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Childhood tb

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childhood tuberculosis

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Childhood tb

  1. 1. CLINICAL ASPECTS OF PAEDIATRIC TUBERCULOSIS Dr . Arun Kumar.T Karpagam Faculty of Medical Sciences and Research
  2. 2. Primary infection • Compared to adults, children: – TB infection occurs for first time – Tend to develop primary active TB more often after initial infection (0-4yrs) – Are more likely to have extrapulmonary disease, especially TB meningitis (0-4yrs) – More lymphnode involvement – Are more likely to have disseminated TB infection – Are less contagious • Paucibacillary disease (fewer organisms) • Cannot cough/spread infection as well
  3. 3. Children vs. Adults  Cavitatory TB uncommon  Majority of deaths by EPTB  Are more difficult to diagnose • May not show typical symptoms
  4. 4. Children vs. Adults  In adults, - regional lymphadenitis less marked - bronchial erosion less frequent - less risk of dissemination - infectious - Cause of death - PTB  Thus, adult primary infection tends to be more local and pulmonary.
  5. 5. Risk factors in children  Age < 1yr  Steroid therapy  Malnutrition  Intercurrent infections: Measles,whooping cough  Immunocompromised state  Environment : overcrowding, inadequate ventillation, damp, insanitary and unhygenic conditions
  6. 6. TB infection and disease  Infection (LTBI)  Contact w/ infectious pulmonary TB (adult)  Child asymptomatic  TST +, CXR normal  Disease  Contact w/ infectious pulmonary TB  TST+/-  Child symptomatic or CXR positive for TB
  7. 7. TB overview: infection and disease – Risk of infection depends on disease burden in the index case, proximity and duration of exposure – Household exposure from adult with active disease is strongest source
  8. 8. Primary tuberculosis  Primary TB infection -acquiring TB directly after exposure to someone with active disease  Inhaled TB bacilli penetrate into lungs and settle- ”set up shop”  Parenchymal (Ghon) focus develops- At the site of first implantation - usually single and Subpleural - mostly - heals and disappears, or fibroses or calcifies  Bacilli drain to regional nodes  Upper lobes to paratracheal nodes  Middle and lower lobes to hilar nodes
  9. 9. Primary tuberculous infection  Infection is contained in a small area without spread or replication (latent TB infection or LTBI)  These individuals are not infectious to anyone  Primary Complex: primary focus + lymphangitis +lymphadenitis.  complications arise more commonly from regional adenitis than from the primary focus
  10. 10. Progressive primary complex  Progressive primary infection: Progression of recently acquired pulmonary primary infection  Progression depends on age of the child, number of tubercle bacilli, and host resistance.  Apparently healed focus or nodes may contain viable organisms for many years.  During 1st 4-8 weeks, organisms are disseminated in the blood stream.
  11. 11. Progressive primary complex  Incomplete bronchial obstruction with ball valve thrombus leads to Obstructive emphysema.  Aspiration of caseous material results in bronchopneumonia, consolidation.  Complete obstruction results in collapse of lung distal to the obstruction or collapse consolidation.
  12. 12. Secondary tuberculosis(adult type of TB)  All active tuberculosis which occur after primary infection due to Endogenous reactivation or Exogenous reinfection  Cavity formation seen in lung apices.  Cavitating tuberculosis seen in younger children due to high adult TB incidence in community.
  13. 13. Clinical features  Physical manifestations differ by age of onset  Less compared to degree of radiographic changes  Majority develop no signs or symptoms  Young infants & adolescents more likely to have significant symptoms.  Infants --- smaller airways  School age children often have clinically silent disease
  14. 14. Symptoms  Primary complex – mild fever, anorexia, weight loss, decreased activity, cough  Progressive primary complex – high grade fever, cough. Expectoration and hemoptysis – usually associated with cavity and ulceration of bronchus. Abnormal chest signs – decreased air entry, dullness, crepts
  15. 15. Symptoms  Pleural effusion -follows a rupture of a subpleural focus. -Also by hematogenous spread from primary focus. Fever, cough, dyspnea, pleuritic chest pain.
  16. 16. Radiology  In extra pulmonary tb, presence of lesions on chest radiograph supports diagnosis.  Enlarged lymph nodes in hila, right paratracheal region  Consolidation in progressive primary disease – heterogenous, poorly marginated with predilection to apical or posterior segments of upper lobe or superior segments of lower lobe.  Pleural effusion  Miliary tb – millet sized lesions
  17. 17. Extrapulmonary tuberculosis  Includes TB adenitis(75%) , TB meningitis(13%) , TB effusions (pleural, pericardial & peritoneal), bone & joint TB, miliary TB, abdominal TB, ocular TB, cutaneous TB, genito-urinary TB.
  18. 18. Tuberculous adenitis
  19. 19. Tuberculous adenitis  Commonest form of EPTB  LNTB is local manifestation of systemic disease  Isolated cervical lymphadenopathy more common in 2/3 rd with Painless, matted nodes.  Lymphnode abscess can burst & lead to non healing TB sinus and ulcer  FNAC  Excision biopsy confirmatory
  20. 20. Tuberculous meningitis  TB meningitis seen in 1/300 Primary infections  Rupture of a subcortical caseous focus (Rich’s) into the subarachnoid space.  Inflammatory meningeal exudates, ependymitis, vasculitis, encephalitis & diturbance of CSF circulation & absorption.  Cerebral endarteritis narrows lumen, reduces blood flow, leads to cerebral thrombosis and infarction.  Hydrocephalus
  21. 21. CN palsy 3, 6, 7 Involvement of cranial nerves III VI VII and optic chiasma
  22. 22. Tuberculous meningitis  Risk factors : Age < 5 years, contact with an adult suffering from tuberculosis, PEM grade III and IV, and HIV infection
  23. 23. Stages of TB meningitis Stage I Irritability, anorexia, personality change Occasional vomiting, fever Poor school performance Stage II Focal neurological signs, cranial nerve palsies, Seizures, hemiplegia, squint Stage III Loss of consciousness, Coma, Papilloedema Decerebrate rigidity
  24. 24. Complications of TB meningitis  Hydrocephalus  Subdural effusion  Hemiplegia / Paraplegia Late :  Intellectual impairment  Blindness  Deafness  Intracranial calcifications leading to  hypothalamic and pituitary dysfunction  Growth failure  Diabetes insipidus  Failure of development of secondary sexual  characteristics
  25. 25. Diagnosis of TB meningitis  Signs of meningeal irritation  X-ray chest  CT scan – basal exudates, inflammatory granulomas etc  Tuberculin testing  Retinoscopy for choroidal tubercles  Lumbar puncture Elevated CSF pressure(30 – 40cm h2o) Cobweb Coagulum/ pellicle on standing 100 – 500 WBCs / cu.mm >40 mg% protein Low / Normal sugar AFB smear & culture
  26. 26. Prognosis in TB meningitis 100% mortality in 3-4 weeks without treatment 100% survival with treatment started in Stage I 75% survival with treatment started in Stage II Stage III – variable survival, all will have sequelae
  27. 27. Tuberculomas  Infratentorial tuberculomas  Solitary  A ring enhancing lesion is not pathognomonic of tuberculoma  A larger lesion >20 mm, disc lesion or ring lesion with thicker rim and central nodule favors tuberculoma; while multiple, smaller, thin rim with epicentric nodule favor NCC  MR spectroscopy may help in diagnosis of tuberculoma as it shows lipid peak.  D/D Neurocysticercosis, fungus, other tumours.
  28. 28. Tuberculomas
  29. 29. Miliary tuberculosis  most common within 1st 3 to 6 months after infection  due to heavy hematogenous spread of tubercle bacilli  Onset: Insidious, with Fever and weight loss Palpable liver and/or spleen Generalized lymphadenopathy, Papulonecrotic skin lesions, choroid tubercles Tachypnoea with normal chest findings
  30. 30. Miliary tuberculosis  Hematogenous dissemination leads to progressive development of small lesions throughout the body, with tubercles in the  lung, spleen, liver,  bone marrow, heart, pancreas  brain, choroid, skin  Radiologic diagnosis:  “Snow storm” appearance (Multiple small lung nodules 1mm size and above in both lung fields).
  31. 31. Miliary TB
  32. 32. Choroidal tubercles
  33. 33. Cutaneous Tuberculosis Associated with Hematogenous dissemination  - Papulonecrotic tuberculids papules with soft centers on trunk, thighs and face  - Tuberculosis verrucosa cutis Large tuberculids on arms and legs Associated with hypersensitivity to tuberculin  - Erythema nodosum painful indurated nodules on shins, elbows, forearms that subside in 2-3 weeks
  34. 34. TB verrucosa cutis Large tuberculids on arms and legs
  35. 35. Erythema nodosum painful indurated nodules on shins, elbows, forearms
  36. 36. Guidelines for presumptive diagnosis of tuberculosis Pediatr Infect Dis J 1993;12: 499-504)  A combination of at least 3 of the following:  Symptoms/signs s/o TB: (fever., cough>2wks, weight loss)  History of close contact with TB  Positive tuberculin skin test (Mantoux > 10 mm)  sputum / gastric juice AFB +ve  lymph node / tissue biopsy positivity  Radiologic features suggestive of TB
  37. 37.  History of contact = any child who lives in a household with an adult taking ATT or has taken therapy in the past 2 years
  38. 38. Early morning Gastric aspirate  Fasting for about 6 hours (at night)  Appropriate size intra-gastric tube is passed  Initially the aspirate is drawn from the stomach and further washing with 15-30 mL saline is taken.  The contents are transferred to the laboratory  This specimen can also be collected as an ambulatory procedure after 4-6 hours fasting with some loss of yield
  39. 39. Sputum collection in children  Induced sputum can be done in children as young as 1 month  6h fasting  Pre-treat with inhaled albuterol by MDI  3% hypertonic saline given by jet nebulizer for 15 minutes followed by chest percussion  Samples are collected from throat or nasopharynx using collector attached to a suction at one end and catheter to the other.  The suction catheter provokes cough and the secretions brought up are collected via suction
  40. 40. Treatment for TB 1st line anti-tuberculous drugs  Isoniazid (INAH) 5 mg/kg/day H Rifampicin 10 mg/kg/day R  Pyrazinamide 25 mg/kg/day Z Ethambutol 20 mg/kg/day E  Streptomycin 20mg/kg/day S
  41. 41. Phases of Treatment  Intensive Phase  Eliminate bacterial load  Prevent emergence of drug resistant strains  Atleast 3 Bactericidal Drugs used  Continuation Phase  Continue and complete therapy  Atleast 2 Bactericidal drugs used  Steroids  Anti inflammatory effect – millary, peritonitis, pericarditis  TB meningitis
  42. 42. RNTCP Treatment
  43. 43. Summary and Pearls • Clinical manifestations in pediatric TB may be non- specific • TB is much more difficult to diagnose in children • Undiagnosed or untreated TB in a child is potentially serious, – More likely to develop severe or disseminated disease • Diagnosis of TB in a child is a sentinel event – Contact investigation is critical
  44. 44. CONGENITAL TB  Congenital infection by vertical transmission is rare with only 358 cases reported till 1995 and another 18 cases reported from 2001 to 2005  High neonatal mortality (up to 60%) and morbidity warrant early diagnosis and treatment of newborns suffering from TB
  45. 45. Mother to child transmission of TB  Vertical transmission:  Transplacental transmission through Umbilical veins(occurs in late pregnancy)  Aspiration & swallowing amniotic fluid (occurs in perinatal period)  Transmission through breast milk does not occur  Horizontal transmission in postpartum period is by droplet infection from mother or family members
  46. 46. High risk factors  Extra Pulmonary, miliary and Meningeal TB in Mother  Untreated Mothers.
  47. 47. Diagnosis  Cantwell criteria: Presence of proven tuberculous disease and at least one of the following;  (i) lesions in the newborn baby during first week of life;  (ii) a primary hepatic complex or caseating hepatic granulomata;  (iii) tuberculous infection of the placenta or the maternal genital tract; and  (iv) exclusion of the possibility of postnatal transmission by investigation of contacts, including hospital staff
  48. 48. Clinical Manifestations Of Congenital T.B:  Median Age of Presentation:- 24 days ( 1to 84 days)  FETAL:- IUGR,LBW ,increased risk of mortality  Neonate:- Irritability, Poor Feeding, lethargy (100%) ,Failure to thrive, fever(100%), Cough(88.9%),respiratory distress (66.7) Apnea,Vomiting,cyanosis,seizures,petechiae(<1 0%case)
  49. 49. Examination  Hepatosplenomegaly (100%)  Splenomegaly (77.8%)  Abdominal distension(77.8%)  Lymphadenopathy(38%)  Babies develop meningitis septicemia, pneumonia, DIVC, ascitis, parotitis, osteomyelitis, otitis media, paravertebral abscess, cold abscess, skin lesions
  50. 50. INVESTIGATIONS Conventional Method:-  Morphological & histological examination of placenta.  Screening of house hold contact  Poor response to conventional treatment  Detection of AFB in gastric aspirates,Sputum(induced), tracheal aspirates,ear discharge,Skin lesions, ascitic fluid,CSF,pleural fluid  Broncho Alveolar Lavage - By PCR (diagnostic)
  51. 51.  Chest radiography & computed tomography – may show scattered infiltrates, bronchopneumonia, consolidation or periportal hypodensity (non specific)  Mantoux test-(supportive evidence) Poor utility Used after 3 months of age PPD 2TU
  52. 52. Newer methods  Gene expert (real time PCR )  LED Fluoreseance microscopy and liquid based mycobacteria growth indicator tube (MGIT)  RIGAs, QuantiFERON –TB Gold assay and T-Spot – Inconsistent result in newborn.
  53. 53. Management Of Congenital TB  AIM - To ensure free survival of a newborn infant  Diagnosis of active tubercular lesion  Treatment of the neonate  prevention of infection to the neonate from the mother.
  54. 54. (i)Prevention of Transmission (A)Maternal disease & therapy: Transmission is less when mother complete ATT Before delivery or Have received ATT for at least 2 weeks before delivery.  ATT drugs safe for fetus expect streptomycin in the first trimester  Safety of second line ATT drugs for resistant TB - Insufficient evidence.
  55. 55. Prevention of transmission (B) PROPHYLAXIS ( IAP guildelines )  ISONIAZID for newborn at least 6 month (or)  a minimum of three months until mother is Culture negative  DOSE:-10 mg/kg.
  56. 56. Prevention of transmission (C)Nutrition and breast feeding  Support for breast feeding.  Expressed breast milk-when mother is sick or smear positive or has MDR TB.  Personal hygiene, hand washing, cough hygiene  First line ATT is safe & excreted in breast milk
  57. 57. Prevention of transmission (D) Isolation  Isolation - sick mother, resistant TB, non adherent therapy, received ATT for less then 2 weeks.
  58. 58. Prevention of transmission  (E)Barrier Nursing  Face Mask,  Cough hygiene,  Hand Washing ,  Disinfecting nasal secretions & baby wipes.
  59. 59. TREATMENT  American Academy of Pediatrics recommends treatment with INH 10 to 15 mg/kg po, Rifampin 10 to 20 mg/kg po, Pyrazinamide 30 to 40 mg/kg po, Aminoglycoside (amikacin or kanamycin) for 9-12 months.  Regimen is modified as indicated based on results of testing for resistance.  Pyridoxine is given if the neonate is exclusively breastfed.
  60. 60. (C)FOLLOW UP:- DOTS recommends  clinical surveillance during treatment &  chest x-ray at the end of treatment.
  61. 61. (III)Long Term protection.  IAP Recommendation BCG (Bacillus Calmette Guerin) Vaccination  No utility of BCG Vaccine in neonates with congenital tuberculosis  Advised at birth even with INH prophylaxis (IAP 2012).  Need to conduct more studies to evaluate immunogenicity of BCG Vaccine in infants receiving INH prophylaxis.
  62. 62.  Congenital tuberculosis is diagnosed by Cantwell criteria and treatment includes three or four anti- tubercular drug regimen.  Prophylaxis with isoniazid (3-6 months) is recommended in neonates born to mother with TB who are infectious.  Breastfeeding should be continued in these neonates and isolation is recommended only till mother is infectious, has multidrug resistant tuberculosis or non adherent to treatment.  BCG vaccine is recommended at birth or after completion of prophylaxis (3-6 months) in all neonates.
  63. 63. Peds TB Cases
  64. 64. Meron 4 ½ months old  Well appearing, Normal PE (wt in 10%) developmental screen.  Screened for TB, Hepatitis, syphilis, HIV, parasites, lead  Vision/hearing screening: high frequency hearing loss  Received BCG at birth  TST 12 mm enduration, HIV –  Hx repeated respiratory infections in orphanage, treated w/ multiple antibiotics
  65. 65. Meron  CXR 2 views  Alert radiologist you are looking for TB
  66. 66. Meron  Laboratory testing  Microbiological testing  Sputum, sputum induction (?)  BAL (?)  Gastric aspirates  CBC, U/A & U/Cx, electrolytes & renal fct, LFT Treatment? How many drugs?
  67. 67. Meron  Gastric aspirate positive Mtb on second aspirate  Started on 4 drug regime by DOT  Resistant to INH, RIF. Sensitive to PZA, EMB, SM  MAC also grew on purity plates
  68. 68. Meron  Use all first line drugs available (unless previously used & associated w/ failing regime)  Use injectable drug (SM, amikacin, capreomycin, kanamycin) by Broviac  Use fluroquinolone  Use additional second line drugs to have 4-6 drugs in the regime
  69. 69. Meron  Treatment changed: aminoglycoside (by broviac x 4 mos), PZA, EMB, ethionamide and levofloxacin, Vit B6 by DOT  2 negative gastric aspirates on therapy  Gained many pounds  CXR normalized  Normal growth and development
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childhood tuberculosis

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