Esposito Susanna, Giannini Alberto, Biondetti Pietro, Bonelli Nicola, Nosotti Mario, Bosis Samantha, Calderini Edoardo, Principi Nicola
Pediatric Clinic 1, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy.
BMC Infect Dis. 2013 Oct 4;13:461. doi: 10.1186/1471-2334-13-461.
Children make up a significant proportion of the global tuberculosis (TB) caseload, and experience considerable TB-related morbidity and mortality. Unfortunately, it is not easy to diagnose TB in the first years of life because of the diversity of its clinical presentation and the non-specific nature of most of its symptoms.
A 26-month-old male child was admitted to hospital because of the sudden onset of rapidly increasing swelling of the neck, face and upper trunk a few hours before. Upon admission, his temperature was 36.5°C, pulse rate 120/min, respiratory rate 36/min, and O2 saturation 97% in air. Palpation revealed subcutaneous emphysema (SE) over the swollen skin areas, and an examination of the respiratory system revealed crepitations in the left part of the chest without any significant suggestion of mediastinal shift. Chest radiography showed enlargement of the left lung hilum with pneumomediastinum and diffuse SE. Bronchoscopy was carried out because of the suspicion that the SE may have been due to the inhalation of a peanut. This excluded the presence of a foreign body but showed that the left main bronchus was partially obstructed with caseous material and showed significant signs of granulomatous inflammation on the wall. Contrast-enhanced computed tomography of the lungs confirmed the SE and pneumomediastinum, and revealed bilateral hilum lymph node disease with infiltration of the adjacent anatomical structure and a considerable breach in the left primary bronchus wall conditioning the passage of air in the mediastinum and subcutaneous tissue. As a tuberculin skin test and polymerase chain reaction for Mycobacterium tuberculosis on bronchial material and gastric aspirate were positive, a diagnosis of TB was made and oral anti-TB therapy was started, which led to the elimination of M. tuberculosis and a positive clinical outcome.
This is the first case in which SE was the first relevant clinical manifestation of TB and arose from infiltration of the bronchial wall secondary to caseous necrosis of the hilum lymph nodes. Physicians should be aware of the fact that SE is one of the possible initial signs and symptoms of early TB infection, and act accordingly.
儿童在全球结核病病例中占相当大的比例，并经历相当多与结核病相关的发病和死亡情况。不幸的是，由于其临床表现的多样性以及大多数症状的非特异性，在生命的最初几年诊断结核病并不容易。
一名26个月大的男童因数小时前颈部、面部和上躯干突然迅速肿胀入院。入院时，他的体温为36.5°C，脉搏率120次/分钟，呼吸率36次/分钟，空气中氧饱和度97%。触诊发现肿胀皮肤区域有皮下气肿（SE），呼吸系统检查发现左胸部有捻发音，无明显纵隔移位迹象。胸部X线检查显示左肺门增大伴有纵隔气肿和弥漫性SE。由于怀疑SE可能是吸入花生所致，进行了支气管镜检查。这排除了异物存在，但显示左主支气管被干酪样物质部分阻塞，且管壁有明显的肉芽肿性炎症迹象。肺部增强计算机断层扫描证实了SE和纵隔气肿，并显示双侧肺门淋巴结病变，伴有相邻解剖结构浸润，左主支气管壁有相当大的破损，导致空气进入纵隔和皮下组织。由于支气管材料和胃吸出物的结核菌素皮肤试验及结核分枝杆菌聚合酶链反应呈阳性，诊断为结核病并开始口服抗结核治疗，这导致结核分枝杆菌被清除且临床结果良好。
这是首例SE为结核病首个相关临床表现且由肺门淋巴结干酪样坏死继发支气管壁浸润引起的病例。医生应意识到SE是早期结核感染可能的初始体征和症状之一，并据此采取行动。
