Empyema necessitans due to aspergillus in a 3-year-old paediatric patient at a referral hospital in Nairobi, Kenya

We present a case of empyema necessitans due to aspergillus in a young child. The incidence of deep fungal mycoses in children, especially in developing countries is not known. There is paucity of data and access to diagnostics is usually limited. Our patient had received treatment for pulmonary tuberculosis which is endemic in Kenya for four months before diagnosis was made. We present this case to highlight the importance of considering alternative diagnosis when there is non-response to anti-tuberculous therapy.


Introduction
We present a case of empyema necessitans due to aspergillus in a young child. The incidence of deep fungal mycoses in children, especially in developing countries is not known. There is paucity of data and access to diagnostics is usually limited.

Patient and observation
A male child aged three years was referred to our hospital from a rural health facility. He had been initiated on empiric anti-tuberculous therapy with no clinical improvement after three months of treatment.
The patient had been in good health until six months prior when he developed cough and intermittent fever. He was admitted with a clinical diagnosis of pneumonia for which unspecified antibiotic therapy was given with transient improvement. Similar symptoms recurred two months later and he was readmitted. A chest radiograph showed right upper lobe consolidation with volume loss, right paratracheal and left hilar adenopathy and bilateral fine reticulonodular opacification (Figure 1 A, B). A Gene ®Xpert™(MTB/RIF) performed on fasting gastric aspirates was negative. A clinical diagnosis of pulmonary tuberculosis was made based on the algorithm for diagnosis of paediatric tuberculosis [1] and standard anti-tuberculous therapy (2HRZE/4HR) was initiated. His condition continued to deteriorate; he developed a mass on the right upper chest wall and was referred to our facility three months into tuberculosis (TB) treatment, for evaluation of suspected malignancy. At presentation, he had persistent fever and cough with dyspnea that disrupted feeding. The cough was scantily productive of white sputum.
Progressive swelling had been noted on the right chest wall and there was marked weight loss. There was no recent travel history. There had been no contact with domestic livestock or birds nor with any person with tuberculosis. He was HIV negative. At presentation, temperature was 39.4°C, respiratory rate 40/min, pulse rate 125/min, blood pressure 100/70 mmhg, spO2 88%.
He had no conjunctival pallor or jaundice. He had multiple enlarged discrete right axillary lymph nodes, largest 2cm in diameter; firm, nontender and mobile. He had a firm, tender, diffuse swelling on the right

Discussion
This three-year-old child initially presented with sub-acute respiratory symptoms, fever, weight loss and right upper lobe opacification.
Pulmonary tuberculosis was considered because it is endemic in our country [1,2]. TB diagnosis is difficult in children and frequently relies on an algorithm relying on characteristic history, typical clinical signs and suggestive radiograph findings [1]. When the child failed to respond to anti-tuberculous therapy and developed the chest wall mass with draining sinuses, invasive fungal infection was considered including invasive aspergillosis and actinomyces. The incidence of invasive aspergillosis in developing countries is not known due to limited diagnostics and paucity of data [3]. Data for the paediatric population are even more scarce, as most of the reported cases are in adults. The commonest risk factor is a cavitary lung lesion, which in developing countries is often due to tuberculosis. There are reports of aspergilloma occurring in the context of chronic cavitary pulmonary aspergillosis [4]. Most cases of invasive aspergillosis in developing countries are due to Aspergillus fumigatus, which is ubiquitous and thrives in a hot, humid environment. The environmental load of conidia is increased by construction or renovation. The respiratory tract is the usual port of entry and the most common site of infection.

Conclusion
This case highlights the importance of considering less common diagnoses in our setting particularly when there is poor response to empiric anti-tuberculous therapy. Among these considerations are deep fungal infections and therefore timely and aggressive diagnostic evaluation should be undertaken.