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An Approach to a Child with

Tuberculosis
Abdelaziz Y. Elzouki
Professor of Pediatrics
Consultant Pediatric Nephrologist
Faculty of Medicine & Medical Sciences
Umm Al-Qura University
Makkah, Saudi Arabia.

Tuberculosis

TB continue to be a major health hazard especially in


developing countries.
The emergence of HIV & deterioration of socioeconomic
status making difficulties to eradicate the disease.
8,000,000 new TB cases are diagnosed per year.
95% in developing countries.
3,000,000 death annually.
Mycobacterium tuberculosis is an acid-fast bacillus.
Aerobic, non motile, non sporing, forming short bacillus.
Acid fastness is attributed to high lipid content.
In addition to M.tuberculosis other species can cause TB e.g.
M.ofricanum, M.bouvis.

Pathogenesis
Incubation

period = 4 8 weeks.
Tuberculi bacilli mostly acquired by inhalation of
infected droplets.
Droplets lodge in alveoli, they are engulfed by
alveolar macrophages.
They are draining by lymphatics to the regional
lymph node (LN).
The parenchymal lesion drain lymphatics & the
involved regional LN constitute the primary
complex.

Pathogenesis

During acute stage, it can disseminate to spleen, bone


marrow (BM), kidney, liver through blood.
Most haematogenous spread is sub-clinical except in
immuno comprised patients are very young infant who
might develop miliary TB.
After the primary dissemination cellular immunity
stimulated resulting in formation of granuloma.
The center of granuloma become necrotic & might result
in caseous formation.
These granuloma have dormant bacilli which have 3 8%
chance of reactivation during person lifetime.

PULMONARY TB
10

20% of infected children have


symptomatic infection.
Young infant are more susceptible.
In contrast to adult, childrens disease result
from primary infection.

PULMONARY TB
Symptoms :

Low-grade fever, cough, malaise, appetite & failure to


growth.
All symptomatic children will have abnormal chest
radiograph.
The most common radiological findings include hilar
lymphadenopathy, followed by segmented or lobar
consolidation .
Lymphadenoapthy may result in bronchial obstruction
resulting in atelectosis in or hypoaeration.
Pleural effusion in 5 8% & it is usually unilateral.

EXTRAPULMONARY TB
30%

of children develop extrapulmonary

TB.
These include lymphadenopathy or
lymphadenitis skin, bone, CNS, miliary TB.

TUBERCULOUS LYMPHADENITIS
15

20% of infected children.


Cervical LN are especially involved.
It should be differentiated from staph &
strept.

CNS TB
CNS

TB is more common in children.


In children, it occur mostly as meningitis,
other tuberculomas, brain abscess.

TB MENINGITIS
2

5% of untreated children.
Usually affect infant <1 year.
Presentation is not different from other
forms of meningitis.
CSF reveal mild to moderate pleocytosis
initially neutrophilic turn to lymphatic
predominance later.

BONE & JOINT


Usually

present 1 2 year of the primary

disease.
Affected patient have reactive tuberculin
skin test.

TB SPONDYLITIS
Vertebral

osteomyelitis is commonest
tuberculous bone disease.
Usually involved the dorsal & lumber
vertebrae.
Wedging of the involved vertebra is a rare
consequence resulting in kyphosis
deformity (Potts disease).
Diagnosing by CT scan & MRI.

TB ARTHRITIS
Rare.
Knee

is the most common joint involved


then the hip.
Clinical manifestation: include prolonged
joint pain & swelling.

MILIARY TB
Most

common in young infant (<1 year).


TB seed liver, lung, meninges, & BM.
Patient present with acutely ill, fever,
lethargy, hepatosplenomegaly,
lymphadenopathy & respiratory distress.
PPD skin test = ve.
CXR: show bilateral miliary infiltration.

Diagnosis
TB

is one of the most difficult to diagnose.


In contrast to adult, where most of diagnosis
relies on microbiological identification,
diagnosis in children is mostly based on
clinical & epidemiological back ground.

TUBERCULIN SKIN TEST


Is

a skin test which elicit & delayed


hypersensitivity.
Two antigen are used, purified protein
derivative (PPD) & old tuberculin (OT),
both obtained from supernatant extract of
M.tuberculosis.

MANTOUX TEST
Performed

by intradermal injection of PPD.


There are 3 strength of PPD:
1 tuberculin unit (Tu), 5 Tu & 250 Tu.
Recommended to use 5 Tu unit in all
cases.

CXR
Suspected

child should have CXR.


20 25% of child with TB will have
abnormal CXR.
In majority hilar lymphadenopathy, other
lesion lung collapse &/or consolidation.
Cavity are rare in child & calcification are
indication of old infection.

CULTURE
Gastric

washing: mycobacterium organism


can be recovered in up to 40% of cases of
pulmonary TB.
Gastric washing is collected early morning
before the child wake up.

MOLECULAR METHODS
PCR

is technique which amplifies the DNA


of the organism.
It can be applied directly to the specimen
(sputum, BM, bronchial washing).

PROPHYLAXIS
INH

is recommended in all child contact


with +ve adult smear of open TB.
After 3 months PPD should be reported if
ve INH is stopped, if +ve continue INH for
9 months.

PREVENTION:
Vaccine

BCG.
BCG is live attenuated vaccine derived from
M.bouvis.
The dose is 0.05 to 0.1 cc given intradermally in
neonate the lower dose is advised.
BCG lead to miliary TB & TB meningitis.
Side effect are rare including local lymphopathies.