Isoniazid- and Streptomycin-Resistant Miliary Tuberculosis Complicated by Intracranial Tuberculoma in a Japanese Infant

Isoniazid- and Streptomycin-Resistant Miliary Tuberculosis Complicated by Intracranial Tuberculoma in a Japanese Infant

NARUHIKO ISHIWADA,¹ OSAMU TOKUNAGA,² KOO NAGASAWA,³ KEIKO ICHIMOTO,³ KAORI KINOSHITA,³ HARUKA HISHIKI³ and YOICHI KOHNO³

¹Division of Control and Treatment of Infectious Diseases, Chiba University Hospital, Chiba City, Chiba, Japan
²Department of Pediatrics, National Hospital Organization Minami-Kyoto Hospital, Joyo City, Kyoto, Japan
³Department of Pediatrics, Chiba University Graduate School of Medicine, Chiba City, Chiba, Japan

In Japan, the incidence of severe pediatric tuberculosis (TB) has decreased dramatically in recent years. However, children in Japan can still have considerable opportunities to contract TB infection from adult TB patients living nearby, and infants infected with TB may develop severe disseminated disease. A 3-month-old girl was admitted to our hospital with dyspnea and poor feeding. After admission, miliary TB and multiple brain tuberculomas were diagnosed. Anti-tuberculous therapy was initiated with streptomycin (SM), isoniazid (INH), rifampicin and pyrazinamide. Symptoms persisted after starting the initial treatment and mycobacterial cultures of gastric fluid remained positive. Drug sensitivity testing revealed the TB strain isolated on admission as completely resistant to INH and SM. Treatments with INH and SM were therefore stopped, and treatment with ethambutol and ethionamide was started in addition to rifampicin and pyrazinamide. After this change to the treatment regimen, symptoms and laboratory data gradually improved. The patient was treated with these four drugs for 18 months, and then pyrazinamide was stopped. After another 2 months, ethambutol was stopped. Treatment of tuberculosis was completed in 24 months. No adverse effects of these anti-TB drugs were observed. The patient achieved a full recovery without any sequelae. On the other hand, the infectious source for this patient remained unidentified, despite the extensive contact investigations. The incidence of drug-resistant TB is increasing in many areas of the world. Continuous monitoring for pediatric patients with drug-resistant TB is therefore needed.

keywords —— infant; isoniazid-resistant; Japan; miliary tuberculosis; tuberculoma

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Tohoku J. Exp. Med., 2013, 229, 221-225

Correspondence: Naruhiko Ishiwada, Division of Control and Treatment of Infectious Diseases, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba 260-8677, Japan.

e-mail: ishiwada@faculty.chiba-u.jp