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pediatric
TUBERCULO
SIS
By: CC Ma. Celine N.
Villo

National Tuberculosis Control Program, Manual of Procedures, 5th Edition

Nelsons Textbook of Pediatrics, 20th Edition

WHAT IS
TUBERCULOSIS?
Infectious disease: Mycobacterium
tuberculosis
Transmission: coughing, sneezing
and spitting (AIR)
LUNGS commonly affected
Can affect other organs: bone,
kidney, heart, brain
TB is curable and preventable

WHAT IS
Infectious disease : over 4000 years
TUBERCULOSIS?

First Recognized by Schonlein 19th

century
1830: termed Tuberculosis from
English word Tubercle meaning
Lesion of consumption
LUNGS commonly affected organ
But can affect other organs: bone,
kidney, heart, brain

What is Mycobacterium
A complex: M. tuberculosis, M. bovis, M.
tuberculosis?
africanum, M. microti, M. Canetti.
Non spore forming, non motile, weakly
gram positive
Curved slender rods (1-5um): beaded
or clumped

Obligate Aerobes
Grows best at 37-41 deg. Celsius
Generation time: 12-24 hours

LIPID RICH CELL WALL

WHAT ABOUT
TRANSMISSION?

inhalation of
droplet nuclei from
coughing, sneezing,
spitting

WHAT ABOUT
No transmission within several days to 2
TRANSMISSION?

weeks beginning adequate chemotherapy

YOUNG CHILDREN with TB RARELY

infect other children and adults
Tubercle bacilli are sparse in the endobronchial
secretions of children
Cough is often absent or lacks in tussive force
to suspend infectious bacteria

WHAT IS THE
EPIDEMIOLOGY?

MOST
COMMUNICABLE
2nd Leading cause
23 million people
of Death
95 percent in
Developing
countries : Asia,
Africa,
Adults
M>F
Mediterranean
Children M=F
Young Adults and
< 5yo

WHAT IS THE
2010
EPIDEMIOLOGY? Year
6 Leading Cause of
th

Death
More males (17,
103) died that
Females (7,611)
2011: Drug
resistant
New Cases is 2%

Malnourished and
Immunocompromised
Higher Prevalence among

2x

increased prevalence in urban poor

THREE MAJOR CLINICAL

STAGES
1. EXPOSURE- Child had significant
contact (shared the air with) with a person with
infectious TB but lack proof of infection

2. INFECTION- Individual inhales droplet

nuclei containing M. tuberculosis, which
survives intracelluarly in the lung and lymphoid
tissue
-Hallmark: positive TST (tuberculin skin test) or
IGRA (interferon gamma release assay)

THREE MAJOR CLINICAL

STAGES

WHAT IS THE
PATHOGENESIS?
It starts with Primary Infection.
Develops in person previously

unexposed

LUNGS is the portal of entry in >

98% of cases
Bacilli implants in basal part or upper
part of UPPER LOBE

GHON FOCUS FORMS then to

WHAT IS ghoN focus?

1-1.5 cm Grey White Inflammation
with consolidation which can also
Caseats
Tuberculous Granuloma:
1. Rounded Outlines
2. Central Solid or caseous Necrosis
3. Transformed Macropahges and
epitheloid cells
4. Lymphocytes, Plasma Cells and
Fibroblasts

WHAT IS THE
PATHOGENESIS?

1. ENDOCYTOSIS
2. PROLIFERATIO
N
3. PHAGOSOMELYSOSOME
FUSION
4. TH1
RESPONSE
5. MACROPHAGE
ACTIVATION
6. GHON FOCUS
7. LYMPH NODE

WHAT IS ghoN COMPLEX?

PRIMARY COMPLEX- Local
infection at portal of entry
and regional lymph nodes.
Tissue reaction intensifies
in the next 2 to 12 weeks:
hypersensitivity
Parenchyma often heals by
FIBROSIS or
CALCIFICATION after
undergoing CASEOUS
NECROSIS AND

PRIMARY TUBERCULOSIS
A 14 yr old child
with proven
primary
tuberculosis.
hyperinflation,
prominent left
hilarlymphadenopa
thy, and alveolar
consolidation
involving the
posterior segment
of the left upper
lobe as well as the
superior segment
of the left lower
lobe.

PRIMARY TUBERCULOSIS

1. Hilar lymphadenopathy 2. External

compression
3. partial obstruction of the bronchus 4. focal
hyperinflation 5.atelectasis

PRIMARY TUBERCULOSIS
tuberculousbronchial obstruction: resolve
fully with appropriate treatment
Occasionally, (+) residual calcification of the
primary focus or regional lymph nodes
Calcification: lesion is present for at least 612 mos
Healing can be complicated by scarring or
contraction
Children can have lobar pneumonia without
impressive hilar lymphadenopathy

FATE OF PRIMARY
TUBERCULOSIS
MNEMONICS: DDD
1. DEATH- Bacilli will be completely
erradicated

2. DORMANCY- Bacilli is contained and

inactive

3. DIFFUSE/ DISSEMINATEDBacilli continued to progress

RISK FACTORS

CLINICAL MANIFESTATIONS
symptoms and physical
signs
inadequate/limited
considering the degree
of radiographic
changes
most common
symptoms:

Nonproductive

CLINICAL MANIFESTATIONS
difficulty gaining
weight or develop a
true failure-to-thrive
syndrome
bronchial obstruction
have localized
wheezing or decreased
breath sounds with
tachypnea or, rarely,
respiratory distress

CLINICAL MANIFESTATIONS
EXTRAPULMONARY
TB

DIAGNOSTICS
TUBERCULIN SKIN TEST or
MANTOUX TEST
intradermal injection-0.1 mL
purified protein derivative (PPD)
stabilized with Tween 80
T cells sensitized by prior
infection
Release lymphokines- induce
induration through local
vasodilation, edema, fibrin
deposition and recruitment of

DIAGNOSTICS
CHILDREN FOR WHOM IMMEDIATE TST OR IGRA
IS INDICATED
Contacts of people with confirmed or
suspected contagious TB
With radiographic or clinical findings
suggesting TB
Immigrants or travel histories from countries
with endemic infection and substantial
contact with indigenous people
Who should have annual TST or IGRA

CASE FINDINGS
identification and diagnosis of TB cases
among individuals with signs and symptoms
presumptive of tuberculosis
passive and intensified case finding
Available tests utilized
direct sputum smear microscopy
TB culture and drug susceptibility test
tuberculin skin test and
rapid molecular diagnostic tests

CASE FINDINGS
DIRECT SPUTUM SMEAR MICROSCOPY
(DSSM)
fundamental to the detection of infectious
cases and is recommended for case finding
among adults and children who can
expectorate
the primary diagnostic method adopted by
the NTP among such individuals because it is
DEINITIVE, SIMPLE, ECONOMICAL AND
PORTABLE.
It a basis for categorizing TB cases according

CASE FINDINGS
HOW TO PRODUCE QUALITY SPUTUM?
1. Clean mouth thoroughly by rinsing with
water.
2. Breathe deeply, hold breath for a second
or two, and then exhale slowly. Repeat the
entire sequence two (2) more times.
3. Cough strongly after inhaling deeply for
the third time and try to bring up sputum
from deep within the lungs.
4. Expectorate the sputum in the sputum cup
or conical tube.
5. Collect at least 1 teaspoonful (5-10ml) for

CASE FINDINGS

CXR
complement bacteriologic testing, has low specificity
TB CULTURE AND DRUG SUSCEPTIBILITY TEST
(DST)
using solid (Ogawa or Lowenstein Jensen) or liquid
media (MGIT) is a routine diagnostic test for drugresistant TB cases under the NTP.

RAPID MOLECULAR DIAGNOSTIC TESTS

WHO-endorsed available diagnostic tests in the
country are XpertMTB/RIF and Line-Probe Assay (LPA)

CASE FINDINGS
Classification based on bacteriological status
Bacteriologically-confirmed
patient who is biological specimen is positive
Clinically-Diagnosed
patient who does not fulfill the criteria for
bacteriological confirmation but has been
diagnosed with active TB by a clinician or
other medical practitioner who has decided to
give the patient a full course of TB treatment.
( basis of CXR abnormalities or suggestive
histology, and extra-pulmonary cases without

CASE FINDINGS
2. Classification based on anatomical site
Pulmonary TB (PTB)
Refers to a case of tuberculosis involving
the lung parenchyma.
or with both pulmonary and extrapulmonary
Extrapulmonary TB (EPTB)
Refers to a case of tuberculosis involving
organs other than the lungs (e.g., larynx,
pleura, lymph nodes, abdomen,
genitourinary tract, skin, joints and bones,

CASE FINDINGS
Classification based on history of previous
treatment
New case A patient who has never had
treatment for TB or who has taken anti-TB
drugs for less than one (1) month.
Retreatment case A patient who has been
previously treated with anti-TB drugs for
at least one (1) month in the past.

CASE FINDINGS
Classification based on drug-susceptibility
testing
a. Monoresistant-TB one first-line anti-TB drug
only.
b. Polydrug-resistant TB more than one first-line
anti-TB drug (other than both Isoniazid and
Rifampicin).
c. Multidrug-resistant TB (MDR-TB) at least both
Isoniazid and Rifampicin.
d. Extensively drug-resistant TB (XDR-TB)
Resistance to any fluoroquinolone and to at
least one of three second-line injectable drugs

CASE FINDINGS

IDENTIFICATION OF PRESUMPTIVE TB
1. Note the patients general information on patients chart.
2. Ask or check for clinical signs and symptoms to identify a
presumptive TB.
For patients 15 years old and above, a presumptive TB has
any of the ff:
Cough of at least 2 weeks duration with or without
the ff symptoms
Significant and unintentional weight loss
Fever
Bloody sputum
Chest/back pains not referable to any
musculoskeletal disorders

CASE FINDINGS
IDENTIFICATION OF PRESUMPTIVE TB
2. Ask or check for clinical signs and symptoms to identify a
presumptive TB.
For patients 15 years old and above, a presumptive TB has
any of the ff:
Unexplained Cough of any duration in:
Close contact of a known active TB case
High-risk clinical groups
High-risk populations

CASE FINDINGS

2. Ask or check for clinical signs and symptoms to identify a

presumptive TB.
For patients below 15 years old, a presumptive PTB has
any of the ff:
i. At least three (3) of the following clinical criteria:
Coughing/wheezing of 2 weeks or more, especiallu unexplained
Unexplained fever of 2 weeks or more after common causes such as
malaria or PNA have been excluded
Loss of weight/failure to gain weight/weight faltering/loss of appetite
Failure to respond to 2 weeks of appropriate antibiotic therapy or
lower respiratory tract infection
Failure to regain pervious stat of health2 weeks after a viral infection
or exanthema
Fatigue, reduced playfulness or lethargy

CASE FINDINGS
IDENTIFICATION OF PRESUMPTIVE TB
2. Ask or check for clinical signs and symptoms to identify a
presumptive TB.
For patients 15 years old and below, Presumptive extrapulmonary TB may have any of the following:
gibbus esp of recent onset (resulting from verterbral TB)
non-painful enlarged cervical lymphadenopathy with or
without fistula formation
Neck stiffness (or nuchal rigidity) and/or drowsiness
suggestive of meningitis that is not responding to
antibiotic treatment with subacute onset or raised
intracranial pressure
Pleural effusion

CASE FINDINGS
IDENTIFICATION OF PRESUMPTIVE TB
3. Ask and verify the following:
a. History of previous anti-TB treatment and its detail
b. Exposure to active TB cases or presumptive TB (including
MDR-TB, if applicable) within the workplace, family or
household
c. Presence of clinical or other high-risk factors (e.g.,
HIV/AIDS, diabetes, end stage renal disease, cancer,
connective tissue diseases, autoimmune diseases, silicosis,
patients who underwent gastrectomy or solid organ
transplantation and patients on prolonged systemic steroids)

CASE FINDINGS
E. Tuberculin skin testing(for
patients less than 15 years old)
1.Perform the TST according to the standard
set of procedures
2.Read and interpret the test between 48 to
72 hours from the time it was administered.
3.A positive TST is an area of induration of the
skin with diameter of 10mm or more.

CASE FINDINGS
F. DIAGNOSIS OF EXTRAPULMONARY
TB
Can be done through Xpert MTB/RIF for body
fluids such as Cerebrospinal Fluid and gastric
aspirate. Tissue Biopsy is another option.

SION ON DIAGNOSIS BASED ON LABORATORY RESULTS

CASE FINDINGS
G. DECISION ON DIAGNOSIS BASED ON
LABORATORY RESULTS
1.If sputum smear-positive, classify as
bacteriologically-confirmed PTB.
2.For patients who are at least 15 years old
with negative DSSM results or DSSM not
done, refer the patient for CXR.
a. If CXR findings are suggestive of TB and
patient has access to XpertMTB/RIF, refer
the patient to an XpertMTB/RIF site for
testing.

CASE FINDINGS

G. DECISION ON DIAGNOSIS BASED ON

LABORATORY RESULTS
b. If CXR findings are suggestive of TB but
patient has no access to XpertMTB/RIF or
could not expectorate, the DOTS physician
will use his best clinical judgment to decide
if active TB. Referral to a specialist or a TB
Diagnostic Committee may be done if
reasonably accessible or able to render a
decision within 2 weeks. If the physician or
TBDC decides to treat as active TB, classify

CASE FINDINGS

G. DECISION ON DIAGNOSIS BASED ON

LABORATORY RESULTS
3. For patients below 15 years old who are smearnegative but can expectorate, refer to an
XpertMTB/RIF site if accessible.
If patient has no access to an XpertMTB/RIF site or
cannot expectorate, perform TST.
If TST is negative, request for CXR.a. Decide to treat as
active TB if the child has any three of the following
criteria
i.

Positive exposure to an adult/adolescent with active TB

disease;

CASE FINDINGS
G. DECISION ON DIAGNOSIS BASED ON
LABORATORY RESULTS
b. If patient fulfills three (3) out of five (5)
criteria, classify as clinically-diagnosed
PTB.
c. If patient does not fulfil at least three (3)
out of five (5) criteria, investigate further
or refer to a specialist.

CASE HOLDING
set of procedures which ensures
that patients complete their
treatment involves
assignment of the appropriate
treatment regimen based on
diagnosis and previous history of
treatment,
supervised drug intake with support
to patients, and
monitoring responses to treatment

TREATMENT
Basic principles in management of TB in
children and adolescents are the same in
adults
Recommendations by CDC and American
Academy of Pediatrics:
standard therapy of intra thoracic
tuberculosis (pulmonary disease and/or
hilar lymphadenopathy) in children,
6 mos regimen of isoniazid and rifampin
supplemented in the 1st 2 mos of
treatment by pyrazinamide and

TREATMENT
experts recommend that all drug
administration be directly observed,
meaning that a healthcare worker is
physically present when the medications
are administered to the patients
When directly observed therapy is used,
intermittent (twice or thrice weekly)
administration of drugs after an initial
period as short as 2 wk of daily therapy is
as effective in children as daily therapy

TREATMENT
Extrapulmonary tuberculosis
Treatment is same as for pulmonary
tuberculosis
bone and joint, disseminated, and CNS
tuberculosis treated for
9-12 mo.
Surgical debridement in bone and joint
disease and shunting in CNS disease may
be necessary adjuncts to medical therapy.

TREATMENT
Tuberculosis in HIV-infected children
optimal treatment of tuberculosis in HIVinfected children has not been stablished
Data for children are limited; most
experts believe that HIV-infected children
with drug susceptible tuberculosis should
receive the standard 4-drug regimen for
the 1st 2 mos followed by isoniazid and
rifampin for a total duration of at least 9
mos

TREATMENT
1.Inform patient that he/she has TB and motivate
him/her to undergo treatment.
2.For patients less than 18 years old, talk to the
parent/guardian regarding the need for the child to
undergo treatment. Provide, as necessary, the following
key messages for TB patients and their families:
Need for at least 6-8 months of supervised, well
documented TB treatment with good compliance
Free anti-TB drugs in DOTS program
Public health facilities offer free bacteriology
service
Schedule of ff-up DSSM for monitoring
Tracing mechanism if lost to ff-up by which the

TREATMENT
FOLLOW-UP VISITS
Ask for the patients Form 5. NTP ID Card
and inquire how he/shehas been since the
last clinic visit.
Ask the patient about the following:
a. General well-being;
b. Progression or resolution of symptoms;
c. Adverse drug reactions or side effects;
d. Compliance to treatment and DOTS;
e. Any problem or concerns regarding the

THE
END