Subcutaneous emphysema as the first relevant clinical sign of complicated tubercular lymph node disease in a child

Nicola Principi,Alberto Giannini,Samantha Bosis,Edoardo Calderini,Mario Nosotti,Nicola Bonelli,Susanna Esposito,Pietro Biondetti

doi:10.1186/1471-2334-13-461

Abstract

BackgroundChildren 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.Case presentationA 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.ConclusionsThis 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.

Highlights

Children make up a significant proportion of the global tuberculosis (TB) caseload, and experience considerable TB-related morbidity and mortality
This is the first case in which subcutaneous emphysema (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
SE and pneumomediastinum are relatively common in critically ill patients affected by blunt or penetrating trauma, soft-tissue infections, or any condition that creates a gradient between intra-alveolar and perivascular interstitial pressures [9]

Summary

Conclusions

SE and pneumomediastinum are relatively common in critically ill patients affected by blunt or penetrating trauma, soft-tissue infections, or any condition that creates a gradient between intra-alveolar and perivascular interstitial pressures (as in the case of inappropriate mechanical ventilation or foreign body inhalation) [9] In children, they can occur at birth, or as a consequence of violent cough or straining at defecation, or during a severe asthma attack ( in subjects treated with inhaled bronchodilators and nebulisation) [10], or during the course of infectious diseases such as staphylococcal pneumonia [11], measles [12], Pneumocystis jiroveci pneumonia [13], influenza [14], bronchiolitis [15] or pertussis [16].

Background

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