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?
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