Introduction

An acute or chronic infection caused by Mycobacterium tuberculosis, tuberculosis (TB) is characterized by pulmonary infiltrates, formation of granulomas with caseation, fibrosis, and cavitation. People living in crowded, poorly ventilated conditions are most likely to become infected.

Tuberculosis is the most common cause of infection-related death worldwide. In 1993, the World Health Organization (WHO) declared TB to be a global public health emergency. Tuberculosis in children has not been given much attention until that time when the WHO recognized the burden of tuberculosis in children. Most cases in children are due to the spread of tuberculosis from sputum positive adults. In industrialized countries, the frequency of tuberculosis will be less than 10 per 100,000 population, though in slum dwellers, this may rise to 60/100,000. In the Philippines, a prevalence study in a rural community involving 240 children showed that 52.1% who got exposed to sputum positive adults and only 43.1% with exposure to adults with PTB based on positive chest x-ray findings, were positive purified protein derivative (PPD) reactors.

Children exposed to Mycobacterium tuberculosis may sometimes develop a tuberculosis (TB) infection called Primary Complex. The most common route of infection is through inhalation. A person with active TB coughs up the germ and it is inhaled by a healthy child. The TB then travels to the lungs. The immune system kicks in and quarantines the germ at the local site and at the neighboring lymph nodes (this forms the walled-in complex). The child remains healthy and usually has no symptoms. They may remain symptom free until their immune system declines and the disease becomes active.

As most patients have no symptoms, they only find out they have Primary Complex through a tuberculin skin test (also called a Mantoux test or PPD test). A small amount of purified protein derivative (PPD) of the TB germ is injected superficially into the forearm and should be read 48-72 hours later by experienced personnel. An itchy, raised, red reaction past 10mm wide bleb is considered positive. In 20% of cases, a PPD test will be negative in patients with TB infection. Other times, children will have a falsely positive PPD test because they had the BCG (Bacillus Calmette-Guerin) vaccine. Some children, especially with immune system problems, can have a negative tuberculin skin test and still be infected with tuberculosis.

The immune system of young children is less developed than that of an adult and the risk of developing active TB disease is therefore higher in young children. The chance of developing TB disease is greatest shortly after infection. When children present with active tuberculosis disease their family members and

other close contacts should be investigated for TB to find the source of the disease and treat them as necessary. Therefore a good TB control programme, which will ensure early diagnosis and treatment of adults with infectious form of TB is the best way to prevent TB in children.

Vaccination has been the primary TB prevention method in children. In fact, BCG is the most widely used vaccine in the world. Although it is relatively ineffective in preventing infectious forms of TB, it does prevent more serious forms of TB disease in children. Nevertheless, a quarter of a million children still develop TB every year: Particularly vulnerable to infection from household contacts, many of them have been infected in their own homes, by parents or other relatives with active, infectious TB. Diagnosis of TB in children is notoriously difficult, as the early symptoms and signs are easily missed. Most national TB control programs have little in the way of services for children. TB in the family also has a serious impact on children.

STAGES OF TUBERCULOSIS Stage 1 Exposure has occurred, implying that the child has had recent contact with an adult who has contagious TB. The child has no physical signs or symptoms and has a negative tuberculin skin test (TST) result (see Tuberculin Skin Test). Chest radiography does not reveal any changes at this stage. Not all patients who are exposed become infected, and the TST result may not be positive for 3 months. Unfortunately, children younger than 5 years may develop disseminated TB in the form of miliary disease or TB meningitis before the TST result becomes positive. Thus, a very high index of suspicion is required when a young patient has a history of contact.

Stage 2 This second stage is heralded by a positive TST result. No signs and symptoms occur, although an incidental chest radiograph may reveal the primary complex.

Stage 3 In stage 3, TB disease occurs and is characterized by the appearance of signs and symptoms depending on the location of the disease. Radiographic abnormalities may also be seen.

Stage 4 Stage 4 is defined as TB with no current disease. This implies that the patient has a history of previous episodes of TB or abnormal, stable radiographic findings with a significant reaction to the TST and negative bacteriologic studies. No clinical findings suggesting current disease are present.

Stage 5 TB is suspected, and the diagnosis is pending.

Patients Profile Patients name Gender Age Birth date Civil status Fathers name Mothers name Address Nationality Religion Date of consultation Consulting Physician Consulting Diagnosis

: : : : : : : : : : : : :

J.S. Female 1 year and 6 months old July 12, 2010 Single (Child) P.S. L.S. Barangay Landayan, San Pedro, Laguna Filipino Catholic August 5, 2011 Dr. B Primary Complex

HISTORY OF PRESENT ILLNESS 5 months prior to consultation the patient was exposed to her grandmother who had PTB with undetermined activity and no treatment. Consultation and diagnostics (CBC, x-ray, PPD) was done and revealed (+) primary complex. Patient was advised to take anti-TB medications for 6 months. Patient is currently in the 5th month of treatment.

HISTORY OF PREVIOUS OR PAST ILLNESS No history of past illness

FAMILY HISTORY (+) PTB Grandmother without treatment

SOCIAL HISTORY Baby JS is often left to the care of her grandmother whenever her parents go to work.

GROWTH AND DEVELOPMENT The patient sits without support, walks on her own, tries to form words and uses actions to tell what she wants. Baby JS does not like being away from her parents and has fear of strangers. Baby JS wants to do things herself and refuses help, she easily gets frustrated.

Baby JS has no developmental delay.

IMMUNIZATION HISTORY Vaccine BCG DPT OPV HEP B Measles Number of Doses 1 3 3 3 1