1. Tuberculosis in children BY MBBSPPT.COM

2. Learning objective
At the end of the lecture you should be able to understand:
Epidemiology of childhood tuberculosis
Case definitions of pediatric TB
Diagnostic algorithm including investigations of childhood TB
Categorization & Treatment of childhood TB as per National guidelines
Chemo prophylaxis

3. Case definitions (RNTCP)
Failure to respond: If within 12 weeks of compliant intensive phase treatment fails to achieve
Bacteriological conversion from +ve to -ve AFB
Clinical response
Clinical improvement ( deterioration of condition)
Relapse:
A case of pediatric TB declared cured /completed therapy & again shows bacteriological & clinical evidence of TB

4. Case definitions (RNTCP)
Treatment after default:
A case who took at least 4 wks of ATT & comes after interruption of treatment for>=2 mths & has active disease (clinical/bacteriological)
Others:
For program purpose all retreatment cases where bacteriological confirmation could not be made but ATT started on clinical ground

5. Diagnostic algorithm of pediatric TB
Persistent fever/cough>2 wks & or
Loss of wt/no wt gain & or
History of contact of infectious TB
Sputum exam
Sputum +ve
Sputum –ve/N.A
Received full course of antibiotic or
Sick look or respiratory distress or
Any other indications for Xray chest
Smear +ve PTB
Treat according to guidelines

6. Yes NO X-ray chest & Mx Course of antibioticx7days
X-ray suggestive & Mx +ve
No response
Either or both -ve
Review for alt diagnosis
GL/IS/BAL
Smear +ve
Smear -ve
Snear –ve PTB
Treat as per guidelines
Treat as per guidelines

7. Diagnostic algorithm of pediatric TB
If X-ray chest- non specific shadow & Mx +ve or –ve  Rpt X-ray chest after a course of antibiotics if not given earlier  still persistent non specific shadow with Mx +ve or –ve  do GL/IS/BAL  smear +ve smear +ve PTB & treat as per guidelines.
If smear is negative  look for alt diagnosis (if no alt diagnosis then treat as smear –ve PTB & treat as per guidelines)

8. Diagnostic algorithm of pediatric TB
If X ray normal & Mx +ve  review for alt diagnosis & treat accordingly
If no alt diagnosis established  look for extra pulmonary sites
If no extra pulmonary sites involved take expert opinion (CT chest may be rqd.)

9. Diagnosis contd… USG abdomen for lymph nodes
FNAC & biopsy of involved lymph nodes/organs
CT scan rarely rqd.
Sero diagnosis- antibody or antigen tests not recommended (TB Elisa)
Interferon gama release assay –Early secretion antigen target 6 (ESAT6) & Culture filtrate protein(CFP10)- Quantiferron gold test and T- spot test
TB PCR-NAAT –Poor sensitivity but real time PCR-recommended by WHO

10. Treatment categories Two categories: Treatment of all new cases
Treatment of all previously treated cases
Two phases of treatment:
Intensive phase (2-3 mths)
Continuation phase ( 4 – 7 mths, extendable up-to a total period of treatment to 12 months on a case to case basis)
During intensive phase of TB meningitis, streptomycin to be replaced by tab. Ethambutol

11. DOTS
All critically sick patients should be given daily treatment in the hospital
At discharge to be referred to nearest DOTS center & alternate day therapy recommended
At DOTS center separate box for individual child maintained
Drugs are given at DOTS center & if child vomits in half hour- dose is repeated

12. Anti tubercular drugs First line Second line INH Rifampicin Ethambutol
Pyrazinamide
Streptomycin
Rifabutin*
Rifapentene*
Cycloserine
Para aminosalisylic acid
Ethionamide
Amikacin/Kanamycin
Capreomicin
Levofloxacin
Moxifloxacin
Gatifloxacin

13. Treatment categories & regimen
Category of treatment
Type of patient
TB treatment regimens (intensive phase)
TB treatment regimens (continuation phase)
New cases
New smear positive cases
New smear negative pulmonary TB
New extra pulmonary TB
2H3R3Z3E3*
4H3R3
Previously treated case
*Relapse, failure to respond or treatment after default
* Retreatment
2S3H3R3Z3E3 +
1H3R3Z3E3
5H3R3E3

14. Drug dosage INH- 10 mg/kg/day (max- 300 mg/day)
Rifampicin mg/kg/day (max- 600 mg/day)
Ethambutol mg/kg/day (max 1500 mg/day)
Pyrazinamide mg/kg/day (max 2000mg/day)
Streptomycin- 15 mg/kg/day (max 1gm/day)

15. Chemoprophylaxis Indications:
All asymptomatic contacts of a smear positive case( < 6 yrs age)after ruling out active disease & irrespective of BCG and nutritional status.
HIV infected children in contact with smear positive case or Mx positive (>+ 5mm) but not active disease

16. Chemoprophylaxis contd….
All Mx positive children receiving immunosuppressive therapy e.g nephrotic syndrome, acute leukemia etc.
Infant of mothers with TB diagnosed in pregnancy ( BCG vaccine can be given along with chemoprohylaxis
Chemoprophylaxis is given with INH- 10 mg/kg/day x 6 mths.

17. MDR & XDR TB MDR TB- resistant to INH & Rifampicin
X-DR TB – MDR TB+ resistant to Quinolones + resistant to any one of the following kanamycin/capreomycin/amikacin

18. TB bacillus concn & microscopic yeild
No. of bacilli
Observed
Estimated concentration of
bacilli per ml of specimen
Probability of a
positive result
0 in 100 or more field
<1000
<10%
1-2 in 300 fields
50%
1-9 in 100 fields
about
80%
1-9 in 10 fields
about
90%
1-9 per field
about
96.2%
10 or more per field
about
99.95%

19. Thank You