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2. TUBERCULOSIS in children
Prepared by:
Dr. Mostafavi SN
Department of Pediatric Infectious Disease
Isfahan University of Medical Science
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3. Epidemiology 1/3 of the world infected Poor income
Greatest mortality
1/3 of the world infected
Poor income
Africa, south east Asia,east Mediterranean
Afghanistan, Pakistan & Iraq
High resistance: MDR & XDR
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4. Characteristics Weekly G+ bacilli, acid fastness
Slow growth( Prolonged courses, culture)
Obligate aerobe (Lung, lymph node, bone involvement)
Low infectivity (Close contact, Prolonged contact, Low ventilated area)
Sensitive to sun light( 5 min) & drying
Intracellular( cell mediated immunity)
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5. Transmission Cough( 5000 particle), Talk, Sneeze
Large droplet, Small droplet,
droplet nuclei
From adult smear positive
respiratory type disease
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6. Pathogenesis Replication Local spread Dissemination Cellular immunity
Resolution or disease
Reactivation
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7. Clinical Outcome No infection 80% Primary infection 20%
Asymptomatic infection( LTBI) 18%
Progressive Primary disease 1%
Reactivation disease 1%
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8. Pulmonary Clinical findings( 70-85%)
Chronic cough( > 21 days)
Prolonged fever( > 14 days)
Weight loss or failure to thrive
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9. Extra-pulmonary Clinical findings ( 15-30%)
Highly suggestive:
Gibbus deformity
Cervical lymphadenopathy with fistula
Suggestive:
Sub -acute not responding meningitis with hydrocephalus
Pleural effusion
Pericardial effusion
Ascites
Lymphadenopathy
Non-painful arthritis
Signs of tuberculin hypersensitivity (e.g. phlyctenular conjunctivitis, erythema nodosum).
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10. Phlyctenular conjunctivitis
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11. Erythema nodosum
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12. Diagnosis Groups at high risk of infection and disease
Suspecting clinical finding
Confirmatory tests
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13. Groups at high risk of infection
Close contact of TB
Residence in high risk countries
Low income populations
High risk settings(injection drug users, correctional institutions, nursing home, homeless persons, drug treatment centers)
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14. Groups at high risk for disease once infected
Immunosuppression( HIV, cancer, malnutrition, injection drug users,< 4 yr. old )
Certain medical conditions( silicosis, DM, ESRD, gastrectomy)
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15. Diagnostic confirmatory tests
CXR
Microbiologic tests( sputum, induced sputum, gastric lavage)
Tuberculin Skin Test and IGRA tests
Pathology in extra-pulmonary disease
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16. Suggestive CXR findings
Children
Persistent opacification with hilar or subcarinal lymphadenopathy
Miliary pattern of opacification
Adolescent
Large pleural effusions
Apical infiltrates with cavity formation
Infiltrate with hilar adenopathy
Collapse lesions
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17. Persistent opacification with hilar or subcarinal lymphadenopathy
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18. Miliary pattern of opacification
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19. Large pleural effusions
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20. Apical infiltrates with cavity formation
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21. Infiltrate with hilar adenopathy
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22. Collapse lesions
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23. Tuberculin skin test Heat killed TB bacilli( PPD)
0.1 ml, ID, volar of forearm
48-72h later, induration
Specificity %
Interpretation based on risk of TB
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24. Interpretations of TST
>5 mm in: Contact with infectious cases
Abnormal CXR
Immunosuppresion like HIV
>10 mm in: Age< 4 yr
Close contact with a high risk adult
Residence in endemic country
Residence in high risk setting
Medical risk factors like DM, ESRD
>15 mm in: All
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25. Microbiologic exam( stain, culture)
Mycobacterial staining: ziehl- neelson or auramine - rodamine
Mycobacterial culture:
PCR… not standardized, on CSF useful
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26. Interferon-gamma release assays (IGRAs)
In vitro blood tests
Measure TB-T cell release of IFN-gamma
Not affected by BCG
Results in 24 to 48 hours
Specificity >95 percent, sensitivity 80-90% for LTBI
Low sensitivity in < 2-5 yr
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27. Diagnosis Pulmonary: Extrapulmonary: symptoms+ 2 sputum smear positive
symptoms+ 1 sputum smear positive+ suggestive CXR
symptoms+ 1 sputum culture positive
symptoms+ no sputum positive+ suggestive CXR+ expert opinion
Extrapulmonary:
symptoms+ positive culture
symptoms+ positive staining+ expert opinion
symptoms+ positive pathology+ expert opinion
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28. Diagnosis in children History of exposure Suggestive finding
3 of the following:
History of exposure
Suggestive finding
Positive TST
Suggestive CXR
Suggestive pathology/microbiologic finding
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29. Management
Isolation
Treatment
Prevention in close contacts
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