Tuberculosis in an Adoptee

December 2007

Case History

A 6-year-old girl presented to her pediatrician with decreased hearing acuity found by routine elementary-age screening. She had been adopted from a Korean orphanage at 9 months of age and had a history of poor growth there. She had scarlet fever and pneumonia prior to the age of 4, but no other recent significant illnesses since adoption. Adoption records did not indicate vaccination with BCG and she had no vaccination scar. She had four documented Tine tests (multi-puncture test for TB infection) during the adoption process, all of which were negative. She had a Tine test at a community hospital prior to presenting to her physician, results of which are unknown.

In response to her abnormal hearing test, she underwent bilateral irrigations to remove wax. Smears and cultures of the drainage fluid were negative. For the next two years she continued to suffer recurrent mild to moderate hearing loss, and was finally referred to an otolaryngologist, who performed bilateral myringotomy and placement of tympanostomy tubes four years after first presenting with hearing problems. Mucopurulent fluid was noted in the middle ear. Because of persistent drainage, cortisporin drops were begun. Tobradex drops were begun 2 weeks later. After one month on treatment, drainage had subsided in the right ear with cortisporin and Tobradex drops and suctioning; drainage persisted in the left ear. Audiology testing showed progressive hearing loss and testing 2 months later revealed hearing loss with very viscid mucus or possible scar bands. Treatment with topical and oral antibiotics continued. However, hearing loss and drainage persisted, despite intermittent treatment with topical tobramycin, gentamicin and amoxicillin. An allergist diagnosed allergic rhinitis and atopic dermatitis, and an antihistamine was administered. Hearing loss persisted, and otorrhea continued in the right ear.

Six months later (December), right tympanomastoidectomy and ossiculoplasty with tympanic membrane reconstruction and left ear exploration were performed. Postoperative diagnoses were right chronic otorrhea and mastoiditis, right hearing loss and incus erosion, and left hearing loss with middle-ear granulomas. All cultures were negative for bacteria, acid-fast bacilli and fungus. The pathology report mentioned granulation tissue. A left tympanomastoidectomy was performed 4 months later and a ventilating tube was placed. Biopsy of the left ear was reported as cholesteatoma. Further consultation demonstrated no evidence of immune deficiency or autoimmune disease.

In April of the next year, earaches and hearing loss were still reported. The middle ear tubes were completely crust covered, and were replaced. The middle ear fluid grew acid-fast bacilli. A TST gave a reading of 20 mm induration. Chest radiograph demonstrated a 3 cm extrapleural paraspinous cold abscess in the left lung apex and calcified lesions of healed primary tuberculosis cervical spine x-ray demonstrated tuberculous spondylitis at C7 and T1 with spine compression and marked gibbus formation. Isoniazid, rifampin, pyrazinamide and ethambutol were initiated on May 18. The initial culture of ear drainage eventually grew pansensitive Mycobacterium tuberculosis. Marked improvement in the appearance of the ears was found. A hearing aid greatly improved her ability to function in school. A pediatric orthopedist recommended surgical stabilization of the spinal deformities.

Teaching Points

References

Barnett, E. D. (2005). "Immunizations and infectious disease screening for internationally adopted children." Pediatric Clinics of North America 52(5), pp. 1287-309.

CDC, American Thoracic Society, et al. (2003). "Treatment of tuberculosis. [erratum appears in MMWR Recommendations & Reports, 2005 Jan 7;53(51):1203 Note: dosage error in text]." Morbidity & Mortality Weekly Report Recommendations & Reports 52(RR-11), pp. 1-77.

Cohen, T. and M. Murray (2005). "Incident tuberculosis among recent US immigrants and exogenous reinfection." Emerging Infectious Diseases 11(5), pp. 725-8.

Khan, A., T. R. Sterling, et al. (2006). "Lack of weight gain and relapse risk in a large tuberculosis treatment trial.[ see comment]." American Journal of Respiratory & Critical Care Medicine 174(3), 344-8.

Mandalakas, A. M., H. L. Kirchner, et al. (2007). "Predictors of Mycobacterium tuberculosis infection in international adoptees." Pediatrics 120(3), pp. e610-6.

Mazurek, G. H., M. E. Villarino, et al. (2003). "Guidelines for using the QuantiFERON-TB test for diagnosing latent Mycobacterium tuberculosis infection. Centers for Disease Control and Prevention." Morbidity & Mortality Weekly Report Recommendations & Reports. 52(RR-2), pp. 15-8.

Nalini, B. and S. Vinayak (2006). "Tuberculosis in ear, nose, and throat practice: its presentation and diagnosis." American Journal of Otolaryngology 27(1), pp. 39-45.

Heartland National TB Center
2303 SE Military Drive
San Antonio, Texas 78223
Phone: 1 (800) TEX-LUNG
Fax: (210) 531-4590
http://www.heartlandntbc.org/