Paediatric Tuberculosis

1. PEDIATRIC
TUBERCULOSIS
(EPIDEMIOLOGY, RISK FACTORS, PATHOPHYSIOLO
AND CLINICAL FEATURES)

2. INTRODUCTION
• Different names-King’s evil, phthisis, Rajyakshma, Tapedic
etc,…
• “Tubercle” – Franciseus sylvius
• “Tuberculosis”- Laurent bayle.

3. MAGNITUDE OF PROBLEM IN COMMUNITY
• 2.2 lakhs children affected each year ( 22% of global TB burden)
• Males> females
• Children< 14 yrs- 10%

4. EPIDEMIOLOGY
• Agent: M.tuberculosis, M. bovis
• Reservoir: case
• Mode of entry: droplet infection, dust, ingestion, mucous
membrane

5. RISK FACTORS
For TB infection For TB disease
Increased eposure:
Living in high TB endemic communities
Children of families living with HIV
Over crowding and poor sanitation
Air pollution including environmental
Tobacco smoke
Young age ( 0to 2 yrs)
Source case:
Cavitatory disease/smear positivity
Cough frequency cough hygiene
Delay in treatment of adult case
HIV infection:
Risk of infection and disease
Lack of contact screening Other immuno supression:
Malnutrition
Post-measles, post- viral
Diabetes
Contact with source case Lack of prophylaxis
Not BCG vaccinated:
Risk of disseminated disease with
increased severity.

6. Drug resistant TB:
Personal or contact history of treatment for TB
Contact of patients with drug resistant TB
Birth or residence in a country with high rate of drug resistance
Poor response to standard therapy
Positive sputum smears or culture >_ 2 months after initiating appropriate thera

7. CLINICAL STAGES OF TUBERCULOSIS
Exposure Infection Disease
Contact with
infectious
case
Yes
Lacks proof of
infection
yes yes
Clinical signs
and symptoms
No No yes
Chest
radiography
Normal Normal or
granuloma/
calcification in
lungs
Abnormal
TST/IGRA Negative positive positive

8. CASE DEFINITIONS
Presumptive pediatric TB:
Children with persistent fever and or cough for more than 2
weeks, loss of weight/no weight gain and/or history of contact with infectious
TB cases.
Presumptive Extra pulmonary TB:
presence of organ specific symptoms and signs (swelling of
lymph nodes, neck stiffness, disorientation etc..) and/or constitutional
symptoms.

9. Presumptive DR TB:
TB patients who have failed treatment with first line drugs.
Paediatric TB non-responders.
TB patients who are contact of DR-TB.

10. NATURAL HISTORY OF DISEASE

11. CLASSIFICATION OF CHILDHOOD TB
• Primary disease
• Progressive primary disease
• Reactivation disease

12. PRIMARY TUBERCULOUS INFECTION
Primary focus( Ghon’s focus):
At the site of first implantation
Usually single and sub pleural
In most cases, heals and disappears/fibrosis/calcifies.
Primary complex- primary focus + hilar/paratracheal lymphnodes+
draining lymphatics

13. PROGRESSION OF PRIMARY TB TO
PROGRESSIVE PRIMARY DISEASE
Progression of
Ghon’s
complex
Regional lymph
node
Ghon’s focus
Airway
involvement
Intra bronchial
spread
Bronchopneumoni
c consolidation
obstruction
cavitation
Parenchymal
cavitation with intra
bronchial spread
Contiguous
rupture
Pleural effusion
Pericardial
effusion
Milliary TB

14. TIME TABLE OF PRIMARY TUBERCULOSIS
stage Duration Features
Stage 1 3 to 8 weeks Primary complex develops.
Conversion to tuberculin
positivity
Stage 2 About 3 months Hematogenous
dissemination ( miliary
disease, TB meningitis)
Stage 3 3 to 4 months Tuberculous pleurisy
( hematogenous or direct
spread)
Stage 4 Upto 3 years Until primary complex
resolves.
Extra pulmonary lesions
Stage 5 Upto 12 years Genitourinary TB

15. REACTIVATION/POST PRIMARY
• Disease of adolescence and adulthood.
• Apical /posterior segment of upper lobes or superior segment of
lower lobes.
• Patchy heterogenous consolidation, consolidation with cavitation
or pleural extension.

16. CLINICAL MANIFESTATIONS
• Primary pulmonary disease
• Progressive primary disease
• Reactivation disease
• Pleural effusion
• Pericardial disease
• Lymphohematogenous (disseminated) disease
• Upper respiratory tract disease
• Lymph node disease
• CNS disease
• Cutaneous disease
• Bone and joint disease
• Abdominal and joint TB
• Genitourinary disease
• Congenital TB

17. PLEURAL EFFUSION
• Localised or generalised. Asymptomatic local effusion is
considered to be part of primary complex.
• Uncommon in children < 6 yrs, disseminated tuberculosis.
• Usually unilateral
• Low to high grade fever, shortness of breath, chest pain and
dimnished breath sounds.
• Prognosis- excellent
• Scoliosis- in long standing effusion.

18. PERICARDIAL DISEASE
• Pericarditis
• Direct invasion or lymphatic drainage
• Symptoms- non specific. Friction rub, distant heart sounds and
pulsus paradoxus.
• Constrictive pericarditis.

19. LYMPHOHEMATOGENOUS
( DISSEMINATED)
• Usually asymptomatic, indolent and prolonged course.
• Organs involved- liver, spleen, skin, lung apices, bone marrow
and meninges.

20. MILIARY DISEASE
• 2 or more organs involvement
• Within 2 to 6 months of primary infection
• Most common in infants and young children.

21. Insidious , systemic signs( low grade
fever, anorexia and weight loss)
Abnormal physical signs absent.
Hepatosplenomegaly, generalised
lymphadenopathy.
Fever- high grade & sustained
Normal chest signs.
Progressive pulmonary involvement
Alveolar air block syndromes
Meningitis , peritonitis, choroid tubercles (
most specific), papulo necrotic
tuberculides.

22. TB OF SUPERFICIAL LYMPH NODE
( SCROFULA)
• MC form of extra pulmonary TB in children.
• Usually unilateral; bilateral( chest and lower neck)
• Discrete, non tender, firm and fixed. Later matted nodes.
• Tonsillar / sub mandibular ( from paratracheal nodes)
• Supraclavicular ( from primary lung lesion)
• Axillary/ epitrochlear ( from skin lesion on hand)
• Inguinal (from foot ulcers)
*Rupture- draining sinus tract.

23. NEURO TUBERCULOSIS
• 1% of all cases of tuberculosis.
• High mortality and neurological morbidity

24. CLASSIFICATION
Intracranial:
Tubercular meningitis
Space occupying lesions(
tuberculoma, tubercular abcess)
Tubercular encephalopathy
Tubercular vasculopathy
Spinal:
Pott’s spine and paraplegia
Tubercular arachnoiditis
Non osseous spinal tuberculoma
Spinal meningitis

25. TB MENINGITIS
• MC form of CNS tuberculosis.
• Incidence- 1 in 300 primary infections
• Common between 6 months and 4 years.

26. PATHOLOGY
Primary infection
Lymphohematogenous dissemination
Metastatic caseous lesion in cortex and meninges
Discharges tubercle bacilli in to sub arachnoid space
Gelatinous exudate
Infiltrate corticomeningeal blood vessels
Inflammation, obstruction & infarction of cerebral cortex
Brain stem Interferes CFF flow
Dysfunction of CN III, VI, VII Hydrocephalus

27. STAGES OF TB MENINGITIS
Stage I
• Irritability, anorexia, personality change, vomiting, fever
• Poor school performance
Stage II
• Focal neurological signs, cranial nerve falsies, seizure, hemiplegia, squint
Stage III
• Loss of consciousness, coma, papilloedema
• Decerebrate rigidity

28. COMPLICATIONS OF TB MENINGITIS
• Hydrocephalus
• Subdural effusion
• Late : Hemiplegia
Paraplegia
Deafness
Blindness
Intracranial calcification
Growth failure
Failure of development of secondary sexual characters

29. TUBERCULOMA
• Tumor like mass formed by aggregation of caseous tubercles.
• Single / multiple
• Fever, headache, vomiting, focal neurological signs and convulsions.
Sites:
Supra-tentorial in adults.
Infratentorial in children
At the base of the brain near cerebellum

30. Tuberculoma Neurocysticercosis
Any age Rare below 3 years
Progressive neurological deficit No progressive deficit
Size > 20mm smaller
Irregular outline Regular rounded outline
Marked cerebral edema Less cerebral edema
Supratentorial/infratentorial Usually supratentorial
Midline shift seen No midline shift
MRS has lipid peak MRS has no lipid peak

31. UPPER AIRWAY DISEASE
• Laryngeal TB- croup like cough, sore throat, hoarseness and dys
• Tuberculosis of middle ear- painless unilateral otorrhea, tinnitus
facial paralysis and perforated TM.
• Preauricular and Ant cervical nodes.

32. CUTANEOUS TB
• Associated with primary complex: (direct invasion into traumatised area)
Painless nodule leading to non healing ulcer with regional lymphadenitis
Scrofuloderma over ruptured caseous lymph node
• Associated with hematogenous dissemination:
Papulo necrotic tuberculides
Tuberculosis verucosa cutis

33. • Associated with hypersensitivity to tuberculin:
Erythema nodosum

34. ABDOMINAL & GI TB
• Principle agent- M.tuberculosis
• Rare- M. bovis and non tuberculous mycobacteria.
• Complicates 6 to 38% of pulmonary TB cases.
• Hematogenous spread from lungs or swallowing of infected sputum

35. PATHOGENESIS OF ABDOMINAL TB
Primary complex
Hematogenous
spread
Rapid
spread
Miliary tubercles
Omentum
Peritoneum
Nodes
Spleen
Serosal surface of
intestine
Intermittent silent
Low grade
bacteremia
Nodal TB and
payer’s patches
Ulceration/hypertrophic/
ulcerohypertrophic
stricture
Caseous rupture
Peritoneal
Plastic
Ascites

36. TYPES OF ABDOMINAL TB IN CHILDREN
• Tuberculosis of intestine:
Ulcerative
Hypertrophic
Ulcerohypertrophic
Stricture formation
Fistula
Miliary
• Peritonal TB:
Peritonitis
Miliary TB peritoneum
Omental TB

37. • TB of lymph node:
Tabes mesenterica
Retroperitoneal
Peripancreatic
Porta hepatis
• Other organs:
Hepatobiliary
Spleen
pancreas

38. CLINICAL MANIFESTATIONS
• Painless ulcer in gingivolabial sulcus with submental and sub
mandibular adenopathy.
• Ulcers on tonsil
• Esophageal: Mid/upper, dysphagia, odonyphagia
• Tracheoesophageal fistula/ aorto esophageal fistula(
rare)
• Colicky abdominal pain, vomiting and constipation
• Doughy abdomen
• Rolled up omentum presenting as irregular nodular mass with
ascites.
• Hepatosplenomegaly
• TB enteritis

39. OCULAR TB
• Primary tuberculous conjunctivitis: (Trauma)
Yellowish grey nodules on palpebral conjunctiva with preauricula
lymphadenopathy.
• Phlyctenular conjunctivitis: ( Hypersensitivity)
Nodules on limbus recurring in crops.
• Tubercles on choroid (Miliary TB)

41. SKELETAL TB
• Bones involved: vertebrae> knee> hip > elbow
• Tuberculous spondylitis: thoracic > lumbar
• Radiology : Narrowing of disc space
Collapse of vertebral body
Extensive destruction with kyphosis
Complications: Paravertebral abcess
Psoas abcess
Paraplegia
Quadriplegia

42. GENITAL TB
• Uncommon before puberty
• Lymphohematogenous spread/ direct etension from bone or intestine.
• Females: fallopian tube> endometrium> ovary> cervix
• Male : epidydimis ,testis and scrotum.
Genital lesions and a positive TST in an adolescent boy
or girl suggest genital TB.

43. RENAL TB
• Caseous foci in parenchyma releases bacilli into tubules.
• Large mass near the cortex.
• Early- sterile pyuria and microscopic hematuria
• Late – dysuria, loin pain and gross hematuria
Complications: Urteral stricture
Hydronephrosis.

44. CONGENITAL TB
• Associated with tuberculous endometritis or disseminated tb in mother
• Mode of transmission: Hematogenous
Fetal aspiration
• Clinical features: Respiratory distress
Hepatosplenomegaly
Poor feeding
Lethargy
Irritability
Low birth weight

45. CANTWELL CRITERIA
• Proven TB lesion in infant
plus one of the following
• Lesion occuring in the first week of life
• Primary hepatic complex
• Maternal genital tract or placental TB
• Exclusion of postnatal transmission by investigation of contacts.

46. THANK YOU