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| LETTER TO EDITOR |
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| Year : 2022 | Volume
: 70
| Issue : 2 | Page : 796-798 |
Is Tuberculosis or PDA the Truth of the 11-Year-Old-Boy Headache? A Case Report
Yang Liu, Yang Wen, Yu Zhu, Chaomin Wan, Yibin Wang
Department of Pediatrics, West China Second Hospital, Sichuan University; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, People's Republic of China
| Date of Submission | 29-Dec-2019 |
| Date of Decision | 09-Feb-2020 |
| Date of Acceptance | 18-May-2020 |
| Date of Web Publication | 3-May-2022 |
Correspondence Address:
Dr. Yibin Wang
Department of Pediatrics, West China Second Hospital, Sichuan University, No. 20, 3rd Section of Renmin South Road, Chengdu - 610 041
People's Republic of China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.344605
How to cite this article:
Liu Y, Wen Y, Zhu Y, Wan C, Wang Y. Is Tuberculosis or PDA the Truth of the 11-Year-Old-Boy Headache? A Case Report. Neurol India 2022;70:796-8 |
To the Editor,
Tuberculosis (TB) and patent ductus arteriosus (PDA) has been a few described together in some previously reported cases.[1],[2] It has been reported that in the cerebral circulation whose with PDA is marked decrease in flow velocity in the cerebral arteries during diastole.[3] The combined effect of PDA-induced lower blood pressures and left-to-right ductal blood steal lead hypoxic-ischemic of the brain.[4]
An 11-year-old boy presented a pediatric patient diagnosed with TB and PDA for the last 1 month. The subjects presented with sudden onset headache for 10 days ago. On examination, he had fever; no BCG scar and abnormalities were in the neurological examination. The continuous mechanical murmur was heard on the left sternal border. The weight was 22.5 kg, which was lower than the 3% of the peer. The blood pressure was 95/46 mm Hg. The Cardiac Ultrasound revealed PDA (tubular) [Figure 1]. The X-ray revealed a diffuse miliary shadow and patch in the lungs [Figure 2]. Acid-fast bacilli were not found in the sputum. And, the tuberculin skin test (TST) was positive. The interferon-gamma release assays (IGRA) test was strongly positive. The cerebrospinal fluid (CSF) was decreased level for GLU, chloride. The CSF-protein and the count of CSF-nucleated cells were increased, meanwhile no acid-fast bacilli or negative CSF-GeneXpert MTB/RIF assay. The magnetic resonance imaging (MRI) of the brain demonstrated that the meninges and cerebellum were thickened and strengthened, and there were a few abnormal signals in the parenchyma [Figure 3]. The diagnosis of TB meningitis (TBM) was confirmed by the above evidence. | Figure 1: The cardiac ultrasound. (a) Left heart function measurement: EF = 70%, FS = 40%. (b) Color Doppler ultrasound: large blood vessel level and continuous left-to-right shunt, Vmax = 4.4 m/s. (c and d) Two-dimensional and M-mode ultrasound: the left heart was enlarged; left atrium = 43 mm, left ventricular = 61 mm. (e) Pulmonary artery-widening to 31 mm. (f) The PDA with an inner diameter of about 8 mm
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 | Figure 2: The X-ray of the lungs. (a and b) X-ray demonstrated a diffuse miliary shadow and patch in the lungs
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 | Figure 3: The MRI of the brain. (a and b) The meninges were thickened and strengthened. (b and c) The brainstem and cerebellar hemispheres emit abnormal signals, which enhance the obvious ring enhancement. (c) The cerebellum was thickened and strengthened
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Thus, standard anti-TB treatment and diuretics to reduce brain edema 1 week later, the patient's temperature returned to normal. However, headache repeated even worse to vomit, sleepiness. The phenomenon that has been overlooked was the headache is accompanied by a decrease in activity tolerance. The headache was construed as an assumption caused by heart failure courageously. Therefore, digoxin was taken, and the activity of the patient was limited. It's obvious that the patient no longer had headache after 6-day treatment. The PDA was closed with Amplatzer duct occlude (ADO) [Figure 4]. After the intervention, the patient has never any headache, while the blood pressure was 93/52 mm Hg. The patient was discharged well. | Figure 4: The cardiac angiography. (a) Left-to-right ductal shunting. (b) Close PDA with ADO. (c) The ductal shunting was disappeared
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After 3 months, the patient visited the doctor for follow-up with weight gain to 26 kg, improved TB symptoms, disappeared headache at the clinic. CT of the lungs demonstrated patchy shadow is minor than before [Figure 5]. | Figure 5: The CT scan of the lungs in follow-up after 3 months. (a) Cable shadow in the right lung tip cord. (b) Double hilar lymph nodes were enlarged. (c) Cable shadow in lungs. (d) High-density shadow between the pulmonary artery and the aorta in the mediastinum
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Thus the diagnosis of this problem is difficult. However, in cases with rapid progression of clinical symptoms, the reason for the headache was confusing as there was an association of both PDA and TB (possibly leading to hypoxia and vasospasm). Medication and intervention established the diagnosis. When the patient vigorous activity, diastolic time was shortened due to tachycardia to aggravate hypoxia in the brain, which leads to cerebral vasospasm. Coupled with the increase of intracranial pressure caused by TBM, the patient had headache.
Sometimes intervention needs to be considered, although TB is a contraindication, thereby better for patients. Its association together requires treatment of both etiologies, if they lead to conflicting symptoms like headache etc.
Acknowledgements
Thanks for all the staff in Pediatric Cardiology Department and Infected Pediatrics Department of West China Second Hospital, Sichuan University.
Financial support and sponsorship
This study was funded by the Pediatric Clinical Research Center Foundation of Sichuan Province, China (grant No. 2017-46-4) and Key Project of Science and Technology Agency of Sichuan Province (No.2020YFS0042).
Conflicts of interest
There are no conflicts of interest.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| » References | |  |
| 1. | Lee CH, Leung YL, Kwong NP, Kwok OH, Yip AS, Chow WH. Transcatheter closure of patent ductus arteriosus in Chinese adults: Immediate and long-term results. J Invasive Cardiol 2003;15:26-30.  |
| 2. | Suematsu Y, Uchimoto S, Tsumura K, Ishimura E, Kishimoto H, Nishizawa Y, et al. A case of dextrocardia concomitant with tetralogy of Fallot, patent ductus arteriosus and bronchiectasia. Kokyu To Junkan 1993;41:293-6. |
| 3. | Perlman JM, Hill A, Volpe JJ. The effect of patent ductus arteriosus on flow velocity in the anterior cerebral arteries: Ductal steal in the premature newborn infant. J Pediatr 1981;99:767-71. |
| 4. | Lemmers PM, Toet MC, van Bel F. Impact of patent ductus arteriosus and subsequent therapy with indomethacin on cerebral oxygenation in preterm infants. Pediatrics 2008;121:142-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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