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decreased in size under antibiotic ther- program which, as a rule, will be en-
apy. At this point there was a choice tirely s u e c e s s f u 1 without radical
between artificial pneumothorax and surgery.
resective surgery. The latter resulted CASE REPORTS
in one of the very few fatalities on CASE 1 . ~ A n d r e w A., a 16-month-old
our service. In contrast to this stands infant, was admitted to the hospital on
the record of the comparable ease of J u l y 22, 1950, with tuberculous men-
Doris S. (Case 9) who, also with a ingitis, with a partially calcified pri-
m a r y tubercle, and also a calcified, very
giant cavity, long before the advent Of large hilar lymph node. Spinal fluid
antibacterial and excisional therapy, was positive. Streptomycin 0.5 Gin.
obtained prompt cavity closure and and P A S 1.5 @m. were given daily
permanent healing following conven- from J u l y 22, 1950, till Jan. 23, 1951.
tional collapse t h e r a p y by pneumo- The patient was discharged on May 24,
1951, completely recovered and with-
out any neurological residuals. On the
last follow-up examination, Jan. 28,
1954, he was completely well.
CaSE 2.--Patricia D., a 26-month-old
infant, was admitted to the hospital
on Dee. 20, 1943. There was a small
left hilar lesion, no visible peripheral
tubercle, tuberculous serous peritonitis,
and, a few months later, bilateral
tubereulous ~ephritis. Gastric and
urine eultures were positive for tuber-
culosis. Also, there was a cold abscess
of the cervical gland, as well as tuber-
culous a r t h r i t i s with destructive
epiphysitis of the left knee. The pri-
m a r y and metastatic processes showed
a progressively favorable healing tend-
ency without chemotherapy. The chest
film of Sept. 26, 1946, showed a com-
J~'ig. ] . - - C a s e 1. Calcified p r i m a r y c o m p l e x pletely calcified p r i m a r y complex.
followed by tuberculous meningitis. On S e p t . 23, 1949, streptomycin
t h e r a p y was started prior to fusion
thorax. Our last ease, that of L a r r y operation on the l e f t knee, on
A., presents the rare clinical picture ,Ian. 12, 1949. O n March 22, 1950,
of extensive necrosis and liquefaction the patient was discharged, with the
p r i m a r y tuberculosis, tuberculous peri-
in the right lung of a 3-year-old Negro tonitis, renal tuberculosis, and tuber-
child. Extensive resections, preceded culous arthritis of left knee appar-
and followed by combined chemo- ently healed.
therapy, apparently resulted in com- CASE 3.--Jesse N., 2 years 8 months
of age, was admitted to the hospital
plete healing without any vestige of on June 9, 1949, with extensive left
radiological residuals. tuberculous pneumonitis. Cultures
Our conclusion is that the proper were positive. F o r four months he
identification and classification of iso- was given streptomycin. Then, after
a four-month period of intermission,
lated nodular lesions in children's he was give~ streptomycin and P A S
lungs will lead to a p r o p e r therapeutic for three months. The patient was
KASSOWITZ: I~UL2vIONARY T I J B E R C U L O S I A I N CItILDItOOD 157
discharged on April 28, 1951, with the bronchitis with stenosis. Streptomy-
tuberculosis inactive. There have been cin 0.3 Gin. daily (without PAS) was
periodic re-examinations at from three- administered from June 10 till Sept.
to six-month intervals, during which 24, 1949. The first gastric culture
three gastric cultures have been taken. was positive; all others were negative.
The patient remained healed when The patient was discharged on Dee.
last examined, on Jan. 18, 1954. 29, 1950. He remained completely
~'ig. 2 . - - C a s e 2. : P r i m a r y c o m p l e x f o l l o w e d b y t u b e r c u l o u s p e r i t o n i t i s , t u b e r c u l o u s nephritis,
t u b e r c u l o u s l y m p h a d e n i t i s , a n d t u b e r c u l o u s a r t h r i t i s of k n e e
hospital on Aug. 19, 1947, with tuber- hospital on May 25, 1951, having had
culous pneumonitis with hilar ade- a primary hilar lesion since 1948
nopathy, guinea pig inoculation posi- (proved family exposure). In May,
tive. Streptomycin 0.5 Gin. was given 1951, she developed a nodular lesion
for only ten days. The patient was dis- in the right mid-lung field. Strepto-
charged on Sept. 7, 1947. Close fol- mycin and PAS were administered
low-up examinations were given at daily from May 30, 1951, till Aug. 8,
Fig. 4.--Case 4. Tuberculous !aneumonitis with residual large central calcification; patient
r e m a i n e d h e a l e d f o r t h r e e to f o u r y e a r s .
from three- to six-taonth intervals. 1951, then twice a week till discharge
The patient remained completely on Sept. 2, 1951. Thoraeotomy with
healed at the last examination, Feb. 2, resection was recommended on Oct.
1954. 16, 1951, but was declined by the par-
CASE 6.--Patricia E., 9 years 4 ents. Previous therapy was continued
months of age, was admitted to the until March 20, 1952. There was al-
KASSOW[TZ: PULMONARY TUBERCULOMA IN CHILDHOOD 159
most complete disappearance of the given daily from Feb. 11, 1952, till
coin lesion, and the patient remained discharge on Oct. 1, 1952, then twice
completely healed when observed in a week until Dec. 3, 1952. The pa-
February, 1954. tient's parents refused reseetive sur-
CASE 7 . - - J o a n A., 11 years 9 months gery. The last re-examination, on Feb.
of age, was admitted to the hospital 10, 1954, showed the patient appar-
on Feb. 5, 1952, with left minimal pul- ently healed, and gastric cultures
monary tuberculosis and a coin lesion were negative.
Fig. 6.--Case 6. Secondary tubereuloma with small calcified residual; patient apparently healed
for two years.
Fig. 7,--Case 7. Secondary subapieal tuberculoma; patient apparently healed for two years.
type). The gastric culture was posi- right lower lobe. Sputmn was persist-
tive. Therapy consisted of streptomy- ently positive. Pneumothorax treat
cin and I N H for six Weeks, added P A S ment was started on Nov. 18, 1931, and
for three months; it was changed to was continued until April 26, 1933.
intermittent streptomycin and P A S on
Sept. 29, 1953. L e f t p u h n o n a r y resec- The patient left the sanitorium against
tion was offered but was declined by advice on April 29, 1933. She re~
the parents. The patient was dis- mained u n d e r continuous periodic ob-
eharged on Oct. 1, 1953, on ambulatory servation, with the last x-ray exami-
treatment previously given. There nation on Jan. 19, 1954. There was
was clearing of the coin lesion and no reactivation at any time. The pa-
bacteriological conversion. tient remained completely h e a 1 e d
Fig. 10.--Case i0. Isolated tuberculoma of right mid-lung, followed by excavation, followed by
giant cavity formation, followed by reduction through chemotherapy; unsuccessful resection.
minimal tuberculosis; a small, solid, 28, 1952, resection of the anterior seg-
circular lesion was present in the right ment of the right upper lobe was per-
mid-lung field. Three sets of gastric formed as well a s wedge resection of
cultures and one bronchial specimen the inferior division of the right lower
were negative. The patient was dis- lobe. Dihydrostreptomyein 0.5 Gin.
charged on Oct. 14, 1948. He was re- and PAS 3 Gin. were continued till
admitted on Aug. 4, 1949, with a discharge o n May 1, 1953. The pa-
small cavity in place of ttie tuber- tient remained healed with negative
culoma. C u l t u r e s were positive. gastric cultures on last examination,
Streptomycin 1.0 Gin. was given daily, Feb. 16, 1954.
starting Oct. 14, 1949. The size of the
SUMMARY
cavity increased. Streptomycin was
discontinued on Jan. 11, 1950, owing 1. A classification of tuberculomas
to partial resistance. The condition in the puhnonary parenchyma of chil-
became worse; there was a cough and
fever. Streptomycin and PAS were dren is given: (a) the primary tuber-
resumed on Feb. 17, 1950. The con- culoma of minute size, (b) the more
dition improved. There was a choice or less extensive nodular residual fol-
between artificial pneumothorax and lowing postprimary tuberculous pneu-
resective surgery. On April 6, 1950, monitis, (e) the reinfection type of
a lobeetomy of the right lower and
middle lobe was performed. The pa- isolated tuberculomas, (d) cavitary
tient died owing to operative shock. lesions following reactivation of pri-
Fig. 1 1 . - - C a s e 11. T u b e r c u l o u s p n e u m o n i t i s w i t h e x c a v a t i o n a n d l i q u e f a c t i o n ; s u c e e s s f u I e x t e n -
sive resection.
ary tubercu]omas (coin lesions) under 4. Hughes, F. A., Lowry, C. C., and Polk,
J.W.: Thoracoplasty and Resection for
p r o p e r c h e m o t h e r a p y is i l l u s t r a t e d . Pulmonary Tuberculosis, J. Thoracic Surg.
4. T h e t r e a t m e n t of t h e r a r e in- 25: 454, 1953.
stances of cavitary lesions in children 5. Miller, J. A., Wallgren, A. : Pulmonary
Tuberculosis in Adults and Children, New
by resective surgery and by pneumo- York, 1939j Thos. Nelson & Sons.
t h o r a x is d i s c u s s e d . 6. Price, D. S. : Tuberculosis in Childhood,
Baltimore, 1948, Williams & Wilkins Com-
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I~ Alexander, John: Symposium on Treat- 7. Houghton, L. E. : Collapse Therapy and
ment of Pulmonary Tuberculosis; Basic the Bronchus, Tubercle 31: 50~ I950.
Principles of Successful Treatment, Tr. 8. Shields, D. O., Chapman, John, S. Jr.,
Nat. Tuberc. A. 47: 222, 1951. Carswell, James, Jr., and Wollenman, O.
2. Overholt, 1%. H., and Kenney, L. J. : The J.: ~odular Tuberculosis, J. Thoracic
Place of Pulmonary Resection in the
Treatment of Tuberculosis, Dis. Chest 21: Surg. 24: 568, 1952.
32, ]952. 9. Mitchell, Roger S.: Late Results of
3. Levitin, M., and Zelman, M. : Excisional Treatment of the Solitary Dense Tuber-
Surgical Treatment of Pulmonary Tuber- culous Pulmonary Focus (Tubereuloma)
culosis in Children~ Am. J. Dis. Child. 79: Without Resection or Chemotherapy, Ann.
30, 1950. Int. Med. 39: 471, ]953.