Childhood Tuberculosis

1. TuberculosisTuberculosis
in Childrenin Children
Prof. Imran Iqbal
Prof of Paediatrics
(2003-2018)
Multan, Pakistan

2. Case Scenario
• A four year old child presents to OPD with
intermittent fever and mild cough for the last
20 days.
• Mother says child has become weak and does
not like to move about.
• 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.
• Child has been to different doctors and
received multiple antibiotics.

3. QUESTIONS
• What further data is needed ?
• What is your most likely diagnosis ?

4. Case Scenario
• A four year old child presents to OPD with intermittent fever and
mild cough for the last 20 days. Mother says child has become weak
and does not like to move about. 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. Child has been to different doctors and
received multiple antibiotics.
• On detailed examination, OPD doctor
finds three small lymph nodes palpable
in Rt. Axilla. He is also able to hear a few
crepitatations in Rt. Infrascapular area.

5. QUESTIONS
• What is your most likely diagnosis ?
• What other diseases can be
suspected ?
• How will you manage this child ?

6. Case Scenario
• A four year old child presents to OPD with intermittent fever and
mild cough for the last 20 days. Mother says child has become weak
and does not like to move about. 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. Child has been to different doctors and
received multiple antibiotics.
• On detailed examination, OPD doctor finds three small
lymph nodes palpable in Rt. Axilla. He is also able to
hear a few crepitatations in Rt. Infrascapular area.
• He pescribes antipyretics and requests
certain investigations.

7. Differential diagnosis

8. Differential diagnosis
• Tuberculosis
• Unresolved Pneumonia
• Bronchiectasis
• Asthma
• Cystic fibrosis
• Chronic bronchitis

9. TuberculosisTuberculosis
in Childrenin Children

10. Causative agent
Mycobacterium tuberculosis
(Acid-fast bacilli)

11. Transmission
• Source _ Adult Patients with cavitory
tuberculosis
• Transmission – DROPLET infection
• Host – susceptible children

13. Factors favouring
Transmission
• Close contact
• Overcrowding
• Darkness and lack of ventilation

14. Tubercle Bacillus
• Subclinical infection
• Clinical disease

15. Tuberculous
Infection OR Disease
• Dose of infecting bacilli
• Immunity in the child

16. Immunity in the child
• Genetic factors
• Age
• Nutritional status
• Immunosupression
• BCG vaccination

17. Pathogenesis

20. Clinical Features
• General Symptoms
• Local symptoms and signs

21. General Symptoms
• Failure to thrive
• Loss of weight
• Loss of appetite
• Low grade fever
• Apathy

22. Primary Complex in Lungs

23. Primary
Pulmonary Tuberculosis
• Asymptomatic
• General features only
• Pulmonary symptoms
- mild cough
- persistent crepitations

25. Radiology – Pul TB

29. TUBERCULOSIS OF
CERVICAL LYMPH NODES

30. Lymph nodes
• Persistent enlargement
• Non – tender
• Discharging sinus

37. TUBERCULOUS
MENINGITIS

38. TUBERCULOUS MENINGITIS
• Headache - 15 d
• Vomiting - 15 d
• Drowsy / unconcious -- 3 d
• Convulsions -- 3 d

41. Choroid Tubercles

42. CT / MRI findings
• All Ventricles Enlarged
• Hypodense areas /Infarction
• Basal Meningeal Enhancement
• Tuberculoma

44. CT scan - TBM

45. Tuberculoma

46. Abdominal Tuberculosis

47. Abdominal Tuberculosis
• Pain abdomen
• Abdominal distension
• Ascites
• Thickened terminal ileum / Cecum
• Intestinal obstruction

48. TB Spine / Bones
• Gibbus / local kyphosis
• Paraparesis
• Limp
• Joint swelling
• Discharging sinus on a bone

49. Pott’s Disease of Spine
• Vertebral collapse
• Wedge shaped vertebra

50. Pott’s Disease of Spine

51. • Pott’s Disease
of Spine

52. Miliary Tuberculosis
• General symptoms
• Hepatosplenomegaly
• Choroidal tubercles

53. Miliary Tuberculosis

55. HRCT – Miliary TB

56. Diagnosis of Tuberculosis

57. Problems with Diagnosis of
Tuberculosis in Children
• Symptoms and signs are non-specific
• Pyogenic vs Tuberculous Infection
• AFB usually not detected
• PCR tests not performed on blood

58. Investigations for Tuberculosis
• X – Ray Chest
• CBC
• Tuberculin test
• IGRA (Interferon Gamma Release Assay)
• Fluid Examination
• Cytology
• Biopsy
• PCR for MTB

59. KJ scoring criteria

60. Diagnosis of Tuberculosis
(3 out of 5)
• General and Local symptoms (history)
• Local signs (examination)
• History of contact
• Tuberculin test / IGRA
• Suggestive investigations

61. Treatment of Tuberculosis

62. Treatment of Tuberculosis
• Adequate diagnosis
• Standard regimes
• Drug compliance
• Evaluate sources / contacts

63. Treatment Regimens
• Asymtomatic infection
• Primary pulmonary tuberculosis
• T.B. Meningitis / bone / miliary disease

64. Asymtomatic infection
• 6HR
• INH – 6 months
• Rifampicin – 6 months

65. Primary pulmonary tuberculosis
• 2HRZE,6HR
• INH – 6 months
• Rifampicin – 6 months
• Pyrazinamide – 2 months
• Ethambutal – 2 months

66. T.B. Meningitis / Bone /
Miliary TUBERCULOSIS
• 2HRZE,10HR
• INH – 10 months
• Rifampicin – 10 months
• Pyrazinamide – 2 months
• Ethambutal – 2 months

67. Steroids for 4 - 6 weeks
• T.B. Meningitis
• Miliary TUBERCULOSIS
• Pericardial effusion
• Pleural effusion

68. Paeditric doses
• INH – 5 -10 mg / kg / day
• Rifampicin – 10 - 20 mg / kg / day
• Pyrazinamide – 25-30 mg / kg / day
• Ethambutal – 15-20 mg / kg / day
• Amikacin – 15 mg / kg / day

69. Question ?
• Mother with Tuberculosis gives birth to
a baby
• What should be done ?

70. Newborn with Tuberculous mother
• DO NOT separate mother and baby
• START mother feeds
• Give treatment to mother
• INH for baby
• Re – evaluate baby at 3 months
• Give BCG to baby at 3 months

71. Drug Resistant
Tuberculosis

72. Definitions
– Primary DR: Resistance in person treated <1
month or not at all
– Acquired DR: Resistance in person treated >
1 month
– Mono-drug resistance: Resistance to 1 drug
– Poly-drug resistance: Resistance to >1 drug,
but not MDR.
– MDR: resistant to isoniazid and rifampin
– XDR: MDR & resistance to Quinolones &
Injectable 72

73. 73
Rational selection of MDR-TB
regimen
Group 1
Group 2
Group
3
Group
4
Group
5
Isoniazid Rifampin
Ethambutol Pyrazinamide
Streptomycin Kanamycin
Amikacin Capreomycin
Ofloxacin Levofloxacin
Moxifloxacin Gatifloxacin
Ethionamide Prothionamide
Cycloserine Terizidone
Thioacetazone P-aminosalicylic acid
Clofazimine Imipenem
Amoxacillin/Clavulanate
Macrolides Linezolid

74. Drugs for Resistant TB

75. PREVENTION

76. PREVENTION
• Case finding
• Treatment of active cases
• BCG vaccination (variable efficacy)

77. BCG vaccine
• Bacillus Calmette–Guérin
• Live Mycobacteria
• Mycobacterium bovis
• first used in 1921

78. BCG vaccine - history
BCG strain
was isolated
after subculturing
Mycobacterium bovis
239 times
during 13 years
from virulent strain
on glycerine potato medium

79. Efficacy of BCG Vaccine
Literature Review

80. Variation in efficacy of BCG
The most controversial aspect
of BCG is the variable efficacy
found in different clinical
trials, which appears to
depend on geography
Colditz, Graham A.; Brewer, TF; Berkey, CS; Wilson, ME; Burdick, E;
Fineberg, HV; Mosteller, F (1994). "Efficacy of BCG Vaccine in the
Prevention of Tuberculosis". JAMA. 271(9): 698–702

81. Variation in efficacy of BCG
The BCG vaccine can be
from 0 to 80% effective
in preventing tuberculosis
for a duration of 15 years;
Venkataswamy, Manjunatha M.; Goldberg, Michael F.; Baena,
Andres; Chan, John; Jacobs, William R., Jr.; Porcelli, Steven A. (1
February 2012). "In vitro
culture medium influences the vaccine efficacy of
Mycobacterium bovis BCG". Vaccine. 30 (6): 1038–1049.

82. Variation in efficacy of BCG
• genetic differences in the
populations
• changes in environment
• exposure to other bacterial
infections
• conditions in the lab where the
vaccine is grown
Colditz, Graham A.; Brewer, TF; Berkey, CS; Wilson, ME; Burdick, E; Fineberg,
HV; Mosteller, F (1994). "Efficacy of BCG Vaccine in the Prevention of
Tuberculosis". JAMA. 271(9): 698–702

83. Efficacy of BCG
Among children
it prevents about 20% from getting infected
and
among those who do get infected
it protects
half from developing disease
• Roy, A; Eisenhut, M; Harris, RJ; Rodrigues, LC; Sridhar, S; Habermann, S; Snell, L; Mangtani, P; Adetifa, I; Lalvani, A; Abubakar, I (5
August 2014). "Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systematic review and meta-analysis."
. BMJ (Clinical research ed.). 349: g4643.

84. Efficacy of BCG
BCG vaccine
reduced infections by 19–27%
and
reduced progression to
active TB by 71%
Roy A, Eisenhut M, Harris RJ, et al. (2014). "Effect of BCG vaccination against Mycobacterium
tuberculosis infection in children: systematic review and meta-analysis".BMJ. 349