Symptomatic hypercalcaemia in paediatric tuberculosis

To the Editors: A 13-yr-old Congolese female presented in early spring with a 6-month history of productive cough, progressive exertional dyspnoea and weight loss of 4.5 kg. 2 weeks prior to presentation she had developed high fevers and increasing lethargy. She had immigrated to the UK at the age of 2 yrs. She had not been overseas since and there was no history of contact with anyone with tuberculosis (TB). She had no past medical history and was fully immunised except for bacilli Calmette–Guerin. On examination she was cachectic and lethargic. There were no signs of clubbing, rickets or oedema. Her weight was 34 kg (less than third centile), height 148 cm (10th centile) and body mass index 15 kg·m−2 (less than first centile). She was tachycardic and tachypnoeic with oxygen saturations of 90% in air. There was dullness to percussion and widespread coarse crackles on auscultation throughout the left lung field and at the right apex. The chest radiograph showed extensive left lung and right upper lobe consolidation (fig. 1). Her C-reactive protein was 160 mg·L−1 and erythrocyte sedimentation rate was 90 mm·h−1. Her corrected calcium and phosphate were low, 1.96 mmol·L−1 (normal range 2.18–2.47 mmol·L−1) and 0.80 mmol·L−1 (0.75–1.50 mmol·L−1), respectively, with albumin and alkaline phosphatase levels of 23 g·L−1 (35–40 g·L−1) and 118 mmol·L−1 (30–200 mmol·L−1), respectively. Her Mantoux test was strongly positive (20 mm induration) and acid-fast bacilli were present in her sputum, which subsequently cultured Mycobacterium tuberculosis . In addition to consolidation, her chest computed tomography scan showed cavities within the distal bronchi, widespread tree-in-bud appearances throughout the left lower lobe and extensive mediastinal, paratracheal and subcarinal adenopathy. Standard quadruple anti-tuberculous therapy (isoniazid, rifampicin, ethambutol and pyrazinamide) was started. In view of her …