A 12-year-old girl presented with gradual onset of continuous, low to high grade fever, and cough which was initially non-productive but later productive of yellow sputum over 20 days. She had anorexia and lost weight. She developed respiratory distress which gradually worsened. Family history was significant for tuberculosis in grandmother who lived with her. She was unvaccinated. Initially they took treatment from a family physician but later referred to other facility where she was admitted and worked up as no improvement was noted. Her x-ray chest showed bilateral pleural effusions (Fig.1) and ultrasound of the chest revealed large effusions on both sides with thick internal echoes. At thoracocentesis, pus was aspirated from both the sides. She was started on anti-tuberculous treatment (Inj. streptomycin, isoniazid, rifampicin and pyrizinamide). After the thoracocentesis, her condition worsened and x-ray chest revealed left pneumo-thorax, (Fig.2) and she was referred to our centre.
Figure 1: Bilateral pleural effusions.
Figure 2: Bilateral pleural effusions with pneumothorax on left side.
At arrival, examination revealed a thin, emaciated, 21 kgs, tachypneic girl, with a respiratory rate of 52/min and heart rate of 118/min. BCG scar was not found. Chest movements were equal but air entry was reduced on both sides. Bilateral tube thoracostomies were offered. About 250 cc thin yellow pus was drained initially from the right side and 20 cc thick yellow pus drained from the left side along with air-leak. Post intubation x-ray chest showed partial lung expansion on the right side (Fig.3).
Figure 3: Post intubation chest X-ray.
Laboratory investigations showed Hemoglobin of 9 gm/dl and ESR of 40 mm/1st hour. She was started on ceftazidime and amikacin injectables, empirically along with anti-tuberculous drugs and supportive treatment. The initial pleural fluid examination revealed numerous WBCs, proteins 5.7 gm%, and gram negative rods. Pseudomonas aeruginosa was isolated from the pus and no AFB was seen on Ziehl Nelson (ZN) staining. Antibiotics were changed to tazobactam (according to culture report) and anti-tuberculous drugs continued.
Her condition worsened despite optimal medical treatment. Respiratory distress increased together with persistent air leak and oxygen desaturation. She was shifted to intensive care unit and x-ray chest was repeated which showed bilaterally well expanded lungs with pneumonic patches. Both chest tubes were in place that drained pus though she required re-adjustments multiple times. She was also given nutritional supplementation. The pus culture were repeated that grew Morganilla morgani sensitive to tazobactam.
Gradually her condition settled. Respiratory distress improved and fever subsided. Repeat x-ray chest showed bilaterally well expanded lungs except for a cavitatory lesion at the right lower zone. Ultrasound (US) chest showed collection with internal echoes measuring 5.4 cm × 4.5 cm, and 10 cc pus was aspirated under US guidance and sent for culture. Proteus vulgaris was isolated with same sensitivity pattern. At 42nd and 48th day of intubation, left and right sided chest tubes were removed respectively after the x-rays when the patient was asymptomatic (Fig. 4). She was sent home on anti-tuberculous treatment and vitamin supplements after a total hospital stay of 66 days. On last telephonic conversation with family the patient was reported as thriving well, gained weight and was asymptomatic.
Figure 4: X-ray chest satisfactory lung expansion.