Childhood Tuberculosis

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Information about Childhood Tuberculosis
Health & Medicine

Published on December 12, 2008

Author: guest1f0af

Source: slideshare.net

Description

a presentation describing TB in a specific age group which is childhood

BY Prof. Abdelsadek Al-Aarag prof. Of Chest Diseases & Tuberculosis Faculty of Medicine-Benha University Dr. Abdelsadek Al-Aarag

Dr. Abdelsadek Al-Aarag

Tuberculosis is among the world’s major diseases . It is estimated that one-third of the world’s population is infected with Mycobacterium tuberculosis . Each year ~ 9 million people , including 1 million children aged < 15 years , become infected and > 2 million die. Although tuberculosis is mainly pulmonary disseminated disease is more common in children. Dr. Abdelsadek Al-Aarag

Tuberculosis is among the world’s major diseases . It is estimated that one-third of the world’s population is infected with Mycobacterium tuberculosis . Each year ~ 9 million people , including 1 million children aged < 15 years , become infected and > 2 million die. Although tuberculosis is mainly pulmonary disseminated disease is more common in children.

Children with tuberculosis are markers of recent disease transmission, usually from an infectious adult . They provide a reservoir of disease for future but are rarely infectious themselves , so their treatment -particularly in endemic areas- is often not a priority. Dr. Abdelsadek Al-Aarag

Children with tuberculosis are markers of recent disease transmission, usually from an infectious adult . They provide a reservoir of disease for future but are rarely infectious themselves , so their treatment -particularly in endemic areas- is often not a priority.

The true extent of childhood tuberculosis morbidity and mortality is rarely appreciated as the available data underestimates the true disease burden due to difficulties in confirming the diagnosis and the low levels of notification in many areas of the world. Dr. Abdelsadek Al-Aarag

The true extent of childhood tuberculosis morbidity and mortality is rarely appreciated as the available data underestimates the true disease burden due to difficulties in confirming the diagnosis and the low levels of notification in many areas of the world.

Dr. Abdelsadek Al-Aarag

In endemic areas ,the clinical diagnosis of tuberculosis represents a major challenge ? symptoms associated with tuberculosis ,such as cough , loss, fatigue, fever and night sweats are all common in the community and frequently reported in children without tuberculosis . Dr. Abdelsadek Al-Aarag

In endemic areas ,the clinical diagnosis of tuberculosis represents a major challenge ?

symptoms associated with tuberculosis ,such as cough , loss, fatigue, fever and night sweats are all common in the community and frequently reported in children without tuberculosis .

However , a persistent non remitting cough and fatigue of recent onset have been shown to be sensitive and specific features in children with tuberculosis Dr. Abdelsadek Al-Aarag

However , a persistent non remitting cough and fatigue of recent onset have been shown to be sensitive and specific features in children with tuberculosis

The combined presence of three well-defined symptoms at presentation : * persistent non-remitting cough of > 2 weeks duration. * objective weight loss ( documented failure thrive , during the preceding 3 months ) . * reported fatigue. has been shown to provide good diagnostic accuracy in HIV-uninfected children ≥3 years of age. Dr. Abdelsadek Al-Aarag

The combined presence of three well-defined symptoms at presentation :

* persistent non-remitting cough of > 2 weeks duration.

* objective weight loss ( documented failure

thrive , during the preceding 3 months ) . * reported fatigue. has been shown to provide good diagnostic accuracy in HIV-uninfected children ≥3 years of age.

In non-endemic areas , where tuberculosis is often very uncommon ,remembering to think of tuberculosis in children as a possible diagnosis is often the major issue . Dr. Abdelsadek Al-Aarag

In non-endemic areas , where tuberculosis is often very uncommon ,remembering to think of tuberculosis in children as a possible diagnosis is often the major issue .

Although there are no specific characteristic features of pulmonary tuberculosis on clinical examination , some features , such as gibbus of recent onset, are highly suggestive of extra-pulmonary tuberculosis . Dr. Abdelsadek Al-Aarag

Although there are no specific characteristic features of pulmonary tuberculosis on clinical examination , some features , such as gibbus of recent onset, are highly suggestive of extra-pulmonary tuberculosis .

The major difficulty in diagnosing tuberculosis in children is that the gold standard “confirmation of infection by demonstration of M.tuberculosis on direct microscopy of sputum or culture”is commonly not achieved and is often not attempted . Dr. Abdelsadek Al-Aarag

The major difficulty in diagnosing tuberculosis in children is that the gold standard “confirmation of infection by demonstration of M.tuberculosis on direct microscopy of sputum or culture”is commonly not achieved and is often not attempted .

What are the difficulties in demonstration of M.tuberculosis ? 1. Most children with active pulmonary tuberculosis have paucibacillary disease and are rarely infectious . 2. Sputum-smear microscopy (which may be the only test available in many endemic areas is positive in < 10-15 % of children with probable tuberculosis . Dr. Abdelsadek Al-Aarag

What are the difficulties in demonstration of M.tuberculosis ?

1. Most children with active pulmonary tuberculosis have paucibacillary disease and are rarely infectious .

2. Sputum-smear microscopy (which may be the only test available in many endemic areas is positive in < 10-15 % of children with probable tuberculosis .

3. Obtaining adequate samples in children is often difficult .Sputum microscopy may more valuable in older children with adult-type disease. 4. Culture is little better .Yields of positive cultures for M.tuberculosis of 30-40 % in children with uncomplicated hilar adenopathy are typical . Dr. Abdelsadek Al-Aarag

3. Obtaining adequate samples in children is often difficult .Sputum microscopy may more valuable in older children with adult-type disease.

4. Culture is little better .Yields of positive cultures for M.tuberculosis of 30-40 % in children with uncomplicated hilar adenopathy are typical .

Investigations of children suspected of having tuberculosis is difficult. In many cases the diagnosis reached is one of probable rather than proven, tuberculosis . Dr. Abdelsadek Al-Aarag

Investigations of children suspected of having tuberculosis is difficult. In many cases the diagnosis reached is one of probable rather than proven, tuberculosis .

Because tuberculosis in young children generally develops from recent disease transmission, contact screening is of great importance in the detection of children with a high likelihood of developing infection .It aims to detect not just those with tuberculous disease, but also those with latent disease or evidence of recent exposure Dr. Abdelsadek Al-Aarag

Because tuberculosis in young children generally develops from recent disease transmission, contact screening is of great importance in the detection of children with a high likelihood of developing infection .It aims to detect not just those with tuberculous disease, but also those with latent disease or evidence of recent exposure

In endemic areas , 50% of household contacts are found to have latent tuberculosis and 10-20% tuberculous disease. In this setting 6% of all contacts could be expected to have tuberculous disease . Dr. Abdelsadek Al-Aarag

In endemic areas , 50% of household contacts are found to have latent tuberculosis and 10-20% tuberculous disease. In this setting 6% of all contacts could be expected to have tuberculous disease .

The radiological finding in tuberculosis are neither specific nor diagnostic of tuberculosis except in miliary tuberculosis. Hilar adenopathy on chest radiography is the commenest disease manifestation in children with tuberculosis and is usually regarded as the hallmark of recent primary tuberculosis . By convention ,asymptomatic hilar adenopathy in a child is currently treated as active tuberculous disease. Dr. Abdelsadek Al-Aarag

The radiological finding in tuberculosis are neither specific nor diagnostic of tuberculosis except in miliary tuberculosis. Hilar adenopathy on chest radiography is the commenest disease manifestation in children with tuberculosis and is usually regarded as the hallmark of recent primary tuberculosis .

By convention ,asymptomatic hilar adenopathy in a child is currently treated as active tuberculous disease.

Lateral views and CT have been used to improve the accuracy of diagnosis . Lateral views have not been shown to improve the results .CT is very sensitive, probably overdiagnoses hilar adenopathy and is not currently recommended in the diagnosis of tuberculosis in asymptomatic , immunocomptent children exposed to tuberculosis. Dr. Abdelsadek Al-Aarag

Lateral views and CT have been used to improve the accuracy of diagnosis . Lateral views have not been shown to improve the results .CT is very sensitive, probably overdiagnoses hilar adenopathy and is not currently recommended in the diagnosis of tuberculosis in asymptomatic , immunocomptent children exposed to tuberculosis.

Dr. Abdelsadek Al-Aarag

There are now two tests that can be used to help decide whether a child has been infected with M.tuberculosis. The tuberculin skin test and the interferon(IFN)-Y test Dr. Abdelsadek Al-Aarag

There are now two tests that can be used to help decide whether a child has been infected with M.tuberculosis. The tuberculin skin test and the interferon(IFN)-Y test

The TST (Mantoux or Heaf Test) has been used for > 50 years to support the diagnosis of tuberculosis .The test should be standardised for each country using either 5 tuberculin units(TU) of tuberculin PPD-s or 2TU of tuberculin PPD-RT23, as these give similar reactions in TB-infected children. Dr. Abdelsadek Al-Aarag

The TST (Mantoux or Heaf Test) has been used for > 50 years to support the diagnosis of tuberculosis .The test should be standardised for each country using either 5 tuberculin units(TU) of tuberculin PPD-s or 2TU of tuberculin PPD-RT23, as these give similar reactions in TB-infected children.

Dr. Abdelsadek Al-Aarag

It is one of the most important recent developments in TB diagnosis. It is one in vitro T-cell-based assays. A number of tests are commercially available ,the QuantiFERON TB Gold and T-SPOT tests. Dr. Abdelsadek Al-Aarag

It is one of the most important recent developments in TB diagnosis. It is one in vitro T-cell-based assays. A number of tests are commercially available ,the QuantiFERON TB Gold and T-SPOT tests.

These whole- blood assays measure IFN-Y production by previously sensitised lymphocytes in response to the M-tuberculosis-specific protein antigen ESAT6 and CFP-10.Only one visit is required and the test offers a number of potential advantages over the TST. Dr. Abdelsadek Al-Aarag

These whole- blood assays measure IFN-Y production by previously sensitised lymphocytes in response to the M-tuberculosis-specific protein antigen ESAT6 and CFP-10.Only one visit is required and the test offers a number of potential advantages over the TST.

Compared with TST ,IFN-Y tests have higher specificity ,correlate better with exposure to M. tuberculosis and have less cross-reactivity with the BCG vaccine and environmental mycobacteria . However ,recent guidelines do not recommend the routine use and the need for future research comparing TST and IFN-Y tests in young children . Dr. Abdelsadek Al-Aarag

Compared with TST ,IFN-Y tests have higher specificity ,correlate better with exposure to M. tuberculosis and have less cross-reactivity with the BCG vaccine and environmental mycobacteria . However ,recent guidelines do not recommend the routine use and the need for future research comparing TST and IFN-Y tests in young children .

Dr. Abdelsadek Al-Aarag

Bacteriological confirmation is difficult in children , as there are few organisms and obtaining clinical samples can often be difficult .Sputum is smear positive in ≤10-15% of those with probable tuberculosis . Dr. Abdelsadek Al-Aarag

Bacteriological confirmation is difficult in children , as there are few organisms and obtaining clinical samples can often be difficult .Sputum is smear positive in ≤10-15% of those with probable tuberculosis .

Culture is the only way to differentiate M.tuberculosis from other mycobacteria and is particularly important if drug-resistance is suspected.Unfortunately , culture is positive in <40% of children with probable tuberculosis . Appropriate samples for bacteriology include : sputum , gastric aspirates ,and biopsied nodes or fine-needle aspirate s . Dr. Abdelsadek Al-Aarag

Culture is the only way to differentiate M.tuberculosis from other mycobacteria and is particularly important if drug-resistance is suspected.Unfortunately , culture is positive in <40% of children with probable tuberculosis . Appropriate samples for bacteriology include : sputum , gastric aspirates ,and biopsied nodes or fine-needle aspirate s .

Older children or adolescents may be able to produce sputum spontaneously . This is more likely to be positive than other samples . Three specimens are recommended ; one on the spot , an early morning specimen and a second on the spot at follow up . Dr. Abdelsadek Al-Aarag

Older children or adolescents may be able to produce sputum spontaneously . This is more likely to be positive than other samples . Three specimens are recommended ; one on the spot , an early morning specimen and a second on the spot at follow up .

Gastric aspiration using a nasogastric feeding tube can be performed on young children who are unable or unwilling to produce sputum . Samples are collected on each of three consecutive mornings , following an overnight fast of 8-10 hours which requires admission to hospital . Even after optimal circumstances <50% of samples will be positive in those with tuberculosis . Dr. Abdelsadek Al-Aarag

Gastric aspiration using a nasogastric feeding tube can be performed on young children who are unable or unwilling to produce sputum . Samples are collected on each of three consecutive mornings , following an overnight fast of 8-10 hours which requires admission to hospital . Even after optimal circumstances <50% of samples will be positive in those with tuberculosis .

Nasogastric aspirates can be used as an alternative . The procedure can be done at any time of the day , does not require admission and is inexpensive . One study showed a yield of 30% in nasopharyngeal aspirates compared with 38% in gastric aspirates in the same unit . Dr. Abdelsadek Al-Aarag

Nasogastric aspirates can be used as an alternative . The procedure can be done at any time of the day , does not require admission and is inexpensive . One study showed a yield of 30% in nasopharyngeal aspirates compared with 38% in gastric aspirates in the same unit .

Induced sputum is safe and well tolerated in children . It can be carried out as an outpatient, even in very young children . Several studies have shown it to be superior to gastric lavage . Bronchospasm was the only significant adverse effect and can be prevented by nebulising with salbutamol prior to the procedure . Dr. Abdelsadek Al-Aarag

Induced sputum is safe and well tolerated in children . It can be carried out as an outpatient, even in very young children . Several studies have shown it to be superior to gastric lavage . Bronchospasm was the only significant adverse effect and can be prevented by nebulising with salbutamol prior to the procedure .

One recent study from Peru described a test , in which a capsule is swallowed and the string attached to the capsule is taped to the cheek . The capsule is then withdrawn over a 5-second period and sent for culture along with the string . The yield was higher than induced sputum and less risky to health workers . It needs further assessment before it can be recommended . Dr. Abdelsadek Al-Aarag

One recent study from Peru described a test , in which a capsule is swallowed and the string attached to the capsule is taped to the cheek . The capsule is then withdrawn over a 5-second period and sent for culture along with the string . The yield was higher than induced sputum and less risky to health workers . It needs further assessment before it can be recommended .

Bronchoscopy may be useful in selected cases to look for airway compression or endobronchial tuberculosis , which may be present in up to 60% of children with tuberculous disease . In terms of bacteriology , specimens obtained by BAL have a lower yield than gastric aspirates . Dr. Abdelsadek Al-Aarag

Bronchoscopy may be useful in selected cases to look for airway compression or endobronchial tuberculosis , which may be present in up to 60% of children with tuberculous disease . In terms of bacteriology , specimens obtained by BAL have a lower yield than gastric aspirates .

Although new diagnostic methods ( PCR-based detection system and DNA fingerprinting ) are available and in development , they have not yet been extensively validated in children . The expense and the facilities required preclude their use in many areas with endemic tuberculosis . Dr. Abdelsadek Al-Aarag

Although new diagnostic methods ( PCR-based detection system and DNA fingerprinting ) are available and in development , they have not yet been extensively validated in children . The expense and the facilities required preclude their use in many areas with endemic tuberculosis .

Treatment of tuberculosis in children is classified into two types of treatment : 1-Preventive treatment . 2-Curative treatment . Dr. Abdelsadek Al-Aarag

Treatment of tuberculosis in children is classified into two types of treatment : 1-Preventive treatment . 2-Curative treatment .

1-PREVENTIVE TREATMENT Is recommended for : 1- Children exposed to smear-positive tuberculosis and have no evidence of tuberculous infection or disease .Young children(<3 years) , neonates and HIV-positive children are included in this high-risk group . 2- Children exposed to smear-positive disease where there is evidence of infection but not of disease i.e latent infection . Dr. Abdelsadek Al-Aarag

1-PREVENTIVE TREATMENT

Is recommended for :

1- Children exposed to smear-positive tuberculosis and have no evidence of tuberculous infection or disease .Young children(<3 years) , neonates and HIV-positive children are included in this high-risk group .

2- Children exposed to smear-positive disease where there is evidence of infection but not of disease i.e latent infection .

2-CURATIVE TREATMENT Is recommended for children with clinical or radiological evidence of tuberculosis . Dr. Abdelsadek Al-Aarag

2-CURATIVE TREATMENT Is recommended for children with clinical or radiological evidence of tuberculosis .

Chemoprophylaxix refers to preventive treatment given to children who have been exposed to a case of tuberculosis without proof of infection , where as treatment of latent infection (documented by a positive TST)has been documented . Dr. Abdelsadek Al-Aarag

Chemoprophylaxix refers to preventive treatment given to children who have been exposed to a case of tuberculosis without proof of infection , where as treatment of latent infection (documented by a positive TST)has been documented .

Isoniazid for 6-9 months is the best studied chmoprophylactic agent . This has been shown to reduce the risk of tuberculosis by two-thirds and by as much as 90% if there good adherence to treatment . Dr. Abdelsadek Al-Aarag

Isoniazid for 6-9 months is the best studied chmoprophylactic agent . This has been shown to reduce the risk of tuberculosis by two-thirds and by as much as 90% if there good adherence to treatment .

There some evidence that shorter courses of treatment (3 months of isoniazid and rifampicin ) are as effective and have higher rates of adherence (69.9% , compared with only 27.6% in the group given 6 months of isoniazid alone ) . Adherence might also be improved by using supervised preventive treatment therapy Dr. Abdelsadek Al-Aarag

There some evidence that shorter courses of treatment (3 months of isoniazid and rifampicin ) are as effective and have higher rates of adherence (69.9% , compared with only 27.6% in the group given 6 months of isoniazid alone ) . Adherence might also be improved by using supervised preventive treatment therapy

BCG vaccination BCG vaccination is the most widely preventive strategy and has been in use since the 1920s.It offers significant protection against the most severe forms of disseminated disease such as miliary TB or TB meningitis, in very young children but less protection against adult-type pulmonary TB. Dr. Abdelsadek Al-Aarag

BCG vaccination

BCG vaccination is the most widely preventive strategy and has been in use since the 1920s.It offers significant protection against the most severe forms of disseminated disease such as miliary TB or TB meningitis, in very young children but less protection against adult-type pulmonary TB.

In countries with a high prevalence of tuberculosis, BCG is recommended by the WHO for neonates as soon as possible after birth. Data from some studies suggest that efficacy wanes from 80% initially to 59% 10-15 years after vaccination. Dr. Abdelsadek Al-Aarag

In countries with a high prevalence of tuberculosis, BCG is recommended by the WHO for neonates as soon as possible after birth. Data from some studies suggest that efficacy wanes from 80% initially to 59% 10-15 years after vaccination.

Treatment is divided into two phases 1.The intensive phase : lasts for 2 months and aims to rapidly reduce the organism load, improve symptoms and prevent the development of resistance. During this phase, four drugs are recommended(pyrazinamide, ethambutol, rifampicin, and isoniazid) Dr. Abdelsadek Al-Aarag

Treatment is divided into two phases

1.The intensive phase : lasts for 2 months and aims to rapidly reduce the organism load, improve symptoms and prevent the development of resistance. During this phase, four drugs are recommended(pyrazinamide, ethambutol, rifampicin, and isoniazid)

2.The continuation phase: during the next 4 months, two drugs (isoniazid and rifampicin) are sufficient to eradicate the disease. With this regimen, 90% of patients are completely cured, 99% show significant improvement and clinically important adverse effects.occur in<2% of children Dr. Abdelsadek Al-Aarag

2.The continuation phase: during the next 4 months, two drugs (isoniazid and rifampicin) are sufficient to eradicate the disease. With this regimen, 90% of patients are completely cured, 99% show significant improvement and clinically important adverse effects.occur in<2% of children

Intermittent therapy (3 times per week) using higher doses of drugs is as effective as daily therapy, and is recommended for patients undergoing supervised therapy in both UK and WHO guidelines. Its main disadvantage is that it may involve large number of tablets or volumes of unpleasant liquids, harder for children to tolerate, decreasing adherence and completion of therapy. Dr. Abdelsadek Al-Aarag

Intermittent therapy (3 times per week) using higher doses of drugs is as effective as daily therapy, and is recommended for patients undergoing supervised therapy in both UK and WHO guidelines. Its main disadvantage is that it may involve large number of tablets or volumes of unpleasant liquids, harder for children to tolerate, decreasing adherence and completion of therapy.

The WHO and US guidelines recommend DOTS in all children with TB disease. The UK guidelines do not recommend a universal DOTS approach but suggest the use of DOTS if risk factors such as, adverse social circumstances, a previous history of poor adherence or non attendance of clinic are identified .Twice-weekly regimens are no longer recommended. Dr. Abdelsadek Al-Aarag

The WHO and US guidelines recommend DOTS in all children with TB disease. The UK guidelines do not recommend a universal DOTS approach but suggest the use of DOTS if risk factors such as, adverse social circumstances, a previous history of poor adherence or non attendance of clinic are identified .Twice-weekly regimens are no longer recommended.

Dr. Abdelsadek Al-Aarag

Pyridoxine to counteract the peripheral neuropathy that can occur with isoniazid is not required in most children. It is indicated in : - HIV-positive children - malnourished children - breast-fed or premature infants Dr. Abdelsadek Al-Aarag

Pyridoxine to counteract the peripheral neuropathy that can occur with isoniazid is not required in most children. It is indicated in :

- HIV-positive children

- malnourished children

- breast-fed or premature infants

Steroids are used with anti-TB Therapy for the management of some complicated forms of TB, e.g. -Tuberculous meningitis (reduce mortality and long-term sequelae) -Airways obstruction by TB lymph glands and pericardial TB. Dose regimens : 2 mg/kg prednisolone for 4 weeks with subsequent tapering over 1-2 weeks. Dr. Abdelsadek Al-Aarag

Steroids are used with anti-TB Therapy for the management of some complicated forms of TB, e.g.

-Tuberculous meningitis (reduce mortality and long-term sequelae)

-Airways obstruction by TB lymph glands and pericardial TB.

Dose regimens : 2 mg/kg prednisolone for 4 weeks with subsequent tapering over 1-2 weeks.

The aims of monitoring during therapy are : * to assure adherence to therapy * to ensure that the disease is under control. (reflected in symptom resolution and weight gain) A child who is not responding to anti- TB treatment needs a careful assessment to identify problems with adherence, complications of TB or drug-resistance Dr. Abdelsadek Al-Aarag

The aims of monitoring during therapy are :

* to assure adherence to therapy

* to ensure that the disease is under control. (reflected in symptom resolution and weight gain)

A child who is not responding to anti- TB treatment needs a careful assessment to identify problems with adherence, complications of TB or drug-resistance

The use of follow up chest radiology is controversial. The WHO guidance suggests that follow-up radiography is not routinely required. Others suggest radiography 3 times, one at the start of treatment, the second 1-2 months into treatment and the third at the end of treatment Dr. Abdelsadek Al-Aarag

The use of follow up chest radiology is controversial. The WHO guidance suggests that follow-up radiography is not routinely required. Others suggest radiography 3 times, one at the start of treatment, the second 1-2 months into treatment and the third at the end of treatment

Two-thirds of children will have persistently abnormal (but improved), chest radiography at the end of treatment. This is not an indication to continue treatment providing the child is well, but follow-up should continue until the radiography is either normal or stable. Dr. Abdelsadek Al-Aarag

Two-thirds of children will have persistently abnormal (but improved), chest radiography at the end of treatment. This is not an indication to continue treatment providing the child is well, but follow-up should continue until the radiography is either normal or stable.

Dr. Abdelsadek Al-Aarag

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