Childhood TB

59
CHILDHOOD TUBERCULOSIS CHILDHOOD TUBERCULOSIS Arun George Arun George

description

Paediatric tuberculosis

Transcript of Childhood TB

Page 1: Childhood TB

CHILDHOOD CHILDHOOD TUBERCULOSISTUBERCULOSIS

Arun GeorgeArun George

Page 2: Childhood TB

TuberculosisTuberculosis Tuberculosis is a chronic infectious disease Tuberculosis is a chronic infectious disease

caused by caused by Mycobacterium tuberculosisMycobacterium tuberculosis characterized by vague constitutional symptoms characterized by vague constitutional symptoms and a protracted course of illness with remissions and a protracted course of illness with remissions and exacerbations.and exacerbations.

Tuberculosis is the reaction of tissues of the Tuberculosis is the reaction of tissues of the human host to the presence and multiplication of human host to the presence and multiplication of Mycobacterium tuberculosisMycobacterium tuberculosis..

The clinical states arising from TB infection are The clinical states arising from TB infection are the outcome between the capacity of the host to the outcome between the capacity of the host to contain and eliminate the organism versus the contain and eliminate the organism versus the capacity of the organism to multiply and capacity of the organism to multiply and proliferate. proliferate.

Page 3: Childhood TB

MagnitudeMagnitude 1/31/3rdrd of the world’s population is or has of the world’s population is or has

been infected with tubercle bacilli.been infected with tubercle bacilli. India accounts for one third of the word India accounts for one third of the word

TB burdenTB burden

Prevalence of the disease in IndiaPrevalence of the disease in India:: 15-25 per 1000 population 15-25 per 1000 population 15 million infected, 25% sputum positive15 million infected, 25% sputum positive 3 to 4 million infected are children3 to 4 million infected are children

Page 4: Childhood TB

EpidemiologyEpidemiology

Agent : Mycobacterium tuberculosis, M. bovisAgent : Mycobacterium tuberculosis, M. bovis Reservoir : Infected patientReservoir : Infected patient Mode of infection : Droplet infection, dust, Mode of infection : Droplet infection, dust,

ingestion, skin, mucous membrane, skiningestion, skin, mucous membrane, skin Host FactorsHost Factors

Age : all ages affected, congenital is rareAge : all ages affected, congenital is rare Sex : Girls > boys at PubertySex : Girls > boys at Puberty Malnutrition : more succeptibleMalnutrition : more succeptible Intercurrent infections : eg measles, whooping coughIntercurrent infections : eg measles, whooping cough

Environment : overcrowding, inadequate Environment : overcrowding, inadequate ventillation, damp, insanitary and unhygenic ventillation, damp, insanitary and unhygenic conditionsconditions

Page 5: Childhood TB

Portal of entry for Portal of entry for tuberculosistuberculosis

Inhalation of Tubercle bacilli in >95% Inhalation of Tubercle bacilli in >95% (M.TB)(M.TB)

Ingestion of milk containing Bovine Ingestion of milk containing Bovine Tubercle bacilli (M. bovis)Tubercle bacilli (M. bovis)

Contamination of superficial skin or Contamination of superficial skin or mucous membrane lesion with tubercle mucous membrane lesion with tubercle bacillibacilli

Congenital infection when mother has Congenital infection when mother has lymphohematogenous spread during lymphohematogenous spread during pregnancy pregnancy OROR tuberculous endometritis tuberculous endometritis

Page 6: Childhood TB

Primary tuberculous Primary tuberculous infectioninfection

Primary Focus (Ghon’s focus)Primary Focus (Ghon’s focus) at the site of first implantationat the site of first implantation usually single and Subpleuralusually single and Subpleural in most, - heals and disappears, orin most, - heals and disappears, or - fibroses or calcifies.- fibroses or calcifies.Primary Complex:Primary Complex: primary focus + Hilar lymphnodes + primary focus + Hilar lymphnodes +

draining lymphaticsdraining lymphatics complications arise more commonly from complications arise more commonly from

regional adenitis than from the primary regional adenitis than from the primary focusfocus

Page 7: Childhood TB

Primary infectionPrimary infection Children vs. AdultsChildren vs. Adults

In adults, In adults,

- regional lymphadenitis less - regional lymphadenitis less markedmarked

- bronchial erosion less frequent- bronchial erosion less frequent

- less risk of dissemination- less risk of dissemination Thus, adult primary infection tends Thus, adult primary infection tends

to be more local and pulmonary.to be more local and pulmonary.

Page 8: Childhood TB

Progressive primary Progressive primary tuberculosistuberculosis

Progression of TB depends on the Progression of TB depends on the age of the child, number of tubercle age of the child, number of tubercle bacilli, and host resistance.bacilli, and host resistance.

Apparently healed focus or nodes Apparently healed focus or nodes may contain viable organisms for may contain viable organisms for many years.many years.

During 1During 1stst 4-8 weeks, organisms are 4-8 weeks, organisms are disseminated in the blood stream.disseminated in the blood stream.

Page 9: Childhood TB

Progressive pulmonary Progressive pulmonary diseasedisease

Progressive primary infectionProgressive primary infection: : Progression of recently acquired Progression of recently acquired pulmonary primary infection pulmonary primary infection

Endogenous exacerbationEndogenous exacerbation: reactivity : reactivity of organisms and breakdown of of organisms and breakdown of primary lesions acquired > 5 years primary lesions acquired > 5 years previouslypreviously

Exogenous exacerbationExogenous exacerbation: Re-: Re-infection by newly acquired bacilli in infection by newly acquired bacilli in persons with healed primary lesionspersons with healed primary lesions

Page 10: Childhood TB

Symptoms of childhood Symptoms of childhood tuberculosistuberculosis

1.1. Failure to thrive } &Failure to thrive } &2.2. Intermittent fever } are the commonest Intermittent fever } are the commonest

symptoms symptoms 3.3. Pleural effusionPleural effusion4.4. AscitesAscites5.5. Abdominal mass (Painless)Abdominal mass (Painless)6.6. Limp / ArthritisLimp / Arthritis7.7. Painless lymphadenopathyPainless lymphadenopathy8.8. Persistent skin ulcerPersistent skin ulcer9.9. Sterile pyuriaSterile pyuria10.10. MeningitisMeningitis

Page 11: Childhood TB

Pulmonary lesions in Pulmonary lesions in tuberculosistuberculosis

- the primary complex- the primary complex

Page 12: Childhood TB

Complications of the Complications of the primary focusprimary focus

1. Rupture of focus into pleural space causing serous effusion

2. Rupture of focus into bronchus causing cavitation

3. Enlarged focus, sometimes laminated or “coin” shadow

Page 13: Childhood TB

Complications of regional Complications of regional nodesnodes

1. Incomplete (ball-valve) bronchial obstruction, emphysema of middle & lower lobes

2. Complete bronchial obstruction, collapse of right lower lobe

3. Erosion of node into bronchus & segmental consolidation

4. Rupture of node into pericardium: tuberculous pericardial effusion

Page 14: Childhood TB

Sequelae of bronchial Sequelae of bronchial complicationscomplications

1. Stricture of bronchus at site of erosion

2. Cylindrical bronchiectasis in area of old collapse

3. Wedge shadow: contracture & fibrosis of segmental lesion

4. Linear scar of fibrosis following segmental lesion

Page 15: Childhood TB

SymptomsSymptoms

Primary complex – mild fever, anorexia, Primary complex – mild fever, anorexia, weight loss, decreased activity, coughweight loss, decreased activity, cough

Progressive primary complex – high Progressive primary complex – high grade fever, cough. Expectoration and grade fever, cough. Expectoration and hemoptysis – usually associated with hemoptysis – usually associated with cavity and ulceration of bronchus. cavity and ulceration of bronchus. Abnormal chest signs – decreased air Abnormal chest signs – decreased air entry, dullness, crepsentry, dullness, creps

Page 16: Childhood TB

Endobronchial tb – wheeze!! Endobronchial tb – wheeze!! Fever, troublesome cough, dyspnea, Fever, troublesome cough, dyspnea, wheezing and cyanosiswheezing and cyanosis

Pleural effusion – follows a rupture of a Pleural effusion – follows a rupture of a subpleural focus. Also by hematogenous subpleural focus. Also by hematogenous spread from primary focus. Occurs coz of spread from primary focus. Occurs coz of hypersensitivity to tuberculoproteins. hypersensitivity to tuberculoproteins. Fever, cough, dyspnea, pleuritic chest Fever, cough, dyspnea, pleuritic chest pain. pain.

Page 17: Childhood TB

Miliary tuberculosisMiliary tuberculosis

most common within 1most common within 1stst 3 to 6 3 to 6 months after infectionmonths after infection

due to heavy hematogenous spread due to heavy hematogenous spread of tubercle bacilliof tubercle bacilli

Onset: Insidious, with Onset: Insidious, with Fever and weight lossFever and weight loss Palpable liver and/or spleenPalpable liver and/or spleen Tachypnoea with normal chest Tachypnoea with normal chest

findingsfindings

Page 18: Childhood TB

Miliary tuberculosisMiliary tuberculosis Hematogenous dissemination leads to Hematogenous dissemination leads to

progressive development of small lesions progressive development of small lesions throughout the body, with tubercles in the throughout the body, with tubercles in the

lung, spleen, liver, lung, spleen, liver, bone marrow, heart, pancreasbone marrow, heart, pancreas brain, choroid, skinbrain, choroid, skin Radiologic diagnosisRadiologic diagnosis:: ““Snow stormSnow storm”” appearance appearance

(Multiple small lung nodules 1mm (Multiple small lung nodules 1mm size and above in both lung fields).size and above in both lung fields).

Page 19: Childhood TB

Miliary TBMiliary TB

Page 20: Childhood TB

Cutaneous Cutaneous TuberculosisTuberculosis

1.1. Associated with primary complexAssociated with primary complex (Direct inoculation into Traumatized Area) (Direct inoculation into Traumatized Area)

- Painless nodule, leading to non healing ulcer with - Painless nodule, leading to non healing ulcer with regional lymphadenitisregional lymphadenitis

- Scrofuloderma over ruptured caseous lymph node- Scrofuloderma over ruptured caseous lymph node2.2. Associated with Hematogenous disseminationAssociated with Hematogenous dissemination - Papulonecrotic tuberculids- Papulonecrotic tuberculids papules with soft centers on trunk, thighs and facepapules with soft centers on trunk, thighs and face - Tuberculosis verrucosa cutis- Tuberculosis verrucosa cutis Large tuberculids on arms and legsLarge tuberculids on arms and legs3.3. Associated with hypersensitivity to tuberculinAssociated with hypersensitivity to tuberculin - Erythema nodosum- Erythema nodosum painful indurated nodules on shins, elbows, forearms painful indurated nodules on shins, elbows, forearms

thatthat subside in 2-3 weekssubside in 2-3 weeks

Page 21: Childhood TB

TB verrucosa cutis TB verrucosa cutis

Page 22: Childhood TB

Erythema nodosumErythema nodosum

Page 23: Childhood TB

Tuberculosis of Tuberculosis of superficial superficial

lymph nodes (scrofula)lymph nodes (scrofula) Tonsillar / submandibular Tonsillar / submandibular

(Spread from paratracheal nodes)(Spread from paratracheal nodes) Supraclavicular Supraclavicular

(From primary lesion in upper lobe)(From primary lesion in upper lobe) Axillary / epitrochlear Axillary / epitrochlear

(From skin lesion on hand)(From skin lesion on hand) Inguinal Inguinal

(From ulcer on sole of foot)(From ulcer on sole of foot)

Page 24: Childhood TB

Ocular TuberculosisOcular Tuberculosis

Primary tuberculous conjunctivitisPrimary tuberculous conjunctivitis (after (after trauma)trauma)

Yellowish – gray nodules on palpebral Yellowish – gray nodules on palpebral conjunctiva with preauricular adenopathyconjunctiva with preauricular adenopathy

Phlyctenular conjunctivitisPhlyctenular conjunctivitis (Hypersensitivity) (Hypersensitivity)

Nodules on limbus recurring in crops for Nodules on limbus recurring in crops for weeksweeks

Tubercles of choroidTubercles of choroid (with miliary TB) (with miliary TB)

Page 25: Childhood TB

Choroidal tuberclesChoroidal tubercles

Page 26: Childhood TB

Tuberculous otitis mediaTuberculous otitis media

Primary with Preauricular adenitisPrimary with Preauricular adenitis Metastatic spread with primary Metastatic spread with primary

elsewhereelsewhere

SymptomsSymptoms: Painless otorrhea, may be : Painless otorrhea, may be blood-stainedblood-stained

ComplicationsComplications: Secondary infection: Secondary infection DeafnessDeafness TB meningitisTB meningitis

Page 27: Childhood TB

GI and Abdominal TBGI and Abdominal TB

Hematogenous spread from lungs or Hematogenous spread from lungs or swallowing of infected sputum. swallowing of infected sputum.

Painless ulcer in gingivolabial sulcus Painless ulcer in gingivolabial sulcus with submental or submandibular with submental or submandibular adenopathyadenopathy

Ulcer on tonsilUlcer on tonsil Esophageal diverticulum secondary Esophageal diverticulum secondary

to rupture of mediastinal nodes into to rupture of mediastinal nodes into lumenlumen

Page 28: Childhood TB

Tuberculous toxemiaTuberculous toxemia Present with colicky abdominal pain, Present with colicky abdominal pain,

vomiting and constipation. vomiting and constipation. Abdomen feels doughy. Abdomen feels doughy. Rolled up omentum and enlarged lymph Rolled up omentum and enlarged lymph

nodes may appear as irregular nodular nodes may appear as irregular nodular masses with ascitesmasses with ascites

Tuberculous enteritisTuberculous enteritis Ulcers, mesenteric adenitis, peritonitisUlcers, mesenteric adenitis, peritonitis Adhesions, subacute intestinal Adhesions, subacute intestinal

obstruction,obstruction, HepatosplenomegalyHepatosplenomegaly

Page 29: Childhood TB

Renal tuberculosisRenal tuberculosis

Tubercles in glomeruli lead to shedding Tubercles in glomeruli lead to shedding of tubercle bacilli into tubules of tubercle bacilli into tubules

Caseous mass / Cavity between cortex Caseous mass / Cavity between cortex and pyramidsand pyramids

TB of bladder (Tuberculous cystitis)TB of bladder (Tuberculous cystitis) SymptomsSymptoms: dysuria, hematuria, : dysuria, hematuria,

pyuria with TB bacillipyuria with TB bacilli

Page 30: Childhood TB

Caseous renal Caseous renal tuberculosistuberculosis

Page 31: Childhood TB

Skeletal tuberculosisSkeletal tuberculosis Bones involved in order of frequencyBones involved in order of frequency: : Vertebrae > knee > hip > elbowVertebrae > knee > hip > elbow Upper extremities and non-weight-bearing bonesUpper extremities and non-weight-bearing bones (skull, clavicle) rarely (skull, clavicle) rarely

involvedinvolved Tuberculous spondylitisTuberculous spondylitis most commonly most commonly Thoracic / Lumbar / Both (Decreasing frequency)Thoracic / Lumbar / Both (Decreasing frequency) X-ray findingsX-ray findings: : Narrowing of disc space, Collapse of vertebral Narrowing of disc space, Collapse of vertebral

bodybody Extensive destruction with kyphosis (Pott Extensive destruction with kyphosis (Pott

disease)disease) ComplicationsComplications:Para vertebral abscess (Pott :Para vertebral abscess (Pott

abscess)abscess) Psoas Abscess. Paraplegia, Quadriplegia Psoas Abscess. Paraplegia, Quadriplegia

(cervical)(cervical)

Page 32: Childhood TB

Genital tuberculosisGenital tuberculosis

Uncommon before pubertyUncommon before puberty Usually due to lympho-Usually due to lympho-

hematogenous spreadhematogenous spread Occasionally by direct extension Occasionally by direct extension

from adjacent lesion of bone, gut, from adjacent lesion of bone, gut, or urinary tractor urinary tract

Page 33: Childhood TB

Genital tuberculosisGenital tuberculosis SalpingitisSalpingitis EndometritisEndometritis OophoritisOophoritis Cervicitis Cervicitis Infertility is commonest sequel Infertility is commonest sequel in malesin males:: Primary tuberculosis of penis after Primary tuberculosis of penis after

circumcision with inguinal circumcision with inguinal adenopathyadenopathy

Epididymitis / Epididymo – orchitis in Epididymitis / Epididymo – orchitis in early childhoodearly childhood

Page 34: Childhood TB

Tuberculous meningitisTuberculous meningitisTB meningitis seen in 1/300 Primary infectionsTB meningitis seen in 1/300 Primary infectionsPathophysiology:Pathophysiology:Rupture of a subcortical caseous focus (Rich’s) into Rupture of a subcortical caseous focus (Rich’s) into

the subarachnoid space.the subarachnoid space.Inflammatory exudates form about base of brain and Inflammatory exudates form about base of brain and

along cerebral vessels as they pass over along cerebral vessels as they pass over hemispheres.hemispheres.

Raised intracranial pressure due to increased Raised intracranial pressure due to increased secretion of CSF secretion of CSF

Adhesions along base and roof of 4Adhesions along base and roof of 4thth ventricles lead ventricles lead to obstruction to CSF flow and hydrocephalus,to obstruction to CSF flow and hydrocephalus,

involvement of cranial nerves III VI VII and optic involvement of cranial nerves III VI VII and optic chiasma.chiasma.

Cerebral endarteritis narrows lumen, reduces blood Cerebral endarteritis narrows lumen, reduces blood flow, leads to cerebral thrombosis and infarction. flow, leads to cerebral thrombosis and infarction.

Page 35: Childhood TB

Stages of TB meningitisStages of TB meningitis

Stage I Irritability, anorexia, personality Stage I Irritability, anorexia, personality changechange

Occasional vomiting, feverOccasional vomiting, fever

Poor school performancePoor school performance

Stage II Focal neurological signs, cranial nerve Stage II Focal neurological signs, cranial nerve palsies,palsies,

Seizures, hemiplegia, squintSeizures, hemiplegia, squint

Stage III Loss of consciousness, Coma, Stage III Loss of consciousness, Coma, Papilloedema Papilloedema

Decerebrate rigidityDecerebrate rigidity

Page 36: Childhood TB

Complications of TB Complications of TB meningitismeningitis

HydrocephalusHydrocephalusSubdural effusionSubdural effusionLate: Hemiplegia / ParaplegiaLate: Hemiplegia / Paraplegia Intellectual impairmentIntellectual impairment BlindnessBlindness DeafnessDeafness Intracranial calcifications leading to Intracranial calcifications leading to hypothalamic and pituitary dysfunctionhypothalamic and pituitary dysfunction - Growth failure- Growth failure - Diabetes insipidus- Diabetes insipidus - Failure of development of secondary sexual - Failure of development of secondary sexual characteristicscharacteristics

Page 37: Childhood TB

Diagnosis of TB Diagnosis of TB meningitismeningitis

Signs of meningeal irritationSigns of meningeal irritation X-ray chestX-ray chest CT scan – basal exudates, inflammatory CT scan – basal exudates, inflammatory

granulomas etcgranulomas etc Tuberculin testingTuberculin testing Retinoscopy for choroidal tuberclesRetinoscopy for choroidal tubercles Lumbar punctureLumbar puncture Elevated CSF pressure(30 – 40cm h2o)Elevated CSF pressure(30 – 40cm h2o)

Cobweb Coagulum/ pellicle on Cobweb Coagulum/ pellicle on standing standing

100 – 500 WBCs / cu.mm100 – 500 WBCs / cu.mm >40 mg% protein>40 mg% protein Low / Normal sugarLow / Normal sugar AFB smear & cultureAFB smear & culture

Page 38: Childhood TB

Prognosis in TB Prognosis in TB meningitismeningitis

100% mortality in 3-4 weeks without treatment100% mortality in 3-4 weeks without treatment

100% survival with treatment started in Stage 100% survival with treatment started in Stage II

75% survival with treatment started in Stage 75% survival with treatment started in Stage IIII

Stage III – variable survival, all will have Stage III – variable survival, all will have sequelaesequelae

Page 39: Childhood TB

Direct tests for Direct tests for tuberculosistuberculosis

Ziehl-Neelsen staining for AFB in clinical Ziehl-Neelsen staining for AFB in clinical specimens (sputum, gastric juice, biopsy)specimens (sputum, gastric juice, biopsy)

AFB culture on Lowenstein-Jensen solid AFB culture on Lowenstein-Jensen solid medium (4 weeks)medium (4 weeks)

PCR amplification of targeted PCR amplification of targeted mycobacterial DNA sequences mycobacterial DNA sequences

DNA probes: fluorescence DNA probes: fluorescence in situin situ hybridization assays hybridization assays

Page 40: Childhood TB

CultureCulture

LJ mediumLJ medium BACTEC radiometric assayBACTEC radiometric assay Septichek AFB systemSeptichek AFB system MGIT – mycobacterial growth MGIT – mycobacterial growth

indicator tube systemindicator tube system

Page 41: Childhood TB

PCR – rapid resultsPCR – rapid results

Serodiagnosis – ELISASerodiagnosis – ELISA

QuantiFERON- TB test (QFT) – for QuantiFERON- TB test (QFT) – for diagnosing latent TB. Based on IFN-diagnosing latent TB. Based on IFN-gamma released from sensitized gamma released from sensitized lymphocytes.lymphocytes.ELISPOTELISPOT

Page 42: Childhood TB

Positive Positive MantouxMantoux

Page 43: Childhood TB

Mantoux TestMantoux Test

MC used test for establishing diagnosis MC used test for establishing diagnosis of TB in childrenof TB in children

Delayed type hypersensitivity reactionDelayed type hypersensitivity reaction 0.1 ml of 5 TU PPD is injected 0.1 ml of 5 TU PPD is injected

intradermally into the volar aspect of the intradermally into the volar aspect of the forearm (or 2 TU of PPD RT 23)forearm (or 2 TU of PPD RT 23)

A weal of 5 mm should be raisedA weal of 5 mm should be raised Reaction is read after 48 – 72 hrsReaction is read after 48 – 72 hrs Look for induration and erythemaLook for induration and erythema

Page 44: Childhood TB

Observation and Observation and InferenceInference

48-72 hours later 48-72 hours later diameter of diameter of induration is measured transversely to induration is measured transversely to the long axis of the forearm. the long axis of the forearm.

Induration > 10mm is suggestive of Induration > 10mm is suggestive of natural infection. natural infection.

5-10 mm 5-10 mm borderline; considered borderline; considered positive in immunocompromised hostpositive in immunocompromised host

<5mm <5mm Negative mantoux test does Negative mantoux test does not rule out TBnot rule out TB

Page 45: Childhood TB

False NegativesFalse Negatives

Test done in incubation period of TBTest done in incubation period of TB For several weeks following measlesFor several weeks following measles During Corticosteroid therapyDuring Corticosteroid therapy Overwhelming TB infection (milliary, Overwhelming TB infection (milliary,

meningits)meningits) Severe MalnutritionSevere Malnutrition If given Sub Cutaneous instead of Intra If given Sub Cutaneous instead of Intra

dermaldermal Inactive TuberculinInactive Tuberculin

Page 46: Childhood TB

False positiveFalse positive

Atypical mycobacteriaAtypical mycobacteria BCG vaccineBCG vaccine Infection at site of testInfection at site of test

Page 47: Childhood TB

Guidelines for presumptive Guidelines for presumptive diagnosis of tuberculosisdiagnosis of tuberculosis

Pediatr Infect Dis J 1993;12: 499-Pediatr Infect Dis J 1993;12: 499-504)504)

A combination of at least 3 of the following:A combination of at least 3 of the following: Symptoms/signs s/o TB: Symptoms/signs s/o TB:

(fever > 1 mo., cough, (fever > 1 mo., cough, weight loss)weight loss)

History of close contact with TBHistory of close contact with TB Positive tuberculin skin test (Mantoux > Positive tuberculin skin test (Mantoux >

10 mm)10 mm) sputum / gastric juice AFB sputum / gastric juice AFB ++veve lymph node / tissue biopsy positivitylymph node / tissue biopsy positivity Radiologic features suggestive of TBRadiologic features suggestive of TB Response to Anti TB Therapy Response to Anti TB Therapy

Page 48: Childhood TB

History of contact = any child who History of contact = any child who lives in a household with an adult lives in a household with an adult taking ATT or has taken therapy in taking ATT or has taken therapy in the past 2 yearsthe past 2 years

Page 49: Childhood TB

RadiologyRadiology

In extra pulmonary tb, presence of lesions on In extra pulmonary tb, presence of lesions on chest radiograph supports diagnosis. chest radiograph supports diagnosis.

Enlarged lymph nodes in hila, right Enlarged lymph nodes in hila, right paratracheal regionparatracheal region

Consolidation in progressive primary disease – Consolidation in progressive primary disease – heterogenous, poorly marginated with heterogenous, poorly marginated with predilection to apical or posterior segments of predilection to apical or posterior segments of upper lobe or superior segments of lower lobe. upper lobe or superior segments of lower lobe.

BronchiectasisBronchiectasis Pleural effusionPleural effusion Miliary tb – millet sized lesionsMiliary tb – millet sized lesions

Page 50: Childhood TB

Treatment for TBTreatment for TB

11stst line anti-tuberculous drugs line anti-tuberculous drugs Isoniazid (INAH) 5 mg/kg/day H Isoniazid (INAH) 5 mg/kg/day H

Rifampicin 10 mg/kg/day RRifampicin 10 mg/kg/day R Pyrazinamide 25 mg/kg/day Z Pyrazinamide 25 mg/kg/day Z

Ethambutol 20 mg/kg/day E Ethambutol 20 mg/kg/day E Streptomycin 20mg/kg/day SStreptomycin 20mg/kg/day S

Page 51: Childhood TB

22ndnd Line drugs Line drugs Drug resistant cases or when first line Drug resistant cases or when first line

drugs cant be useddrugs cant be used Eg. Cycloserine, ethionamaide, PAS, Eg. Cycloserine, ethionamaide, PAS,

kanamycinkanamycin

Other drugsOther drugs Strictly for drug resistant casesStrictly for drug resistant cases Eg. Quinolones, rifamycin, amikacin, Eg. Quinolones, rifamycin, amikacin,

imipenem, ampicillinimipenem, ampicillin

Page 52: Childhood TB

Phases of TreatmentPhases of Treatment

Intensive PhaseIntensive Phase Eliminate bacterial loadEliminate bacterial load Prevent emergence of drug resistant strainsPrevent emergence of drug resistant strains Atleast 3 Bactericidal Drugs usedAtleast 3 Bactericidal Drugs used

Continuation PhaseContinuation Phase Continue and complete therapyContinue and complete therapy Atleast 2 Bactericidal drugs usedAtleast 2 Bactericidal drugs used

SteroidsSteroids Anti inflammatory effect – millary, peritonitis, Anti inflammatory effect – millary, peritonitis,

pericarditispericarditis TB meningitis TB meningitis

Page 53: Childhood TB

RNTCP TreatmentRNTCP Treatment

Page 54: Childhood TB

Treatment policies in Treatment policies in children with children with

tuberculosis (IAP)tuberculosis (IAP) Preventive Therapy In Mantoux Positive : 6 HRPreventive Therapy In Mantoux Positive : 6 HR Primary complex }Primary complex } Isolated LNE } 2 HRZ + 4 HRIsolated LNE } 2 HRZ + 4 HR Pleural Effusion }Pleural Effusion }

Progressive Pulmonary Tuberculosis }Progressive Pulmonary Tuberculosis } Multiple LNE } 2 HRZE + 4 HRMultiple LNE } 2 HRZE + 4 HR

Miliary, Bone, Renal, Pericardial } 2 HRZE + 7HRMiliary, Bone, Renal, Pericardial } 2 HRZE + 7HR TB Meningitis } 2 HRZE + 10 HRE TB Meningitis } 2 HRZE + 10 HRE

++ Prednisolone / Prednisolone /

DexamethasoneDexamethasone

Page 55: Childhood TB

The 5 components of DOTS

Political & administrative commitmentDiagnosis by good quality sputum microscopyAdequate supply of good quality drugsDirectly observed treatmentSystematic monitoring & Accountability

Page 56: Childhood TB

Drug ResistanceDrug Resistance

Natural or PrimaryNatural or Primary AcquiredAcquired InitialInitial Multidrug resistance (MDR)Multidrug resistance (MDR)

Page 57: Childhood TB

Treatment of Treatment of resistant tuberculosisresistant tuberculosis

INH-resistant TB: 18 RZEINH-resistant TB: 18 RZE Rifampicin-resistant TB: 18 – 24 HZERifampicin-resistant TB: 18 – 24 HZE Multidrug-resistant TB:Multidrug-resistant TB:

Treat for 24 mo. after culture Treat for 24 mo. after culture conversion with regimen containing conversion with regimen containing 3 second-line drugs, including IM 3 second-line drugs, including IM aminoglycoside/ SM, one aminoglycoside/ SM, one fluoroquinolone and one oral 2fluoroquinolone and one oral 2ndnd line line drug.drug.

Page 58: Childhood TB
Page 59: Childhood TB

ReferencesReferences

Nelson’s textbook of paediatricsNelson’s textbook of paediatrics OP Ghai – Essential PaediatricsOP Ghai – Essential Paediatrics Preventive and Social Medicine – Preventive and Social Medicine –

Park & ParkPark & Park The Internet…The Internet…