An 8-year-old girl developed persistent daily fever, weight loss, and cough for two months. Her grandmother had pulmonary tuberculosis 15 months prior to the onset of symptoms. The family sought medical advice first in a local hospital where investigations revealed bilateral pneumonia, left-sided pleural effusion, and bilateral pulmonary nodules. There was a history of animal contact but no raw milk ingestion. She had normal bowel habits with no jaundice, dysphagia or any other GI symptoms. She had no neurological, rheumatological, ophthalmologic, or dermatological symptoms.
Examination
Physical examination revealed a pale girl at the 10th percentile for weight and height and hepatosplenomegaly. The laboratory examination was remarkable for anaemia (haemoglobin 7.9 g/dL), erythrocyte sedimentation rate (ESR) of 120 mm/h, and an alanine aminotransferase of 75 U/L (normal, 0-35 U/L), serum calcium 2.6 mmol/L, and low albumin level 31 g/L. Abdominal computed tomography (CT) revealed hepatosplenomegaly and hypodense non-enhancing lesions throughout the liver (variable in size from a few millimetres to 3 centimetres), and multiple enlarged abdominal lymph nodes. Chest CT scan showed basal and peripheral nodular opacities. Tests for mycobacterium tuberculosis (MTB), including tuberculin skin test and serum QuantiFERON showed negative results. Liver biopsy showed noncaseating granulomas. In light of the strong epidemiological exposure, antituberculous medications were initiated (combination of isoniazid, pyrazinamide, ethambutol, and rifampicin). Despite compliance with treatment and proper dosing, the patient persisted to be febrile with further weight loss.
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