Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis that primarily affects the lungs. It spreads through inhaling droplets from infected individuals and can affect other organs. Young, malnourished, and immunocompromised children are most at risk. Diagnosis involves clinical features, tuberculin skin testing, chest x-rays, and microscopic examination of samples. Treatment consists of a multi-drug regimen over several months. Close contacts of active TB cases, such as young children, should receive preventive treatment to avoid infection.

1. Tuberculosis
Tuberculosis is a chronic infectious
disease caused by Mycobacterium
tuberculosis.
Tuberculosis is widely prevalent
throughout the world with nearly
1,70,000 children dying of it every
year

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 The disease primarily affect
lungs.
 It can also affect intestine,
meninges, bones and joints, lymph
glands, skin and other tissues of
the body
 Young and malnourished children
are more vulnerable to this
disease

5. Transmission:
 The usual mode of infection
transmission is through inhalation of
droplets of infected secretions
 The infected sputum spitted carelessly
by cases of TB dries up and the
tubercle bacilli are resuspended in the
dust and air
 This may be a source of infection
through breathing

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 Infection through ingestion of infected
materials is rare
 Rarely infection may be transmitted
through skin, mucous membrane or
transplacentally

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9. Predisposing factors
Age: Younger children are more susceptible to
TB infection than the older children
 Congenital tuberculosis is extremely rare
Sex: The adolescent children especially the
girls are more prone to develop tuberculous
disease during puberty
Immune deficiency: Children with primary or
secondary immune deficiencies are more
susceptible

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Nutritional status:
 Undernourished children are more
susceptible to develop tuberculosis
 A malnourished patient who does not respond
to the dietary therapy should be promptly
investigated for tuberculosis
Environment:
 There is little difference in the prevalence
of the disease in the rural and urban
communities
 Children living in overcrowded apartments
with inadequate ventilation and little
sunshine are at high risk

11. Pathophysiology:
Inhalation of mycobacterium by susceptible person
Transmission of bacteria through the airways to the alveoli
where they are deposited and begin to multiply
Bacilli are also transported via the circulation to other parts
of the body (kidneys, bones, cerebral cortex) and other
areas of lungs
Inflammation with hyperemia and congestion
Initially polymorphonuclear leukocytes infiltrate at the site of
lesion

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Tissue reaction results in accumulation of exudates in the
alveoli,
Granuloma, new tissue masses of live and dead bacilli, are
surrounded by macrophages, which form a protective wall
They are then transformed to a fibrous tissue mass, the
central portion of which is called a Ghon tubercle
The material (bacteria and macrophage) become necrotic,
forming a cheesy mass
This mass may be calcified and form a collagenous scar. At
this point the bacteria becomes dormant

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After initial exposure and infection, active disease may
develop because of a compromised or inadequate immune
system response
Active disease also may occur with reinfection and activation
dormant bacteria
When the Ghon tubercle ulcerates releasing cheesy material
into bronchi, the bacteria becomes airborne
Ulcerated tubercle heals and forms scar tissue
Infected lungs become more inflamed
Unless the process is arrested, it spreads slowly downward to
the hilum of lungs and extends to the adjacent lobes

14. Clinical features:
Incubation period:
 The incubation period varies between 4
and 8 weeks
 Gradual onset of fever of unexplained
origin, dyspnoea, coughing, pleural
effusion may present if lungs are
affected
 Loss of interest in play and child is
fatigued easily

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 Loss of appetite and loss of weight
 Night sweat
 Dry or often productive cough
 Hemoptysis may also occur
 Cyanosis and wheezing may also
occur

17. Types:
i. Intrathoracic tuberculosis:
Primary infection
 Pulmonary primary complex is formed
 It usually passes of unrecognized
Progressive primary disease
 It is the result of the progression of
primary disease
 Children may present with high grade
fever and cough

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Miliary tuberculosis:
 It is characterized by heavy
hematogenous spread and progressive
development of innumerable small foci
throughout the body
 Disease is most common in infants and
young children
 Children may have high-grade fever,
which is quite unlike other forms of
tuberculosis

19. ii. Extrathoracic tuberculosis:
 The most common forms of extrathoracic
disease in children include tuberculosis of
the superficial lymph nodes and the central
nervous system
 Other rare forms of extrathoracic disease
in children include abdominal,
gastrointestinal, genitourinary, cutaneous
etc.
 TB of superficial lymph nodes can be
associated with drinking unpasturized cow’s
milk or extension of primary lesions

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 Central nervous system disease is the
most serious complication of
tuberculosis in children and arise from
formation of caseous lesion in the
cerebral cortex or meninges
 Infants and young children are likely to
experience a rapid progression to
hydrocephalous, seizures and cerebral
edema.
 TB of abdomen is often due to
hematogenous spread from the lungs

21. Diagnosis:
 The diagnosis of TB is based on clinical
features, history of contact with adult
patients
 Clinical features may be non-specific
 A history of contact with an infective
case contact is defined as any child who
lives in a household with an adult taking
antitubercular therapy or has taken
such therapy in past 2 years.

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 Tracing of contact is important not only
for confirming the diagnosis but also
for the protection of other vulnerable
children from the disease
 Symptoms suggestive of TB include
fever for more than weeks, recent loss
of appetite and weight or failure to
thrive
Tuberculin test:
 The tuberculin test is a useful
diagnostic aid. Montoux test and
multiple puncture test are used in this

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Montoux reaction:
 0.1 mL of a suitable dilution of tuberculin
PPD (purified protein derivative) is injected
intradermal on the forearm
 A weal of 5mm should be raised
 The reaction is read after 48 hours to 72
hours
 Antigen should not be drawn into the
syringe more than one hour before use
 An induration of more than 10mm is
suggestive of infection

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Laboratory tests:
a. ESR and blood counts have no value in
diagnosis or follow up of TB
b. Demonstration of acid-fast bacilli:
 Most children do not expectorate out
the sputum but swallow it
 Therefore the sputum is not available
for examination
 A laryngeal swab may be obtained for
smear and culture examination for
mycobacteria

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c. Histopathology: Glands, liver and
other tissues may be examined for
histological evidence of TB by FNAC
d. Radiology: Chest X-ray is usually
sufficient. CT scan of chest is not
routinely required
 Ultrasonography is useful of enlarged
lymph or peritoneal fluid in suspected
abdominal tuberculosis

27. Causes of false positive and false
negative Mantoux test
False positive results:
 BCG vaccination, infection at the site of test
False negative results:
 Infections- Viral ( measles, mumps, HIV),
Bacterial ( Typhoid, leprosy)
 Metabolic derangements- Chronic renal
failure, severe malnutrition
 Drugs- Corticosteroids, other
immunosuppressive agents
 Age- Newborns, elderly patients

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 Stress- Surgery, burns, mental illness
 Factors related to the tuberculin used-
Improper storage, improper dilutions,
chemical denaturation
 Factors related to the method of
administration- injection of too little
antigens, subcutaneous injection, delayed
administration after drawing into the
syringe, injection too close to other skin
tests
 Factors related to reading the test and
recording the results- inexperienced reader,
conscious or unconscious bias, error in
recording

29. Treatment of tuberculosis:
Principle of treatment:
 The diagnosis should be made early
 Treatment should be prompt, adequate,
vigorous and prolonged depending upon
the severity of illness
 All drugs should be given in a single
daily dose on empty stomach
 Pyridoxine (vitamin B6) is not necessary
in children taking isoniazid

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 Nutrition of the child should be
improved by an appetizing, nutritionally
balanced diet with adequate calories
and protein
 Intercurrent infections should be
prevented or treated vigorously
 Living condition should be improved by
better hygienic measures and improved
sanitation

31. Standarized clinical categories and
clinical conditions
Categories Suggested conditions Suggested regimens
in children
Category I PPC,PPD,TBL,Pleural effusion, 2 HRZE+ 4 HR
Abdominal TB, Osteoarticular TB, or
Genitourinary TB, CNS TB, 2 SHRZ+ 4 HR
Pericardial TB
Category II Relapse, treatment failure, 2 SHRZE+
Interrupted treatment 1 HRZE + 5HRE
Category III Single lymph node, small 2 HRZ+ 4 HR
effusion, skin TB

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 PPC- pulmonary primary complex
 PPD- progressive primary disease
 TBL- Tubercular lymphadenitis
 INH- Isoniazid
 R- Rifampicin
 Z- Pyrizinamide
 E- Ethambutol
 S- Streptomycin
 The numerical denotes the no. of months
for which the drug is to be given

33. Doses and important side effects
of antitubercular drugs:
Drugs Dose Side effects
(mg/kg/day)
Isoniazid 5 Hepatotoxicity, hypersensitivity
rash, fever, peripheral or optic
neuritis, psychosis, seizures
Rifampicin 10 Nausea, vomiting, hepatotoxicity,
arthralgia, wheezing
Streptomycin 10-30 Ototoxicity, rash, fever, arthralgia,
neuromuscular blockade, peripheral
neuritis, anaphylaxis

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Drugs Dose Side effects
(mg/kg/day
Ethambutol 15-25 Hypersensitivity reaction, rash,
fever, joint pain, optic neuritis,
GI upset, confusion, dizziness
Pyrazinamide 25-35 GI upset, hepatotoxicity, dysuria,
photosensitivity, malaise, fever,
arthralgia, thrombocytopenia
Ethionamide 15-20 GI upset,hepatotoxicity,peripheral
neuropathy, gynaecomastia, rash,
alopecia, headache, depression
Cycloserine 15-20 Seizures, psychosis, peripheral
neuritis

35. Corticosteroids:
 Corticosteroids, in addition to
antitubercular drugs, are useful in
treatment of patients with CNS TB and
occasionally PTB
 Short courses of corticosteroids are
indicated in children with endobronchial
TB
 The most commonly used medication is
prednisolone, at doses of 1-2mg/kg/day
for 4-6 weeks

36. Management of an infant born to
mother with TB
 Congenital TB is rare.
 The fetus may be infected either by
hematogenously through umbilical vessels or
through ingestion of infected amniotic fluid
 Infants born to mothers with TB should be
screened for evidence of disease by a through
physical examination, tuberculin test and CXR
 If physical examination and investigations are
negative for disease, the infant should be started
on isoniazid prophylaxis at doses of 5mg/kg/day
for 6 months

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 After 3 months, the patient should be
examined for evidence of infection and a
repeat tuberculin test is done
 If tuberculin test is negative, the infant can
be immunized with BCG and INH can be
stopped
 If tuberculin test is positive, but the infant
is asymptomatic, INH prophylaxis is
continued for another 3 months
 Infants with congenital TB should be treated
with 4 drugs (isoniazid, rifampicin,
pyrizinamide, streptomycin) in the intensive
phase

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 It is followed by two drugs (isoniazid,
rifampicin) during maintenance phase for
next 4 months
 Intensive phase: (two months) the goal of
this phase is to eliminate the bacterial
overload and prevent the emergence of drug
resistant strains
- At least 3 bactericidal drugs (Rifampicin,
isoniazid, pyrizinamide, streptomycin) are
used during this phase
 Continuation Phase: (four months) At least
two bactericidal drugs are used to continue
and complete the therapy

39. Management of a child in contact
with an adult with tuberculosis
 Nearly one third of the children (aged less than 5
years) in contact with adult tuberculosis disease
may have evidence of tuberculosis
 The infection is more commonly associated with
younger age, severe malnutrition, absence of BCG
vaccination and exposure to environmental tobacco
smoke
 It is suggested that children below 5 years of age
in contact with adult patient with sputum positive
TB should receive 6 months of isoniazid prophylaxis