Arch Dis Child: first published as 10.1136/adc.24.118.135 on 1 June 1949. Downloaded from

CASE REPORTS FUGITIVE BY 0. D. BERESFORD, M.B., M.R.C.P. (From the Department of Child Health, University of Bristol) The following case is reported as an example of 98^ F., and the 120 per minute, regular, but a little known complication of primary tuberculous of poor volume. The cardiac impulse was diffuse infection. and wavy and the was in the sixth left interspace in the anterior axillary line. A loud A female child aged two and a half years was pericardial friction rub was audible all over the admitted to Southmead Hospital, Bristol, on Dec. 3, precordium; the sounds were muffled, but 1946. Her parents and sister were in good health there were no murmurs. There were no signs of

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FIG. 1.-Electrocardiogram on Dec. 7, 1946, showing FIG. 2.-Electrocardiogram on Dec. 11, 1946, showing elevation of the S-T segment in leads I and I. inversion of T wave in lead I. and no history of tuberculosis was obtained. Apart pulmonary or systemic congestion. At the apex of from mumps at the age of two years, the child had the right lung the percussion note was impaired, been well until an attack of measles a month before the breath sounds being tubular and the voice sounds admission. She was left with a cough and failed increased. There were no adventitious sounds. to regain her usual vigour. On Nov. 30, 1946, she An x-ray of the chest showed a greatly enlarged refused her food, became pale, dyspnoeic, and cardiac silhouette, a suggestion of fullness at the distressed. right hilum, and an opacity at the apex which was On examination on admission she looked pale considered to be due to collapse or consolidation of and ill and was orthopnoeic. The temperature was part of the right upper lobe. An electrocardiogram 135 Arch Dis Child: first published as 10.1136/adc.24.118.135 on 1 June 1949. Downloaded from 136 ARCHIVES OF DISEASE IN CHILDHOOD showed in addition to , elevation of the tuberculous allergic serofibrinous pleurisy and S-T segments in leads I and II (fig. 1). A blood differed from the usual tuberculous pericarditis in count showed haemoglobin 102 per cent. and white that recovery was rapid and complete. In view of cells, 7,000 per c.mm , with a normal differential. the favourable prognosis an analogy with the Eighty thousand units of penicillin were given tuberculous serous meningitis described by Lincoln daily in divided three-hourly doses for a week. (1947) is al sug d. The interval of one month The child rmained critically ill for three days, but between the initial infection and the complicatng subsequent improvement was rapid. By Dec. 11 pencarditis corresponds to the stage of generaliza- an x-ray showed some ckaring of the opacity at the tion of the infection when miliary tuberculosis or right apex, and in the cardiogram the T wave was tuberculous meningitis most often develops. As inverted in lead I (fig. 2). The Mantoux test was Walxen pointed out this raises the possibility of a positive on that date. blood stream infection of the , but Improvement continued until Dec. 18 when her direct extension from enlarged mediastinal glands transference to an isolation hospital was necessitated is just as likely. by an attack of chickenpox. An x-ray of the chest The case reported bears a close resemblance to taken on Jan. 9, 1947, showed a normal sized heart Wallgren's two cases. The symptomatology, and almost complete clearing of the right apical positive Mantoux test, radiological appearances, opacity. She was sent for convalscence on recovery, and subsequent good health show a Jan. 15. When seen three months later the child's similar trend of events. This case was much health was fully restored, her lung fields were clear, younger than Wallgren's: two and a half years and her heart was normal. She was kept under compared with nine years and six years. observation for a further nineteen months and An alternative diagnosis which must be con- remained well. sidered is acute rheumatism, but the age of the Discusion patient, the absence of suggestive symptoms and While the etiology of this case remains in doubt signs during the acute stage, and of any relapse there are reasons for regarding it as an example of during the next twelve months, is against a rheumatic benign pericarditis associated with a primary etiology. Pneumonia with purulent pericarditis was tuberculous as by Wallgren considered in the differential diagnosis, but was complex reported excluded by the course of the illness. (1947). This author described two patients with copyright. the combination of pericarditis and a primary tuberculous complex. His first case developed pericarditis one month after the onset of an illness A description is given of pericarditis associated characterized by fever and enlargement of the left with a lung lesion and hilar glands. A tuberculin skin test was positive complete recovery within soon after symptoms were noted. The child was two months. It is suggested that this is an example ill for two months and then went on to make a of acute benign pericarditis associated with a complete recovery which was maintained for the primary complex as described by Wallgren (1947).

subsequent three years of observation. His second http://adc.bmj.com/ case was very similar: again there was fever and I wish to thank Dr. P. Phillips, medical enlargement of the hilar glands, and in addition superintendent, Southmead Hospital, Bristol, for erythema nodosum. Recovery was equally rapid permission to publish this case. and good health was maintained three years later. The excellent prognosis and freedom from relapse REFERENCES were especially strssed. Lincoln, E. (1947). Amer. Rev. Tuberc., 56, 95. Wallgren stated that the acute benign pericarditis Wallgren, A. (1947). Act. med. scand. Suppi., 196, of his two cases was comparable to that of acute 1 32-144. on October 2, 2021 by guest. Protected