1. Case Discussion 2 - TB IN CHILDREN by Dr. Jeyaseelan P. Nachiappan & Dr. Suryati Adnan 1 Picture of CPG Cover

2. Extended Family

3. History Father is a lorry driver Mother is a factory worker Grandmother – is the primary caregiver for the children – sleeps in the same room with the children 3

4. About the Grandmother Prolonged cough – 2 month Haemoptysis – 3 days CXR – right upper lobe opacity Sputum smear AFB – strongly positive Diagnosed as PTB – treatment started 4

5. Q1 What else would you need to do for the children in the household? 5

6. A1 Consultation with a doctor: History – presence of cough, loss of weight & fever Examination – focusing on the respiratory system – presence of lymphadenopathy 6

7. Management of Tuberculosis (3 rd Edition) Screening of TB contacts is important among those exposed to patients with PTB for early detection of TB & to reduce its transmission 7

8. History (cont.) 11 year-old boy – has mild cough on & off – known asthmatic (intermittent mild) – requires salbutamol MDI 4 times in a month – no fever, no loss of weight, no loss of appetite – physical examination – normal – BCG scar present Q2. What would you do for this child? 8

9. A2 Mantoux test CXR Sputum smear & culture 9

10. History (cont.) Mantoux test – 15 mm CXR – normal Sputum smear – negative Q3. What is your diagnosis & management? 10

11. A3 Diagnosis – Latent TB Follow-up to review for asthma Follow-up for 2 years at 3 - 6 monthly Parents explained on features of TB – fever, loss of weight, prolonged cough, haemoptysis RISK SITUATION 11

12. Latent TB Management of Tuberculosis (3 rd Edition) Not treated for Latent TB

13. Management of Tuberculosis (3 rd Edition) Risk of progression to disease is increased when primary infection occurs before adolescence, particularly in the very young (0 - 4 years old) & in immunocompromised children Active TB usually develops within 2 years of infection but the time-lag can be as short as a few weeks in infants WHO, 2006 13

14. Terminology TB infection = Latent TB TB disease = Active TB 14

15. History (cont.) 8 year-old girl Cough 1 month Not known to be asthmatic No fever Loss of weight, loss of appetite Air entry decreased right upper zone Q4. What would you do? 15

16. A4 Mantoux test CXR Sputum for AFB smear & culture ESR 16

17. Management of Tuberculosis (3 rd Edition) 17 RECOMMENDATION 18 Children suspected of PTB should have sputum examination, CXR & TST performed. (Grade C)

18. History (cont.) ESR – 117 Sputum AFB taken Mantoux test done CXR – scattered consolidation bilaterally – Imp: Pneumonia/PTB 18

19. History (cont.) I/V amoxicillin & oral erythromycin Isolation room Mantoux test – 17 mm Sputum AFB smear – negative Q5. What is the diagnosis & management? 19

20. A5 Pulmonary TB Need to start on antiTB treatment 20

21. Management of Tuberculosis (3 rd Edition) Active TB usually develops within TWO years of infection but the time-lag can be as short as a few weeks in infants WHO, 2006 21

22. History (cont.) TB treatment started – HRZ regimen AFB culture results 1 month latter – positive for M. tuberculosis – sensitivity not ready Diagnosis – Pulmonary TB 22

23. Management of Tuberculosis (3 rd Edition) 23 WHO, 2006 WHO, 2005

24. Management of Tuberculosis (3 rd Edition) 24 Pyridoxine 5 - 10 mg daily needs to be added if isoniazid is prescribed.

25. History (cont.) 4 year-old boy Asymptomatic BCG scar present Q6. What would you do? 25

26. A6 Mantoux test CXR 26

27. History (cont.) Mantoux test – 0 mm CXR – normal Q7. What is the diagnosis & management? 27

28. A7 Normal child – no infection No need for sputum AFB smear Follow-up – 3 - 6 monthly for 2 years 28

29. Management of Tuberculosis (3 rd Edition) 29

30. But….. Grandmother is – primary caregiver – CLOSE contact – smear AFB positive Q8. Why is the Mantoux only 0 mm? 30

31. A8 Has there been an error in the test due to… – solution expired? – technique of dilution? – administration? – reading? 31

32. Management plan for the 4 year-old should be: Treat as Latent TB isoniazid – 10 mg/kg daily for 6 months No need for sputum AFB smear Follow-up at 2 weeks with LFT Follow up at 3 - 6 monthly for 2 years 32

33. Why a CXR? Mantoux test is not specific & sensitive for LTBI or active TB History taking (exposure & s/s of active TB) & physical examination may be done poorly & may result in missing active TB Some areas have high TB burden e.g. OA villages 33

34. Why a CXR? CXR can be omitted if adequate history & physical examination are done after factoring in:- – severity of exposure – age of the child – disease burden in community – logistics for follow-up for 2years CXR IS DONE ONLY TO EXCLUDE ACTIVE PTB 34

35. Management of Tuberculosis (3 rd Edition) 35

36. Management of Tuberculosis (3 rd Edition) 36 Chart is a guide. Following it exactly may miss some LTBI & active TB

37. Management of Tuberculosis (3 rd Edition) 37

38. History (cont.) 2 year-old boy Asymptomatic Examination is normal Q9. What would you do? 38

39. A9 Mantoux test CXR 39

40. History (cont.) Mantoux test – 15 mm CXR – normal Q10. What is the diagnosis & management? 40

41. A10 No need for sputum AFB smear Treat as Latent TB Follow-up at 2 weeks with LFT Follow-up at 3 - 6 monthly for 2 years 41

42. Management of Tuberculosis (3 rd Edition) 42

43. Management of Tuberculosis (3 rd Edition) The risk of developing disease after infection is much greater for infants & young children under 5 years. Active TB usually develops within 2 years of infection but the time-lag can be as short as a few weeks in infants. WHO, 2006 43

44. Take Home Messages Adult with PTB is potential source of infection to a child The closer the contact, the higher the risk of transmission Risk of disease (infection to disease) is highest for the younger child & in first 2 years of transmission 44

45. Take Home Messages If symptomatic – investigate & treat as active TB If asymptomatic – investigate – if no signs/symptoms of TB but significant Mantoux test Diagnosis - Latent TB (Tx depends on age) Exclude Active TB before treating for Latent TB 45

46. 46 THANK YOU  drsuryati_adnan@phg.moh.gov.my drsuryati_adnan@phg.moh.gov.my  jaynachi@gmail.com jaynachi@gmail.com