The challenges in diagnosing isolated epididymal tuberculosis (TB) in an adolescent male: a case report.

BACKGROUND: Genitourinary tuberculosis (GUTB) is a common form of extrapulmonary TB (EPTB) in children. An example of GUTB is epididymal TB, which usually presents unspecific chronic clinical manifestations. Definitive diagnosis can be conducted based on bacteriologic confirmation and histopathologic results, but this is challenging due to the paucibacillary nature of EPTB. Therefore, we reported the challenges in diagnosing isolated epididymal TB in an adolescent male. CASE PRESENTATION: A 16-year-old male presented to respirology clinic with painful swelling of the left scrotum for 3 months before visiting to the hospital. The symptoms were associated with persistent coughing for 2 months, and physical examination of the left scrotum showed swelling accompanied by cardinal signs. A palpable hard mass was found on the left scrotum, with firm borders, measuring 7 × 4 cm. Laboratory examination and tumor markers were within normal limits, although leukocyturia was found, and the urine culture was negative. Genital ultrasound (US) showed epididymitis sinistra with septal hydrocele, while magnetic resonance imaging (MRI) indicated inhomogeneous left epididymitis with bilateral inguinal lymph node enlargement. Although TB evaluation presented a negative purified protein derivative (PPD) test and bacteriologic examination, chest X-ray (CXR) showed perihilar lymphadenopathy. Based on the clinical and radiologic results suggesting TB, the patient was diagnosed with isolated epididymal TB and received quadruple antituberculosis therapy (ATT) for 6 months. After treatment, the left testicle size started to shrink and was equal to the right testicle, also, there were no signs of inflammation, the body weight increased by 5 kg, and cough disappeared. Sperm analysis at the end of treatment indicated teratozoospermia, which was subsequently treated by the urologic surgery department. CONCLUSIONS: Biopsy and bacteriologic confirmation for TB epididymitis were challenging to perform in the clinical setting. Epididymal TB should be considered in adolescent males with complaints of chronic scrotal swelling and pain. Clinical judgment based on history taking, physical examination, and radiologic features supporting TB features could be helpful in accurate and fast diagnosis for favorable outcome.

Mediastinal teratoma in children: A case series of misdiagnoses in a high-endemic tuberculosis setting.

INTRODUCTION AND IMPORTANCE: Mediastinal teratoma is a rare extragonadal teratoma that frequently manifests with non-specific symptoms and is commonly misdiagnosed, particularly in Indonesia, where tuberculosis (TB) is endemic. CASE PRESENTATION: Herein, we present two cases of children aged 19 months and 17 years old who were referred with chronic nonspecific symptoms of cough, tachypnea, chest pain, and hemoptysis. Both children were initially diagnosed with TB and both completed anti-tuberculosis treatment. After visiting several healthcare facilities, a mediastinal mass was finally diagnosed and they all underwent thoracotomy without any further complication. The histopathology findings revealed mature teratoma. All patients had satisfactory outcomes at follow-up visits. CLINICAL DISCUSSIONS: Patients presented with non-specific symptoms are often clinically diagnosed with TB. However, primary healthcare doctors should consider other differential diagnoses when a child has non-specific respiratory symptoms, especially when chest X-ray findings are nonspecific and TB workup is negative. CONCLUSIONS: The diagnosis of mediastinal masses is still challenging in Indonesia, as the diagnosis requires a vast array of work-up examinations, therefore, early recognition and referral are crucial for management.

Diagnostic challenges of an atypical presentation of ear and mastoiditis tuberculosis in a-5-year-old child in a developing country: A case report and review of literature.

We report a case of a 5-year-old girl who came to Otolaryngology Outpatient Clinic of our hospital with the chief complaint of recurrent ear discharge which had started to appear since 3 years ago and had recurred every month despite repeated antibiotics and antifungals ear drops treatments, given by general practitioners and otolaryngologists. Gram staining, acid-fast staining and Mycobacterium tuberculosis culture examination from the discharge had never been conducted. There was a history of inadequate weight increment since she was 2 years old. Her uncle who often met her died about 6 months ago due to TB disease. She was initially diagnosed with otitis media from the previous clinicians before finally referred to our hospital due to the perforated tympanic membrane. Otoscope examination showed perforated tympanic membrane. CT scan showed right osteomastoiditis with cholesteatoma with destruction of right mastoid antrum and right ear bone. We did not find pale-looking granulomatous tissue or multiple perforated tympanic membrane. The patient was diagnosed with chronic suppurative otitis media (CSOM) of the right ear with right mastoiditis and right posterior auricle fistulae. Afterwards, canal wall up, canaloplasty, mastoid obliteration, tympanoplasty, and rotational flap right ear were performed. Histopathology examination revealed the presence of caseous necrosis and datia langhans cells. Based on her chronic illness supported by the histopathological findings, anti-tuberculosis therapy was commenced. No more ear discharge complained and her body weight started to increase after oral anti tuberculosis treatment.

Polymorphisms of SLCO1B1 Gene in Sundanese Ethnic Population of Tuberculosis Patients in Indonesia.

BACKGROUND: The blood level of rifampicin, one of the tuberculosis (TB) drugs, depends on the organic anion transporting polypeptide 1B1 (OATP1B1) in hepatocytes. This protein is encoded by the solute carrier organic anion 1B1 (SLCO1B1) gene. Its genetic variation has been reported to have an impact on clinical outcomes and drug efficacy. However, the polymorphism in the SLCO1B1 gene has not been examined in Indonesia yet. We aimed to identify the frequency of polymorphism in SLCO1B1 gene among pulmonary TB patients in Bandung, Indonesia. METHODS: Cross-sectional study was conducted in West Java. 145 pulmonary TB patients who were treated with first-line drugs treatment (including rifampicin 450 mg daily) were analyzed for polymorphism in SLCO1B1 gene. Patients aged between 18-64 years old and mainly came from Sundanese ethnic group (92.4%). Genetic variants were detected using Polymerase Chain Reaction (PCR) and Sanger sequencing. RESULTS: Polymorphism of c.463C>A(rs11045819) was not identified, while heterozygous and homozygous polymorphism of c.85-7793C>T(rs4149032) were identified in 74 (51.0%) and 56 (38.6%) patients, respectively. The minor allele frequency (MAF) of T (mutant) allele of c.85-7793C>T(rs4149032) was 64.13% (186/209), higher than in the general population, which the MAF of rs4149032 is 53.6% based on 1000 genome database. CONCLUSION: This study highlights the presence of different allele frequencies of polymorphisms within the population, which might affect treatment outcomes.

Convalescent plasma therapy in obese severe COVID-19 adolescents: Two cases report.

BACKGROUND: In Indonesia, 175 cases resulted in death in children from March to December 2020. Studies regarding Convalescent Plasma Therapy's (CPT) safety and efficacy in children are scarce. Our case report was the first to write CPT in Indonesian children. CASE PRESENTATION: In our case, two obese children with progressive shortness of breath, worsening cough, and high fever, the findings met severe COVID-19 criteria. We performed CPT for these patients and the patient's condition was improved and able to be discharged. DISCUSSION: Severe COVID-19 with or without comorbid was the indication of CPT which had been approved by the U.S. FDA and Indonesian Pediatrics Society. The key factors associated with CPT efficacy were the donor's titer antibody, the treatment time point, and the patient's comorbidities. The clinical impact showed an improvement by the combination therapy of CPT and remdesivir. CONCLUSION: We noted that CPT might be well tolerated, could improve the clinical impact of severe COVID-19 in adolescents, and have no adverse events as well. CPT for severe COVID-19 cases in children had the potential to be developed in studies with better designs and stronger levels of evidence.

Unusual Recurrence of Antituberculosis Drug-Induced Hepatotoxicity in Children: A Case Series.

BACKGROUND Antituberculosis drug-induced hepatotoxicity (ADIH) is a possible adverse event of antitubercular treatment. There are still no official guidelines for ADIH management in children. Recurrent ADIH is infrequently reported. CASE REPORT In this article, we report 6 unusual cases of recurrent ADIH in children. Five children developed ADIH during the intensive phase. Streptomycin and ethambutol were given to those with tuberculosis meningitis, urinary tract tuberculosis, and one patient with pulmonary tuberculosis with HIV infection and cardiac comorbidities. Five patients experienced a second ADIH episode after reintroduction. One patient developed ADIH symptoms again before reaching a full dose of isoniazid. The patient with pulmonary tuberculosis, HIV infection, and dilated cardiomyopathy experienced secondary episodes of ADIH and received levofloxacin and ethambutol as additional drugs. CONCLUSIONS Recurrent ADIH is relatively uncommon in children but may be encountered in daily practice. Reintroduction of previous treatment regimens should be tailored individually. There is an urgent need for standardized guidelines for ADIH in children.

The role of flexible bronchoscopy in lung tuberculosis mimicking mediastinal mass in an Infant: A rare case report.

Tuberculosis (TB) is a systemic disease that can affect all parts in the body. The clinical manifestations sometimes mislead to other diagnoses. Mediastinal mass-like of TB in children is a rare manifestation. A 5-month-old boy presented to our hospital with respiratory distress, fever for 2 months, body weight loss, cough, and history of recurrent pneumonia. The lung sound decreased on the right hemithorax. Lung computed tomography revealed multiple irregular cysts with thick walls on the anterosuperior mediastinal area, consolidation on the right lobe, and suspected gangrenous lung disease. The right main bronchus stenosis with cheesy-like vegetation was found on flexible bronchoscopy procedure. Xpert/MTB RIF from bronchoalveolar lavage revealed Mycobacterium tuberculosis and sensitive to rifampicin. Anti-TB drugs were given for 12 months. He has clinical and radiological improvement. We must increase the awareness of TB disease in case of mediastinal mass-like appearance in the high-endemic area. The flexible bronchoscopy plays an important role in diagnostic purpose.

Multifocal Osteomyelitic Tuberculosis at Rare Locations with Metastatic Tuberculosis Abscess.

BACKGROUND Multifocal tuberculosis (TB) with more than 1 tuberculous osteoarticular lesion is rare. Furthermore, metastatic tuberculous abscess (MTA) is also a very rare manifestation of cutaneous TB in children. A non-specific, often subtle, early clinical presentation in conjunction with a low prevalence rate constitute obstacles for diagnosis. CASE REPORT A 9-years old female patient was referred to Hasan Sadikin Pediatric Respirology Outpatient clinic from the Orthopedic Department with lumps at the left elbow joint, lateral side of the left hand, and lateral side of the left foot. Fine needle aspiration biopsy of the lumps suggested a chronic inflammation due to TB. The patient was then started with a course of anti-TB drugs consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol. During the treatment course, she experienced anti-TB drug-induced hepatotoxicity (ADIH). We then switched the regimen to streptomycin and ethambutol for 2 weeks, then reintroduced treatment with the modified British Thoracic Society guidelines regimen. The nodules appeared shrunken after 3 months of treatment with anti-TB drugs. CONCLUSIONS Increased awareness of unusual manifestations of TB will likely allow for proper diagnosis and management of this common infection. Accordingly, timely diagnosis and management will prevent further debilitating sequelae.

Unrecognized and delayed to diagnose of adolescence tuberculosis case in a boarding school in West Java, Indonesia.

Adolescent is a high-risk population for developing tuberculosis (TB) disease, unfortunately adolescence TB remains to be neglected. Clinical manifestations of TB are usually chronic and nonspecific that could be mimicking other disease. Unrecognized TB disease will lead to misdiagnosis, delayed, and inappropriate management. A 15-year-old female adolescent, admitted to the hospital due to severe anemia, loss of body weight accompanied with recurrent fever and tend to be easily tired. She was through investigation for hematology disorder with normal results. She was studying in a Muslim boarding school with overcrowded environment. History of contact with TB patient was unclear. Tuberculosis diagnosed based on positive genXpert result, detected sensitive to rifampicin Mycobacterium tuberculosis although acid-fast bacilli sputum smear and culture yielded results were negative. Worsening of the chest X-ray were obtained, initially showed infiltrate of the lung and then revealed bronchogenic spread. Lymph nodes enlargement of the neck-proven TB from fine-needle aspiration biopsy. Anti-TB drugs were started, and after the treatment, there were clinical improvement. TB among adolescents against many unique challenges such as difficulty in case detection, wider potential transmissions and problem on adherence; hence, this age group should be identified as a primary issue in the community.

Role of combined zinc, vitamin A, and fish oil supplementation in childhood tuberculosis.

This objective of this study was to determine benefit of one month combined supplementation (zinc, vitamin A, fish oil) along with anti-tuberculosis drugs (ATD) on increasing serum leptin levels and decreasing tumor necrosis factor-alpha (TNF-alpha) in children with tuberculosis (TB). A quasi experimental study was conducted on 22 children (aged 5-14 years) with a positive acid-fast bacilli (AFB) smear. The children were divided into 2 groups. A history, physical examination, anthropometric measurements, serum leptin levels, TNF-alpha levels, retinol and zinc levels were examined in all subjects before and after treatment. Nutritional supplementation and ATD were given to group I while ATD only were given to group II. The change in leptin, TNF-alpha, retinol and zinc levels were analyzed with the Mann-Whitney test, while a t-test was used to determine changes in body mass index (BMI). Group I had a higher significant increase in serum leptin levels than group II (p=0.034). Group I had a significantly greater decrease in TNF-a levels than group II (p=0.032). No significant differences in retinol or zinc levels were seen between the two, but both groups had an increase after treatment. Both groups had a significant increase in BMI (p=<0.001) post-treatment compared to pre-treatment. Supplementation with zinc, vitamin A and fish oil is associated with a significant increase in leptin levels and a significant decrease in TNF-alpha levels among children treated for TB. No significant benefit was seen in BMI among children receiving supplementation compared to those without it, although ATD resulted in a significant increase in BMI in both groups.