番茄社区

SAN DIEGO -- Ear involvement is a rare, but potentially devastating, manifestation of tuberculosis, as was shown in a case report presented here.

A 3-year-old boy was referred from a local hospital after a week of vomiting, dehydration, and mental status changes, which apparently had begun with an ear infection, explained Amber Machin, of Texas Tech University Health Sciences Center in Lubbock, at the annual meeting of the Society of Hospital Medicine.

The boy had been treated for the otitis media, and prior to referral had been scheduled to have an outpatient tympanostomy tube placed because of presumptive chronic otitis media.

During the week after admission to the tertiary care center, extensive diagnostic tests were performed, including CT and MRI, which demonstrated left lepto-meningeal enhancement suggestive of meningitis, hydrocephalus, and middle ear and mastoid sinus fluid typical of mastoiditis.

Laboratory tests for bacteria, fungi, viruses, and acid-fast bacilli were negative, but empiric broad-spectrum antimicrobial treatment was initiated.

Despite the placement of an extra-ventricular drain to remove fluid, hydrocephalus developed along with palsy of the oculomotor nerve.

The patient failed to respond to antibiotic and antiviral treatment, and mental status continued to worsen, Machin told 番茄社区 during a poster presentation.

"At this point we consulted with the family again, and they admitted having visited the child's great-grandmother in Mexico," she said. The great-grandmother was identified to be the source of infection.

Contact investigation confirmed the relative to be the source of infection, and a T.SPOT.TB test was positive.

A Purified Protein Derivative (PPD) skin test also was positive, with 18 mm induration, so an anti-TB treatment regimen was begun that included rifampin, isoniazid, pyrazinamide, and ethambutol, along with dexamethasone.

A tympanostomy tube was placed and fluid drained, which was cultured and turned out to be positive for Mycobacterium tuberculosis.

The boy's ocular and neurologic symptoms gradually improved, although left-sided weakness and speech problems persisted, requiring 6 weeks of inpatient rehabilitation and ongoing outpatient rehabilitation a year later, according to Machin.

"Ear involvement in [TB meningitis] is unusual, with reports suggesting that 4 in 6,000 persistent, unexplained infections may be tubercular," she said. "A clue to this, particularly when there may have been exposure, is a purulently draining ear infection that doesn't get better with treatment."

In addition, with a clinical picture of purulent drainage from the ear, a chest x-ray may reveal the presence of infiltrates in more than half of cases, further suggesting TB meningitis.

"Hopefully, if the infection is caught at the point when it is limited to otomastoiditis, it won't end up as TB meningitis as happened with this child, who still has some neurologic sequelae," she said.

The group cautioned that the causal relationship between TB meningitis and otomastoiditis was not clear, but that they consider otomastoiditis to be likely source of infection in this case.

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