Tuberculosis in Children

Tuberculosis in Children

by Dr Alpana Santosh Kondekar (Lect: Dept of Pediatrics, TNMC)

for MBBS students only for rapid review

http://www.geocities.com/drkondekar/TBLECTURE.doc clickon this link to down load and save in word format.

http://ep.bmj.com/cgi/content/extract/91/1/ep1

above link takes u to anice article about pediatric pulmonary
TB, from Archieves Diseases in children, Education and Practice issue;

although following article is not derived from above article.

Magnitude of Pediatric tuberculosis:

As the children get infection from adults with chronic
pulmonary tuberculosis; the extent of infection or disease in children is
directly related to prevalence of chronic pulmonary tuberculosis in adults.

Annual rate of infection is 2.1%/year for under 5 year age
group.

Nearly 40 million children are likely to be exposed to the
risk and nearly 3-4 million children under 5 years are estimated to be
infected.

Agent: Mycobacterium Tuberculosis (human type)

Predisposing factors:

• Low socioeconomic group


• Poverty


• Poor ventilation,


• Overcrowding


• Close contact with sputum positive cases


• Unhygienic living conditions

Precipitating factors:

• Infections like measles, whooping cough


• Chronic diarrhea


• Severe malnutrition


• Compromised immune status

Transmission:

Droplet Infection

Incubation period: 4-8 weeks

Evolution and timetable of untreated of untreated primary TB
infection

Wallgreen’s Calender of TB events (modified)

Time scale since infection	Comments	Events
0-4 weeks	Infection	None
4-8 weeks	Hypersensitivity / Latent TB, most children get MT positive	Febrile illness, E nodosum, Phlyctenular conjunctivitis
2-4 months	Primary focus, nonspecific resistance, greater risk of local and disseminated	Ghons complex with progressive healing in most cases, Pleural effusion
3-12 months	Focus complications	Pleural effusion (75% cases), Cavity, Coin shadow,
3-9 months	Complications of nodes	Rupture, empyema, bronchopneumonia, consolidation, hyperinflation,
9 – 24 months	Diminished risk of dissemination	Meningitis, military, subcortical tuberculoma rupture, in < 5 yr age, in < than 4% cases
1-3 yrs		Bone, joints, kidneys (>3 yrs)
Resistance reduced by early infection, PEM, measles, whooping cough, steroids etc

Differentiation between Adult and Pediatric TB

Adult type	Childhood
Tissue has already acquired allergy and immunity by prior infection	Infection occurs for the first time, tissue has no immunity to TB proteins
Lowering of immune response/ defense locally in the lungs leads to reactivation & mainly locally progressive disease	T cell response plays a significant role causing disseminated disease in globally immunocompromised children
No significant hilar or regional lymphadenopathy	Well marked regional lymphadenopathy
Hematogenous spread is uncommon	Lymphatic and hematogenous spread more common than local spread !
Cavitatory lesion may be seen	Common with MDR & HIV positive patient
Chronic pulm. TB is highly infectious	Iary infection is usually noninfectious
In adults main cause of death and disability is pulm. TB	Main cause of death and disability is non pulmonary TB
Healing of the lesion is mainly by calcification/ fibrosis	Calcification is more common, fibrosis is unusul

Pulmonary Pathogenesis of Pediatric TB

Parenchymal Progression

Ghon’s focus = lymphangitis + enlarged Lymph nodes

Primary complex

Healed Primary complex

Pneumonia

Massive pneumonia

Primary cavity

Bronchopneumonia

Pleurisy

Lymphatic progression:

Mediastinal LN

Partial bronchial obstruction

Complete Bronchial obstruction

Obstructive emphysema

Collapse

Collapse consolidation

Synpneumonic effusion

Rupture of bronchus/ fistula

Subcarinal LN causing tracheal splaying

Hematogenous Progression:

Acute military TB

Protracted or disseminated TB

CNS – tuberculoma, TB Meningitis,
Ritchies focus

Dactylitis

Spinal TB (Potts)

TB psteomyelitis

Chronic Pulmonary TB:

Assman’s focus (subapical)

Pulmonary infiltration – cavity

Bronchogenic spread – bronchiectasis

Extensive bilateral fibrocaseous TB

Fibrous phthisis

Investigations:

Family History and family screening

Hematological = Hb ESR

MT test

XR chest

AFB gastric Lavage

USG abdomen – for LN and ileocaecal
Tb

CTscan Brain – tuberculoma and
exudates

LN biopsy

Sputum , CSF , pleural fluid, urine,
blood, culture

Tr Br Lavage

ELISA/ TB PCR Tests

Mantaux Test:

TU PPD with RT 23 or 1: 1000 is used with preferably a dose
of 5 TU, to detect greater number of true positives,

Given intradermally, read after 48-72 hrs

Palpate and measure induration , not erythema

Positive test reaction = 10 mm or more

Mild / + 0-14
mm

Moderate / ++ 15-20
mm

Severe +++ 21-30
mm

Very severe reaction ++++ blisters/ necrosis
or more than 30 mm

Treatment:

General supportive

Dietary

Environmental and psychological counseling

Chemotherapy with AKT

RNTCP

DOT regimen

IAP

Intensive phase + continuation phase

Indian Academy of Pediatrics ( IAP) consensus for TB
management in children

Cases divide in 5 groups

• Group I: 6 HR




• Asymptomatic MT positive < 3 yr age


• Asymptomatic MT positive <5 yr with PEM III IV


• MT positive : recent converter (no sings or healed
  lesions)


• Child less than 3 yr with family contact history


• Child < 5 yr with PEM III IV and contact

Group II: 2 HRZ + 4 HR

• Primary complex


• Symptomatic MT positive < 3yr, without localization


• Symptomatic MT positive < 5 yr + PEM III IV without
  localization


• Isolated LN disease


• Pleural effusion

Group III: 2 HRZE + 4 HR

Progressive
pulmonary disease

Multiple TB LN disease

-------- if
nonresolving, can be extended by 3 months

Group IV: 2HRZE + 7 HR

Miliary or
disseminated disease

Cavity
disease or bronchopneumonia

Osteoarticular
disease

Abdominal
pericardial or GU disease

Group V: 2 HRZE + 10 HR

Neuro TB

Dosage
recommendations: mg/kg/ dose/ day

Drug	Daily therapy	Intermittent therapy
INH	5	15
RMP	10	15
PZA	25	30
EMB	20	30
SM	20	30
Prednisolone	1-2	-

Prednisolone:

Indicated
in:

Neuro TB,
Miliary TB

Serous TB

Endobronchial
Tb/ segmental lesion

GU TB/
sinus formation

Special cases:

Baby born to TB mother: in IIIrd
trimester

Breast
feeding may be continued

BCG to be
given at birth

If XRChest
normal, give 6 HR

If XRchest
abnormal 2HRZ+7HR

Congenital
TB 2 HRZ + 7 HR

BCG adenitis:

If LN is
small. < 1.5 cm = no treatment required

Increasing
or fluctuant = 6 H

Excision
+/-

Drugs for MDR TB:

1. Ethionamide

2. .Fluroquinolones:
double dose

a. Ciprofloxacxin

b. Ofloxacin

c. Sparfloxacin

d. lamefloxacin

3. Aminoglycosides

a. Kanamycin

b. Amikacin

4. Cycloserine

5. rifamycin
derivatives

a. rifabutin

b. rifapentin

c. rifadine

d. CGP.
FCE etc

For any queries, write to drdoctor@hotmail.com

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Dr Kondekar Santosh venketraman is a MD pediatrician at seth GS medical college and
KEM HOSPITAL MUMBAI INDIA