GP70 Pulmonary miliary tuberculosis in a toddler after initial presentation with tuberculous meningitis

<h3>Introduction</h3> Even though tuberculosis is considered to be a rare disease in developed countries, Romania is facing an important public health problem despite the fact that every newborn receives a BCG vaccine in maternity. <h3>Case report</h3> We report a case of a 1 year and 9 months age female toddler from the roma community, otherwise previously healthy, born outside of Romania therefore she was not immunized against tuberculosis who presented with fever, choreiform movements, malaise, fatigue, anorexia, vomiting and generalized seizure. Clinical assessment showed positive signs of meningeal irritation and a Glasgow Coma Score of 8–9/15. CSF studies showed lymphocytosis and decreased glucose suggesting TB etiology. Thoracic radiography revealed the presence of a right hilar adenopathy and confluent right pericardial lesions. Head CT showed internal hydrocephalus and right maxillary sinusitis confirmed by MRI which also revealed areas of infarction and multiple inflammatory lesions suggestive of meningeal inflammation. <i>M. tuberculosis</i> was not detected in CSF PCR and cultures were negative. Considering close household contact with uncle and grandmother with active TB disease, the diagnosis of TB meningoencephalitis was made. Treatment with tetra conjugated tuberculostatics, corticosteroids and anticonvulsants was started. The patient continued to deteriorate so she had a temporary external CSF drainage placed. In evolution she developed cerebral venous and arterial thrombosis and she was started on anticoagulants. Consequently, she developed cortical blindness. Despite all this her state gradually improved and she was discharged after 70 days to follow anticonvulsant and tuberculostearic treatment at home but she was lost to follow up. After 9 months the mother interrupted treatment by her own will and she returned to the hospital a year after the first admission with high fever and presenting generalized seizures. Neurologic assessment showed a delay in language and mental retardation, normal sight. Thoracic radiography revealed hilar adenopathy and miliary aspect. Etiologic treatment was initiated and she was discharged to continue antituberculous treatment being closely monitored by a pneumologist, with favorable outcome. <h3>Discussion</h3> The case has an emotional and social impact, the patient coming from the roma community, without social security number thus impossibility of receiving treatment on the national programme, unimmunized, raising the question of BCG vaccination of certain ethnic groups regardless of the country of birth.