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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.
  •