Tuberculosis in children
Tuberculosis (TB) is a granulomatous inflammatory condition, and is the most common cause of infection-related death worldwide
>In 1993, the World Health Organization (WHO) declared TB to be a global public health emergency
>Mycobacterium tuberculosis is the most common cause of TB in both adults and children
> Other rare causes are
>In 1993, the World Health Organization (WHO) declared TB to be a global public health emergency
>Mycobacterium tuberculosis is the most common cause of TB in both adults and children
> Other rare causes are
Mycobacterium bovis and. Mycobacterium africanum
>The proportion of both paediatric and adults TB cases caused by M. bovis is very low and is generally associated with close contact with cattle
>TB equally affects children of both genders, but an increased risk of mortality exists at the extremes of age
>Young children and especially newborns are at a high life risk when they are exposed to a contagious source
> In about 95 % of cases, TB is an airborne disease
> Development of the disease depends much on the competence of the immune system to resist multiplication of the organisms
>The immune competence depends on age, nutritional status, coexisting infections like HIV/AIDS, measles, and whooping cough
> TB most commonly attacks the lungs (as pulmonary TB), but can also affect the CNS, lymphatic system, circulatory system, the GUS, bones, joints and even the skin
> Internationally, according to the WHO, more than 8 million new cases of TB occur each year
>The incidence and prevalence of paediatric TB worldwide varies according to the burden of the disease in different countries
> It has been estimated that 3.1 million children under 15 years of age are infected with TB worldwide
According to the WHO, children with TB represent 10 % to 20 % of all TB cases
>The majority of these cases occur in low-income countries where the prevalence of HIV and AIDS is high
>The WHO states over 250,000 children develop TB annually and 100,000 children will continue to die each year from TB
>The proportion of both paediatric and adults TB cases caused by M. bovis is very low and is generally associated with close contact with cattle
>TB equally affects children of both genders, but an increased risk of mortality exists at the extremes of age
>Young children and especially newborns are at a high life risk when they are exposed to a contagious source
> In about 95 % of cases, TB is an airborne disease
> Development of the disease depends much on the competence of the immune system to resist multiplication of the organisms
>The immune competence depends on age, nutritional status, coexisting infections like HIV/AIDS, measles, and whooping cough
> TB most commonly attacks the lungs (as pulmonary TB), but can also affect the CNS, lymphatic system, circulatory system, the GUS, bones, joints and even the skin
> Internationally, according to the WHO, more than 8 million new cases of TB occur each year
>The incidence and prevalence of paediatric TB worldwide varies according to the burden of the disease in different countries
> It has been estimated that 3.1 million children under 15 years of age are infected with TB worldwide
According to the WHO, children with TB represent 10 % to 20 % of all TB cases
>The majority of these cases occur in low-income countries where the prevalence of HIV and AIDS is high
>The WHO states over 250,000 children develop TB annually and 100,000 children will continue to die each year from TB
clinical Features
•> Chronic cough for 14 days or more
•>Positive history of TB contact (especially with a positive sputum smear)
•> Suspected HIV or AIDS
•> Prolonged fever
•> Failure to thrive
•> Cases of malnutrition, failing to respond to adequate nutritional, and anti-infective
•> Chronic cough for 14 days or more
•>Positive history of TB contact (especially with a positive sputum smear)
•> Suspected HIV or AIDS
•> Prolonged fever
•> Failure to thrive
•> Cases of malnutrition, failing to respond to adequate nutritional, and anti-infective
treatment
Failure to return to health after infections, particularly after measles, whooping cough or
streptococcal infection
Failure to return to health after infections, particularly after measles, whooping cough or
streptococcal infection
Localizing Signs and Symptoms
> Chronic cough, respiratory wheezing and wasting
>Febrile illness with pleural pain (pleurise) and effusion
> Pneumonia not improving in spite of adequate treatment
> Chronic swelling of lymph nodes with or without drainage
> Abdominal swelling with Ascites ( accumulation of fluids in peritoneum)
> Signs of heart failure with pericardial effusion (accumulation of fluids in the heart chamber)
>Chronic painful swelling in a weights bearing joint
> Refusal to bend, stiff painful back, spinal deformity and paraplegia may indicate TB spine (Pott’s disease)
>Unexplained change of temperament, irritability, fever, vomiting, headache, convulsions, meningeal signs, cranial nerve involvement and finally paralysis and coma-may indicate TB meningitis
>Signs of space occupying intracranial tumour
>Painless haematuria or sterile pyuria (puss)
> Chronic cough, respiratory wheezing and wasting
>Febrile illness with pleural pain (pleurise) and effusion
> Pneumonia not improving in spite of adequate treatment
> Chronic swelling of lymph nodes with or without drainage
> Abdominal swelling with Ascites ( accumulation of fluids in peritoneum)
> Signs of heart failure with pericardial effusion (accumulation of fluids in the heart chamber)
>Chronic painful swelling in a weights bearing joint
> Refusal to bend, stiff painful back, spinal deformity and paraplegia may indicate TB spine (Pott’s disease)
>Unexplained change of temperament, irritability, fever, vomiting, headache, convulsions, meningeal signs, cranial nerve involvement and finally paralysis and coma-may indicate TB meningitis
>Signs of space occupying intracranial tumour
>Painless haematuria or sterile pyuria (puss)
Disseminated TB (spreading)
> Although the usual site of tuberculosis is the lungs, other organs can be involved
(disseminated TB)
> This develops in small number of infected people whose immune systems do not successfully contain the primary infection into the primary focus
>Disseminated disease can occur within weeks after the primary infection, or may lie dormant for years before causing illness
>Infants, the elderly, those infected with HIV and those who take immune-suppressing medications are at higher risk for the disease worsening, because of their weaker immune systems
>In disseminated disease, organs and tissues affected can include:
o Bones and joints
o Bronchus
o Cervical lymph nodes
o Eye
o Larynx (voice box)
o Lining of the abdominal cavity (peritoneum)
o Lining of the brain and spinal cord (meninges)
o Lining of the heart (pericardium)
o Organs of the male or female urinary and reproductive systems
o Skin
o Small bowel
o Stomach
> Although the usual site of tuberculosis is the lungs, other organs can be involved
(disseminated TB)
> This develops in small number of infected people whose immune systems do not successfully contain the primary infection into the primary focus
>Disseminated disease can occur within weeks after the primary infection, or may lie dormant for years before causing illness
>Infants, the elderly, those infected with HIV and those who take immune-suppressing medications are at higher risk for the disease worsening, because of their weaker immune systems
>In disseminated disease, organs and tissues affected can include:
o Bones and joints
o Bronchus
o Cervical lymph nodes
o Eye
o Larynx (voice box)
o Lining of the abdominal cavity (peritoneum)
o Lining of the brain and spinal cord (meninges)
o Lining of the heart (pericardium)
o Organs of the male or female urinary and reproductive systems
o Skin
o Small bowel
o Stomach
Tuberculous Adenitis(lymphoid)
> TB lymphadenitis (TB adenitis) is the inflammation and/or enlargement of a lymph node in response to local, or generalized TB infections
>Tuberculous adenitis may affect a single node or a localized group of nodes (regional adermopathy) and may be unilateral or bilateral
> Tuberculous adenitis presents as painless swelling of the lymph nodes most commonly at cervical and supraclavicular sites
> Lymph nodes are usually discrete in early disease but later become matted together
>May be inflamed and have a fistulous tract draining caseous material
> Systemic symptoms are usually limited to HIV-infected patients, and concomitant lung disease may or may not be present
> TB lymphadenitis (TB adenitis) is the inflammation and/or enlargement of a lymph node in response to local, or generalized TB infections
>Tuberculous adenitis may affect a single node or a localized group of nodes (regional adermopathy) and may be unilateral or bilateral
> Tuberculous adenitis presents as painless swelling of the lymph nodes most commonly at cervical and supraclavicular sites
> Lymph nodes are usually discrete in early disease but later become matted together
>May be inflamed and have a fistulous tract draining caseous material
> Systemic symptoms are usually limited to HIV-infected patients, and concomitant lung disease may or may not be present
The diagnosis is established by fine a needle aspiration or surgical biopsy
>Acid fast bacilli (AFB) are seen in up to 50% of cases
>Cultures are positive in 70-80%
>Acid fast bacilli (AFB) are seen in up to 50% of cases
>Cultures are positive in 70-80%
Tuberculous Arthritis (joints)
> Chronic arthritis caused by extra pulmonary TB
>Presents with the following specific features in addition to the above general features:
o Limping (chechemea)
o Non-tender swollen joint
> Chronic arthritis caused by extra pulmonary TB
>Presents with the following specific features in addition to the above general features:
o Limping (chechemea)
o Non-tender swollen joint
Tuberculous Osteomyelitis (bones)
>This refers to infection of the bone by M. tuberculosis
> Involves mainly the thoracic and lumbar vertebrae (known as Pott's disease) followed by knee and hip
Clinically, there may be extensive necrosis and bony destruction with compressed
fractures (with kyphosis) and extension to soft tissues, including psoas "cold"
abscess
>This refers to infection of the bone by M. tuberculosis
> Involves mainly the thoracic and lumbar vertebrae (known as Pott's disease) followed by knee and hip
Clinically, there may be extensive necrosis and bony destruction with compressed
fractures (with kyphosis) and extension to soft tissues, including psoas "cold"
abscess
Tuberculous (TB) meningitis.
> Occurs when tuberculosis bacteria (M. tuberculosis ) invade the membranes and fluid surrounding the brain and spinal cord
>The infection usually begins elsewhere in the body, usually in the lungs, and then travels through the bloodstream to the meninges where small abscesses (called microtubercles) are formed and when these abscesses burst, TB meningitis results
> Fever and headache are the cardinal features
>Confusion is a late feature and coma bears a poor prognosis
>Meningism is absent in a fifth of patients with TB meningitis. Patients may also have focal neurological deficits
>In areas where TB prevalence is high, TB meningitis is most common in children aged 0 - 4 years, and in areas where TB prevalence is low, most cases of TB meningitis are in adults
> Occurs when tuberculosis bacteria (M. tuberculosis ) invade the membranes and fluid surrounding the brain and spinal cord
>The infection usually begins elsewhere in the body, usually in the lungs, and then travels through the bloodstream to the meninges where small abscesses (called microtubercles) are formed and when these abscesses burst, TB meningitis results
> Fever and headache are the cardinal features
>Confusion is a late feature and coma bears a poor prognosis
>Meningism is absent in a fifth of patients with TB meningitis. Patients may also have focal neurological deficits
>In areas where TB prevalence is high, TB meningitis is most common in children aged 0 - 4 years, and in areas where TB prevalence is low, most cases of TB meningitis are in adults
Important Points to Remember
• A history of a positive TB contact is a very positive marker
• Only 15% of TB children have a positive smear, so a negative smear does not exclude pulmonary TB (PTB)
• There are no typical radiological features for PTB
• A history of a positive TB contact is a very positive marker
• Only 15% of TB children have a positive smear, so a negative smear does not exclude pulmonary TB (PTB)
• There are no typical radiological features for PTB
Tuberculin Test
• The Mantoux test is performed by intradermal injection of 5 TU = 0.1 ml 1:2.000 diluted OT or 0.1 ml PPD (strength 0.0001 mg per dose) with a special Mantoux syringe
• Read after 72 hours depending on the solution used
• Measure the diameter of the induration
o Less than 10 mm: negative
o 10 mm or more: positive (if the child did not receive BCG vaccine)
o At least 15mm: positive (if the child did receive BCG vaccine)
• A negative test does not exclude tuberculosis infection or disease:
o If the test is performed before the hypersensitivity has developed (may take 10 weeks after infection)
o If the child is anergic after measles, in severe malnutrition, during steroid or cytotoxic drug therapy or in miliary tuberculosis or HIV/AIDS
o An unequivocal (6-10 mm) reaction may occur in atypical mycobacterial infections
and within 3 years after BCG.
• Note: Prior BCG vaccination is not a good reason to omit a Mantoux test if TB is suspected
• Gastric aspirate/ Sputum
o Smear for AFB
o Culture for Mycobacterium
• X-ray
o Serial X-ray of lungs (if not too expensive) is more helpful than only one
examination, primary focus may be difficult to see
o Common X-ray findings:
√enlarged lymph nodes,
√ effusion,
√ cavitation,
√consolidation,
√atelectasis,
√ calcification, miliary "snowstorm" appearance
o X-ray of abdomen may show calcified lymph nodes in abdominal TB
Other examinations
• Blood- FBP and ESR
• Urine in selected cases
• CSF in selected cases (low sugar plus lymphocytosis in meningitis)
• Biopsy of lymph node, synovial, bone-marrow, pleura
• Ophthalmoscopy- choroidal tubercles often present in miliary TB
• Ascitic tap for suspected abdominal TB with ascitis (⅓Btn the umbicus and anterior illiac spine)
• X-ray of the spine for spinal TB, collapsed intervertebral discs
• The Mantoux test is performed by intradermal injection of 5 TU = 0.1 ml 1:2.000 diluted OT or 0.1 ml PPD (strength 0.0001 mg per dose) with a special Mantoux syringe
• Read after 72 hours depending on the solution used
• Measure the diameter of the induration
o Less than 10 mm: negative
o 10 mm or more: positive (if the child did not receive BCG vaccine)
o At least 15mm: positive (if the child did receive BCG vaccine)
• A negative test does not exclude tuberculosis infection or disease:
o If the test is performed before the hypersensitivity has developed (may take 10 weeks after infection)
o If the child is anergic after measles, in severe malnutrition, during steroid or cytotoxic drug therapy or in miliary tuberculosis or HIV/AIDS
o An unequivocal (6-10 mm) reaction may occur in atypical mycobacterial infections
and within 3 years after BCG.
• Note: Prior BCG vaccination is not a good reason to omit a Mantoux test if TB is suspected
• Gastric aspirate/ Sputum
o Smear for AFB
o Culture for Mycobacterium
• X-ray
o Serial X-ray of lungs (if not too expensive) is more helpful than only one
examination, primary focus may be difficult to see
o Common X-ray findings:
√enlarged lymph nodes,
√ effusion,
√ cavitation,
√consolidation,
√atelectasis,
√ calcification, miliary "snowstorm" appearance
o X-ray of abdomen may show calcified lymph nodes in abdominal TB
Other examinations
• Blood- FBP and ESR
• Urine in selected cases
• CSF in selected cases (low sugar plus lymphocytosis in meningitis)
• Biopsy of lymph node, synovial, bone-marrow, pleura
• Ophthalmoscopy- choroidal tubercles often present in miliary TB
• Ascitic tap for suspected abdominal TB with ascitis (⅓Btn the umbicus and anterior illiac spine)
• X-ray of the spine for spinal TB, collapsed intervertebral discs
Treatment
• Give a full course of treatment to all confirmed or highly suspected cases
• When there is doubt (e.g. when the child is highly suspected or a child fails to respond to other likely diagnoses)
• Follow National guidelines for treatment of TB as shown below
• Give a full course of treatment to all confirmed or highly suspected cases
• When there is doubt (e.g. when the child is highly suspected or a child fails to respond to other likely diagnoses)
• Follow National guidelines for treatment of TB as shown below
• Precaution:
Avoid streptomycin in children as the injections are painful and there is a risk for irreversible damage to the auditory nerve
Avoid streptomycin in children as the injections are painful and there is a risk for irreversible damage to the auditory nerve
Used to Treat TB
TB Treatment Categories
Figure 1: TB Treatment Categories
Category 1 New sputum smear, positive PTB and severe forms of EPTB
Category II Relapse, treatment failure and sputum smear positive return after default
Category III New Sputum smear negative and EPTB (less severe)
Category III New Sputum smear negative and EPTB (less severe)
Category IV Chronic cases
• Less severe extra-pulmonary TB: lymph node, bone (other than spine), unilateral
pleural effusion, peripheral joint and adrenal gland.
• Severe extra-pulmonary TB: meningitis, miliary, pericarditis, bilateral or extensive
unilateral effusion, spinal, intestinal and genito-urinary tract
• Most children diagnosed to have tuberculosis are treated as category
• Less severe extra-pulmonary TB: lymph node, bone (other than spine), unilateral
pleural effusion, peripheral joint and adrenal gland.
• Severe extra-pulmonary TB: meningitis, miliary, pericarditis, bilateral or extensive
unilateral effusion, spinal, intestinal and genito-urinary tract
• Most children diagnosed to have tuberculosis are treated as category
Complications of Tuberculosis
• Pleurisy with or without pleural effusion
• Pneumothorax
• Empyema
• Pleurisy with or without pleural effusion
• Pneumothorax
• Empyema
• Respiratory failure
• Right ventricular failure
• Fungal colonization of the cavities (e.g Aspergilloma)
• Blood borne dissemination
• Right ventricular failure
• Fungal colonization of the cavities (e.g Aspergilloma)
• Blood borne dissemination
Prevention
• Early detection and treatment of all TB cases as soon as possible
• Making sure that all patients are compliant with their treatment
• Contact tracing by investigating all family members and other close contacts
• Isolating all sputum – positive open TB cases as far as possible
• Avoiding overcrowding and improving housing conditions
• Separation and isolation of suspected TB cases in hospital (TB infection control)
• Isoniazid preventive therapy for children exposed to TB
• Child spacing advices to mothers who have active TB
• Drink only pasteurized or properly boiled milk
• Ensuring BCG immunization is done to all under five year olds
o BCG is contraindicated for children with symptomatic HIV disease or AIDS
• Improving nutritional status of all families and communities
• Giving education to the community on how the disease is spread
• Early detection and treatment of all TB cases as soon as possible
• Making sure that all patients are compliant with their treatment
• Contact tracing by investigating all family members and other close contacts
• Isolating all sputum – positive open TB cases as far as possible
• Avoiding overcrowding and improving housing conditions
• Separation and isolation of suspected TB cases in hospital (TB infection control)
• Isoniazid preventive therapy for children exposed to TB
• Child spacing advices to mothers who have active TB
• Drink only pasteurized or properly boiled milk
• Ensuring BCG immunization is done to all under five year olds
o BCG is contraindicated for children with symptomatic HIV disease or AIDS
• Improving nutritional status of all families and communities
• Giving education to the community on how the disease is spread
Keys
• Childhood TB infection is widespread, but development of disease depends much on the
immune status of the child.
• Immunization by BCG is essential to prevent severe form of the disease and disease progression but BCG vaccination does not prevent pulmonary TB in older children and adults
• Severe forms of the disease are seen in children with HIV/AIDS and malnutrition.
• Tuberculous adenitis is the most common form of extra pulmonary TB.
• Childhood TB infection is widespread, but development of disease depends much on the
immune status of the child.
• Immunization by BCG is essential to prevent severe form of the disease and disease progression but BCG vaccination does not prevent pulmonary TB in older children and adults
• Severe forms of the disease are seen in children with HIV/AIDS and malnutrition.
• Tuberculous adenitis is the most common form of extra pulmonary TB.
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