Bilateral tuberculous mastoiditis and facial palsy.

The patient was first seen at Red Cross Children’s Hospital in September 2001, aged 3 years and 2 months. He was living with his unemployed single-parent mother in an informal settlement. He had bilateral suppurative submandibular lymphadenitis, requiring incision and drainage. Two weeks after discharge, pus swabs revealed a positive culture for Mycobacterium tuberculosis. The local TB clinic was notified, but his mother could not be contacted, having relocated to central Cape Town where she had obtained temporary employment. In March 2002 he was seen at Somerset Hospital, Cape Town, with a suppurative discharge from both ears. Pus swabs again cultured M. tuberculosis. Attempts at contact via the local TB clinic faced the same problems as previously and the follow-up outpatient appointment was not kept. The third contact with the health care system was in May 2002, when his aunt, who had taken over his care, brought him to Red Cross Hospital. He had bilateral profuse suppurative discharges from his ears, discharging neck sinuses, facial palsies, profound conduction deafness, microcytic anaemia and kwashiorkor. There was no evidence of exposure to HIV. Pus swabs from the ears and neck yielded mixed bacterial and M. tuberculosis culture. Computed tomography (CT) of the temporal bones demonstrated extensive destruction of the mastoid bone and ossicular chain bilaterally, consistent with tuberculous mastoiditis (Fig. 1).