1. Unit 9 Diagnosis and Treatment of Paediatric TB: B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

2. Slide 2 Unit 9: Case Studies B Family Background Remember the B Family? Mr. B is on TB retreatment and ART Because he is receiving streptomycin injections, he is not eligible for DOTS The B’s have 3 children: BB (3 mos) KB (3 yrs) JB (7 yrs)

3. Slide 3 Unit 9: Case Studies B Family Case (1) BB Mrs. B’s 3 month-old daughter Mrs. B states BB is eating well, hasn’t had a fever or cough and is active BB is afebrile, has age appropriate behaviour and weighs 5 kg KB Mrs. B’s 3 year-old son Mrs. B states KB is playing with children, doesn’t have a fever or cough and has a healthy appetite KB is afebrile, has age- appropriate behaviour and weighs 15 kg

4. Slide 4 Unit 9: Case Studies B Family Case (2) Mrs. B is HIV positive Mr. B has smear-positive TB A breast-feeding child of a smear-positive mother has a higher risk of infection (compared to a child living in the same household as a smear-positive patient). Both are eligible for INH (if not symptomatic for TB)

5. Slide 5 Unit 9: Case Studies B Family Case: Question 1 1.What is your management plan for BB? 2.What is your management plan for KB? 3.Would you give pyridoxine in either of these cases?

6. Slide 6 Unit 9: Case Studies B Family Case: Answer 1 BB (3 month-old girl) INH at 5mg/kg = 25 mg/day x 6 months Repeat BCG if no scar on forearm Note that CXR and TST are NOT necessary HIV test KB (3 year-old boy) INH at 5mg/kg = 75 mg/day, but you give 100 mg/day due to drug formulation available Note that CXR and TST are NOT necessary HIV test Neither of these cases should get pyridoxine

7. Slide 7 Unit 9: Case Studies B Family Case: Question 2 JB is Mrs. B’s 7 year-old daughter Mrs. B. states that JB has had an intermittent cough for 4 weeks She has not been to school for 3 days because she has been complaining of feeling tired She has not been eating well lately JB is short for her age, appears thin, is febrile (38.1 C) and weighs 18 kg

8. Slide 8 Unit 9: Case Studies B Family Case: Question 2 What do you do for Mrs. B’s daughter, JB?

9. Slide 9 Unit 9: Case Studies B Family Case: Answer 2 TB investigations TST Sputum collection CXR HIV test

10. Slide 10 Unit 9: Case Studies B Family Case: Question 3 JB is found to be HIV negative Mantoux is 12mm Only 1 sputum was sent and it was negative Chest x-ray shows a pleural effusion Source: B. Marais, Stellenbosch University What do you do next for JB?

11. Slide 11 Unit 9: Case Studies B Family Case: Answer 3 Start JB on Category III treatment: Intensive phase: 2HRZ 2 tabs R60H30Z150 daily x 2 months Continuation phase: 4HR 2 tabs R60H30 x 4 months She will likely show marked improvement after 2 weeks NOTE: the dose will change as JB gains weight

12. Unit 9 Diagnosis and Treatment of Paediatric TB Additional Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

13. Slide 13 Unit 9: Case Studies Additional Case (1) Agnes is 2 years old Her mother was just diagnosed with smear- positive pulmonary TB Agnes is brought to the hospital by her parents Agnes’ father says she has been ill for 3 weeks She eats poorly, is losing weight, doesn’t play, and feels hot most days

14. Slide 14 Unit 9: Case Studies Additional Case (2) Physical exam T 39°C Weight 70% of the expected weight for her age Enlarged lymph nodes in the neck, axilla, and inguinal areas Swollen parotid glands, enlarged liver and spleen Malaria smear negative Management Prescribe ampicillin Educate the parents, and ask them to return in 3 days

15. Slide 15 Unit 9: Case Studies Additional Case: Question 1 1.What are common signs and symptoms of TB in small children? 2.What tests provide a confirmed diagnosis of tuberculosis disease in small children? 3.What tests provide supporting evidence of TB in small children?

16. Slide 16 Unit 9: Case Studies Additional Case: Answer 1 (1) 1.Signs and symptoms in small children: Chronic cough not improving and present for two to three weeks Night sweats Fever of >38 degrees for two weeks Weight loss or failure to thrive Fatigue Blood-streaked sputum

17. Slide 17 Unit 9: Case Studies Additional Case: Answer 1 (2) 2.Confirmed TB in small children Positive gastric aspirate smear or culture Other positive culture Positive acid-fast stain on lymph node aspirate Caseous material on biopsy Cheesy material on visual inspection of biopsied lymph node

18. Slide 18 Unit 9: Case Studies Additional Case: Answer 1 (3) 3.Supportive evidence of TB in small children Positive TST BUT do not treat active TB in children based only on positive TST Suggestive x-ray images Widened mediastinum from hilar or mediastinal lymphadenopathy Miliary pattern Pleural effusion

19. Slide 19 Unit 9: Case Studies Additional Case: Question 2 What signs and symptoms are helpful in making a presumptive diagnosis of TB if microbiologic or radiologic testing is not possible?

20. Slide 20 Unit 9: Case Studies Additional Case: Answer 2 Prolonged cough Fatigue No response to broad spectrum antibiotic Fever Weight loss Positive PPD A minority of patients with active TB will have a negative skin test, particularly if malnourished or otherwise debilitated

21. Slide 21 Unit 9: Case Studies Additional Case: Question 3 1.Knowing what you know now about Agnes, should she be started on treatment for tuberculosis disease? 2.If Agnes improves on ampicillin, the treatment for bacterial pneumonia, would you do anything additional for her?

22. Slide 22 Unit 9: Case Studies Additional Case: Answers 3 (1) 1.Yes, she should receive TB treatment because: She is the child of a smear-positive patient She has all the symptoms of TB and did not respond to antibiotics There were non-specific chest X-ray changes

23. Slide 23 Unit 9: Case Studies Additional Case: Answers 3 (2) 2.Remember that in immunosuppressed patients, more than one disease frequently exists at the same time Due to the presence of enlarged lymph nodes, liver, and spleen, Agnes may have HIV or pneumonia that is superimposed on TB– test her for HIV She needs further evaluation before starting on IPT (lymph node aspirate, etc.)