PRATHIMA INSTITUTE OF MEDICAL COLLEGE 2nd YEAR MD.PEDIATRICS

1. RNTCP UPDATED
PEDIATRIC
TUBERCULOSIS GUIDELINES
2019
DR.P. ROHITH
MENTOR: DR.G.V. HARISH
PROFESSOR, DEPT.OF PEDIATRICS
1.Natural history of childhood TB.
2.Pulmonary TB diagnostic algorithm.
3.Treatment and monitoring of TB.
4.Neuro tuberculosis.
5.Drug resistant TB.
6.TB in HIV.

2. Natural history of childhood TB
Source case
No diseasePersistent ‘latent’
infection
Primary disease
infection No infection
contacts
Late reactivation
disease
70%30%
90-95%
Risk of developing disease
5-10% lifetime,
>50% infancy,
25% in 1-5yr.

3. Risk factors for TB infection and disease in children
For TB infection:
Increased exposure
living in high TB endemic communities
children of families living with HIV
overcrowding
air pollution including environmental
tobacco smoke
Source case
cavitary disease/smear positivity
cough frequency/cough hygiene
delay in treatment of adult case
Contact with source case
closeness of contact
duration of contact
For TB disease:
Young age
especially 0-2 years
HIV infection
risk of infection and disease
Other immunosuppression
malnutrition
post-measles
Not BCG vaccinated
risk of disseminated disease
Lack of prophylaxis

4. Radiological picture of a typical Ghon’s complex

5. Progression of
ghon’s, complex
Progressive
primary TB
Partial or complete
obstruction
Parenchymal
cavitation with
intra-bronchial
spread
Bronchopneumoni
c consolidation
Intra bronchial
spread
Ghon’s focus
Airway
involvement
Regional lymph
nodes
cavitation
Contiguous rupture
Pleural effusion
Pericardial effusion
Miliary TB

6. PULMONARY TB DIAGNOSTIC ALGORITHM

7. Highly suggestive chest x-ray refers to miliary shadows,or lymphadenopathy(hilar or mediastinal) or
chronic fibro-cavitary shadows.
Non specific chest x-ray: refers to pattern other than highly suggestive like consolidations, in –
homogenous shadows or broncho pneumonia,etc.
RNTCP approved NAAT include CB NAAT and LPA.
If a specimen is positive by any of these methods, the case is labelled a microbiologically confirmed TB.
If a specimen is negative by RNTCP approved NAAT(or smear),the second aliquot or a fresh specimen
should be submitted for liquid culture.
Antibiotics of choice include amoxycillin or co-amoxiclav.
Antibiotics like linezolid or any quinolone should not be used as they have anti-TB action.

8. TREATMENT AND MONITORING OF
TB

9. Treatment of TB
Intensive phase(IP)
Early rapid killing of Mtb, prevents deterioration
and death.
Reduced infectivity
Addition of Z reduces duration to 6 months due to
its sterilizing effect
Addition of E is useful if initial drug resistance to
INH is high.
Continuation phase(CP)
Eliminates most residual bacilli
Reduces failures and relapses
Small number of bacilli left: fewer drugs are
required.
In presence of background resistant to the
companion drugs; more drugs needed to
prevent amplification of drug resistance.

11. Drug dosages

12. Adjunctive therapy in TB
STERIODS:
Interaction between the microbial factors and host immunological factors in lung,lymph nodes,
intracranial tuberculosis lesion may cause worsening of symptoms due to release of pro-
inflammatory markers like IL-2 and interferon gamma which may have severe life threatening
manifestations and sequelae.
In some of these circumstances there may be relief in symptoms if inflammation can be supressed by
steroids.
Prednisolone: 2mg/kg/day (max 60 mg/day)
Dexamethasone: 0.6 mg/kg/day
For 4 weeks, followed by reducing course over 4 weeks.

13. PYRIDOXINE:
Isoniazid interferes competitively with pyridoxine metabolism by inhibiting their formation of the active
form of the vitamin, and hence often results in peripheral neuropathy.
Current recommendation:
routine pyridoxine supplementation to all children receiving ATT.
Dose
Prophylaxis:10 mg daily
DRTB: 50-100 mg depending on dose drugs
Evidence of vit B deficiency: may require upto 50mg daily.

14. Monitoring of treatment

15. Clinical response
Commonly patients show defervescence, reduction in cough by the end of
first 2-4 weeks.
Weight gain usually starts by 4 weeks

16. NEUROTUBERCULOSIS
TB meningitis:
Most commonly presents between 6 months to 4 years of age.
Most severe form of tuberculosis in children.
Uniformly leads to mortality if not treated timely and effectively.

17. 3 clinical stages.
Usually progresses over several weeks from stage one to three
Infants and young children may progress rapidly over days.
Stage 1 lasts 1 to 2 weeks.
Non specific symptoms
Fever,headache,irritability/drowsiness,malaise,anorexia,inadequate weight gain or
weight loss,stagnation or regression of developmental milestones.
Stage 2 Begins abruptly.
characterized by increased intracranial pressure,meningeal irritability,and vasculitis
without marked changes in sensorium.
Clinical constellation lethargy,nuchal rigidity,kernig and Brudzinski signs,
seizures,hypertonia,vomiting,cranial nerve palsies with basal meningitis and other
neurological deficits.
Stage 3 coma,hemiplegiaor paraplegia,decerebrate posturing,deterioration in vital signs and
finally death.

18. Hydrocephalus in TBM
Common complication of TBM.
Timely recognition of intracranial hypertension and shunt placement markedly reduces morbidity and
mortality.
Substantial benefits from ventricular drainage in children with TB meningitis associated with
hydrocephalus even in TBM stage 3.
Tuberculoma is a manifestation of CNS tuberculosis.
Presents as ICSOL.
Presents with seizures headache and neurological focal deficits.
Should be differentiated from NCC.

19. Treatment
ATT 12 months (2HRZE+10HRE)
Steroids: prednisolone 2 mg/kg/day(or equivalent dose dexamethasone: 0.6 mg/kg/day) in divided
doses,for at least 4 weeks and then tapered over next 4 weeks.
Decongestive therapy: as needed
mannitol,acetazolamide,glycerol.
Antiepileptics: as needed
Surgical intervention,if raised ICT not controlled by medical management
shunt/EVD/ventricular tap

20. DRUG RESISTANT TB
Definitions:
Mono resistance: resistance to any first line ATT other than R (HZE)
MDR-TB : Resistance to atleast H & R
Poly resistance: resistance to 2 first line drugs but not both H & R
XDR-TB: MDR-TB + resistance to any fluroquinolones AND any second-line injectable drugs
(Am/Km/cap)

21. Situation where DRTB is suspected
Treatment after lost to follow up(Defaulter)– received ATT for > 1 m from any source and was
Lost to follow-up in most recent course of treatment and subsequently found microbiologically
confirmed.
Recurrent TB (relapse)--child who was declared successfully treated in past and now has a
bacteriological evidence of reccurance.
Re-treatment after failure—children who have previously been treated for TB and whose treatment
failed at the end of their most recent course of treatment.
All of the above are DRTB suspects in addition to children who are at high risk of DR TB viz.
Contacts of MDR patients and/or CLHA and/or history of TB death in the household.

22. Approach to diagnosis of MDR TB in children
Careful history: history of contact with MDR-TB case is critical information
Consider in child failing first-line TB treatment despite adherence
Clinical examination
HIV testing: Failure to respond to TB treatment –should consider HIV-related lung disease that is not
TB as well as the possibility of MDR-TB
Microbiological confirmation and drug susceptibility testing is paramount and should always be
attempted.

23. MDR TB DIAGNOSIS
Microbiological confirmation should always be done
CBNAAT(e.g. Xpert Rif/LPA/culture and DST
Make all out efforts to get clinical samples from the affected site
pulmonary: sputum, gastric lavage, BAL, lung tap
Extra pulmonary: lymph node aspiration ,excision biopsy
CSF
laparoscopic tissue biopsy
Diagnosis of drug resistant TB in absence of microbiological diagnosis must be thoroughly
reviewed as it may often be untenable
Sometimes if there is high DRTB suspicion ,microbiologically negative clinically diagnosed MDR TB can be
considered provided all other alternative causes for symptoms have been ruled out in the absence of
negative cultures or culture is not feasible due to lack of a specimen(probable MDR-TB)

24. Perform LPA/CBNAAT and liquid cultures for every DRTB suspect at baseline
Molecular methods for every suspect:
For rapid detection of rifampicin resistance to decide the treatment regime.
To decide whether only first line DST or both first line and second line DST needs to be done additionally.
Additional liquid culture to detect baseline resistance to other drugs:
FLDs(S H R Z E with level of INH resistance) if Rif sensitive. If any resistance to FLD, test for SLDs also.
FLD & SLD if Rif resistant (H E Z with level of INH resistance, Mfx,Lfx,Km,Am,Cm).

25. DR TB SUSPECT
Specimen for
smear/CBNAAT and MGIT
sputum/GA/IS/EP TB
SAMPLE
Specimen AFB positive
CBNAAT TB
RIF resistance
Specimen AFB
and CBNAAT TB
Mtb negative
Specimen AFB positive
CBNAAT TB
Rif sensitive

26. Specimen for AFB,
GeneXpert
Send MGIT cultures
Specimen AFB positive
GeneXpert sensitive
Specimen AFP positive
GeneXpert RIF resistance
Specimen AFB and
GeneXpert negative
Plan further invetigations for
alternative diagnosis in association
with pediatric pulmonologist
Might need a CT chest and flexible
bronchoscopy
Note: still can be DR TB

27. REGIMENS OF DRUG RESISTANT TB(0-18 YRS)

28. TB IN HIV
HOW THEY WORK HAND IN HAND
TB---- can hasten disease progression in HIV
Can increase mortality in HIV
HIV---- promotes progression of TB infection to active TB disease
Can drive MDR TB

30. HIV infected child
TB suspected
Extra pulmonary TB suspectedPulmonary TB suspected
1 CBNAAT + X-ray chest X-ray chest
and other
radiological
examination
Cytology
histopatholo
gical
examination
Culture/CBNAAT
Positive specimen
from extra
pulmonary site
Xpert positive
CBNAAT
negative+ x-ray
suggestive of TB
CBNAAT negative
+ X-ray negative
for TB
Any one or more suggestive of
TB
Microbiologically
positive TB
Clinically diagnosed TB Non TB Extra pulmonary TB

31. Treatment of TB in CLHIV
Using daily treatment. Follow RNTCP guidelines.
Standard regime, pyridoxine supplements.
Response to therapy is difficult to ascertain because of HIV/other disease.
Cotrimoxazole prophylaxis if indicated.
Early initiation of ART within 2-8 weeks of starting TB treatment(within 2 weeks if CD4<50).
Immune reconstitution inflammatory syndrome(IRIS) may occur especially once ART is started.
Standard duration of therapy is 6 months followed by 6 months of INH preventive therapy.

32. MANAGEMENT OF HIV-TB CO-INFECTION IN INFANTS AND
CHILDRENHIV infected infants, children ad adolescents co-infected with all forms of TB.
Start ART regardless of theCD4 count:
Start ATT first, initiate ART as soon as TB treatment is tolerated(between 2 weeks and 2 months)
HIV –TB co-infected patients with CD4 count <50 cells/ (in children aged> 5years of age),need to be
started on ATT first and then ART within 2 weeks with strict clinical monitoring.
Efavirenz is the preferred drug, whenever children are being treated with rifampicin containing drug
regimen for TB co-infection.
However, in children aged <3 years and in children weighing <10 kg, efavirenz is not recommended;
super-boosted lopinavir/ritonavir must be given.

34. SAATHII
SAATHII is solidarity and action against HIV/AIDS in India.
SAATHII strengthens the capacity of organisations working against the HIV/AIDS epidemic in India.
Objectives:
To mobilize increased attention and political commitment on HIV/AIDS.
To bring people from multiple sectors together and foster collaboration.
To bridge knowledge gaps.
To strengthen and expand HIV/AIDS services in India.

35. THANK YOU