Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand 

A 6-week old female infant, newly diagnosed with HIV, was started on appropriate doses of anti-tuberculosis treatment on day five of her sentinel hospital admission with pneumonia, in view of poor weight gain (severe acute malnutrition: weight 3.1 kg (weight-for-age Z-score: -3.29 SD), a ‘suggestive chest X-ray’ and splenic microabscesses visualised on the abdominal ultrasound (Figure 1).

Figure 1: Abdominal ultrasound from first hospital admission

Ultrasound of the spleen demonstrates a diffuse coarse echogenicity with multiple hypoechoic lesions highly suggestive of microabscesses. The radiologic differential for microabscesses in the spleen includes disseminated TB, non-tuberculous mycobacterial infection (Mycobacterium avium complex), and fungal infections.

Her CD4 count was 53 cells/mm3 (2.02%). The baseline viral load was 4,170,560 RNA copies/mL. There was no known TB contact.

She was treated for community-acquired pneumonia, and responded well to therapy. She was discharged four days later in good health, with a plan to initiate her onto antiretroviral therapy (ART) in 4 weeks, once stabilised on anti-TB treatment.

Question 1: According to the World Health Organization, what clinical stage of HIV does this child fall into?

Question 2: What investigations can be sent to confirm a microbiological diagnosis of tuberculosis in this infant?

Question 3: What anti-tuberculosis regimen would you use in such a child?

Question 4: What doses of first-line anti-tuberculosis drugs are recommended for children, according to the South African TB Guidelines?

Question 5: What additional medication is warranted in such a child, and why?

Continue to Answers