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.