Tuberculosis in children Etiology Pathophysiology Diagnosis Symptoms Treatment Management

1. MENINGEAL
TUBERCULOSIS
IN CHILDREN
MOHAMED ABDULLAH RIZWAN
6A ФИУ

2. A FEW FACTS
Meningitis is an infection and inflammation
of the fluid and membranes surrounding the
brain and spinal cord
Marked intoxication may also lead to
irritation of meninges without inflammation
and this is called “meningissimus”
MTB were first isolated from CSF in 1893

3. WHY DEALING WITH PEDIATRIC TB IS HARDER?:
TB in different ages have specific features, thus in children it is difficult to diagnose because
of their different changes in anatomical and physiological features with age, it is difficult to
diagnose becayse children have less pronounced symptoms of disease and rarely
expectorate sputum and in children the course of all forms of TB is more aggressive than
adults
ANATOMICAL
AND
PHYSIOLOGICAL
FEATURES OF
EARLY
CHILDHOOD;
IMMATURITY OF CELL MEDIATED AND HUMORAL IMMUNITY
HIGH AIRWAY RESISTANCE DUE TO NARROW AND SHORT NASAL PASSAGES
AND BRONCHI
DECREASED MUCOCILIARY CLEARANCE
INADEQUATE AMOUNT OF SURFACTANT
LACK OF COLLATERAL VENTILATION IN LUNGS
WEAKLY DEVELOPED INTERLOBULAR AND INTERSEGMENTAL PLEURA
WEAKLY DEVELOPED COUGH REFLEX

4. CLINICAL PICTURE OF
MENINGEAL TB IN CHILDREN
LASTING FROM 3-5 TO 21-26
DAYS
MAIN SIGNS OF INTOXICATION
INCLUDE: MALAISE,GENERAL
WEAKNESS,HEADACHE,FLACCIDIT
Y ,DECREASED WORK
CAPACITY,SLEEP
DISORDERS,UNEXPLAINED
LETHARGY AND APATHY
1.PRODROMAL PERIOD
GENERAL INFECTIOUS SYNDROME(CONSTANT
ELEVATED BODY TEMP. RANGING FROM SUBFEBRILE
TO HECTIC WHICH PRECEDES OR APPEARS WITH
HEADACHE ).
MENINGEAL SYNDROME (TB MENINGITIS MANIFESTS
ITSELF BY
HEADACHE,NAUSEA,VOMITING,HYPERESTHESIA,MENI
NGEAL POSTURE,RIGID OCCIPITAL
MUSCLES,KERNIG,BRUDINZKI SIGNS AND ZYGOMATIC
SYMPTOM OF BECHETEROW
CRANIAL NERVES AND SPINAL ROOTS INFILTRATION
CHANGES IN CEREBROSPINAL FLUID
2. PERIOD OF CLINICAL SYMPTOMS OF
MENINGEAL AND CRANIAL NERVES
SYMPTOMS OF BRAIN MATTER
IRRITATION AND LOSS OF FUCTION
APHASIA,HEMIPARESIS,HEMIPLEGIA
AND PARALYSIS
RESULT FROM PROGRESSIVE
ENDERARTERITIS OF CEREBRAL
VESSELS WITH THEIR COMPLETE
OCCLUSION,ISCHEMIA AND NECROSIS
3. PERIOD OF CLIINICAL SIGNS
OF BRAIN TISSUE
IMPAIRMENT

5. HOW TO DIAGNOSE TBM?
IN THE ABSENCE OF STANDARDIZED DIAGNOSTIC CRITERIA, IN 2010, A CONSENSUS CASE DEFINITION FOR
TBM WAS PROPOSED FOR USE IN FUTURE CLINICAL RESEARCH. THESE CRITERIA ARE APPLICABLE
IRRESPECTIVE OF THE PATIENTS’ AGE, HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS, OR
RESOURCES AVAILABLE IN THE RESEARCH SETTING. PATIENTS ARE STRATIFIED AS DEFINITE, PROBABLE, AND
POSSIBLE DIAGNOSIS OF TBM AS PER THESE CRITERIA.[2] THESE ARE DETAILED AS FOLLOWS:
CLINICAL CRITERIA
THESE INCLUDE SYMPTOM DURATION >5 DAYS
(SCORE: 4),
SYSTEMIC SYMPTOMS SUGGESTIVE OF TB (>1
OF THE FOLLOWING): WEIGHT LOSS/POOR
WEIGHT GAIN, NIGHT SWEATS, COUGH
>2WEEKS (SCORE: 2),
HISTORY OF RECENT (PAST 1 YEAR) CLOSE
CONTACT WITH PULMONARY TB OR POSITIVE
TUBERCULIN SENSITIVITY TEST OR INTERFERON
(IFN) GAMMA RELEASE ASSAYS,
ONLY IN CHILDREN <10 YEARS (SCORE 2),
FOCAL NEUROLOGICAL DEFICIT (EXCLUDING
CRANIAL NERVE PALSIES) (SCORE: 1),
CRANIAL NERVE PALSY (SCORE: 1)
ALTERED CONSCIOUSNESS (SCORE: 1).
THE MAXIMUM CATEGORY SCORE IS 6.
CEREBROSPINAL FLUID CRITERIA
THESE INCLUDE CLEAR APPEARANCE
(SCORE: 1),
CELLS 10–500/ΜL (SCORE: 1),
LYMPHOCYTIC PREDOMINANCE >50%
(SCORE: 1),
PROTEIN CONCENTRATION >1G/L
(SCORE: 1),
CEREBROSPINAL FLUID (CSF) TO
PLASMA GLUCOSE RATIO <50% OR
ABSOLUTE CSF GLUCOSE <2.2 MMOL/L
(SCORE: 1).
THE MAXIMUM CATEGORY SCORE IS 4.
CEREBRAL IMAGING CRITERIA
HYDROCEPHALUS (SCORE: 1),
BASAL MENINGEAL ENHANCEMENT (SCORE: 2),
TUBERCULOMA (SCORE: 2), INFARCT (SCORE: 1),
PRE-CONTRAST: BASAL HYPERDENSITY(SCORE: 2).
THE MAXIMUM CATEGORY SCORE IS 6.
IMPORTANT:
DIFFERENTIAL DIAGNOSIS OF TBM AND NEURO-TB SHOULD INCLUDE
MENINGITIS OF OTHER ETIOLOGY, CLINICAL SIGNS OF
MENINGOENCEPHALITIS IS SIMILAR,THE ONLY DIFFERENCES USUALLY
ARE IN CSF COMPOSITION

6. Total Number of Cases

7. OTHER DIAGNOSTIC TESTS IN MTB
TUBERCULIN SKIN TEST (MANTOUX TEST): IT MAY BE
NONREACTIVE IN 50% CASES OF CNS TB. HENCE, IT IS HELPFUL IN
SUPPORTING THE DIAGNOSIS OF TBM WHEN POSITIVE, BUT AN
ISOLATED POSITIVE MANTOUX CANNOT BE USED TO LABEL A CASE
OF TBM AS FALSE POSITIVE/FALSE NEGATIVE REACTIONS ARE
COMMONLY KNOWN.
CHEST X-RAY: IT HELPS TO LOCALIZE THE SIGNS OF ACTIVE TB
BUT IT MAY BE NORMAL IN 20%–50% OF THE CASES OF TBM.
MEASUREMENT OF IFN-Γ RELEASED BY LYMPHOCYTES: IT IS A
SPECIFIC (70%–90%) TEST BUT WITH A LOW SENSITIVITY (50%–
70%). IT IS AVAILABLE AS ENZYME-LINKED IMMUNOSPOT
(ELISPOT) AND QUANTIFERON GOLD FOR THE DIAGNOSIS OF
LATENT TB. BUT CURRENTLY, THE USE OF THESE TESTS IS
RESTRICTED IN THE DEVELOPING COUNTRIES BECAUSE OF THE
HIGH COST.
XPERT MTB/RIF ASSAY: WITH A SENSITIVITY OF 67%–85% AND A
SPECIFICITY OF 94%–98%, IT IS A DEFINITIVE DIAGNOSTIC TEST
THAT USES REAL-TIME POLYMERASE CHAIN REACTION TO
AMPLIFY AND DETECT M. TUBERCULOSIS AND IDENTIFIES DRUG
RESISTANCE. A META-ANALYSIS OF STUDIES REPORTED UP TO
OCTOBER 2011 ESTIMATED THAT XPERT MTB/RIF WAS 80.4%
SENSITIVE COMPARED WITH CULTURE. A STUDY OF XPERT
MTB/RIF IN INDIA FOR THE DIAGNOSIS OF EXTRAPULMONARY TB
INCLUDED 142 CSF SAMPLES AND REPORTED THAT THE ASSAY
WAS NEARLY 12 TIMES MORE SENSITIVE THAN MICROSCOPY. THE
COST OF PROCESSING ONE XPERT MTB/RIF TEST, HOWEVER, WAS
82 TIMES HIGHER THAN THE COST OF MICROSCOPY. LARGER
STUDIES TO ASSESS XPERT MTB/RIF FOR THE DIAGNOSIS OF TBM
ARE URGENTLY NEEDED. IT MAY BE USED AS AN ADJUNCTIVE TEST
FOR TBM.
1.
2.
3.
4.
CECT HEAD
(AXIAL)
CEMRI BRAIN
(AXIAL)
CEMRI BRAIN
(SAGITTAL)
CECT HEAD
(AXIAL)

8. TB IN CHILDREN
IN SRILANKA
TUBERCULOSIS IS THE
SECOND LEADING
INFECTIOUS DISEASE IN SRI
LANKA APART FROM
DENGUE. THE HIGHEST
NUMBER OF DEATHS AMONG
INFECTIOUS DISEASES IS
REPORTED FOR TB PATIENTS
IN SRI LANKA WHICH IS
AROUND 500 – 600
ANNUALLY.

10. SRI LANKA IS A COUNTRY WITH A LOW PREVALENCE
OF TB. IN THE YEAR 2018, SRI LANKA’S
WHO ESTIMATED NEW AND RELAPSE TB CASES
WERE 64 PER 100 000 POPULATION. BY THE
END OF 2018, THE ESTIMATED NUMBER OF TB
DEATHS WAS 3.8 PER 100 000 POPULATION
(EXCLUDING TB/HIV DEATHS).
THE GOALS OF THE END TB STRATEGY ARE ACHIEVING A 90 % REDUCTION IN
TB INCIDENCE AND A 95% REDUCTION IN TB DEATHS IN 2035 (COMPARED TO
2015).
NATIONAL PROGRAM FOR TB CONTROL AND CHEST DISEASES (NPTCCD) IS
THE CENTRE FOR THE DEVELOPMENT OF POLICIES WHERE RESPONSIBILITY IS
DIVIDED AMONG GOVERNMENT AND NON-GOVERNMENT HEALTH
INSTITUTIONS (BOTH CURATIVE AND PREVENTIVE) AND THE COMMUNITY.
MAINTAINING AN ACCURATE,TIMELY REPORTING SYSTEM IN HOSPITALS, AND
SUB- AND DISTRICTCHEST CLINICS ARE ESSENTIAL FOR SURVEILLANCE OF
SUSPECTED/CONFIRMED TB CASES.
ONCE A PATIENT IS DIAGNOSED WITH TB, THE PATIENT SHOULD CONTINUE
REGULAR TREATMENT FOR A SPECIFIED PERIOD UNDER DOTS (DIRECTLY
OBSERVED TREATMENT) BY A HEALTH CARE WORKER OR ANOTHER SUITABLY
APPOINTED PERSON AT A DOT CENTRE. THIS WILL HELP TO IDENTIFY ANY
COMPLICATIONS OF DISEASE AND SIDE EFFECTS OF DRUGS AND ANY OTHER
MENTAL OR SOCIO-ECONOMIC PROBLEMS LEADING TO REDUCING THE
NUMBER OF DEFAULTERS, MDR-TB CASES, AND TOTAL CASELOAD HEALTH
EDUCATION OF THE PATIENT AND THE FAMILY IS ESSENTIAL. THEY SHOULD
ADHERE TO STANDARD PRECAUTIONS OF RESPIRATORY HYGIENE. THE
PATIENT SHOULD BE ISOLATED IN A SEPARATE ROOM AND TREATED
TRAIN ALL HEALTH STAFF ABOUT THE DISEASE AND TREATMENT,IDENTIFYING
COMPLICATIONS OF THE DISEASE AS WELL AS SIDE EFFECTS OF TREATMENT,
HOW TO COMMUNICATE WITH A PATIENT EMPATHICALLY, WHEN TO ADMIT A
PATIENT, AND STANDARD PRECAUTIONS OF RESPIRATORY HYGIENE.

11. CASE PRESENTATION
THE 14-YEAR-OLD FEMALE PRESENTED TO THE HOSPITAL WITH INTERMITTENT FEVER,
HEADACHE, AND BLURRED VISION. HER CEREBROSPINAL FLUID (CSF) SHOWED A
LYMPHOCYTIC PLEOCYTOSIS, AN ELEVATED PROTEIN LEVEL, AND A DECREASED
CHLORIDE LEVEL. AND HER CSF TESTED POSITIVE FOR TB-RNA. XPERT MTB/RIF
DETECTED MYCOBACTERIUM TUBERCULOSIS IN HER CSF, BUT THE RIFAMPIN
RESISTANCE TEST WAS UNKNOWN. SUBSEQUENTLY, HER CSF CULTURE WAS POSITIVE
FOR MYCOBACTERIUM TUBERCULOSIS. THE DRUG SENSITIVITY TEST (DST) REVEALED
RESISTANCE TO ISONIAZID, RIFAMPIN, AND FLUOROQUINOLONES. A COMPUTED
TOMOGRAPHY (CT) OF THE CHEST SHOWED DIFFUSE MILIARY NODULES IN BOTH
LUNGS. INTRACRANIAL ENHANCED MAGNETIC RESONANCE IMAGING (MRI) SHOWED
“MULTIPLE INTENSIFIED IMAGES OF THE BRAIN PARENCHYMA, CISTERNS, AND PART OF
THE MENINGES.” THE FINAL DIAGNOSIS IS MILIARY PULMONARY TUBERCULOSIS AND
PRE-EXTENSIVE DRUG-RESISTANT TBM. AFTER 19 MONTHS OF AN ORAL,
INDIVIDUALIZED ANTITUBERCULOSIS TREATMENT, SHE RECOVERED WITH NO
SIGNIFICANT NEUROLOGICAL SEQUELAE.
AN INTERESTING CASE REPORT ON TBM.
CONCLUSION;
FOR PATIENTS WITH MILIARY PULMONARY
TUBERCULOSIS, ESPECIALLY CHILDREN, EVEN IF
THERE ARE NO TYPICAL CLINICAL SYMPTOMS, IT IS
NECESSARY TO KNOW WHETHER THERE IS TBM AND
OTHER CONDITIONS. ALWAYS LOOK FOR THE
RELEVANT AETIOLOGICAL BASIS TO CLARIFY
WHETHER IT IS DRUG-RESISTANT TUBERCULOSIS.
ONLY A RAPID AND ACCURATE DIAGNOSIS AND
TIMELY AND EFFECTIVE TREATMENT CAN IMPROVE
THE PROGNOSIS AND REDUCE MORTALITY AND
DISABILITY RATES.

12. REFERENCES
HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC6413593/#REF
2
HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC9906903/#CR1
0
HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC6829784/
HTTPS://DATA.WHO.INT/COUNTRIES/144
HTTPS://DATA.UNICEF.ORG/COUNTRY/LKA/
HTTPS://CHILDMORTALITY.ORG/DATA/SRI%20LANKA
HTTPS://WORLDHEALTHORG.SHINYAPPS.IO/TB_PROFILES/?
_INPUTS_&ENTITY_TYPE=%22COUNTRY%22&LAN=%22EN%22&ISO2=%
22LK%22
HTTPS://WWW.EPID.GOV.LK/STORAGE/POST/PDFS/VOL_49_NO_37-
ENGLISH_1.PDF
HTTPS://IRIS.WHO.INT/BITSTREAM/HANDLE/10665/352523/978924004
6832-ENG.PDF?SEQUENCE=1
PG 332-335, PHTHISIOLOGY BY PROFESSOR V.I. PETRENKO SECOND
EDITION WWW.MEDPUBLISH.COM.UA

13. THANK YOU
FOR YOUR TIME