PRATHIMA INSTITUTE OF MEDICAL COLLEGE 2nd YEAR MD.PEDIATRICS

1. RNTCP UPDATED PEDIATRIC TUBERCULOSIS
GUIDELINES
2019
DR.SANDHYA
MENTOR: DR.G.V. HARISH
PROFESSOR, DEPT.OF PEDIATRICS PIMS.

2. TUBERCULOSIS DIAGNOSTICS

3. SYMPTOM CHARACTERISATION IN TB
Common symptoms.
Fever for 2weeks
Unremitting cough for 2wks or more
Loss of weight more than 5% of weight in past 3days
Peripheral painless swellings
Meningitis of insidious onset
Spine gibbus
Any non specific symptoms in a contact of an infectious tb case

4. INVESTIGATIONS IN TUBERCULOSIS
Non confirmatory
Chest xray
Tuberculin skin test
Interferon gamma assays
Confirmatory
Smear for AFB
ZN staining
Fluorescent microscopy
Nucleic acid amplification test
CBNAAT
LIN PROBE ASSAY
TB-lamp
TrueNat

5. CHEST X-RAY IN TB DIAGNOSIS
CXR is an important tool for diagnosis of TB in children
Childhood TB Is pauci- bacillary , therefore microbiological diagnosis less
sensitive so chest X-ray will be helpful
Remember the TB suggestive and not suggestive shadows on chest X-ray
Adenitis , miliary , and chronic fibro - cavitation lesions are considered TB
suggestive radiological findings
Clinicians must learn the skill of X-ray reading to improve TB diagnosis
Lateral views are also useful
CECT and USG are contributory and recommended in select situations

6. X-RAY CHEST FINDINGS
Highly suggestive
Pattern like
-Hilar /mediastinal
lymphadenopathy
-Chronic fibrocavitary
disease
- Miliary pattern
Non specific
Pattern like
-consolidations
-non homogeneous opacity
- ground glassing
- Thin walled cavities

7. • Chest X-ray interpretation can be effected by
Penetration
Exposure quality
Rotation
Inspiration
Motion

8. ”
“ Sharp border suggesting
atelectasis
Right cardiac border and
right diaphragm
silhouetted

13. TUBERCULAR SKIN TEST
It is a immunological test elicits Delayed type hypersensitivity reaction
Done by the intraermal injection of PPD (protein purified derivative)
Indicates present or past infection with Micobacterium tuberculosis
Not necessarily disease
Used as
Adjunct to other tests in the diagnosis of TB
Screen the children who exposed to TB ,increased risk of M.tuberculosis
Infection

14. 2 Tubercular unit RT23 PPD ( purified protein derivative given as intra dermal
injection on middle 3rd of ventral forearm
Skin should not have any scars , sores, veins at the injection site
Use a single dose syringe with a short 26 gauge with short bevel
0.1 ml of tuberculin given slowly betel up at angle of 5-15
Needle bevel should be visible just below the skin inject gently raising an dermal
wheal of at least 6mm
If intra dermal injection wheal 6mm not present repeat the test 5cm away from the
original site
Note the date and time and location of test site ,tuberculin strength
Tell the patient not to scratch ,putting any creams or lotions

15.  Read the test between 48 to 72 hours
 If the patient comes beyond 72 hours UpTo 7 days
wheal not present repeat the test on other forearm
If wheal present interpret as positive
 If patient comes beyond 7 days repeat the test in other
forearm
 Measure the induration with ruler scale in millimetres
 Induration of 10mm or more is cutoff between the infected
and non infected
 If no induration but huge erythema
May be due to inadvertant subcutaneous leak
Test should be done on other hand

16. • Read : a positive tuberculin skin
test defined as 10 mm or more
induration afternoon the 48-72 hrs
using no more than 2 TURT23
In HIV co infection 5mm may be
taken as the cutoff
False negative
• Incorrect technique of giving
readings
• Improper storage of tuberculin
• Immuno deficiency
• Infections viral bacteria,
vaccination
• Severe TB
• False positive
• Incorrect technique
• Rescent BCG Vaccination
• Infection with other
mycobacterium

17. INTERFERON GAMMA RELEASE ASSAY
• Recommended as a diagnostic aid for TB infection
• Developed to overcome TST limitations
• It is a in vitro blood test. Stimulation of blood with Mtb specific
antigens like
ESAT-6
CFP-10
Tb7.7
• QUANTIFERON GOLD and ELISPOT TB are the two major
commercially available tests

18. • IGRA detects the latent TB infection, that do not detects the actual TB bacilli but
immune response that suggests past or present exposure to Tb bacilli
• They do not distinguish between active TB and latentTB
• Should not use for diagnosis of active TB disease
Benefits
Require single patient visit
Results with in 24 hours
Prior BCG vaccination does not cause false –positive test results
Limitations
Blood sample must be processed within 8-30 hrs
Limited data on use for
children younger than 5yrs
Persons recently exposed to M.Tuberculosis
Immunocompromised persons
Expensive

19. MICROBIOLOGICAL CONFIRMATORY TESTS FOR
TUBERCULOSIS
SMEAR FOR AFB
ZN staining
Fluorescent microscopy
NUCLEIC ACID AMPLIFICATION TESTS
Cartridge based amplification tests
Line probe assays
Tb lamp
True Nat
TB CULTURES
Liquid cultures (mycobacterium growth indicator tube
Solid cultures (LJ medium)

20. • ACID FAST BACILLI ON SMEAR
smear is the cheapest ,simple confirmatory test
High level agreement ,more with increased number of bacilli
Smear less preferred test due to several issues
- problems in getting the specimens
Young children do not cough violently to bring up and spit sputum,
Tend to swallow
Most children do not expectorant
Low sensitivity
Most children have the paucibacillary primary disease in which have the low
bacilli Count
Extra pulmonary Tb a significant problem in children
AFB less often positive

21. • Other respiratory specimens when sputum is not brought up
spontaneously
Gastric aspirates
Gastric lavage
Bronchoscopy and Broncho-alveolar lavage .
 aspirates taken after the overnight fasting
Can done in ambulatory setting
Invasive ,needs better trained staff

22. Bronchoscopy and broncho –alveolar lavage
 Bronchoscopic findings of mucosal involvement is more likely to yield AFB in
BAL
Findings like compression of airways , caseation, bronchiectasis with
mucosal ulceration suggest TB pathology
Used as add on test
• Broncho -alveolar lavage
 Restricted to tertiary centres
 Definite utility in children with persistent pneumonia
Useful to rule out alternative diagnosis

23. CBNAAT
• Cartridge based nucleic acid amplification test
• It is one of the WHO and RNTCP approved NAAT
• Currently available worldwide as Xpert MTB/RIF also known as Gene
Xpert
• It is a cartridge based closed system ,automated processing,less prone
to contamination
• Amplified DNA is detected as the reaction progresses in real time
• Involves two sets of primers for( MTBand for Rif resistance ) used in
two successive runs of pcr
• Detects the M Tb and Rif resistance in <2hrs

24. • Newer Rapid diagnostics tests for tuberculosis
Xpert MTB/RIF UItra
 Is a nested pcr newer generation cartridge
 Ulta has lower detection limit 16 bacilli per ml sputum compared to
131 bacilli per ml for xpert Mtb/rif
 Especially used for paucibacillary disease children
 Recommended by wHo
Truenat MTB-RIFDx
 Developed by the Indian firm molbio diagnostics pvt ltd
 Molecular pcr based test for TB diagnosis and rif resistance
 Not fully automated
 Requires a two step process DNA extraction and then addition
 Approved by RNTCP

25. LINE PROBE ASSAYS
• RNTCP approved newer NAAT
• Hain test /MTBDR plus
• Can be used on smear positive specimen or culture isolates
• first and only WHO recommended rapid test for detection of additional
• resistance in MDR-TB AND XDR TB
Detects the TB
Resistance to RIF and INH detected by FIRST –LINE PROBE ASSAY >.
MTBDRPLUS
Resistance to FQ and 2nd line class SECOND LINE PROBE ASSAY
• MTBDRs
• It gives result in 24-48 hrs
• Helps in decision on the regimen of MDR ,XDR TB

26. MYCOBACTERIUM TB CULTURES
• Diagnostic yields can be improved with Mtb cultures
• Not routinely used, time taking
Liquid cultures changed the scenario
Mycobacterium growth indicator tube now available through the
RNTCP
• MGIT produces results faster than conventional LJ media cultures

27. Thank you