This presentation is a case based discussion detailing the importance of a high index of suspicion for Tuberculosis based on clinical picture

1. Early
CHILDHOOD TUBERCULOSIS
Gopakumar Hariharan
Senior Registrar, NPICU
Royal Hobart Hospital,
Tasmania, Australia

2. Introduction
• Case scenario
• Mode of transmission
• Pathophysiology
• Investigations
• Treatment
• Complications

3. Case Scenario
• 3 months old
• Apnea and respiratory distress
• CXR- Miliary patttern suggestive of TB
• Mum- open case- cavitating lesion of lungs – AFB
positive
• Choroid Tubercles
• On ATT ; Managed in Adult ICU

4. Tuberculosis
• Chronic infection – Mycobacterium
Tuberculosis
• Major public health problem
• Pulmonary and extrapulmonary

5. Russia, India, Southeast Asia, sub-
Saharan Africa, and parts of Latin America
( 95%)

6. Portal of entry for tuberculosis
• Inhalation of Tubercle bacilli in >95% (M.TB) – Reservoir(
infected person)
• Ingestion of milk containing Bovine Tubercle bacilli (M.
bovis)
• Contamination of superficial skin or mucous membrane lesion
with tubercle bacilli
• Congenital infection when mother has
lymphohematogenous spread during pregnancy OR
tuberculous endometritis

7. Epidemiology
• Host Factors
• Age : all ages affected, congenital is rare
• Malnutrition : more susceptible
• Intercurrent infections : e.g. measles, whooping cough
• Environment : overcrowding, inadequate ventilation,
damp, insanitary and unhygienic conditions

8. Primary tuberculous infection
Primary Focus (Ghon’s focus)
• At the site of first implantation
• Usually single and Subpleural
• In most, - heals and disappears, or
- fibroses or calcifies.
Localized inflammatory Process

9. Primary complex
Primary Complex:
• Primary focus + Hilar
lymphnodes + draining
lymphatics ( Tuberculous
lymphangitis)
• Complications arise more
commonly from regional
adenitis than from the primary
focus

10. Progressive primary tuberculosis
• Apparently healed focus or nodes may contain viable
organisms for many years.
• During 1st 4-8 weeks, organisms are disseminated in the blood
stream directly or via lymphatic duct – involves multiple
organs
• Progression of TB depends on the age of the child, number of
tubercle bacilli, and host resistance ( HIV )

11. Complications of the primary
focus
1. Rupture of focus into
pleural space causing
serous effusion ( more
than 5 years)
2. Rupture of focus into
bronchus causing
cavitation
3. Enlarged focus,
sometimes laminated or
“coin” shadow

12. Complications of regional nodes
1. Incomplete (ball-valve)
bronchial obstruction,
emphysema of middle & lower
lobes
2. Complete bronchial
obstruction, collapse of right
lower lobe
3. Erosion of node into
bronchus & segmental
consolidation
4. Rupture of node into
pericardium: tuberculous
pericardial effusion

13. Bronchial complications
1. Stricture of bronchus at
site of erosion
2. Cylindrical bronchiectasis
in area of old collapse
3. Wedge shadow: contracture
& fibrosis of segmental
lesion
4. Linear scar of fibrosis
following segmental lesion
Endobronchial TB – wheeze
Fever, troublesome cough, dyspnea, wheezing and cyanosis

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, creps

15. 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
Tachypnoea with normal chest findings

16. Miliary tuberculosis
• Hematogenous dissemination - 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).

17. Miliary TB
Millets- 1 to 3 mm

18. X ray

19. Tuberculous meningitis
Rupture of a subcortical
caseous focus (Rich’s) into
the subarachnoid space.
Inflammatory exudates form
about base of brain and
along cerebral vessels as
they pass over hemispheres.
Raised intracranial pressure
due to increased secretion
of CSF
Adhesions along base and roof
of 4th ventricles lead to
obstruction to CSF flow and
hydrocephalus,
.
Multiple cranial nerve
involvement - III VI VII and
optic chiasma.
Endarteritis – Neurological
deficits

20. 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

21. Spinal tuberculosis
Skin manifestations
Casseous tuberculosis
TB verrucous cutis Erythema Nodosum

22. )
Scrofula
Phlyctenular conjunctivitis
Cervicitis, salpingitis, infertility
Tuberculous otitis with multiple perforations

23. Choroid Tuberculosis
Tubercles of choroid (with
miliary TB)
Panophtalmitis
Exudative retinal detachment
Responds well to treatment

24. Wallgren A.The time table of Tuberculosis. Tubercle 1948;29:245-251

25. Direct tests for tuberculosis
• Ziehl-Neelsen staining for AFB in
clinical specimens (sputum, gastric juice,
biopsy)
• AFB culture on Lowenstein-Jensen solid
medium (4 weeks)
• PCR amplification of targeted
mycobacterial DNA sequences
• DNA probes: fluorescence in situ
hybridization assays

26. Other tests
• PCR – rapid results ( antigen/ antibodies)
• Serodiagnosis – ELISA
• QuantiFERON- TB test (QFT) – for diagnosing
latent TB. Based on IFN-gamma released from
sensitized lymphocytes.
ELISPOT

27. Mantoux Test
• MC used test for establishing
diagnosis of TB in children
• Delayed type hypersensitivity
reaction
• 0.1 ml of 5 TU PPD is injected
intradermally into the volar aspect
of the forearm (or 2 TU of PPD
RT 23)
• A weal of 5 mm should be raised
• Reaction is read after 48 – 72 hrs
• Look for induration and erythema

28. Observation and Inference
• 48-72 hours later  diameter of induration is measured
transversely to the long axis of the forearm.
• Induration > 10mm is suggestive of natural infection.
• 5-10 mm  borderline; considered positive in
immunocompromised host
• <5mm  Negative mantoux test does not rule out TB

29. False Negatives
• Test done in incubation period of TB
• For several weeks following measles
• During Corticosteroid therapy
• Overwhelming TB infection (miliary, meningits)
• Severe Malnutrition
• If given Sub Cutaneous instead of Intra dermal
• Inactive Tuberculin

30. 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 > 1 mo., cough,
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
• Response to Anti TB Therapy
History of contact = any child who lives in a household with an adult taking ATT or
has taken therapy in the past 2 years

31. 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.
• Bronchiectasis
• Pleural effusion
• Miliary TB

32. Treatment for TB
1st line anti-tuberculous drugs
• Isoniazid H
• Rifampicin R
• Pyrazinamide Z
• Ethambutol E
• Streptomycin S

33. 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 – miliary, peritonitis, pericarditis
• TB meningitis

34. Management of Active TB
( NICE guidelines)
Progressive Pulmonary Tuberculosis and multiple
LNE-
2 HRZE + 4 HR ( 6 month )
Meningeal TB
2 HRZE + 10 HR +Prednisolone
/Dexamethasone
Prednisolone 1–2 mg/kg, maximum 40 mg with
gradual withdrawal of the glucocorticoid
considered, starting within 2–3 weeks of initiation

36. The 5 components of DOTS
 Political & administrative commitment
 Diagnosis by good quality sputum microscopy
 Adequate supply of good quality drugs
 Directly observed treatment
 Systematic monitoring & Accountability

37. Prevention
Children with pulmonary TB disease are
rarely infectious due to
• Their pattern of disease,
• Low bacillary load and
• Lack of coughing force

38. Diagnosing latent TB
• Mantoux testing - household contacts (aged 5 years
and older) of all people with active TB and non-household
contacts (other close contacts for
example, in workplaces and schools).
• Consider Interferon-gamma testing - Mantoux
testing shows positive results, or in people for whom
Mantoux testing may be less reliable, for example
BCG-vaccinated people. ( high specificity)

39. Contacts – outbreak situation
• Active community surveillance
• Large numbers of people may need to be screened,
consider a single interferon-gamma test for people
aged 5 years and older.
• Preventive Therapy In Mantoux Positive : 6 HR

40. Healthcare workers
• Offer a Mantoux test to new employees who will be
in contact with patients or clinical materials if the
employees:
• Have not had BCG vaccination (for example, they
are without scar, other documentation or reliable
history).
• Mantoux test is positive, offer an interferon-gamma
test

41. BCG vaccination for
healthcare workers
• BCG vaccination should be offered to healthcare
workers, irrespective of age, who:
• are previously unvaccinated (that is, without adequate
documentation or a characteristic scar), and
• will have contact with patients or clinical
materials, and
• are Mantoux (or interferon-gamma) negative.

42. BCG vaccination for contacts
of people with active TB
• BCG vaccination should be offered to Mantoux-negative
contacts of people with respiratory TB if
they are previously unvaccinated and are:
• Aged 35 or younger
• aged 36 and older and a healthcare or laboratory
worker who has contact with patients or clinical
materials

43. Infection control
Three levels of isolation for infection control in
hospital settings:
• Negative-pressure rooms
• Single rooms - not negative pressure but are vented
to the outside of the building
• Beds on a ward

44. Isolation guidelines( NICE)
• Should be given a single room. Preferably not
admitted
• Visitors to a child with TB in hospital - screened
as part of contact tracing, and kept separate from
other patients until they have been excluded as the
source of infection
• Isolation for 2 weeks of treatment

45. Barrier nursing
Healthcare workers caring for people with TB should
not use masks, gowns or barrier nursing techniques
unless:
MDR TB is suspected
Aerosol-generating/ cough inducing(
bronchoscopy/sputum production) procedures are
being performed.

46. ?Long term follow up
Regular follow-up clinic visits after treatment
completion were unnecessary.
Patients should be advised to watch for symptoms of
relapse and to contact the TB service rapidly if the
symptoms occur.

47. Multidrug resistant Tuberculosis
• A minority of cases, 6–8% in England and Wales, are
resistant to one of the antibiotics.
• Isoniazid and rifampicin are ineffective in 1% of
cases.
• These are said to be cases of multidrug-resistant
(MDR) TB, which requires special treatment and
careful monitoring.

48. Summary
• Pathophysiology of childhood Tuberculosis
• Various clinical manifestations
• Management
• Treatment
• Preventive measures
• Surveillance

49. “Nothing in life is to be feared, it is only to be
understood. Now is the time to understand more, so that
we may fear less.”
― Marie Curie