Tuberculosis commonly
presents as insidious illness and septicemic
shock is its rare presentation, mostly reported
in HIV patients[1-3]. We report here a case of
septicemic shock due to tuberculosis in a child
with Down syndrome.
Case report
A 16 year old boy, known case
of Down syndrome, was brought with history of
fever and cough for 2 weeks, and cold
extremities and breathing difficulty for last 12
hours. There was no history of diarrhea,
vomiting or blood loss. Child was fully
vaccinated for age and had a BCG scar. Capillary
refill time was prolonged, heart rate was
160/min and blood pressure was 80/60 mm Hg
(below 5th
centile). Except for bilateral crepitations,
systemic examination was normal. Child was
managed on lines of septicemic shock. Normal
saline bolus, antibiotics, vasopressor support,
oxygen and packed red cell transfusion were
given.
Hemogram revealed hemoglobin
8 g/dl, total leucocytes count (TLC) 8600
cells/cubic mm, platelet count-2,10,000/cubic
mm. X-ray chest suggested patchy
opacities with multiple cavitatory lesions in
both lungs. Sonography of abdomen was normal.
Echocardiogram revealed normal structural and
functional cardiac condition. Blood culture was
sterile. Widal test was negative. Sputum
microscopy examination revealed acid fast
bacilli (AFB) (Mycobacterium tuberculosis).
Child was started on 4 drug antitubercular
treatment (ATT). Hemodynamic improvement started
on day 3 and vasopressor treatment was gradually
withdrawn by day 6 of admission. Oxygen support
was gradually withdrawn and weaned off on day 7
of admission. Category I Direct Observed
Treatment Short course (DOTS) [4] was started
and patient was discharged after 10 days of
admission. Patient is on regular follow up and
has clinically improved considerably. Follow up
chest X-ray after 5 months revealed
fibrocystic changes in the lungs suggestive of
healing tuberculosis. Repeat sputum examinations
(as per DOTS protocol) were negative for AFB.
Discussion
There is an increased
incidence of respiratory infections in children
with Down syndrome. Although every arm of immune
system shows evidence of dysfunction in these
patients, particularly T cells (CD4+ and
suppressor T cells) and NK cells show marked
derangement of number and activity [5-9]. No
data has so far shown difference in incidence of
tuberculosis in this syndrome and general
population [10].
Septicemic shock is commonly
caused by pyogenic organisms. It is reported to
be caused by tuberculosis in immunocompromized
patients only [1-3]. We thus suspected some
immunodeficiency or dysfunction in our case.
This case was HIV negative and had normal total
leukocyte count.
In the absence of adequate
facilities, we were not able to exactly point
out the immune defect in our patient. The
possibility of immune dysfunction in Down’s
syndrome as a cause of shock in mycobacterial
infection can be explored further, in view of
similar presentation seen in cases of acquired
immunodeficiency [2,3].
Contributors: BM,
SN and VKG were involved in clinical management
of the case, literature search and writing the
paper. All authors approved the final
manuscript.
Funding: None;
Competing interests:
None stated.
References
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