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    6 6 Presentation Transcript

    • PARMESHVAR DAS VAISHNAV
    • INTRODUCTION
      • 10-20% of all tuberculosis
      • Due to failure of TB control in adults.
      • Commonest age group is 1-4 years.
      • Most children are sputum –ve and not infectious to others.
    • SOURCE OF INFECTION
      • Adult or family member with sputum smear positive.
      • Frequency of infection in a given population depends on:
      • (A) no: of infectious cases
      • (B) closeness of contact with an infectious
      • case
      • (C) age of child when exposed and the age
      • structure of the population
    • PREDISPOSING FACTORS
      • Extent of exposure to infectious droplet nuclei.
      • Infant whose mother has sputum smear positive PTB.
      • Chance of developing infection is greatest shortly after infection
      • Children under 5 yrs- less developed immune system.
      • Young age is a risk factor for sread of disease to other part of body,i.e. dissemination..
    • ClINICAL SYMPTOMS
      • No specific features.
      • Failure to thrive
      • Weight loss( growth faltering)
      • Respiratory symptoms( cough> 3 weeks in child who received a course of broad spectrum anti- biotics.
    • DIAGNOSIS
      • Particularly difficult because they rarely cough up sputum.
      • Exposure
      • Tuberculin skin test
      • Chest X ray.
    • TREATMENT
      • A symptomatic child with a positive Mantoux test(>10mm) is to be treated as a case regardless of BCG vaccination in past
      • Dosages of anti-TB medication for children:-
      DRUGS THERAPY PER DOSE (THRICE A WEEK) Isoniazid 10-15 mg/kg Rifampicin 10mg/kg Pyrazinamide 35mg/kg Streptomycin 15mg/kg Ethambutol 30mg/kg
    • CHEMOPROPHYLAXIS
      • For infant whose mother or any other houshold member is smear-positive,then
      • Chemoprophylaxis should be given for 3 months.
      • Then a mantoux test is done…
      • .If test is negative-stop chemoprophylaxis
      • and BCG is given
      • .If test is positive,chemoprophylaxis is
      • continued for a total duration of 6 months..
    • Guidelines IF AND THEN child has symptoms of TB An MO determines (preferably in consultation with a paediatrician) that the child has TB…. A full course of anti TB treatment (CAT3) should be given… The child does not have symptoms of TB. . A tuberculin test is not available . .A tuberculin test is available Chemoprophylaxis for 6 months (Isoniazide daily-5mg/kg) The child should receive 3 months of INH chemoprophylaxis IF IF THEN The induration is less than 6mm in diameter Stop chemoprophylaxis and give BCG . The induration is 6mm or more in diameter Continued INH chemoprophylaxis for another 3 months
    • TUBERCULOSIS & HIV
    • INTRODUCTION
      • To make global situation worse,
      • tuberculosis has formed lethal partnership
      • with HIV.
      • Co-infection of tb &hiv has increased the risk of activation of infection from
      • 10% over the lifespan to 10%per year.
      • worldwide approximately 1/3 rd of all AIDS related deaths are associated with TB.
      • HIV infection infection increases the risk of developing active TB by a factor of 100.
      • Levels of plasma HIV RNA increase in setting of active TB and decline in setting of successful l TB treatment.
    • EPIDEMIOLOGICAL IMPACT
      • Reactivation of latent infection:
      • 25-30% more likely to develop the disease than the people only with TB.
      • Primary infection
      • Recurring infection
      • In the community
    • CLINICAL FEATURES
      • Depend on the count of the CD4 cells.
      • high low
      • Pulmonary reactivation disseminated disease diffuse or lower
      • fever, cough, dyspnoea, lobe, reticulonodular infiltrates
      • Weight loss, night sweats, miliary spread, pleural effusions,
      • Chest X ray: cavitary apical hilar and/or mediastinal adenopathy.
      • disease of upper lobes
    • DIAGNOSIS
      • Clinical symptoms are similar as in people without HIV infection in the early stage.
      • Diagnosis is more difficult in advanced HIV because:
      • (a) Higher frequency of –ve sputum smears.
      • Sputum culture required for confirmation.
      • (b) Tuberculin skin test fails- immune system damaged- false negative results.
      • (c) Chest radiography may be less useful- less cavitation – decreased immune response
      • (d) Cases of extra pulmonary tuberculosis seem to be more common in people who are co-infection.
    • In short screen:
      • Sputum smear microscopy
      • positive negative( suspected)
      • start
      • treatment
      • treatment if if sputum culture not
      • sputum culture done, treatment given
      • positive according to X ray
      • findings
    • TREATMENT
      • Standard treatment regimens are equally efficacious in HIV +ve and –ve patients.
      • adverse effects are more pronounced.
      • Thiacetazone- fatal skin reactions- not used nowadays.
      • Three important considerations:
      • an incresed frequency of paradoxical reactions.
      • interaction between ART and rifamycins
      • Development of rifampin monoresistance with widely spaced intermittent treatment.
      • IRIS- Immune Reconstitution Inflammatory Syndrome: It is the exacerbation in signs, symptoms, radiographic and laboratory manifestations of TB due to ART administration.
      • IRIS more common in advanced immunosuppressed and extrapulmonary TB.
      • IRIS is an immune response elicited by antigens released as bacilli are killed during effective chemotherapy
      • Temporarily associated with improved immune function.
      • Managed by symptomatic treatment with glucocorticoids.
      • Rifampicin a potent inducer of enzyme of the cytochrome P450 system – lower the serum level of many HIV protein inhibitors and some NNRTIs.
      • Rifabutin- has much less enzyme inducing
      • activity. So recommended in place of Rifampicin.
    • TB IN PREGNANCY
    • INTRODUCTION
      • Encountered in 1-2% of pregnant women.
      • Course of TB is unmodified during pregnancy.
      • Lesions remaining the same, there is no difference in mortality between pregnant and non-pregnant.
    • EFFECT OF TB ON PREGNANCY
      • Pulmonary TB does not affect fertility unless there is associated genital TB.
      • Usually there is no effect on the course of pregnancy except for a slight increase in the incidence of the abortion and premature
      • labour.
      • Rarely affect the foetus by transplacental route.
      • Greater danger is the possibility of infection of the newborn by close contact when the mother has open TB.
      • Diagnosis is based on symptoms, sputum examination and chest radiographs.
    • MANAGEMENT
      • Problem- Possible effect on the foetus of the chemotherapeutic drugs.
      • Time of institution of the treatment should be irrespective of period of gestation.
      • the anti TB drug considered safe are:
      • Ethambutol- 5-25mg/kg daily
      • Isoniazid – 5 mg/kg not to exceed 300mg daily
      • Pyridoxine- 50mg daily to reduce risk of INH induced neuropathy.
      • Rifampicin 10 mg/kg daily not to exceed 600 mg daily.
      • duration – 9 months
      • Routine AN care should be continued and foetal monitoring should be done to diagnose IUGR.
      • Streptomycin, pyrazinamide - teratogenic- contraindicated
      • Congenital TB: foetus affected either haematogenously or through the umbilical vein .
      • The fetus infected by aspiration of infected contents at delivery.
      • Breastfeeding: shouldnot be discouraged.
    • NEONATAL RISK AND THE MANAGEMENT.
      • Tuberculin +ve mother without active disease doesnot pose any risk .
      • If mother is sputum –ve in the last 3 month of gestation with active TB, the risk to infant is negligible.
      • If the mother is sputum +ve, then the neonate needs to be evaluated for active TB.
      • If there is no active TB in neonate, it should receive INH prophylaxis for 3 months until the mother’s sputum becomes –ve.
    •