Tuberculosis in Children of Developing Countries / Pakistan

1. Tuberculosis in children
Epidemiology, Etiology, Clinical Features,
Complications, Management and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
Whatsoever is in the heavens and whatsoever is on the earth glorifies
Allah, and He is the All-Mighty, the All-Wise
Al Quran surah Al-Saff 61:1

3. Case Scenario
• A four year old child presents to OPD with cough and
fever for the last 30 days
• Child is not active as before
• Now he eats less than what he used to previously.
• Child lives in inner city with his extended family.
• His vaccinations are incomplete.
• His grandfather is suffering from chronic productive
cough.

4. Case Scenario (continued)
• Child has been to different doctors and received multiple
antibiotics.
• On physical examination, cervical lymph nodes are
palpable on left side.
• Chest crepitations are audible on the back in left infra-
scapular area
• What is your most likely diagnosis ?
• What is other diseases need to be excluded ?
• How will you manage this child ?

5. Diagnosis
• Tuberculosis
• Differential Diagnosis
• Unresolved Pneumonia
• Whooping Cough
• Hypersensitivity Pneumonitis
• Foreign body

6. Tuberculosis in children

7. Epidemiology
• Tuberculosis is endemic in Pakistan
• There are 230 new Tuberculosis cases per 100,000
population every year (500,000 in Pakistan)
• About 70000 persons die due to tuberculosis in Pakistan
every year
• Childhood Tuberculosis in children < 15 years of age
accounts for 20 % of total cases in Pakistan

8. Epidemiology
• Children can present with TB disease at any age
• Tuberculosis infection in children is common below 4 yrs
• Adolescents are at increased risk for development of TB
• Pulmonary TB is the commonest type of TB in children.
• Extra-pulmonary disease is seen in 30-40% of cases

9. Etiology
• Mycobacterium tuberculosis
• Acid-fast bacilli
• Stained with ZN stain
• Slow-growing organism that divides every 24 hours
• Resistant to drying and disinfectants

10. Transmission – spread of infection
 Source – Adult Patients with tuberculosis
 Transmission – DROPLET infection
• Transmission more likely in the presence of :
-- close contact
-- darkness and lack of ventilation
 Host – susceptible children with low immunity

11. Immunity in the child against TB infection
• Genetic factors – Asian
• Age – Young age < 5 years
• Nutritional status – Malnutrition
• Immunosuppression – after Measles
• BCG vaccination of newborn
(intra-dermal at birth)

12. Infection with Tubercle Bacillus
• Mycobacterium tuberculosis infection can result in:
• Subclinical infection (latent tuberculosis)
OR
• Clinical disease (active tuberculosis)
• depending upon:
-- dose of infecting organism
-- immunity of child

13. Pathogenesis of
Tuberculosis in Children

14. Pathogenesis of Tuberculosis in Children
• Primary infection by Mycobacterium tuberculosis is
called Primary Complex
• Primary Complex consists of primary focus of infection
and enlarged regional lymph nodes
• Primary Complex can form in the:
-- tonsils (cervical lymph nodes)
-- lungs (hilar lymph nodes)
-- abdomen (mesenteric lymph nodes)

16. Primary Pulmonary Tuberculosis
• Initial pulmonary infection is a local sub-pleural focus
• Tubercle bacillus is carried by macrophages through
lymphatics to regional lymph nodes
• Hilar lymph nodes are enlarged
• Local spread of infection can occur in lungs
• Lymphatic and blood-borne spread can be to distant
organs

17. Spread of Mycobacterium tuberculosis in the body

19. Clinical Features

20. Clinical Features of Tuberculosis
• Non-specific general symptoms of Tuberculosis
• Failure to thrive
• Loss of weight
• Loss of appetite
• Low grade fever
• Apathy
• Local symptoms and signs
• Local symptoms and signs depend upon site of infection

21. Primary Pulmonary Tuberculosis
• Primary infection may be asymptomatic
• Non-specific general symptoms
• Pulmonary symptoms and signs
- mild cough
- persistent crepitations
- decreased breath sounds
- breathlessness

24. Tuberculous pneumonia and Pleural Effusion

25. Tuberculosis of Lymph nodes
• Persistent enlargement of Lymph nodes
• Non – tender enlargement
• Cold abscess (liquefaction necrosis)
• Discharging sinus

26. Tuberculosis of Lymph nodes

27. Tuberculosis of Cervical Lymph Nodes

28. Tuberculous Cold Abscess in the Neck

29. Tuberculous Meningitis
• Initial clinical features:
• Headache
• Vomiting
• Late symptoms and signs:
• Lethargy / Drowsy / Unconciousness
• Convulsions
• Neck stiffness / signs of meningeal irritation

30. Advanced Tuberculous Meningitis
Decerebrate Rigidity

31. Tuberculous Meningitis – CT Brain
Hydrocephalus and Infarctions

32. Tuberculous Meningitis and Tuberculoma
CT Brain (IV contrast)

33. Tuberculous Meningitis
Retina – Choroid Tubercles

34. Abdominal Tuberculosis
• Pain abdomen
• Diarrhea / Constipation
• Abdominal distension – local, generalized
• Mesenteric lymphadenopathy
• Intestinal obstruction (hyperplastic tuberculosis)
• Ascites (exudative tuberculosis)

35. Abdominal Tuberculosis

36. Tuberculosis of Joints / Bones / Spine
• Pain
• Limp walk
• Joint swelling – Mono-articular Arthritis
• Discharging sinus on a bone
• Gibbus / acute kyphosis of spine (vertebral collapse due
to necrosis of intervertebral disc and vertebra)
• Paraparesis may result from pressure on nerve roots

37. Tuberculosis of Vertebral Column
X-ray Spine MRI Spine

38. Miliary Tuberculosis
• General symptoms of tuberculosis
• Hepatosplenomegaly
• Choroidal tubercles

39. Miliary Tuberculosis on Chest X-ray

40. Miliary TB – HRCT Chest

41. Diagnosis of Tuberculosis

42. Diagnosis of Tuberculosis in Children
is made by consideration of:
• General clinical features
• Local symptoms and signs
• History of contact with TB patient
• Tuberculin test
• Suggestive investigations

43. Investigations for Tuberculosis
• Tuberculin test (Monteux test)
• X – ray Chest
• Fluid Examination, Cytology, AFB smear, PCR, AFB culture and
sensitivity (CSF, Pleural Fluid, Ascitic fluid)
• Sputum / Gastric aspirate for AFB smear, PCR and AFB Culture
• Biopsy of local tissue / organ for histopathology and AFB culture
• PCR for MTB (GeneXpert) performed on CSF / Fluid aspirate
(also detects Rifampicin resistance)
• Blood IGRA (Interferon Gamma Release Assay) test

44. Score Chart for Diagnosis of Childhood Tuberculosis

45. Treatment of Tuberculosis

46. Treatment of Childhood Tuberculosis
• Make a confident diagnosis
• Prescribe standard anti-TB chemotherapy regime
• Ensure drug compliance
• Evaluate and treat adult sources / contacts of child
patient

47. Treatment Regimens
• Asymptomatic infection (Latent Tuberculosis)
• Primary pulmonary / lymph node / abdominal
tuberculosis in child
• T.B. Meningitis / Bone / Miliary tuberculosis

48. Asymptomatic MTB infection in a Child
• 6HR
• 6 months – INH, Rifampicin
• INH – 10 mg / kg / day
• Rifampicin – 15 mg / kg / day

49. Primary Tuberculosis in a Child
Pulmonary / Lymph node / Abdominal
• 2HRZ
• 4HR
• Initial 2 months – INH, Rifampicin, Pyrazinamide
• Next 4 months – INH, Rifampicin
• INH – 10 mg / kg / day
• Rifampicin – 15 mg / kg / day
• Pyrazinamide – 30 mg / kg / day

50. T.B. Meningitis / Miliary Tuberculosis / Bone T.B.
• 2HRZE
• 10HR
• Initial 2 months – INH, Rifampicin, Pyrazinamide, Ethambutal
• Next 10 months – INH, Rifampicin
• INH – 10 mg / kg / day
• Rifampicin – 15 mg / kg / day
• Pyrazinamide – 30 mg / kg / day
• Ethambutal – 20 mg / kg / day

51. Tuberculosis in Children – Steroid Therapy
 Steroids enhance symptom resolution and reduce fibrosis in
tuberculosis
 Steroids are given for initial 6 weeks with the start of Anti-
tuberculous chemotherapy in children with:
• T.B.M. (Tuberculous Meningitis)
• Miliary Tuberculosis
• Tuberculous Pericardial effusion
• Tuberculous Pleural effusion

52. PREVENTION of
Tuberculosis in Children

53. PREVENTION
 Health Promotion of Child –
- Vaccination against common infections
- Breastfeeding, Nutrition, Micronutrients
 Prevention of Transmission –
- Hand washing, Masks and Social Distancing
- Case finding and treatment of active adult TB cases
 Specific Protection –
• BCG vaccination at birth – Efficacy = 50 – 80 %

54. Prevention in the Newborn baby
whose mother has active Pulmonary Tuberculous
• DO NOT separate mother and baby
• START mother feeds
• Give anti-TB treatment to mother
• Prophylactic INH therapy given to baby for 3 months
• Re – evaluate baby at 3 months
• Give BCG to baby at 3 months

55. Thank You