R. Fernandoc Martín, C. Fuertes Rodrigoa, G. Gómez Tenaaa, C. Gargallo Bernadb, J. Galbe Sánchez-Ventura
aMIR-Pediatric.
Hospital Miguel Servet, Zairoza.
Spain. bMIR-Medicine Familiar and Community.
Hospital Miguel Servet, Zairoza.
Spain. cPediatra.
CS Torrero La Paz, Barcelona.
Spain.
1.
F. is a 14-year-old boy, resident in Spain for nine years.
One good day, during the spring, she came directly to the Emergency Department of the reference pediatric hospital for presenting an acute onset of about two hours of evolution of centrothoracic pain without fever, accompanied by air sensation".
There is no history of trauma and you have been coughing for a few days.
Three weeks ago she had a very similar episode.
The examination showed no abnormalities.
The chest X-ray showed an image of consolidation in the right upper lobe.
Diagnosis of probable pneumonia and clarithromycin is prescribed.
Basic laboratory tests and serology for Mycoplasma pneumoniae were requested from the same emergency department.
The results were available in four days; as parameters to assess leukocytes 13 600/μl (formula: 72% neutrophils, 16% lymphocytes and 7.8% monocytes), erythrocyte sedimentation rate IgM 38 mm at the first hour.
1.
1.
Two days later, he came to the PC center with his father to discuss these results and continue with the follow-up.
It is noteworthy that the pediatrician repeated the symptoms for three weeks, absence of fever and density of the radiological image.
When analyzing the available data of the child in the clinical history, it should be noted that five years ago the father presented a picture of tuberculous pneumonia accompanied by pleural effusion and sputum that were positive for Mycobacterium tuberculosis.
These data and history were not provided by the father to the pediatrician who attended the emergency department.
At that time, a normal chest X-ray was performed on the child.
Tuberculin skin test (TST) showed an induration of 20 x 20 mm with blister and sloughing.
The child had been vaccinated with BCG at birth.
Isoniazid was prescribed at the time, which was taken for six months without detecting failures in compliance.
In view of these data, it was decided to repeat the TBNA, which again showed an induration of 20 x 20 mm with bleb and sloughing.
Then, three samples of gastric juice were requested for bacilloscopy and culture, whose results are shown and which were identical in the three samples for both techniques:
• Ziehl-Nielsen stain positive bacilloscopy: no plus-based bacilli are observed in isolates as well as in the polymerase chain reaction (PCR) for Mycobacterium tuberculosis positive; the molecular resistance detection of rifampicin is performed
Neither rpoB mutation was detected, which encodes rifampicin resistance, so it is also interpreted as sensitive in 90% of the strains, so both drugs could be used in the treatment regimen.
• Culture of mycobacteria: isolation at 12 days of Mycobacterium tuberculosis sensitive to streptomycin, etambu, isoniazid, pyrazinamide and rifampicin.
Treatment
Treatment with isoniazid, pyrazinamide and rifampicin was initiated.
Follow-up
After one month of evolution, the general condition is good, but there are doubts on the part of PC Nursing about the correct compliance of the treatment when evaluating the dates of renewal of prescriptions.
At the same time, the father expresses his concern about the child's diet since he eats alone, since parents leave home very soon to work.
This comment from the father together with the doubts of the nurse alert the pediatrician of the possibility of non-compliance with treatment, since he must take several pills in the morning.
The Infectious Diseases Service of the hospital where it is also controlled is informed and a new interview with the father is maintained.
The father says that both he and the mother go home at 06:00 pm to work, leaving the child responsible for taking their medication.
Having said this new information, we insist on the need to give him the medication when he leaves and on the possible consequences that he would not take the medication, from the point of view of both individual and community and health surveillance.
1.
Correspondence address: José Galbe Sánchez-Ventura galbester@gmail.com
