Unsuspected fatal drug-resistant TB in a child

We report a case of rapidly progressive miliary tuberculosis in a 21-month-old HIV-infected girl exposed to tuberculosis, despite early access to highly active antiretroviral therapy and proven adherence to isoniazid chemoprophylaxis. Post mortem revealed multidrug-resistant tuberculosis. This case report illustrates three important points: a) the consequences of inadequate programmatic management of children exposed to an adult case of sputum smear-positive multidrug-resistant tuberculosis, b) multiple exposures to source cases over time and c) the diffculty in diagnosing childhood tuberculosis in the setting of close supervision. Drug susceptibility testing of the adult source case should become standard of care for all children who have been in close contact with a case of sputum smear-positive tuberculosis, and the choice of chemoprophylactic agents should be based on the sensitivities of the source case organism. Regular inquiry for new exposure to source cases should also be made. New tests are urge...