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1 * MILIARY MOTTLING -- RARE CAUSE DR ARATHI SRINIVASAN FELLOW IN PEDIATRIC HEMATO ONCOLOGY DR A ANDAL DEPARTMENT OF PEDIATRICS DR JULIUS XAVIER SCOTT DEPARTMENT OF PEDIATRIC HEMATO ONCOLOGY KANCHI KAMAKOTI CHILDS TRUST HOSPITAL

2 *3 yrs old female child *Intermittent fever of six months duration *Respiratory symptoms like recurrent cough, fever and wheeze. *Suspected history of contact with tuberculosis

3 *Preliminary work up for tuberculosis were negative (erythrocyte sedimentation rate, Mantoux test, Chest X ray, gastric juice for Acid Fast Bacilli) *Started on preventers for recurrent wheeze

4 1 year later Fever and respiratory symptoms like cough and wheezing splenohepatomegaly ( liver 3 cms below right costal margin, spleen 5 cms below left costal margin) RS: bilateral diffuse crepitations Chest x ray

5 Diffuse Miliary infiltrates

6 *Re work up: Neutrophilic leucocytosis/ AEC: normal Normal immunoglobulin levels HIV: negative *Treated with antibiotics *Planned for bronchoscopy /lung biopsy *Started on ATT

7 6 months later Recurrent cough, fever and progressive respiratory distress Crepitations and splenohepatomegaly Neutrophilic leucocytosis (40400 cells/cumm) C-Reactive Protein: raised/ ESR: raised Chest radiograph : bilateral pulmonary infiltrates worsening than before

8 *High Resolution chest CT --- bilateral diffuse

9 *Broncho alveolar lavage fluid analysis for tuberculosis/other infections -- negative *Bone marrow aspiration normal

10 Thoracoscopic lung biopsy Non Hodgkins Lymphoma -- Diffuse large B cell lymphoma

11 Risk stratified Group B NHL Chemotherapy COP reduction Repeat chest X ray.

12 *Repeat chest X ray: clearance of the pulmonary infiltrates

13 * *Completed 9 cycles of chemotherapy *PET scan negative at end of treatment *Doing well

14 * * Miliary lung mottling is a radiological finding. *The term miliary describes the radiographic picture of diffuse, discrete nodular shadows about the size of a millet seed Most common (2mm) Less frequent Miliary Tuberculosis Tropical pulmonary eosinophilia Fungal infections Varicella pneumonia Hemosiderosis Sarcoidosis Toxoplasmosis, syphilis Rare Metastases Histiocytosis

15 * Chest X ray and Miliary TB *Localizes the site of pathology *Relevant clinical setting + radiological lesions ( miliary, hilar/paratracheal lymphadenopathy / fibrocaseous cavitatory lesions ) ---- may strongly suggest TB

16 *Clinical presentations of Childhood *Precursor lymphoid neoplasms Non Hodgkins Lymphoma T-lymphoblastic lymphoma --- Anterior mediastinal mass B-lymphoblastic lymphoma --- Cutaneous masses, isolated lymph node masses, primary bone lymphoma *Mature B-cell neoplasms Burkitt lymphoma --- Abdominal masses,git Waldeyer's ring Diffuse large B-cell lymphoma --- Nodes, abdominal masses, bone *Mature T-cell neoplasms Anaplastic large cell lymphoma --- Skin, nodes, bone Peripheral T-cell lymphoma

17 * *Miliary infiltrates in Non-Hodgkin's lymphoma are extremely rare. *Primary pulmonary Non Hodgkins lymphoma is very rare and accounts 0.4% of all lymphomas *Involvement of the lung with the lymphomatous process occurs in 5-20% of patients at diagnosis and eventually in 20-60%.

18 *Review of literature *Miyake S, Yoshizawa Y, Ohkouchi Y, Kurashima A, Hebisawa A. Non- Hodgkin's Lymphoma with Pulmonary Infiltrates Mimicking Miliary Tuberculosis. Internal Medicine. 1997; 36: \ *Wrobel T, Dzietczenia J, Sobieszek MP, Mazur G, Piwkowski P. Primary pulmonary diffuse large B-cell lymphoma. Am. J. Hematol. 2011; 00: Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: /ajh *Close PM, Macrae MB, Hammond JM, Aronson I, Johnson CA, Potgieter PD,et al. Anaplastic large-cell Ki-1 lymphoma. Pulmonary presentation mimicking miliary tuberculosis. Am J Clin Pathol. 1993; 99: *Scott JX, Gnananayagam EJ, Sundaravalli EKR,Thomas G, Shanthly N, Kirubakaran C. Unusual Cause for Miliary Lung Mottling in a Child. Indian J Chest Dis Allied Sci 2004; 46 :

19 * Take home message Pediatrician s Perspective Miliary TB is the most common cause for miliary mottling in a developing country, but not the only cause, especially when there is no bacteriological evidence of tuberculosis or if there is no expected response. Miliary infiltrates The importance of obtaining tissue diagnosis rather than empirical ATT and missing occult malignancies needs to be emphasized. Pediatric Oncologist s Perspective Non Hodgkins lymphoma presents commonly as tumors in abdomen. Though Diffuse large B cell lymphoma occurs only in 10% cases of primary pulmonary NHL, rare possibility of B Type NHL should be considered.

20 *THANK YOU

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