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Ana Margarida Garcia1; Flora Candeias1; Marta Oliveira2; Oliveira Santos3; Carlos Martelo4; Maria João Brito1

1- Infectious Diseases Unit, Hospital de Dona Estefânia, CHLC-EPE, Portugal
2- Pediatric Intensive Care Unit, Hospital de Dona Estefânia, CHLC-EPE, Portugal
3- Pneumology Unit, Hospital de Dona Estefânia, CHCL-EPE, Portugal
4- Department of Cardiothoracic Surgery, Hospital de Santa Marta, CHLC-EPE, Portugal

- 9th World Congress of the World Society for Pediatric Infectious Disease, Rio de Janeiro, 18-21 de Novembro de 2015 (Poster)

Introduction: Miliary tuberculosis (MT) is one of the leading infectious cause of death worldwide. A high index of clinical suspicion for early diagnosis and timely treatment institution can be lifesaving.
Case report: A thirty-five-day-old infant presented with fever and cough. Vancomycin, cefotaxime and gentamicin was initiated without clinical improvement. The chest radiography revealed a reticulonodular infiltrate. BCG immunization was performed at birth. Tuberculin skin test was anergic but IGRA (TSpot) was positive and the acid-fast smear and culture of bronchoalveolar lavage and gastric aspirate identified Mycobacterium tuberculosis. Additional investigation also showed choroidal tubercles, mediastinal lymph nodes enlargement, pleural and pericardial effusion and hepatosplenomegaly. HIV serology was negative. Isoniazid, rifampin, ethambutol, pyrazinamide and prednisolone was instituted. A progressive respiratory distress and hypoxemia was noted and computed tomography scan revealed a macropseudocyst formation in right upper lobe, with compression of trachea and principal bronchi. A percutaneous drainage of the cavity followed by a superior right lobectomy was necessary. Hemophagocytic syndrome was diagnosed later, but given the clinical stability of the patient, no specific chemotherapy was initiated. No alteration was identified on primary immunodeficiency screening. Screening of contacts revealed pulmonary tuberculosis of father, tuberculosis infection of mother (without genital tuberculosis) and seven additional cases at the father´s work place.
Conclusion: In Portugal, tuberculosis remains an important public health issue, despite routine BCG immunization at birth. The diagnosis of miliary tuberculosis can be a challenge. The absence of clinical improvement with a specific therapy should prompt a search for an eventual complication. 

Palavras-chave: miliary tuberculosis; Mycobacterium tuberculosis; hemophagocytic syndrome