Tuberculosis in pediatric age group
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discusses TB from epidemiological and clinical point of view, it types, manifestations, treatment, and prevention
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Tuberculosis in pediatric age group
- 1. Tuberculosis in pediatric age group Done by: Muhammed Abbas Kadhim Naser Saeed Naser Supervised by: Dr. Lamyaa
- 2. Definition • A widespread, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. • generally affects the lungs, but can also affect other parts of the body. • It is spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit respiratory fluids through the air. • Most infections do not have symptoms, known as latent tuberculosis.
- 3. Epidemiology • Roughly one-third of the world's population has been infected with M. tuberculosis, with new infections occurring in about 1% of the population each year. • 90–95% of infections remain asymptomatic. • Worldwide, 9.6 million people are estimated to have fallen ill with TB in 2014 with 1.0 million of them were children. • 12% of them were HIV-positive. • 480 000 cases of multidrug-resistant TB (MDR-TB) are estimated to have occurred in 2014
- 4. Epidemiology
- 5. Pathogenesis
- 6. Risk factors
- 7. Clinical stages • Exposure • Infection • Disease • Differentiated by: - TST or IGRA - signs and symptoms - chest x ray
- 8. Clinical manifestations • asymptomatic • Primary pulmonary TB. - Up to 50% of infants and children with radiographically moderate to severe pulmonary tuberculosis have no physical findings. - Nonproductive cough and mild dyspnea are the most common symptoms. - Systemic complaints such as fever, night sweats, anorexia, and decreased activity occur less often.
- 9. Clinical manifestations • asymptomatic • Primary pulmonary TB. - Some infants have difficulty gaining weight or develop a true failure- to-thrive syndrome that often does not improve significantly until several months of effective treatment. - Pulmonary signs are even less common. - Some infants and young children with bronchial obstruction have localized wheezing or decreased breath sounds that may be accompanied by tachypnea or, rarely, respiratory distress.
- 10. Clinical manifestations • asymptomatic • Primary pulmonary TB. - primary complex: includes the parenchymal pulmonary focus and the regional lymph nodes. - 70% of lung foci are sub pleural, and localized pleurisy is common. - All lobar segments of the lung are at equal risk for initial infection. - The hallmark of primary tuberculosis in the lung is the relatively large size of the regional lymphadenitis
- 11. Clinical manifestations • Primary pulmonary TB.
- 12. Clinical manifestations • Progressive Primary Pulmonary Disease - A rare but serious complication of tuberculosis - High fever, severe cough with sputum production, weight loss, and night sweats are common. - Physical signs include diminished breath sounds, rales, and dullness over the cavity. • Reactivation Tuberculosis - rare in childhood but can occur in adolescence. - usually remains localized in the lungs
- 13. Clinical manifestations - Older children and adolescents with reactivation tuberculosis are more likely to experience fever, anorexia, malaise, weight loss, night sweats, productive cough, hemoptysis, and chest pain than children with primary pulmonary tuberculosis. - physical examination findings usually are minor or absent • Pleural effusion - Asymptomatic local pleural effusion is so common in primary tuberculosis - uncommon in children younger than 6 yr of age and rare in children younger than 2 yr of age.
- 14. Clinical manifestations • Pericardial disease - The most common form of cardiac tuberculosis is pericarditis. It is rare, occurring in 0.5-4% of tuberculosis cases in children. • Lymphohematogenous (Disseminated) Disease - usually asymptomatic. - The clinical course is more often it is indolent and prolonged. - spiking fever accompanying the release of organisms into the bloodstream. Multiple organ involvement is common - Meningitis occurs only late in the course of the disease. - The most clinically significant form of disseminated tuberculosis is miliary disease.
- 16. Diagnostic tools • Tuberculin Skin Testing • The Mantoux TST is the intradermal injection of 0.1 mL purified protein derivative • The amount of induration in response to the test should be measured by a trained person 48-72 hr after administration. • Tuberculin sensitivity develops 3 wk to 3 mo (most often in 4-8 wk) after inhalation of organisms.
- 17. Diagnostic tools
- 18. Diagnostic tools
- 19. Variations of +PPD Blisters, granulomas, local necrosis may occur
- 20. Positive PPD Negative CXR + =Latent TB Infection
- 21. Positive PPD TB-Positive CXR + = active TB
- 22. Diagnostic tools • Interferon-γ Release Assays
- 23. Diagnostic tools • MYCOBACTERIAL SAMPLING, SUSCEPTIBILITY AND CULTURE • Nucleic Acid Amplification
- 24. treatment • The basic principles of management of tuberculosis disease in children and adolescents are the same as those in adults. • INH and rifampicin for 6 months, pyrazinamide and ethambutol are added for the first two months. I.e.: 4 drugs 2 months 2 drugs 4 months. • Extra pulmonary TB treatment is also similar to pulmonary, except in; bone, joint, disseminated, and CNS. • The treatment of the previous exceptions is for 9 to 12 months. • HIV-infected children treatment is believed to be for 9 months. • Coadministration of rifampicin and some antiretroviral agents is not recommended
- 25. treatment
- 27. Drug-Resistant tuberculosis • Primary resistance, Secondary resistance • The main predictors of drug-resistant tuberculosis among adults are history of previous anti tuberculosis treatment, coinfection with HIV, and exposure to another adult with infectious drug-resistant tuberculosis. • Treatment duration of 9 mo with rifampin, pyrazinamide, and ethambutol is usually adequate for isoniazid-resistant tuberculosis in children. • When resistance to isoniazid and rifampin is present, the total duration of therapy often must be extended to 12-24 mo, and intermittent regimens should not be used.
- 28. Corticosteroids in TB treatment • Tuberculous meningitis • Endobronchial tuberculosis • Pericardial effusion, pleural effusion • Miliary TB • The most commonly used regimen is prednisone, 1-2 mg/kg/day in 1- 2 divided doses orally for 4-6 wk, followed by a taper.
- 29. Latent Mycobacterium tuberculosis Infection • The recommended regimen is a 9 mo course of isoniazid as self- administered daily therapy or by twice-weekly DOT. • routine biochemical monitoring and supplementation with pyridoxine are not necessary unless the child is HIV-positive. • A 3 mo. regimen of rifampin and isoniazid has been used in Europe. • Rifampin alone for 4-6 mo. has been used when INH isn’t tolerated or contact with INH-resistant but rifampicin-susceptible TB. • INH and rifapentine once weekly under DOT for 12 weeks is the standard treatment for pts. 12 years of age and older. • LTBI in HIV-infected children, INH daily for 9 months. • MDR-TB is treated according to the susceptibility profile.
- 30. Prevention • Case finding and treatment. • All children and adults with symptoms suggestive of tuberculosis disease and those in close contact with an adult with suspected infectious pulmonary tuberculosis should be tested for tuberculosis infection (by TST or IGRA) and examined as soon as possible. • BCG vaccine
- 34. references • Nelson textbook of pediatrics, 20th edition • Global tuberculosis report 2015 by WHO
Editor's Notes
- Tuberculous meningitis complicates approximately 0.3% of untreated tuberculosis infections in children. It is most common in children between 6 mo and 4 yr of age. Occasionally, tuberculous meningitis occurs many years after the infection, when rupture of 1 or more of the subependymal tubercles discharges tubercle bacilli into the subarachnoid space. The clinical progression of tuberculous meningitis may be rapid or gradual. Rapid progression tends to occur more often in infants and young children, who can experience symptoms for only several days before the onset of acute hydrocephalus, seizures, and cerebral edema. More commonly, the signs and symptoms progress slowly over weeks and are divided into 3 stages. The 1st stage typically lasts 1-2 wk and is characterized by nonspecific symptoms such as fever, headache, irritability, drowsiness, and malaise. Focal neurologic signs are absent, but infants can experience a stagnation or loss of developmental milestones. The 2nd stage usually begins more abruptly. The most common features are lethargy, nuchal rigidity, seizures, positive Kernig and Brudzinski signs, hypertonia, vomiting, cranial nerve palsies, and other focal neurologic signs. The accelerating clinical illness usually correlates with the development of hydrocephalus, increased intracranial pressure, and vasculitis. Some children have no evidence of meningeal irritation but can have signs of encephalitis, such as disorientation, movement disorders, or speech impairment. The 3rd stage is marked by coma, hemi- or paraplegia, hypertension, decerebrate posturing, deterioration of vital signs, and eventually death.
- http://info.med.yale.edu/intmed/cardio/imaging/findings/hilar_adenopathy2/graphics/rad2.gif
- Primary resistance occurs when a person is infected with M. tuberculosis that is already resistant to a particular drug. Secondary resistance occurs when drug-resistant organisms emerge as the dominant population during treatment. The major causes of secondary drug resistance are poor adherence to the medication by the patient or inadequate treatment regimens prescribed by the physician. Nonadherence to 1 drug is more likely to lead to secondary resistance than is failure to take all drugs. Secondary resistance is rare in children because of the small size of their mycobacterial population. Consequently, most drug resistance in children is primary, When a child has possible drug-resistant tuberculosis, usually 4 or 5 drugs should be administered initially untilthe susceptibility pattern is determined and a more-specific regimen can be designed.
- Isoniazid should be given to children younger than 5 yr of age who have a negative TST or IGRA result but who have known recent exposure to an adult with potentially contagious tuberculosis disease. This practice is often referred to as window prophylaxis. By the time delayed hypersensitivity develops (2-3 mo), an untreated child already may have developed severe tuberculosis. For these children, tuberculin skin or IGRA testing is repeated 3 mo after contact with the source case for tuberculosis has been broken (broken contact is defined as physical separation or adequate initial treatment of the source case). If the second test result is positive, isoniazid therapy is continued for 9 mo, but if the result is negative, treatment can be stopped.
- Route of administration: intradermal (0.05 mL dose for children under one year) (0.1 mL dose for recipients over one year) Handling of opened multi-dose vials: WHO recommends that opened vials of this vaccine should be discarded 6 hours after opening or at the end of the immunization session, whichever comes first.