When common turns uncommon – an atypical presentation of childhood tuberculosis

Overview

Paediatric tuberculosis presents diagnostic and clinical management challenges distinct from adult disease, characterized by non-specific or absent symptoms, difficulty achieving microbiological confirmation, and increased propensity for extrapulmonary or disseminated forms. This case report documents an atypical presentation of childhood tuberculosis manifesting as a large mediastinal cystic lesion in a child presenting with constitutional symptoms including lethargy and significant weight loss without cough, initially mimicking other pathologies.

Methods and approach

Clinical and laboratory assessment of a paediatric patient with suspected mediastinal pathology included physical examination revealing markedly reduced air entry on the left side, laboratory investigations demonstrating elevated inflammatory markers, and imaging studies identifying a large mediastinal mass. Diagnostic confirmation was achieved through tissue acquisition and histopathological examination rather than initial microbiological testing.

Results

Tissue diagnosis confirmed extrapulmonary tuberculosis presenting as a mediastinal cystic lesion. The case demonstrates that paediatric TB can present without typical pulmonary findings such as cough, with constitutional manifestations predominating. Initial microbiological tests were negative, requiring tissue-based confirmation for definitive diagnosis.

Implications

The case underscores the necessity for elevated clinical suspicion in paediatric populations when extrapulmonary TB is suspected, particularly when initial microbiological testing yields negative results. Atypical presentations as mediastinal masses require differential diagnostic consideration of tuberculosis even in the absence of classical respiratory symptoms. Tissue diagnosis should be obtained in cases of suspected extrapulmonary tuberculosis when microbiological confirmation cannot be readily achieved through conventional means.

Early recognition and timely diagnosis are critical to initiate appropriate anti-tubercular therapy and prevent progression to complications. Management should incorporate monitoring for drug toxicity, although paediatric populations generally demonstrate tolerance of anti-tubercular regimens comparable to adult protocols. The case emphasizes that clinicians must maintain awareness of tuberculosis as a differential diagnosis for mediastinal pathology in children presenting with constitutional symptoms, regardless of microbiological test results.