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CASE 1: PRESENTATION
PAEDIATRIC RESPIRATORY REVIEWS (2001) 2, 195–196 doi:10.1053/prrv.2001.0131, available online at http://www.idealibrary.com on
SELF ASSESSMENT
Short case presentations CASE 1: PRESENTATION A previously well 3-year-old boy developed a lump under his left armpit. He was unable to hold his arm by his side. By the time the lump was ‘the size of a golfball’, his mother noticed some bruising around the swelling (Fig.1). Two weeks later he developed swelling over his left ankle which occurred over a 24-hour period. The ankle swelling persisted for about 4 weeks and caused the boy to limp intermittently but during this time the axillary swelling got smaller. Otherwise he was well with no obvious weight loss. He was referred to an orthopaedic surgeon who aspirated his left ankle joint. The effusion appeared sterile. A few weeks later he had an X-ray of his ankle which was normal, and a bone scan which showed increased uptake in the ankle (Fig. 2). He underwent exploration of his ankle and biopsy. Histology revealed inflamed synovium with non-caseating granulomas and giant cells. Auramine staining was negative for mycobacteria. He received a 2week course of intravenous Augmentin, followed by 1 week of oral antibiotics. After 8 weeks, culture of the ankle aspirate grew Mycobacterium tuberculosis. Two weeks after starting treatment there was an increase in swelling of the axillary mass and a recurrence of the swelling over his ankle. A CT scan revealed a large mass in the left axilla with stretching of the axillary artery over its upper aspect (Fig. 3). Methylprednisolone followed by oral prednisolone for 6 weeks was added to his treatment regime.
4. What other important course of action needs to be taken?
1. What is the initial differential diagnosis? 2. What further investigations need to be performed? 3. What treatment regime would you commence and for how long?
Figure 1
Figure 2
Figure 3
1526–0550/01/020195 + 02 $35.00/0
© 2001 Harcourt Publishers Ltd
SELF ASSESSMENT
Short case presentations CASE 1: PRESENTATION A previously well 3-year-old boy developed a lump under his left armpit. He was unable to hold his arm by his side. By the time the lump was ‘the size of a golfball’, his mother noticed some bruising around the swelling (Fig.1). Two weeks later he developed swelling over his left ankle which occurred over a 24-hour period. The ankle swelling persisted for about 4 weeks and caused the boy to limp intermittently but during this time the axillary swelling got smaller. Otherwise he was well with no obvious weight loss. He was referred to an orthopaedic surgeon who aspirated his left ankle joint. The effusion appeared sterile. A few weeks later he had an X-ray of his ankle which was normal, and a bone scan which showed increased uptake in the ankle (Fig. 2). He underwent exploration of his ankle and biopsy. Histology revealed inflamed synovium with non-caseating granulomas and giant cells. Auramine staining was negative for mycobacteria. He received a 2week course of intravenous Augmentin, followed by 1 week of oral antibiotics. After 8 weeks, culture of the ankle aspirate grew Mycobacterium tuberculosis. Two weeks after starting treatment there was an increase in swelling of the axillary mass and a recurrence of the swelling over his ankle. A CT scan revealed a large mass in the left axilla with stretching of the axillary artery over its upper aspect (Fig. 3). Methylprednisolone followed by oral prednisolone for 6 weeks was added to his treatment regime.
4. What other important course of action needs to be taken?
1. What is the initial differential diagnosis? 2. What further investigations need to be performed? 3. What treatment regime would you commence and for how long?
Figure 1
Figure 2
Figure 3
1526–0550/01/020195 + 02 $35.00/0
© 2001 Harcourt Publishers Ltd