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Endgames Picture quiz

A 2 year old girl with fever, cough, and tachypnoea

BMJ 2009; 338 doi: (Published 10 June 2009) Cite this as: BMJ 2009;338:b1210
  1. Marc Tebruegge, honorary clinical research fellow1,
  2. Nicole Ritz, honorary clinical research fellow1,
  3. Tom Connell, consultant in paediatric infectious diseases1,
  4. Nigel Curtis, professor and head of paediatric infectious diseases2
  1. 1Infectious Diseases Unit, Department of General Medicine & Murdoch Children’s Research Institute, Royal Children’s Hospital Melbourne, Victoria 3052, Australia
  2. 2Department of Paediatrics, University of Melbourne, Royal Children’s Hospital Melbourne, Victoria 3052, Australia
  1. N Curtis nigel.curtis{at}

    A 2 year old girl presented to the accident and emergency department with high grade fever (temperature 39.2oC), cough, tachypnoea (respiratory rate 45 breaths/min), and lethargy. She had been unwell for six weeks with general malaise and intermittent fever. She had also been anorexic for three weeks and had lost about 7% of her body weight. She was born in Australia to parents from the South Pacific Islands. Her routine immunisations were up to date and her past medical history was unremarkable.

    The patient underwent chest radiography (fig 1).

    Fig 1 Chest radiograph of a 2 year old girl with high grade fever, cough, and tachypnoea


    • 1 What two major abnormalities can be seen on her chest radiograph?

    • 2 What is the most likely diagnosis?

    • 3 Which three additional investigations are most useful to confirm the diagnosis?


    Short answers

    • 1 The two major abnormalities that can be seen on the patient’s chest radiograph are a cavitating pulmonary lesion and widespread bilateral fine reticulogranular (miliary) shadowing (fig 2).

    Fig 2 Chest radiograph showing bilateral miliary infiltrates and outlining the cavitating pulmonary lesion in the left lower lobe (arrows)

    • 2 On the basis of the history and the radiographic findings the most likely diagnosis is miliary tuberculosis.

    • 3 A tuberculin skin test (Mantoux test), microscopy and culture of appropriate clinical specimens (such as sputum, gastric aspirates, bronchoalveolar lavage fluid, urine, cerebrospinal fluid, and blood), and an interferon-γ release assay are the most useful …

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