Childhood TB


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Childhood TB was written to enable healthcare workers to learn about the primary care of children with tuberculosis. It covers: introduction to TB infection, the clinical presentation, diagnosis, management and prevention of tuberculosis in children.

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Childhood TB

  1. 1. Childhood TBA learningprogramme forprofessionalsDeveloped by theDesmond Tutu Tuberculosis Centre
  2. 2. Childhood TBA learning programmefor professionalsDeveloped by theDesmond Tutu Tuberculosis
  3. 3. VERY IMPORTANTWe have taken every care to ensure that drugdosages and related medical advice in this bookare accurate. However, drug dosages can changeand are updated often, so always double-checkdosages and procedures against a reliable,up-to-date formulary and the given drug‘sdocumentation before administering it.Childhood TBA learning programme for professionalsUpdated: 17 August 2010First published by EBW Healthcare in 2010Text © Desmond Tutu Tuberculosis Centre 2010Getup © Electric Book Works 2010ISBN (print edition): 978-1-920218-46-1ISBN (PDF ebook edition): 978-1-920218-47-8All text in this book excluding the tests andanswers is published under the Creative CommonsAttribution Non-Commercial No DerivativesLicense. You can read up about this license at multiple-choice tests and answers in thispublication may not be reproduced, stored in aretrieval system, or transmitted in any form or byany means without the prior permission of ElectricBook Works, 87 Station Road, Observatory, CapeTown, 7925.Visit our websites at www.electricbookworks.comand
  4. 4. ContentsAcknowledgements 5 2 Clinical presentation of childhood tuberculosis 24Introduction 7 Early presentation of tuberculosis 24 The Desmond Tutu Tuberculosis Centre 7 Pulmonary tuberculosis 25 Aim of this Childhood TB course 7 Extrapulmonary tuberculosis 26 Self-help education 7 Enlarged tuberculous lymph nodes 26 Format of the Childhood TB Education Tuberculous meningitis 27 Programme 8 Abdominal tuberculosis 27 Study groups 9 Tuberculous bone and joint disease 28 The importance of a caring and Disseminated tuberculosis 28 questioning attitude 9 Scoring systems to identify tuberculosis 29 Copyright 9 Case study 1 29 Final assessment 9 Case study 2 29 Obtaining an exam code 10 Case study 3 30 books in the EBW Healthcare series 10 Case study 4 30 Managing your own course step by step 12 The five most important ‘take-home’ Using the book as a work manual 13 messages 31 Updating of the programme 13 Further information 14 3 Diagnosis of childhood tuberculosis 32 Comments and suggestions 14 Confirming the clinical diagnosis of tuberculosis 321 Introduction to childhood tuberculosis 15 Tuberculin skin tests 33 Tuberculous infection 15 Identifying TB bacilli in sputum 35 Pulmonary tuberculosis 18 Sputum smear examination 36 Extrapulmonary tuberculosis 20 Culture for TB bacilli 37 Case study 1 21 Chest X-ray 38 Case study 2 22 Fine needle aspiration of a lymph node 39 Case study 3 22 Lumbar puncture 39 The five most important ‘take-home’ Screening for HIV 39 messages 23 Case study 1 40 Case study 2 40
  5. 5. Case study 3 41 Case study 2 59 The five most important ‘take-home’ Case study 3 60 messages 41 The five most important ‘take-home’ messages 604 Management of childhoodtuberculosis 42 Tests 61 Planning the management of a child with Test 1: Introduction to childhood tuberculosis 42 tuberculosis 61 Treating tuberculosis 43 Test 2: Clinical presentation of childhood Good adherence 45 tuberculosis 63 Monitoring treatment 46 Test 3: Diagnosis of childhood Drug-resistant tuberculosis 47 tuberculosis 64 Good nutrition 49 Test 4: Management of childhood Treating tuberculosis and HIV co- tuberculosis 66 infection 49 Test 5: Preventing childhood tuberculosis 68 Case study 1 50 Case study 2 50 Answers 71 Case study 3 51 Test 1: Introduction to childhood The six most important ‘take-home’ tuberculosis 71 messages 51 Test 2: Clinical presentation of childhood tuberculosis 715 Preventing childhood tuberculosis 53 Test 3: Diagnosis of childhood Principles of prevention 53 tuberculosis 72 BCG immunisation 53 Test 4: Management of childhood Avoiding exposure to tb bacilli 55 tuberculosis 72 TB prophylaxis in children 56 Test 5: Preventing childhood tuberculosis 73 National tuberculosis programme 57 Writing the exam 73 Community involvement 58 Controlling the spread of hiv infection 58 Illustrations 74 Case study 1 59
  6. 6. AcknowledgementsThe aim of this book is to promote and improve for their innovative vision of presenting thethe care of all children with tuberculosis, text in both book and web-based format. Theespecially in under-resourced communities latter will be made available at no cost togetherin southern Africa. The learning material is with an invitation to contribute in the form ofpresented in a way which enables groups of comments which, after review, will be includedhealthcare workers to take responsibility for in the text. The question-and-answer layouttheir own continuing training. is adapted from that of the highly successful Perinatal Education Programme.We wish to gratefully acknowledge thecontributions of Prof N. Beyers, Prof S. Schaaf, The funding for this project was obtainedProf P. Jeena, Prof R. Green, Prof B. Marais from a United States Agency for Internationaland Dr A. Kutwa. When opinions differed Development (USAID) southern Africabetween contributing colleagues, the simplest grant (under the terms of Agreementmost practical choice was adopted. While every No.GHS-A-00-05-00019-00) to the Desmondeffort has been made to correct any errors in Tutu Tuberculosis Centre. The grant wasthe text, the final decision and responsibility administered by the Tuberculosis Controlwas ours alone. Assistance Programme (TBCAP) through the KNCV Tuberculosis Foundation. TheWe also wish to thank Dr Lindiwe Mvusi from views expressed in this publication do notthe South African National Department of necessarily reflect the views of the USAID orHealth and Ms Nellie Makhaye-Gqwaru of the United States Government. We also wishUSAID for their support and mobilisation of to acknowledge the generous funding fromresources toward this project. Eduhealthcare, a not-for-profit organisation,Where possible, we attempted to comply in writing this book.with the Guidance for the Managementof Childhood Tuberculosis (World HealthOrganisation WH/HTM/2006.371), South Prof David Woods and Prof Robert GieAfrican national tuberculosis programmeguidelines and provincial prevention,diagnostic and management protocols.Our sincere thanks go to the publishers fortheir willingness to support this project and
  7. 7. IntroductionThe Desmond Tutu Although the material was written to be used as a distance-learning course for healthcareTuberculosis Centre professionals in district and regional healthcare facilities, it is also used in theThe Desmond Tutu Tuberculosis Centre training of medical and nursing students.(DTTC) is attached to the Faculty of Health Childhood TB was written by South AfricanSciences, Stellenbosch University, South Africa. paediatricians with the contribution ofThe main focus of the DTTC is to improve colleagues in universities and health services.the health of vulnerable groups through This ensures a balanced, practical and up-influencing policy based on new knowledge to-date approach to common and importantcreated by research. The areas of research clinical problems.that the DTTC have actively been involved ininclude the epidemiology of tuberculosis (TB),childhood tuberculosis, multi-drug-resistanttuberculosis, HIV/TB interaction and Self-help educationoperational research to prevent the spread ofTB and HIV in southern African communities. If high-quality care is to be provided to allIn addition, the DTTC is actively involved children with tuberculosis, training at allin the education of healthcare workers and levels of healthcare workers is members to improve the awareness Unfortunately this is often only achieved inand early diagnosis of TB and HIV. the large centralised tertiary-care hospitals and not in the rural secondary- or primary- care centres. The providers of primary care inAim of this Childhood rural areas usually have the least continuing education as they are furthest away from theTB course training hospitals in urban centres. It is not possible to send teachers to all these rural areasThe aim of this Childhood TB course is to for long periods of time while staff shortagesimprove the care of children with TB in and domestic reasons make it impractical toall communities, especially in poor peri- transfer large numbers of doctors and nursesurban and rural districts of southern Africa.
  8. 8. childhood tbfrom primary- and secondary-care centres to to the question. This method helps learning.centralised tertiary hospitals for training. Simplified flow diagrams are also used, where necessary, to indicate the correct approach toIdeally all medical and nursing staff should diagnosing or managing a particular problem.have regular training to improve and update Copies of these flow diagrams may be of valuetheir theoretical knowledge and practical skills. in the labour ward or nursery.One way of meeting these needs in continuingeducation is with a self-help outreach Different forms of text are used to identifyeducational programme. This decentralised particular sections of the Programme.method allows healthcare workers to takeresponsibility for their own learning and Each question is written in bold,professional growth. They can study at a time like this, and is identified with theand place that suits them. Participants in the number of the chapter, followed by theprogramme can also study at their own pace. number of the question, e.g. 5-23.The education programme should be cheapand, if possible, not require a tutor. Important practical lessons are emphasised by placing them in a box like this.Format of the note Additional, non-essential information isChildhood TB provided for interest and given in notes like this.Education Programme These facts are not used in the case studies or included in the multiple-choice questions.Throughout this programme the participant 3. Case problemstakes full responsibility for his or her ownprogress. This method teaches participants to A number of clinical presentations in storybecome self-reliant and confident. form are given at the end of each chapter so that the participant can apply his or her newly1. The objectives learned knowledge to solve some common clinical problems. This exercise also gives theAt the start of each chapter the learning participant an opportunity to see the problemobjectives are clearly stated. They help the as it usually presents itself in the clinic orparticipant to identify and understand the hospital. A brief history and/or summary ofimportant lessons to be learned. the clinical examination is given, followed by a series of questions. The participant should2. Questions and answers attempt to answer each question before readingTheoretical knowledge is taught by a problem- the correct answer. The knowledge presentedsolving method which encourages the in the cases is the same as that covered earlierparticipant to actively participate in the learning in the chapter. The cases, therefore, serve toprocess. An important question is asked, or consolidate the participant’s knowledge.problem posed, followed by the correct answeror explanation. In this way, the participant 4. Multiple-choice questionsis led step by step through the definitions, An in-course assessment is made at thecauses, diagnosis, prevention, dangers and beginning and end of each chapter in themanagement of a particular problem. form of a test consisting of 20 multiple-choiceIt is suggested that the participant cover the questions. This helps participants manage theiranswer for a few minutes with a piece of paper own course and monitor their own progressor card while thinking about the correct reply by determining how much they know before starting a chapter, and how much they have
  9. 9. introduction learned by the end of the chapter. The correct principles of peer tuition and co-operativeanswer to each question is provided at the end learning play a large part in the success of PEP.of the book. This exercise will help participantsdecide whether they have successfully learnedthe important facts in that chapter and will The importancealso draw participants’ attention to the areaswhere their knowledge is inadequate. of a caring andIn the multiple-choice tests the participant questioning attitudeis asked to choose the single, most correctanswer to each question or statement from A caring and questioning attitude isfour possible answers. A separate loose sheet encouraged. The welfare of the patient is ofshould be used to record the test answers the greatest importance, while an enquiringbefore (pre-test) and after (post-test) the mind is essential if participants are to continuechapter is studied. The list of correct answers improving their knowledge and skills. Thealso indicates which section should be participant is also taught to solve practicalrestudied for each incorrect post-test answer. problems and to form a simple, logical approach to common perinatal problems.5. Skills workshopsSome courses include skills workshops which Copyrightenable the participants to learn the clinicalskills needed. The skills workshops, which To be most effective, the Perinatal Educationalare often illustrated with line drawings, list Programme course should be used underessential equipment and present step-by-step the supervision of a co-ordinator. Using partinstructions on how to perform each task. of the programme out of context will be ofParticipants should find a colleague with the limited value only, while changing part of thenecessary experience to assist them with a programme may even be detrimental to thehands-on demonstration of the particular skill. participant’s perinatal knowledge. Therefore,This enables participants to use local expertise copyright on all PEP materials means thatrather than be dependent on outside tuition. no portion of the programme can be altered. However, for teaching and management purposes only, parts or all of the programmeStudy groups may be photocopied provided that recognition to the programme is acknowledged. If theIt is strongly advised that the courses are routine care in your clinic or hospital differsstudied by a group of participants and not by from that given in the programme, you shouldindividuals alone. Each group of five to ten discuss it with your staff.participants should be managed by a localco-ordinator who is usually a member of thegroup, if a formal trainer is not available. The Final assessmentlocal co-ordinator orders the books and thenarranges the time and venue of the group On completion of each book, participants canmeetings (usually once every three weeks). write a formal multiple-choice examinationAt the meeting the chapter just studied is to assess the amount of knowledge that theydiscussed and the post-tests, and pre-tests have acquired. All the exam questions will befor the next chapter, are done. The skills taken from the tests at the end of each chapter.workshops should also be demonstrated and The content of the skills workshops will notpractised at the meetings. In this way the be included in the examination. Credit forgroup manages all aspects of their course. The
  10. 10. 10 childhood tbcompleting the course will only be given if antenatal card and partogram, measuring bloodthe final examination is successfully passed. pressure and proteinuria, and performingA separate examination is available for each and repairing an episiotomy. Maternal Carebook and successful examination candidates is aimed at professional healthcare workers inwill be able to print their own certificate which level 1 hospitals or clinics.states that they have successfully completedthat course. A mark of 80% is needed to pass Primary Maternal Carethe final examinations. Any official recognitionfor completing a PEP course will have to be This book addresses the needs of healthcarenegotiated with your local healthcare authority. workers who provide both antenatal andSouth African doctors can earn CPD points on postnatal care but do not conduct deliveries.the successful completion of an examination. The content of these chapters is largely taken from the relevant chapters in Maternal Care. It contains theory chapters and skills workshops. This book is ideal for staffObtaining an exam code providing primary maternal care in level 1 district hospitals and clinics.To write the examination, a participant firsthas to purchased an exam code. To purchase Intrapartum Carean exam code, visit: This book was developed for doctors and advanced midwives who care for women whoAn exam code is a unique number for one deliver in district hospitals. The chapters wereparticipant and one course. An exam code developed from selected units in the Maternalenables participants to test their knowledge Care manual. Particular attention is given toand write the final examination online. the care of the mother, the management ofThe fee and how to pay for exam codes are labour, and monitoring the wellbeing of theexplained on the website. fetus. Improved care during labour, delivery, and the puerperium promises to reduce both the maternal and perinatal mortality rates,books in the especially in rural areas. Intrapartum Care was written to support and complement the nationalEBW Healthcare series protocol of intrapartum care in South Africa.Maternal Care Newborn CareThis book addresses all the common and Newborn Care was written for healthimportant problems that occur during professionals providing special care for infantspregnancy, labour and delivery, and the in regional hospitals. It covers resuscitationpuerperium. It includes booking for antenatal at birth, assessing infant size and gestationalcare, problems during the antenatal period, age, routine care and feeding of both normalmonitoring and managing the mother, fetus and high-risk infants, the prevention,and progress during labour, medical problems diagnosis and management of hypothermia,during pregnancy, problems during the three hypoglycaemia, jaundice, respiratory distress,stages of labour and the puerperium, family infection, trauma, bleeding, and congenitalplanning after pregnancy, and regionalised abnormalities, as well as communicationperinatal care. Skills workshops teach the with parents. Skills workshops addressgeneral examination, abdominal and vaginal resuscitation, size and gestational ageexamination in pregnancy and labour, measurement, history, examination andscreening for syphilis and HIV, use of an clinical notes, nasogastric feeds, intravenous
  11. 11. introduction 11infusions, use of incubators, measuring Birth Defectsblood glucose concentration, insertion of This book was written for healthcarean umbilical catheter, phototherapy, apnoea workers who look after individuals withmonitors and oxygen therapy. birth defects, their families, and women who are at increased risk of giving birth to anPrimary Newborn Care infant with a birth defect. Special attentionThis book was written specifically for nurses is given to modes of inheritance, medicaland doctors who provide primary care genetic counselling, and birth defects duefor newborn infants in level 1 clinics and to chromosomal abnormalities, singlehospitals. Primary Newborn Care addresses the gene defects, teratogens and multifactorialcare of infants at birth, care of normal infants, inheritance. This book is being used in thecare of low-birth-weight infants, neonatal Genetics Education Programme which hasemergencies, and important problems in been developed to train healthcare workers innewborn infants. genetic counselling in South Africa.Mother and Baby Friendly Care Perinatal HIVWith the recent technological advances in The HIV epidemic is spreading at anmodern medicine, the caring and humane alarming pace through many developingaspects of looking after mothers and infants countries, increasing the maternal and infantare often forgotten. This book describes better, mortality rates, and adding to the financialgentler, kinder, more natural, evidence-based burden of providing health services to allways that care should be given to women communities. Nowhere is the devastatingduring pregnancy, labour, and delivery. It effect of this infection more obvious than inlooks at improved methods of providing the transmission of HIV from mothers toinfant care with an emphasis on kangaroo their infants. In order to decrease this risk, allmother care and exclusive breastfeeding. A healthcare workers dealing with HIV-positivenumber of medical and nursing colleagues in mothers and infants will need to receiveSouth Africa contributed to this book. additional training. Perinatal HIV was written to address this challenge.Saving Mothers and Babies This book enables midwives, nurses andSaving Mothers and Babies was developed in doctors to care for pregnant women andresponse to the high maternal and perinatal their infants in communities where HIVmortality rates found in most developing infection is present. Special emphasis has beencountries. Learning material used in the book is placed on the prevention of mother-to-infantbased on the results of the annual confidential transmission of HIV.enquiries into maternal deaths and the Saving Chapters have been written on HIV infection,Mothers and Saving Babies reports published in antenatal, intrapartum and infant care, andSouth Africa. It addresses the basic principles counselling. Colleagues from a number ofof mortality audit, maternal mortality, hospitals and universities in South Africaperinatal mortality, managing mortality were invited to review and comment on themeetings, and ways of reducing maternal and draft document in order to achieve a well-perinatal mortality rates. This book should balanced text. It is hoped that this trainingbe used together with the Perinatal Problem opportunity will help to stem the tide of HIVIdentification Programme (PPIP). infection in our children.
  12. 12. 12 childhood tbChildhood HIV Managing your ownChildhood HIV enables nurses and doctors course step by stepto care for children with HIV infection. Itcovers an introduction to HIV in children, the 1. Before you start each chapter, take the testclinical and immunological diagnosis of HIV for that chapter at the back of the book. Doinfection, management of children with and the test by yourself even if you are studyingwithout antiretroviral treatment, antiretroviral with a group of colleagues. Choose the bestdrugs, and infections and end-of-life care. answer for each multiple-choice question and note your answers on a piece of looseChildhood TB paper. This is called your ‘pre-test’ for thatTo help tackle the tuberculosis epidemic in chapter. There is an answer sheet that yousouthern Africa, Childhood TB was written to should use to mark your completed pre-enable healthcare workers to learn about the test. Record your pre-test mark.primary care of children with tuberculosis. The 2. Now work through the chapter. Read eachbook covers an introduction to TB infection, question and answer, and make sure youand the clinical presentation, diagnosis, understand it. Pay particular attentionmanagement and prevention of tuberculosis to the facts in grey boxes as these are thein children. Childhood TB was developed by main messages. Read the case studiespaediatricians with wide experience in the to check whether you have learned andcare of children with tuberculosis, through the understood the important information.auspices of the Desmond Tutu Tuberculosis 3. If you are part of a study group, useCentre at the University of Stellenbosch. this opportunity to discuss with your colleagues any difficulties you may haveChild Healthcare experienced. Talking about what you have read is a very important part of theChild Healthcare addresses all the common learning process. If the book includes skillsand important clinical problems in children, workshops, these should be conducted atincluding immunisation, growth and nutrition, the time of the group meetings. Invite anacute and chronic infections, parasites, and skin experienced colleague who can help youconditions, as well as the home and society. master the particular skill. 4. When you have learned all the knowledgeAdult HIV in that chapter, take the same test again. This second test is called your ‘post-test’.Adult HIV was developed by doctors and nurses Now mark the post-test and compare yourwith a particular interest in HIV infection. The pre-test and post-test marks. Your marksbook covers an introduction to HIV infection, should have improved considerably. In themanagement of HIV-infected adults, preparing answers section of the book, opposite eachpatients for antiretroviral treatment, the drugs correct answer, is the number of the sectionused in antiretroviral treatment, starting and where the question was taken from. Re-maintaining patients on antiretroviral treatment read and learn the sections for any post-testand an approach to opportunistic infections. answers you got incorrect. Now you areThe aim of the book is to enable healthcare ready to move on to the next chapter.workers at primary-care clinics to manage all 5. Repeat steps 1 to 4 for each chapter asaspects of HIV-related patient care. you work your way through the book. This enables you to obtain the knowledge, monitor your progress, and measure how much you are learning. Most people will take about two to four weeks per chapter.
  13. 13. introduction 136. Once you are confident that you have Using the book as mastered all the main lessons in the book, you can write the final examination online a work manual at To write the final examination you will need to have It is hoped that as many participants as an exam code. This is a unique number possible will use these books as work manuals that entitles you to write the examination after they have completed the course. The for a course. If you don’t have one yet, you flow diagrams should be most useful in or your group can buy exam codes. The managing difficult problems and for planning fee and how to pay are described on the management. A further benefit of the books website. This exam code will only work is that they standardise the documentation once for one examination. and management of certain clinical problems.7. You will be able to write the examination, This is particularly useful when patients are consisting of 75 multiple-choice questions, referred within or between healthcare regions. on the website. You will only have a It is further hoped that all those who use these limited time to answer each question and books will enjoy learning about new and better you will not be able to go back and check methods of caring for mothers and newborn previous questions. Set aside an hour to infants. Every opportunity to share knowledge write the examination. When you write the with both patients and colleagues should be examination, do not use the book to look used. By doing this you will find your career up the correct answers. Remember, you are more fulfilling and you will help to improve your own teacher, so be strict with yourself! the perinatal care in your region.8. Your examination answers will automatically be marked as soon as you have completed the last question. If you Updating of the get 80% or better you have passed and will be able to print your own certificate which programme states that you have successfully completed the course. However, if you have failed to Based on the comments and suggestions achieve 80%, you can purchase another made by participants and other authorities, exam code to write the examination again. the chapters and skills workshops of the programme will be regularly edited to makeTips them more appropriate to the needs of• Work through the course with a group of perinatal care and to keep the programme friends or colleagues. up to date with new ideas and developments.• One person in your group (your co- Everyone studying the programme is invited ordinator or ‘convenor’) should take to write to the editor-in-chief with suggestions responsibility for organising meetings to as to how the books could be improved. You discuss each chapter before you write the can also send your comments on parts of the post-test. books on the website• Set yourself targets, such as ‘two units a month’.• Keep your book with you to read whenever you have a chance.• Write the examination only when you feel ready.
  14. 14. Further information Comments and suggestionsFor further information on the Childhood TBEducation Programme please contact: The Childhood TB Education Programme has been produced by a team of TB specialists,By email after wide consultation with colleagues practise in both rural and urban settings, in an attempt to reach consensus on the care ofBy fax children with tuberculosis. The programme is designed so that it can be improved+27 088 021 44 88 336 and altered to keep pace with current developments in health care. Participants using this programme can make an importantBy phone contribution to its continual improvement+27 021 44 88 336 by reporting factual or language errors, by identifying sections that are difficult toOnline understand, and by suggesting improvements to the contents. Details of alternative or forms of management would be particularly appreciated. Please send any comments or suggestions to EBW Healthcare at any of the above contact details.
  15. 15. 1 Introduction to childhood tuberculosisBefore you begin this unit, please take the Tuberculous infectioncorresponding test at the end of the book toassess your knowledge of the subject matter.You should redo the test after you’ve worked 1-1 What is tuberculosis?through the unit, to evaluate what you havelearned. Tuberculosis (TB or TB disease) is a chronic infectious disease which may involve many organs of the body, but most often affects Objectives the lungs. Tuberculosis of the lung is called pulmonary tuberculosis. When you have completed this unit you Tuberculosis is a chronic infectious disease. should be able to: • Explain what tuberculosis is. 1-2 What causes tuberculosis? • Describe how TB bacilli are spread. • Explain the difference between TB Tuberculosis is a bacterial illness caused by Mycobacterium tuberculosis. These bacteria infection and tuberculosis. are also referred to as TB bacilli (tuberculous • Explain why children are at high risk of bacilli). TB infection. • List communities in which tuberculosis Tuberculosis is caused by TB bacilli. is common. • Explain the features of pulmonary note Mycobacterium tuberculosis was tuberculosis. first described by Robert Koch in 1882. • List the common forms of extrapulmonary tuberculosis. 1-3 How are TB bacilli spread? Tuberculosis is an infectious disease which results from the spread of TB bacilli from one person to another. TB bacilli are usually spread
  16. 16. 16 childhood tbwhen a person with pulmonary tuberculosis home. A mother with untreated pulmonarytalks, coughs, spits, laughs, shouts, sings or tuberculosis who is in close contact with hersneezes. This sends a spray of very small children is a great danger to her children.droplets from the person’s infected lungs into Children in close, prolonged contact withthe air (i.e. airborne droplet spread). Live TB adults who have untreated pulmonarybacilli in these droplets then float in the air tuberculosis are at greatest risk. Youngerand may be breathed in by other people. If the children are more likely to spend most of theinhaled TB bacilli reach the alveoli they cause day and night with an adult.a tuberculous infection of the lung.1-4 Who usually spreads TB bacilli? Children in poorly ventilated, overcrowded homes are at greatest risk of infection with TB bacilli.TB bacilli are usually spread from adults withuntreated pulmonary tuberculosis. Therefore,a child with tuberculosis almost always has 1-7 Do all children infected withbeen in close contact with an adult with TB bacilli develop tuberculosis?pulmonary tuberculosis (the source of the TB No. Most children infected with TB bacillibacilli). It is less common for a child to catch do not develop tuberculosis (TB disease)tuberculosis from another child as children because their immune system is able to controlusually do not cough up TB bacilli in large the infection and kill most of the TB bacilli.numbers. Therefore, adults with untreated As a result, the natural immune responsetuberculosis are a danger to children in the protects most children with TB infection fromfamily or household. progressing to tuberculosis. It is very important to understand that a child TB bacilli that infect children are usually spread can only develop tuberculosis if the child is from an adult with untreated pulmonary first infected with TB bacilli. Furthermore, tuberculosis. TB infection does not always progress to tuberculosis (TB disease). Therefore TB note TB bacilli in unpasteurised or unboiled infection without further progression is not cows’ milk (Mycobacterium bovis) can be the same as tuberculosis. drunk and cause infection of the tonsil or gut, but this is very uncommon in South Africa. Fortunately most children infected with TB bacilli1-5 Which children are at greatest do not develop tuberculosis.risk of infection with TB bacilli? The progression of TB infection to tubeculosisChildren, especially those under five years of is more common in children than in adults.age, who are exposed to large numbers of TBbacilli. 1-8 Which children with TB infection are at the greatest risk of developing tuberculosis?1-6 Which children are exposed tolarge numbers of TB bacilli? Children with a weak immune system are at the greatest risk. In these children,Children who live in overcrowded, infection with TB bacilli may progress topoorly ventilated homes or are exposed tuberculosis because they have an inadequateto crowded buses, taxis, schools, crèches immune system which is unable to controland spaces where there are adults with the infection. TB infection caused by largeuntreated pulmonary tuberculosis. A child numbers of TB bacilli is also more likely towith tuberculosis often has an adult with progress to tuberculosis.untreated tuberculosis living in the same
  17. 17. introduction to childhood tuberculosis 17Therefore, both TB infection and progress to The risk of TB infection progressing totuberculosis are most common when a child tuberculosis is greater in young childrenwith a weak immune system is exposed to than in older children or adults. In childrenlarge numbers of TB bacilli. infected under two years of age, the risk is as high as 50%. Children with weak immune systems are at greatest risk of tuberculosis. About 10% of people with TB infection will develop tuberculosis.1-9 Which children have weakimmune systems? 1-12 What do you understand by the incidence of tuberculosis?Young children under five years, and especiallyif under two years, of age have immature The incidence is the number of people with(weak) immune systems which are unable to tuberculosis per 100 000 of the population percontrol severe infections. The immune system year. This is a very useful measure as it allowscan further be weakened in: the frequency of tuberculosis in different communities or countries to be compared. The• Children with HIV infection incidence of a single community can also be• Children recovering from measles or compared from one year to the next. whooping cough• Children with severe malnutrition• Children on large doses of oral steroids 1-13 What is the incidence of tuberculosis in South Africa?HIV infection is the most important cause of aweakened immune system. While tuberculosis is uncommon in most developed countries, it is common in developing countries such as South Africa Children with HIV infection have the highest risk where the number of people with tuberculosis of developing tuberculosis. has increased rapidly in the last few years. The incidence of tuberculosis in South Africa1-10 Is TB infection common? was 948/100 000 in 2007. This is high when compared to developed countries like theYes, infection with TB bacilli (Mycobacterium United Kingdom where the incidence oftuberculosis) is very common, and it is tuberculosis in 2007 was 13/100 000.estimated that almost 50% of adult SouthAfricans have been infected. Most infections In South Africa tuberculosis is particularlytake place during childhood. common in the Western Cape and KwaZulu- Natal. It is estimated that there are 400 new cases of tuberculosis per 100 000 children TB infection is common and usually occurs during each year in the Western Cape. In any clinic childhood. children will make up approximately 15% of all the cases of tuberculosis.1-11 How many children with TB note About ten million new cases ofinfection develop tuberculosis? TB occur worldwide each year with two million deaths due to TB. About 300 SouthOnly about 10% of all people with TB Africans die of TB each day. With the AIDSinfection progress to tuberculosis (TB disease) epidemic this figure is rising rapidly.during their lifetime. Therefore, TB infectionis far more common than tuberculosis.
  18. 18. 18 childhood tb1-14 In which communities is area of inflammation. This is called primarytuberculosis common? tuberculosis. From the primary infection TB bacilli spread along the lymphatics to the localTB is common in poor, disadvantaged lymph nodes at the place where the maincommunities where overcrowding, bronchi divide into branches (hilar nodes).undernutrition and HIV infection are The primary infection in the lung, togethercommon. Tuberculosis is a disease of poverty. with the infected hilar lymph nodes, is calledTuberculosis spreads in any overcrowded the primary complex. Parahilar and otherliving spaces, both at home and in the mediastinal nodes may also be TB is often transmitted bya child’s family member, friend or close After six weeks the immune system usuallyneighbour. However it may also be caught becomes active and kills most of the TB bacilliin a public space if there are many untreated in the lung and lymph nodes. As a result, thepatients in the community. primary infection is asymptomatic in most children and does not cause clinical illness. Tuberculosis is usually seen in poor communities. Therefore, the primary TB infection usually heals and does not spread any further, as the note About 95% of new TB cases and 99% TB bacilli have been contained by the body’s of TB deaths worldwide are in developing natural immunity. countries. In developed countries TB is note The primary TB infection in the lung virtually confined to poor, overcrowded used to be called the Ghon focus. environments and ethnic minorities.1-15 Why is tuberculosis an Inhaling TB bacilli into the lung may result inimportant disease? primary infection.Tuberculosis is a major cause of illness anddeath in many poor countries. These are 1-17 Can the primary TB infectionpreventable deaths, and the large number of cause illness due to spread of thepatients with tuberculosis is a huge drain on infection within the lung?healthcare resources. Sometimes the primary TB infection is not controlled by the immune system and the Tuberculosis is an important cause of illness and child now becomes ill with the signs and death. symptoms of pulmonary tuberculosis. This is a common form of tuberculosis in children. With progression of the primary infectionPulmonary to pulmonary tuberculosis, the TB bacilli continue to multiply and an area oftuberculosis inflammation develops in the lung and lymph nodes in an attempt to prevent the TB bacilli from spreading any further. Often the centre1-16 What is primary TB infection of the inflamed area becomes soft as the tissuesof the lung? die. These dead cells (caseous material) canTuberculous infection usually starts when TB drain into the surrounding tissues.bacilli are inhaled deep into the distant parts There are a number of different ways that theof the lungs, called alveoli. During the first six primary TB infection can spread (progress)weeks of infection the immune system is unable and lead to control the TB bacilli, which multiply rapidlyin the alveoli where they cause a small, local
  19. 19. introduction to childhood tuberculosis 19 measles, the TB bacilli may start to multiply The primary TB infection may spread to cause once more (reactivation) and a local area pulmonary tuberculosis. of tuberculous pneumonia will develop. Therefore, pulmonary tuberculosis due to note The immune response to TB bacilli reactivation of dormant TB bacilli may only is dependent on T lymphocytes. present years after the primary infection.1-18 What are the pulmonary complicationsof the primary TB infection in the lung? Pulmonary tuberculosis with enlarged hilar lymph nodes is the commonest form of• In some children with a weak immune system, the body is unable to control the tuberculosis in children. primary infection in the lung. The TB bacilli continue to multiply and spread 1-19 What are the pulmonary complications into neighbouring parts of the lung to of TB infection in the hilar lymph nodes? cause tuberculous pneumonia. Progression • TB bacilli may multiply rapidly in the hilar from the primary infection to pulmonary lymph nodes, causing the nodes to enlarge tuberculosis usually takes place rapidly and compress the bronchus or trachea within weeks or months and the child (airway). Clinically this may present as becomes ill. This pattern of tuberculosis, wheezing or stridor with either collapse or together with enlarged hilar nodes, is the hyperinflation of a lobe or the whole lung. commonest form of tuberculosis in young • The enlarged lymph node may rupture and undernourished children. into a bronchus spreading large numbers• Cavitary tuberculosis (‘open tuberculosis’) of TB bacilli into other areas of the lung. is usually seen in older children and This results in widespread tuberculous adolescents. The area of tuberculous bronchopneumonia. pneumonia progresses and breaks down to form a hole. This occurs most commonly in the upper parts of the lung and results Enlarged hilar lymph nodes may compress the in an air-filled cavity containing dead airways causing wheezing. (caseous) tissue which contains huge numbers of TB bacilli. This form of 1-20 Why are the lungs the pulmonary tuberculosis is very infectious commonest site of tuberculosis? as TB bacilli grow fast and many TB bacilli enter the airways. From here they are The lungs are the commonest site of coughed into the air where they may be tuberculosis as TB infection is usually caused breathed in and infect the lungs of other by inhaling TB bacilli. people. Children and adolescents with cavitary tuberculosis are very infectious 1-21 What is the difference and can infect other children and adults. between pulmonary tuberculosis• Damage to the large airways by in children and adults? tuberculosis can result in bronchiectasis.• In older children and adults the TB While children usually have lymph node bacilli often remain dormant (inactive or enlargement with few TB bacilli in the sputum, ‘sleeping’) in the lung for many months or adolescents and adults usually have cavitary even years after the primary infection. The tuberculosis with destruction of lung tissue and body has been able to control but not kill large numbers of TB bacilli in their sputum. all the TB bacilli. If the immune system later becomes weakened by malnutrition or another infection, such as HIV or
  20. 20. 20 childhood tb note Cavities are formed in adult-type 1-23 Which other organs can be tuberculosis, usually in the upper lobes or apices involved in tuberculosis? of the lower lobes of the lungs. This can result in permanent lung damage and scarring (fibrosis). Although the lung is the commonest organ infected by TB bacilli, tuberculosis can involve any other organ of the body. SometimesExtrapulmonary more than one organ is infected. The organs which are most commonly infected via thetuberculosis bloodstream in children are: • The meninges (tuberculous meningitis)1-22 Can tuberculous infection spread • Bones, especially the spine (tuberculousfrom the lung to other parts of the body? osteitis) • Joints, especially the hip joint (tuberculousYes. This spread beyond the lungs is called arthritis)extrapulmonary tuberculosis: • Intra-abdominal organs such as liver• Tuberculosis may spread from the lung to and spleen and peritoneum (abdominal the pleura causing a pleural effusion. tuberculous)• Infection with TB bacilli can spread note The skin, tonsils, pericardium, bone from the lung, and especially the hilar marrow, middle ear and genitalia are less lymph nodes, via the bloodstream (TB common sites of tuberculosis in children. bacteraemia) to most organs of the body. Tuberculosis of the kidney usually follows In children the TB bacilli usually spread five or more years after the primary infection at the time of the primary lung infection. and therefore is uncommon in childhood. As a result, tuberculosis of other organs usually presents soon after the primary 1-24 What is disseminated tuberculosis? lung infection. However, the TB bacilli Tuberculosis involving multiple organs is may remain dormant in these organs for referred to as disseminated tuberculosis. many months or years before they start to This follows spread of TB bacilli through the multiply and cause local tuberculosis. This bloodstream to many organs. If disseminated reactivation of TB bacilli is usually due to tuberculosis includes widespread infection of weakening of the immune system. both lungs, it is called miliary tuberculosis.• TB bacilli can also spread to other lymph This is a very serious illness with a high nodes via the lymphatics (e.g. from the mortality rate unless diagnosed and treated hilar lymph nodes up to the cervical lymph early. It usually occurs in young children. nodes or down to the abdominal lymph nodes). Lymph nodes in the axilla or groin may also be involved. However, lymphatic Disseminated tuberculosis is a serious illness spread is usually to the cervical nodes. with a high mortality rate. TB infection of lymph nodes is called tuberculous lymphadenitis. 1-25 Is extrapulmonary tuberculosis infectious? Tuberculous bacilli may spread from the lungs Unlike pulmonary tuberculosis, tuberculosis of to other organs via the bloodstream or the other organs is rarely infectious to other people. lymphatics.
  21. 21. introduction to childhood tuberculosis 211-26 Is extrapulmonary tuberculosis mother to cough over her newborn infant.common in children? TB bacilli do not appear in the breast milk. Therefore breastfeeding is safe as long asYes, extrapulmonary tuberculosis is far more the mother is on treatment and the infantcommon in children than in adults. Cervical receives prophylaxis.lymph node enlargement is the commonestform of extrapulmonary tuberculosis inchildren. Case study 1 Cervical lymph node enlargement is the A child of six years develops primary TB commonest form of extrapulmonary tuberculosis infection in her one lung. She remains in children. clinically well however. When she is weighed by the school nurse, the mother is reassured1-27 Can one have a tuberculous that the child is healthy and thriving.infection more than once? 1. What is the cause of TB infection?Yes. Previous TB infection does not givecomplete immunity to further TB infections. TB bacilli (Mycobacterium tuberculosis).A child with a healed primary infection can,months or years later, have another new 2. Why is this child clinically well ifprimary infection when they are exposed to she has a primary TB infection?an infectious case of tuberculosis, especially Because most children with a primary TBif their immune system is weakened by severe infection have no signs or symptoms ofmalnutrition or HIV. illness. Her immune system has controlledTherefore, pulmonary tuberculosis may be the TB infection.due to immediate spread from the originalprimary infection, reactivation (relapse) 3. Will this child develop tuberculosis?of an old primary infection which had nothealed fully (latent tuberculous infection), Probably not, as most children are able toor spread from a new primary infection prevent the spread of TB bacilli from the(reinfection). In children, spread from the primary infection.primary TB infection to cause tuberculosis ismost common and usually occurs within two 4. Which children are at greatestyears of being infected (90% within one year of risk of the primary infectionbeing infected). progressing to tuberculosis? Children with weak immune systems. These1-28 Can a mother with tuberculosis infect include young children, malnourishedher infant either before or after birth? children and children with HIV infection.Yes. During pregnancy TB bacilli in the mothercan be spread via the bloodstream to the 5. How common is TB infection?placenta. From here the TB bacilli may reach Very common. Almost 50% of adult Souththe fetus via the umbilical vessels or may infect Africans have had a primary TB infectionthe amniotic fluid and then be swallowed by at some time in their lives, most duringthe fetus. Infection during delivery is rare. childhood.However, the spread of TB bacilli from amother to her infant usually happens afterdelivery. The greatest risk is for an infectious
  22. 22. 22 childhood tb6. How many children with TB 4. Is childhood tuberculosisinfection develop tuberculosis? common in South Africa?The risk of progression from TB infection to Yes, especially in poor, disadvantagedtuberculosis during a lifetime is about 10%. communities. Childhood tuberculosis makesHowever the risk is higher in children and is up approximately 15% of all the cases at a TBas high as 50% in children under two years clinic.of age. Therefore TB infection is particularlydangerous in young children. 5. What are the pulmonary complications of primary TB infection in the lung? The primary infection in the lung mayCase study 2 progress to tuberculous pneumonia. In older children and adults this may form a cavity. TheAn 18-month-old child lives in an overcrowded grandfather probably has cavitary tuberculosis.home. During the day he is looked after byhis grandfather who is unwell and has had 6. Are the hilar lymph nodes oftena chronic cough for the past few months. involved in primary TB infection?The clinic nurse is worried as the child ismalnourished and recently had measles. Yes. The primary TB infection in the lung is usually associated with enlarged hilar1. Why is this child at high lymph nodes. Together they are called therisk of TB infection? primary complex. The enlarged hilar nodes can compress a large airway causing wheezeBecause the grandfather probably has or stridor. Further enlargement of the lymphundiagnosed pulmonary tuberculosis. The nodes may result in collapse or overinflationhouse is overcrowded and the child has of a lobe.prolonged contact with the grandfather. Thesefactors all suggest that the child is beingexposed to large numbers of TB bacilli. Case study 32. Why will the TB infection probably The parents are very worried as theirprogress to tuberculosis? daughter has a lump in her neck which hasBecause the child has a weak immune system been diagnosed as tuberculosis. Friends telldue to his young age, malnutrition and recent them that the diagnosis must be wrong asmeasles infection. tuberculosis only affects the lungs.The child’s age and exposure to large numbersof TB bacilli will, therefore, increase his 1. Does tuberculosis only affect the lungs?risk of both TB infection and progress to No. Tuberculosis may affect most organs of thetuberculosis. body. Tuberculosis outside the lungs is called extrapulmonary tuberculosis.3. What other infection mayweaken the immune system? 2. What is the likely cause ofHIV. the lump in her neck? Tuberculosis of a lymph node (tuberculous lymphadenitis).
  23. 23. introduction to childhood tuberculosis 233. What other organs are most The five mostcommonly infected with TB? important ‘take-The meninges (TB meningitis), bones (TBosteitis), joints (TB arthritis) and abdominal home’ messagesorgans (abdominal TB). 1. Children are infected with TB bacilli after4. What is disseminated tuberculosis? exposure to someone with infectious pulmonary tuberculosis.The spread of TB infection to many organs. 2. Most TB infection in children does notThis is a serious illness with a high mortality progress to disease (tuberculosis).rate. 3. The children at greatest risk of progression to disease are children infected when5. Is extrapulmonary tuberculosis less than two years of age, HIV infectedinfectious to others? children, and children with malnutrition.Usually not. However, extrapulmonary and 4. Pulmonary tuberculosis with enlargedpulmonary TB may occur in the same patient. hilar lymph nodes is the commonest formPulmonary tuberculosis is the most infectious of tuberculosis in children.form of the disease. 5. Cervical lymph node enlargement is the commonest form of extrapulmonary tuberculosis in children.6. Can a newborn infant be infectedwith tuberculosis from the mother?Tuberculosis can spread from mother to infantduring pregnancy but this is uncommon.The greatest risk is when a mother withtuberculosis coughs onto her newborn infant.
  24. 24. 2 Clinical presentation of childhood tuberculosisBefore you begin this unit, please take the Early presentationcorresponding test at the end of the book toassess your knowledge of the subject matter. of tuberculosisYou should redo the test after you’ve workedthrough the unit, to evaluate what you havelearned. 2-1 How is the clinical diagnosis of tuberculosis made? The clinical diagnosis of tuberculosis depends Objectives on the following five steps: 1. Having a high index of suspicion. When you have completed this unit you 2. The patient being in contact with an adult should be able to: with pulmonary tuberculosis. 3. Taking a careful history. • Recognise the general symptoms and 4. Completing a full general examination. signs of tuberculosis. 5. Requesting special investigations. • List the symptoms and signs of pulmonary tuberculosis. 2-2 What would make you suspect that • Describe the appearance of tuberculous the child may have tuberculosis? lymph node enlargement. Always suspect tuberculosis if one or more of • Clinically diagnose tuberculous the following are present: meningitis. • A history of close contact with someone • Clinically diagnose abdominal suffering from tuberculosis in the family or tuberculosis. household, especially if recently diagnosed. • Clinically diagnose spinal tuberculosis. • Poor, overcrowded living conditions. • Clinically diagnose disseminated • The child has HIV infection. tuberculosis. • The child is losing weight or is severely malnourished. • The child has a chronic, persistent cough.
  25. 25. clinical presentation of childhood tuberculosis 25• The child has pneumonia which does not symptoms. In young children the parents respond to antibiotics. complain that the child is not as playful• The child has fever for more than 14 days as usual. Older children may complain of and is not responding to antibiotics. feeling weak and tired.• The child is unwell with vomiting and a • A fever for more then two weeks when decreased level of consciousness, with or no other cause of fever can be found and without convulsions. there is no response to antibiotics. Fever due to viral infections usually lasts lessHaving a high index of suspicion that the child than seven days.has been in close contact with someone with • Nights sweats, especially if the childtuberculosis in a community, especially if they is so wet that their clothes need to belive in the same household, is often the most changed. However severe night sweatsimportant step in making the diagnosis. A high are not common in young children withindex of suspicion is very important in the tuberculosis.early diagnosis of tuberculosis, as tuberculosis • Children with tuberculosis have usuallymay present in many different ways and may be been unwell for a few weeks when they firstconfused with a wide range of other diseases. present. Unlike the sudden onset in acute bacterial or viral infections, the symptoms Suspecting tuberculosis is important in making and signs of tuberculosis usually develop the diagnosis. over a number of days or weeks. • There are often no clinical signs on examination in the early stages of2-3 What are the symptoms and tuberculosis.clinical signs of tuberculosis? A detailed history is very important when• The early symptoms and signs of considering a diagnosis of tuberculosis as the tuberculosis are often vague and non- history is often the most important clue to the specific, making the diagnosis difficult. correct diagnosis. Therefore always consider These general symptoms and signs are tuberculosis in a child with a chronic cough, caused by tuberculosis at any site in the weight loss, failure to thrive or unexplained body. Children are usually asymptomatic fever for more than two weeks, especially in the early stages of tuberculosis. if there is an adult with a chronic cough or• The later signs of tuberculosis usually known pulmonary tuberculosis in the family. depend on which organ or organs are infected. The organ most commonly affected is the lung (pulmonary A careful history is very important in the tuberculosis). diagnosis of tuberculosis.Symptoms are what the child or parentcomplains of, while signs are what you observe. Pulmonary2-4 What are the early general tuberculosissymptoms and signs of tuberculosis?• Failure to thrive with poor weight gain or weight loss. Children with tuberculosis are 2-5 What are the symptoms of often thin and undernourished. This may pulmonary tuberculosis? first be noticed when the child’s weight is These symptoms and signs are important as plotted on the Road-to-Health card. pulmonary tuberculosis is the commonest• Feeling generally unwell with loss of form of tuberculosis in children and adults. appetite, apathy and fatigue, are common
  26. 26. 26 childhood tb• In addition to the early general symptoms Commonly there are no clinical signs on chest and signs, the most important sign of examination in children with pulmonary pulmonary tuberculosis is a persistent cough lasting more than two weeks. The tuberculosis. cough may be dry or productive and shows no signs of improving. Children with tuberculosis may also have• The enlarged hilar nodes may press on symptoms and signs of HIV infection. a bronchus (airway) causing wheezing, cough or stridor. The wheeze does not respond to inhaled bronchodilators. Extrapulmonary• Shortness of breath and fast breathing are not common in children with tuberculosis tuberculosis. Chest pain and blood-stained sputum (haemoptysis) may be present in 2-7 What is the clinical presentation adolescents, but are rare in children. of extrapulmonary tuberculosis? This depends on whether TB bacilli spread to A persistent cough lasting longer than two only one organ (e.g. the meninges), or to two weeks is an important symptom of pulmonary or more organs at the same time. tuberculosis.2-6 What are the clinical signs of Enlarged tuberculouspulmonary tuberculosis? lymph nodes• Usually there are no abnormal clinical signs on examination of the chest. Therefore, a lack of signs does not exclude 2-8 What is the common site of the diagnosis of tuberculosis. enlarged tuberculous lymph nodes?• There may be signs of pneumonia (fast Enlarged lymph nodes (lymphadenopathy) breathing, crackles and decreased air due to tuberculosis occur most commonly in entry). the neck (cervical nodes).• There may be wheezing due to airway compression by enlarged hilar lymph nodes. The wheeze does not respond to Enlarged cervical lymph nodes may be due to bronchodilators. tuberculosis.• There may be signs of a pleural effusion (dullness over one side of the chest with 2-9 What are important signs of poor air entry and possibly shortness of enlarged cervical lymph nodes? breath), especially in older children and adolescents. Often the mother first notices that the child• Often children with extensive tuberculosis has lumps in the neck. At first the nodes are are not acutely ill, do not require typically firm and non-tender on examination. supplementary oxygen and have very few Later they may feel matted (stuck together). clinical signs on chest examination but Enlarged tuberculous lymph nodes may lead have extensive changes on chest X-ray. to complications.
  27. 27. clinical presentation of childhood tuberculosis 272-10 What are the complications of Depressed level of consciousness is an importantenlarged cervical lymph nodes? sign of tuberculous meningitis.The lymph nodes may become tender and softdue to inflammation and the breakdown of It is important to suspect tuberculoustissue in the node (lymphadenitis) to form a meningitis in any child with drowsiness,lymph node abscess. Later lymph nodes may headache and vomiting. The onset of symptomsbecome attached to the skin and discharge and signs are often slow over a number of days.the soft (caseous) material onto the skin. This A depressed level of consciousness, convulsionsresults in a fistula. With healing, tuberculous and paralysis are late and dangerous signs.fistulas leave scars. 2-14 Do children with tuberculous2-11 What is a common cause of meningitis always die?enlarged lymph nodes in the axilla? It depends on whether the diagnosis is madeEnlarged lymph nodes in the axilla (arm pit) early or late. Full recovery is possible after anare common a few weeks or months after a early diagnosis. However children who presentBCG immunisation on the upper arm on the late with depressed level of consciousness andright side. This is not caused by tuberculosis signs of a stroke often die despite treatment.but results from the BCG immunisation in Children who survive after the developmentyoung children. Complications of enlarged of late signs may survive with permanentaxillary lymph nodes due to BCG are common disability (blindness, deafness, cerebral palsy,in children with HIV infection. mental retardation and hydrocephalus). It is very important to suspect TB meningitis in any child with unexplained drowsiness,Tuberculous headache or vomiting so that an early diagnosismeningitis can be made and immediate treatment started.2-12 What is tuberculous meningitis? AbdominalInfection of the membranes which cover the tuberculosisbrain (the meninges) by TB bacilli.2-13 What is the clinical presentation 2-15 What is abdominal tuberculosis?of tuberculous meningitis? Tuberculosis of one or more organs in theThe symptoms and signs of tuberculous abdomen. It is usually due to the spread of TBmeningitis are: bacilli from the lungs. Newborn infants may• Drowsiness, irritability and vomiting in a have abdominal tuberculosis as a result of TB child who has been unwell for a few days. bacilli spreading from the infected placenta.• Depressed level of consciousness.• Older children may complain of headaches. 2-16 What are the clinical signs• Convulsions. of abdominal tuberculosis?• The fontanelle may be full with a rapidly The most common presentation of abdominal increasing head circumference. tuberculosis is:• Muscle weakness progressing to one-sided paralysis (hemiplegia) due to a stroke. • Abdominal distension (swelling). This may be due to fluid (ascites) or enlarged lymphOn examination there may be neck stiffness.
  28. 28. 28 childhood tb nodes. The liver and spleen may also be Disseminated enlarged.• Abdominal pain may be present. tuberculosis• Weight loss.• Fever with no obvious cause. 2-20 What is disseminated tuberculosis? Disseminated tuberculosis occurs when TBTuberculous bone bacilli spread throughout the body via theand joint disease bloodstream as the immune system cannot contain them in the lung. This leads to tuberculosis in a number of organs other than2-17 What bones and joints may the lungs, such as the meninges, abdominalbe infected with TB bacilli? lymph nodes, liver, spleen, bones and joints.The most common sites are the spine (spinaltuberculosis) and large joints such as the hip, 2-21 Which children are at high riskknee or ankle. However, any bone or joint can of disseminated tuberculosis?be infected. • Children under the age of one year • Children who have not had BCG2-18 When do children develop immunisationbone tuberculosis? • Children with severe malnutritionBone tuberculosis (tuberculous osteitis) • Children with HIV infectionusually develops months to years after theprimary TB infection. It is due to reactivation Disseminated tuberculosis is most often seen inof TB bacilli that have been dormant in the infants.bone ever since they were first carried thereby blood spread from the lungs. Therefore itis uncommon in young children and usually 2-22 What is the clinical presentationseen in older children and adolescents. of disseminated tuberculosis? • At first the child becomes generally2-19 What is the presentation unwell with loss of appetite, failure toof spinal tuberculosis? thrive and fever. • There may be a history of cough.Tuberculous osteitis of the spine usually • The liver and spleen may be enlarged.occurs in the lower thoracic or upper lumbar • There may be features of tuberculousvertebrae with: meningitis.• Local pain and tenderness• Local deformity (gibbus) 2-23 Why is it important to• Spinal cord compression (difficulty diagnose disseminated tuberculosis walking and passing urine) as soon as possible?Any child with local pain and tenderness over Because these children become extremelythe spine must be suspected of having spinal ill and may die if not diagnosed and treatedtuberculosis. A rapid onset of a gibbus (‘hump rapidly and correctly.back’) is almost always due to tuberculosis. 2-24 What is miliary tuberculosis? Spinal tuberculosis presents with local pain and Miliary tuberculosis is the spread of TB bacilli tenderness. throughout both lungs. It is seen in some
  29. 29. clinical presentation of childhood tuberculosis 29cases of disseminated tuberculosis and can be tuberculosis. You should also ask aboutdiagnosed on chest X-ray. overcrowding and poverty. note The word ‘miliary’ comes from the Latin for millet seed as the X-ray in a 3. Why is the history of the child with miliary tuberculosis shows mother’s death important? small spots throughout both lungs. She might have died of tuberculosis complicating HIV infection. If the child is HIV positive this would greatly increase theScoring systems to risk of tuberculosis.identify tuberculosis 4. What clinical signs would you expect to find?2-25 Can a scoring system be used to helpmake a clinical diagnosis of tuberculosis? Often there are very few clinical signs early in tuberculosis. It would be important to weighScoring methods are available, but they are the child and plot the weight on the Road-not very accurate in children, especially if to-Health chart to assess weight loss. Signs ofHIV infection is also present. However, they malnutrition and HIV infection should also beare useful in identifying children who are at looked for.high risk of having tuberculosis and need to bereferred for further evaluation and special tests. 5. Do children with tuberculosis often have night sweats?Case study 1 No.A grandmother presents at a primary-care 6. Would a scoring system be usefulclinic with her three-year-old granddaughter. in diagnosing tuberculosis?She gives a history that the child has a poor It would be more accurate to identify childrenappetite, weight loss and fever for the past who are at high risk of tuberculosis and needthree weeks. The local general practitioner further investigation.prescribed amoxicillin for a respiratory tractinfection but this has not helped. The motherdied of HIV infection a few months ago. Case study 21. Why should you suspect tuberculosis? A four-year-old child presents with a chronicBecause the child has a number of the general cough for the past month, together withsymptoms which suggest tuberculosis (poor feeling weak and tired. As the examinationappetite with weight loss and prolonged fever). of the chest is normal, the medical officerFailure to respond to the antibiotic treatment assures the parents that the child does not havegiven for a bacterial respiratory tract infection pulmonary tuberculosis.also suggests tuberculosis. 1. Could this child have2. What social history would be important? pulmonary tuberculosis?It would be important to know if anyone Yes. A chronic cough, especially if notin the home has tuberculosis or a chronic improving, should always suggest tuberculosis.cough which may be due to undiagnosed There is not enough information to exclude tuberculosis.