THE PULMONARY TUBERCULOMA IN CHILDHOOD:
AND SURGICAL MANAGEMENT
KARL E . KASSOWITZ,
MILWAUKEE, "WIs.
R E S E C T I V E surgical t r e a t m e n t of
well-defined and isolated tubercu-
lous p u l m o n a r y lesions in adults has
become a widely accepted and success-
ful procedure. Yet the applicability
of radical resection of p e r i p h e r a l pa-
r e n c h y m a l lesions in children has so
f a r not been unequivocally decided.
The following types of p a r e n c h y m a l
tuberculomas (the t e r m used in the
broad sense of a well-defined area of
granulomatous tissue reaction due to
the Mycobacterium tuberculosis of
Koch) can be classified as more or less
distinctive entities.
1. P r i m a r y peripheral tuberculoma
of minute size with the tendency to
heal with or without radiological
residuals.
2. Extensive p r i m a r y or postpri-
m a r y pneumonic lesions which tend
to heal with more or less extensive
fibrocaleifie nodular residuals.
3. Reinfection t y p e of isolated t u -
berculomas, oftentimes called "coin
lesions. ' '
4. C a v i t a r y lesions, an unusually
rare occurrence in children, which m a y
develop either as a reactivation of a
p r i m a r y tuberculoma or as a result of
disintegration of a secondary tuber-
euloma.
If we consider the criteria which
guide us in the therapeutic manage-
ment of adolescent and adult tubercu-
losis, these above-mentioned childhood
types of p u l m o n a r y lesions pose the
F r o m 1VIuirdale S a n a t o r i u m of Milwaukee
County and Milwaukee Children's Hospital.
*Associate Clinical Professor of Pediatrics,
Marquette University iYfedical School.
153
ITS MEDICAL
M.D. ~
question of whether or not resective
surgery, following a p r o p e r course of
chemotherapy, a p p e a r s applicable.
According to Alexander, ~ " T h e re-
moval of the most extensively diseased
tissues, including cavities and caseous
lesions, is obviously advantageous ;
scattered, active or potentially active
p a r e n c h y m a l or bronchial lesions re-
maining in" uneoilapscd parts of the
lungs may, or m a y not, become inac-
tive in the course of t i m e . "
Up to the present there are con-
spieuous]y few reports available on
p u l m o n a r y resections in childhood
tuberculosis. Out of 426 patients who
had undergone resective s u r g e r y for
p u l m o n a r y tuberculosis Overholt 2 men-
tions only one patient 3 years old and
one 8 years old. No details as to the
nature of these resected childhood le-
sions are given. Levitin and Zelman a
published four total pneumonectomies
for advanced and progressive tubercu-
losis in children f r o m Sea View Hospi-
tal. I n a more recent article covering
235 cases of thoracic surgery for tuber-
culosis, }Iughes ~ has not h a d one pa-
tient u n d e r 20 years of age.
There is a basic difference between
the residual lesion, a f t e r chemother-
apy, in the lung p a r e n e h y m a of the
m a t u r e person and the peripheral
tuberculous process in the lungs at
e a r l y a n d raid-childhood. I t is the
collateral lymphadenitis w h i c h repre-
sents the main, if not the only, differ-
154 THE JOURNAL
cntial feature in childhood and adult
tuberculosis. We know that all the
lymphatic organs undergo a progres-
sire involutionary development in ado-
lescence.
Miller and Wallgren 5 stress the fact
that " t h e characteristic feature of pri-
m a r y tuberculosis of the lungs is the
accompanying swelling of the lym-
phatic glands of the hilum. These
swollen glands .are never so prominent
in other forms of tuberculosis."
According to Price 6 the "endoge-
nous spread takes piaee from a pri-
m a r y focus or gland which may be
either active or partially healed or
apparently healed." He f u r t h e r
stated that "because of glandular in-
volvement at this age, the risk of mas-
sive blood stream infection is greater,
the large tumor-form swelling seen
:frequently in infants are but r a r e l y
seen in later childhood. At school age,
glandular enlargement and pcrihilar
activity are f r e q u e n t l y seen but are
less marked; hematogenous spread
from these is usually limited to one
or two metastases."
This prominent role played by the
participation of the central tracheo-
bronchial lymph nodes in the primary
and postprimary tuberculous process
has to be taken into account in con-
sidering the therapeutic management
of such patients.
I n the following we have selected
eleven typical eases from the Chil-
dren's Service of Muirdale Sanatorium
and Milwaukee Children's Hospital of
the last twenty-eight years, a total of
roughly 1,000 inpatients (an average
of thirty-six new admissions per year),
which illustrate the four classes of
childhood lesions previously men-
tioned, with' the idea of evaluating the
OF PEDIATRICS
applicability of radical pulmonary re-
section for these different types of
diseases.
As to the first group, that is, the
typical primary tubercle itself, it
seems an obvious fact that this has so
f a r never been found tempting to the
thoracic surgeoia. The reason for this
reluctance could not possibly be its
harmlessness, because we know that
the initial seed, the so-called Ghon's
focus, may be the starting point of the
most vicious pulmonary and extraput-
monary complications. The contrain-
dication against the surgical approach
rests with the simultaneous involve-
ment of the regional lymph nodes,
which does not permit anything like
a complete removal of all the impor-
tant loci except by total pneumon-
ectomy.
Levitin and Zelman '~ in their article
on pneumonectomy stress the same
point: " A factor which may materi-
ally alter the prognosis in children,
and which is only infrequently en-
countered in adults, is the lymph node
component. This is present in both
the p r i m a r y and the adult types of
pulmonary tuberculosis in c h i l d r e n . "
In considering the bipolar (or multi-
polar) nature of the p r i m a r y complex
in children, we are reminded of the
analogy with a p r i m a r y bronchogenic
carcinoma that has invaded the col-
]ateral lymphatics and thereby pro-
gressed beyond the stage of operability.
Much the same considerations seem
to be in order in questioning the valid-
ity of resective surgery in the second
and third categories (which include
the postprimary pneumonie lesions
with their more extensive nodular
residuals and the isolated secondary
tuberculomas or coin lesions). In both
eases there is the same factor of the
 KASSOWITZ: PULMONARY TUBERCULOMA IN CHILDHOOD
central foci in the tracheobronehial
glands which is invariably present and
would limit, thereby, any surgical pro-
cedure to a subtotal resection.
Houghton's 7 interpretation of these
secondary circular lesions as inspis-
sated cavities that may possibly act
as a " t i m e bomb" is, according to our
observations in middle and later child-
hood, unjustified. While Shields and
co-workerss found the reactivation rate
of multiple nodular disease and of in-
spissated cavities in adults high and
that of residual nodules from tuber-
culous pneumonia low, MitehelP stated
in a recently published survey of un-
treated tubereulomas in adults that
"severe or fatal progressions of such
lesions have been r a r e . "
It is only in the rather exceptional
instances of proved eavitary lesions
that pulmonary resection should be
considered alongside other more con-
servative and reversible methods of
treatment. The danger of a broncho-
genie dissemination or the improba-
bility of cavity closure under non-
resective therapy are strong argu-
ments. The complete therapeutic suc-
cess of exeisional surgery in Case 11
helps to justify this method of treat-
ment in destructive pulmonary tuber-
eulosis in children. However, the one
instance of Case 9, which shows com-
plete disappearance of a giant cavity
under artificial pneumothorax treat-
ment and permanent healing after
twenty-three years of continuous ob-
servation, points toward the validity
of the more conservative approach,
even in the r a r e instances of cavitary
lesions in children.
DISCUSSION
The cases of Andrew A. and Patricia
D., both with distinct primary tuber-
155
cles, impress us with the potential
viciousness of any initial lesion, no
matter how minute and no matter how
distinctly ealeitied according to radio-
logical standards. Andrew A. de-
veloped meningitis in spite of calcified
Ghon's tubercle and hilar nodes. Pa-
trieia D. developed the following
hematogenous metastases: tuberculous
peritonitis, bilateral tuberculous ne-
phritis, e e r v i e a 1 tuberculous lym-
phadenitis, tuberculous arthritis.
There is no doubt that it is not the
harmlessness of the primary tubercle
which constitutes a eontraindication
against radical excision but only the
bifocal nature of the primary complex
as seen invariably in these as in all
other eases of primary tuberculosis.
The postprimary type of extensive
unilobar or multilobar tuberculous
pneumonitis is represented by the cases
Joseph T., Jesse N., and Patrieia J.
All three showed excellent response to
chemotherapy (in one instance to what
we would now consider entirely in-
sufficient chemotherapy) and progres-
sive fibrocalcific involution and heM-
ing for periods of from five to seven
years of close observation. The three
eases of Patricia E., Joan A., and
Dianne K. are quite comparable, as
they represent the emergence of a
secondary isolated tubereuloma which
occurs not infrequently in later child-
hood. All three resulted in complete,
or almost complete, radiographic clear-
ing under chemotherapy.
In the ease of Thomas C. (Case 10)
an apparently solid nodular lesion
either turned out to be an inspissated
cavity or gradually disintegrated into
a small central excavation as one of
the so-called " t i m e bombs." This
grew into a giant cavity which again
t56 THE
decreased in size under antibiotic ther-
apy. At this point there was a choice
between artificial pneumothorax and
resective surgery. The latter resulted
in one of the very few fatalities on
our service. In contrast to this stands
the record of the comparable ease of
Doris S. (Case 9) who, also with a
giant cavity, long before the advent Of
antibacterial and excisional therapy,
obtained prompt cavity closure and
permanent healing following conven-
tional collapse t h e r a p y by pneumo-
J~'ig. ] . - - C a s e 1. Calcified p r i m a r y c o m p l e x
followed by tuberculous meningitis.
thorax. Our last ease, that of L a r r y
A., presents the rare clinical picture
of extensive necrosis and liquefaction
in the right lung of a 3-year-old Negro
child. Extensive resections, preceded
and followed by combined chemo-
therapy, apparently resulted in com-
plete healing without any vestige of
radiological residuals.
Our conclusion is that the proper
identification and classification of iso-
lated nodular lesions in children's
lungs will lead to a p r o p e r therapeutic
J O U R N A L OF P E D I A T R I C S
program which, as a rule, will be en-
tirely s u e c e s s f u 1 without radical
surgery.
CASE REPORTS
CASE 1 . ~ A n d r e w A., a 16-month-old
infant, was admitted to the hospital on
J u l y 22, 1950, with tuberculous men-
ingitis, with a partially calcified pri-
m a r y tubercle, and also a calcified, very
large hilar lymph node. Spinal fluid
was positive. Streptomycin 0.5 Gin.
and P A S 1.5 @m. were given daily
from J u l y 22, 1950, till Jan. 23, 1951.
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-
pletely calcified p r i m a r y complex.
On S e p t . 23, 1949, streptomycin
t h e r a p y was started prior to fusion
operation on the l e f t knee, on
,Ian. 12, 1949. O n March 22, 1950,
the patient was discharged, with the
p r i m a r y tuberculosis, tuberculous peri-
tonitis, renal tuberculosis, and tuber-
culous arthritis of left knee appar-
ently healed.
CASE 3.--Jesse N., 2 years 8 months
of age, was admitted to the hospital
on June 9, 1949, with extensive left
tuberculous pneumonitis. Cultures
were positive. F o r four months he
was given streptomycin. Then, after
a four-month period of intermission,
he was give~ streptomycin and P A S
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

Fig'. 3 . - - C a s e 3. 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 r e s i d u a l t u b e r c u l o m a ; patient apparently healed

f o r t h r e e to f o u r y e a r s .

CaSE 4.--Joseph T., 3 years 3 healed, with large calcareous residual,

months of age, was admitted to the rmmerous negative cultures at the last
hospital on April 18, 1949, with tuber- x-ray examination, Feb. 5, 1954.
culous pneumonitis of the entire right CASE 5.--Patricia J., 3 years 9
upper lobe, as well as tuberculo~as months of age, was admitted to the
158 THE JOURNAL OF PEDIATRICS

hospital on Aug. 19, 1947, with tuber-
culous pneumonitis with hilar ade-
nopathy, guinea pig inoculation posi-
tive. Streptomycin 0.5 Gin. was given
for only ten days. The patient was dis-
charged on Sept. 7, 1947. Close fol-
low-up examinations were given at
hospital on May 25, 1951, having had
a primary hilar lesion since 1948
(proved family exposure). In May,
1951, she developed a nodular lesion
in the right mid-lung field. Strepto-
mycin and PAS were administered
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 .

Fig. 5.--Case 5, T u b e r c u l o u s pneumonitis with calcified nodular residual; patient remained

h e a l e d f o r s i x to s e v e n 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
coin lesion, and the patient remained
completely healed when observed in
February, 1954.
CASE 7 . - - J o a n A., 11 years 9 months
of age, was admitted to the hospital
on Feb. 5, 1952, with left minimal pul-
monary tuberculosis and a coin lesion
given daily from Feb. 11, 1952, till
discharge on Oct. 1, 1952, then twice
a week until Dec. 3, 1952. The pa-
tient's parents refused reseetive sur-
gery. The last re-examination, on Feb.
10, 1954, showed the patient appar-
ently healed, and gastric cultures
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.

of the left subapieal region. Bacterial CASE 8.--Dianne K., 14 years 1

culture was negative. The f a t h e r had month of age, was admitted to the
active tuberculosis. Dihydrostrepto- hospital on Feb. 16, 1953, with a left
mycin 1.0 Gm. and P A S 1.0 Gin. were subapical tuberculoma (reinfection
Fig. 8.--Case 8. S e c o n d a r y l e s i o n of" l e f t u p p e r l o b e ; p a t i e n t a p p a r e n t l y healing, with minimal
s u b a p i c a l c o i n lesion.

Fig. 9.--Case 9. G i a n t c a v i t y s e c o n d a r y to c a l c i f i e d G h o n t u b e r c l e ; pneumothorax therapy;

permanent healing for twenty-two years.
 KASSOWITZ: PULZIONARY TUBERCULOMA IN CHILDHOOD 161

type). The gastric culture was posi-
tive. Therapy consisted of streptomy-
cin and I N H for six Weeks, added P A S
for three months; it was changed to
intermittent streptomycin and P A S on
Sept. 29, 1953. L e f t p u h n o n a r y resec-
tion was offered but was declined by
the parents. The patient was dis-
eharged on Oct. 1, 1953, on ambulatory
treatment previously given. There
was clearing of the coin lesion and
bacteriological conversion.
right lower lobe. Sputmn was persist-
ently positive. Pneumothorax treat
ment was started on Nov. 18, 1931, and
was continued until April 26, 1933.
The patient left the sanitorium against
advice on April 29, 1933. She re~
mained u n d e r continuous periodic ob-
servation, with the last x-ray exami-
nation on Jan. 19, 1954. There was
no reactivation at any time. The pa-
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.

CaSE 9.--Doris S., 10 years 3 months twenty years after pneumothorax

of age, was admitted to the hospital
on 0ct. 31, 1931, with moderately ad-
vanced p u l m o n a r y tuberculosis and
with a large cavity due to reactivation
of calcified p r i m a r y tubercle in the
treatment.
CASK 10.--Thomas C., 13 years 2
months of age, was admitted to the
hospital on May 19, ]948, with right
162 THE JOURNAL OF PEDIATRICS

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.

CASE l l . - - L a r r y A., a 26-month-old mary or disintegration of secondary

infant, was admitted to the hospital tuberculomas.
on June 7, 1951, with far-advanced 2. The prominent role played by the
tuberculosis of the right lung and ex- participation of the collateral lym-
tensive consolidation and excavation in
the mid-lung region. Aspiration of phatic glands in children is demon-
thick purulent material showed it posb strated in eleven representative radio-
tive for tuberculosis. Streptomycin grams, and the impracticality of lim-
0.5 Gin. and PAS were administered ited resective surgery is emphasized.
dMly from July 9, 1951, till July 2,
1952, twice a week till Oct. 2, 1952, 3. The progressive involution and
then daily till Dee. 31, 1952. On Oct. radiological disappearance of second-
 KASSOWITZ: PULI~ONARY TUBERCULOMA IN CHILDHOOD
ary tubercu]omas (coin lesions) under
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 .
4. T h e t r e a t m e n t of t h e r a r e in-
stances of cavitary lesions in children
by resective surgery and by pneumo-
t h o r a x is d i s c u s s e d .
REFERENCES
I~ Alexander, John: Symposium on Treat-
ment of Pulmonary Tuberculosis; Basic
Principles of Successful Treatment, Tr.
Nat. Tuberc. A. 47: 222, 1951.
2. Overholt, 1%. H., and Kenney, L. J. : The
Place of Pulmonary Resection in the
Treatment of Tuberculosis, Dis. Chest 21:
32, ]952.
3. Levitin, M., and Zelman, M. : Excisional
Surgical Treatment of Pulmonary Tuber-
culosis in Children~ Am. J. Dis. Child. 79:
30, 1950.
]63
4. Hughes, F. A., Lowry, C. C., and Polk,
J.W.: Thoracoplasty and Resection for
Pulmonary Tuberculosis, J. Thoracic Surg.
25: 454, 1953.
5. Miller, J. A., Wallgren, A. : Pulmonary
Tuberculosis in Adults and Children, New
York, 1939j Thos. Nelson & Sons.
6. Price, D. S. : Tuberculosis in Childhood,
Baltimore, 1948, Williams & Wilkins Com-
pany.
7. Houghton, L. E. : Collapse Therapy and
the Bronchus, Tubercle 31: 50~ I950.
8. Shields, D. O., Chapman, John, S. Jr.,
Carswell, James, Jr., and Wollenman, O.
J.: ~odular Tuberculosis, J. Thoracic
Surg. 24: 568, 1952.
9. Mitchell, Roger S.: Late Results of
Treatment of the Solitary Dense Tuber-
culous Pulmonary Focus (Tubereuloma)
Without Resection or Chemotherapy, Ann.
Int. Med. 39: 471, ]953.