CASE PRESENTATION:
A 9-year-old male child was presented to the paediatrics department with his mother, reporting symptoms of fever and persistent cough of one month duration, associated with acute respiratory distress. The fever was sudden in onset, low grade, and associated with chills. There were no aggravating factors, and it was alleviated through the use of medication. The child was active during the period between febrile episodes. The cough was productive, not associated with aggravating factors, and not relieved by medications. A history of weight loss and loss of appetite were present. There were no similar complaints among his family members.
The patient had a past medical history of fever and myalgia, which was diagnosed as typhoid fever. He had been given all the scheduled immunisations, including BCG, without experiencing any significant adverse effects.
On examination, the patient was thin-built, not active, and oriented to time, place, and person. The patient was tachypnoeic (38/min), afebrile, and hemodynamically stable. Cervical lymph nodes were palpable, nontender, firm, and 2-3 in number on both sides. A chest examination revealed bilateral crepitations in the mammary, infra-mammary, axillary, and infra-axillary regions. Other systems revealed no abnormalities.
Initial blood investigations (Table 1)  revealed a total leucocyte count (TLC) of 36,000 cells per cubic mm, a differential count of neutrophils of 11%, lymphocytes (13%), and eosinophils of 72%. A peripheral smear showed normocytic normochromic blood with eosinophilic leucocytosis. The absolute eosinophil count (AEC) was 25,920 cells per cubic mm. Liver function tests (LFT) and renal function tests (RFT) were normal. Hepatitis B surface antigen, anti-hepatitis C antibody, and Human Immunodeficiency Virus (HIV-1 and HIV-2) ELISA results were all negative. Mantoux’s skin test was negative. He underwent additional tests, including a peripheral smear for microfilaria, the Widal test, the Dengue NS1 antigen test, toxoplasmosis serology, and sputum fungal staining, all of which were negative. Blood, urine, and stool cultures were also negative. The bone marrow aspiration performed to rule out eosinophilic leukaemia showed a negative result.
A chest X-ray revealed diffuse nodular calcifications in bilateral lungs involving all zones (Figure 1) . High-resolution computed tomography (HRCT) chests show multiple tiny (2–3 mm) centrilobular and peri-broncho-vascular branching nodular densities noted scattered diffusely and equally in bilateral lungs, both in the upper and lower lobes (Figure 2) . Ultrasound (US) of the chest showed mild left-sided pleural effusion with lung consolidation and collapse. The US neck detected sub-centimetrically enlarged cervical lymph nodes (7-8 mm). ZN stain and cartridge-based nucleic acid amplification test (CBNAAT) tests on sputum samples produced normal results.
The child was initially started on amoxicillin and clavulanic acid (a combination antibiotic). Due to his raised eosinophil count, the child was given diethylcarbamazine. Other symptomatic and supportive treatment was given with intravenous fluids, pantoprazole, paracetamol, Lactic Acid Bacillus (a probiotic), and nebulisations with 3% normal saline and levo salbutamol. Chest physiotherapy and spirometric exercises were advised. In view of radiologically diagnosed pulmonary tuberculosis, the patient’s regimen shifted to anti-tubercular therapy (ATT) with a fixed-dose combination of isoniazid, rifampicin, pyrazinamide, and ethambutol with pyridoxine. Complaints of coughing and difficulty breathing subsided at the time of discharge. At one-month follow-up, his eosinophil counts returned to normal levels.