Isolated hepatosplenic tuberculosis: a rare presentation with persistent fever in a 2-year-old female child

A 2-year-old female child from South India presented with persistent fever for 3 weeks, pallor and hepatosplenomegaly. There was no history of contact with tuberculosis (TB) and BCG scar was absent. Tests for TB (Mantoux and gastric aspirate) were negative. Blood and bone marrow tests for other infections, inflammation and infiltration were inconclusive. Chest X-ray was normal. Ultrasound study (USS) of abdomen showed multiple microabscesses in the liver and spleen. USS-guided fine needle aspiration cytology from splenic lesion demonstrated epithelioid granuloma while bacteriology was negative. Commencement of anti-tubercular therapy (ATT) resulted in remarkable clinical improvement in a week with resolution of lesions on follow-up USS in 2 months. Isolated hepatosplenic TB in children, though rare, has a wide, non-specific clinical spectrum and potential of delaying diagnosis. Probability diagnosis and therapeutic trials of ATT are accepted approaches, using treatment response as indirect confirmation of the likely cause.

The outcome of expectant management of congenital cystic adenomatoid malformations (CCAM) of the lung

INTRODUCTION

The appropriate management of asymptomatic congenital cystic adenomatoid malformations of the lung (CCAM) remains controversial. The aim of this study is to determine the outcome of expectant management of these lesions and the sensitivity of antenatal ultrasound diagnosis.

MATERIAL AND METHODS

A retrospective review was undertaken of all cases identified from prospectively collected databases with an antenatal or postnatal diagnosis of CCAM in the Northern region of England between 1985 and 2006 where such lesions underwent resection only when symptomatic.

RESULTS

Thirty-seven cases of confirmed CCAM were identified antenatally or postnatally. Twenty-six (70%) were identified by antenatal ultrasound scans (during a period of near-universal antenatal scanning), of whom 21 (81%) were liveborn. In total, 16 of 29 (55%) liveborn infants with CCAM were symptomatic, and either died within the first postnatal week or underwent resection. Thirteen (45% of livebirths) were managed expectantly and remained asymptomatic. The sensitivity of antenatal ultrasound screening for CCAM increased over the period to 90% in the latter half of the study (p=0.035), although the positive predictive value (66%) did not improve.

CONCLUSIONS

Expectant management was a reasonable option for almost half of the babies, but over one third required surgery for CCAM, most becoming symptomatic in infancy. In view of the uncertainty that surrounds decisions regarding expectant or pre-emptive resection in asymptomatic infants, the authors advocate having an open and honest discussion when counselling parents (particularly antenatally) regarding surveillance or expectant management as a reasonable strategy.