This document summarizes key information about pediatric tuberculosis (TB). It describes that TB is caused by Mycobacterium tuberculosis and can manifest as latent or active disease. Active TB can be pulmonary or extrapulmonary. Worldwide, there are an estimated 8.7 million new TB cases annually, including 490,000 in children. Infants and young children are more susceptible to developing life-threatening forms of TB. Diagnosis involves tests such as tuberculin skin test (TST), chest x-ray, and sputum culture. Treatment consists of a multi-drug regimen including isoniazid and rifampin over 6-12 months depending on disease type.

1. Pediatric Tuberculosis

2. Tuberculosis 411
 Caused by mycobacterium tuberculosis
 Can cause latent TB or primary TB
 Primary TB can be pulmonary or extrapulmonary TB
 Spread by aerosolized particles during coughing,
sneezing, or speaking

Children less likely to spread
 Extrapulmonary TB is not transmitted
 Incubation period is 2-12 weeks
 Time from infection to identification of a primary lesion on
TST

3. Worldwide TB Epidemiology
 8.7 million NEW cases per year
 490,000 pediatric cases
 Low burden countries – 5% pediatric cases
 High burden countries- 20% pediatric cases
 Infants and young children are more prone to
develop life threatening forms
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
Disseminated TB
TB meningitis
 1.4 million deaths
 64,000 pediatric deaths
 Top ten cause of pediatric death

4. Worldwide

5. US Incidence

6. Clinical Features
 Bimodal presentation
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Children < 5 y/o and adolescents >10 y/o
 Most children asymptomatic
 Most common symptoms:
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Chronic cough (>21 days)
+/- wheezing
Dyspnea
Hemoptysis
Fever (>14 days)
Weight loss/FTT
Weakness/lethargy
Night sweats

7. Pulmonary TB
 Pulmonary parenchymal disease and intrathoracic
adenopathy
 Most common: 60-80% of cases

8. Extrapulmonary TB
 Harder to diagnose
 Symptoms highly suggestive of extrapulmonary TB
 Gibbus from vertebral body
 Enlarged or painless joints
 Cervical lymphadenopathy with fistula
 Meningitis or pleural effusion not responsive to antibiotics
 Pericardial effusion
 Abdominal ascites

9. TB meningitis
 CNS involvement is common
 Symptoms include:
 Headache
 Neck stiffness
 Coma
 Hemiplegia
 Seizures
 LP to diagnose
 SIADH is common

10. Latent TB
 Do not show any symptoms of the disease
 Not infectious
 Can transition from LTBI to active TB more
frequently and faster (within weeks)
 Conversion rate is 5% in 2 years

11. Diagnosis
 Must distinguish between latent TB (LTBI) or TB
 Diagnostic tests include
 TST/QFT-GIT
 CXR
 AFB/Sputum culture
 Majority of case ( < 12y/o) are paucibacillary
 Microscopically negative for AFB
 Culture negative
 Smear positive TB only 20-40% of pediatric cases

12. Diagnosis
 TST- Mantoux method: 0.1ml dermal injection of
PPD into volar surface of forearm
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
Positive can mean current or future active TB
False positive in BCG vaccine and non tuberculosis
mycobacteria
 Interferon-gamma release assays (IGRAs)
 IGRAs can not distinguish between current or past
 QuantiFERON-TB Gold in Tube (QFT- GIT) ELISA test
QFT- GIT and TST sensitivity: 38% and 35%
 QFT- GIT and TST specificity: 81% and 84%
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 Nucleic acid amplification tests (NAATs)
 Used in neg. AFB microscopy and to detect drug resistance

13. TST Guidelines

14. Laboratory tests
 TST- Mantoux method: 0.1ml dermal injection into
volar surface of forearm
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
Positive can mean current or future active TB
False positive in BCG vaccine and non tuberculosis
mycobacteria
 Interferon-gamma release assays (IGRAs)
 IGRAs can not distinguish between current or past
 QuantiFERON-TB Gold in Tube (QFT- GIT) ELISA test
QFT- GIT and TST sensitivity: 38% and 35%
 QFT- GIT and TST specificity: 81% and 84%

 Nucleic acid amplification tests (NAATs)
 Used in neg. AFB microscopy and to detect drug resistance

15. Pulmonary TB on CXR
 Primary TB- infiltrate usually in middle or lower lobe
 Ipsilateral hilar adenopathy
 Any lobe can be affected
 25% multilobar
 Endogenous TB- develops from LTBI
 Infiltrate in upper lobes
 Cavitation and collapse
 Both can have atelectasis, pleural effusions,
pericardial effusion, or lymphadenopathy

17. Primary TB Treatment
 Initial phase for 2 months then continuation phase for 4
months
 Isoniazid (INH) and rifampicin (RIF)
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Bactericidal, decrease microbial loads
 RIF and pyrazinamide (PZA)
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Sterilizing drugs that eradicate slow- replicating organism
 Ethambutol (EMB)
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Protects against the emergence of drug resistant TB
Not used in <8 y/o’s due to concerns for optic neuritis
 Disseminated TB and TB meningitis treatment is 12
months
 LTBI treatment:
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INH daily for 6-9 months or RIF for 4 months