TB in Children - University of Cape Town · Case 1. 10 yr referred from PHC PH: Inguinal hernia, Impetigo and submental LN Checked for TB Now LOW, night sweats UWA, pale, Axillary

TB in Children

The diagnostic challenge

Ralph Diedericks

Red Cross Hospital

TB in children

Brief epidemiology

Clinical issues in primary TB

Cases

Rates of TB infection

2005 TST survey reported a TB prevalence of 26.2% in 5 – 8 yr olds

Incr to 52.5% in 14 – 17 yr olds

Positive TST ( > 10mm) among primary school children 37.5% ( 2005)

High rates of TB transmission predate HIV epidemic

Epidemiology

Foll prolonged contact 60-80% children infected

60-80% childrn < 2 infected by household source

Older children > 2 mostly no household contact

Infection vs Disease

60 -80% children < 2 with primary

infection will develop disease

Children > 10 yrs at increased risk of

disease

- increased risk of cavitation

TB prophylaxis

INH prophylaxis in children under 5

Incidence

Paediatric Tb 400 - 600 new cases / 100 000

50 474 new cases ( < 15 yrs ) notified in

2010

Primary TB

Young children

Paucibacillary disease

Sputum sampling is a challenge

CXR : LN enlargement ( Ghon Complex )

Primary TB

Allergic manifestations:

- Phlyctenular conjunctivtis

- Erythema nodosum

- Polyarticular arthritis ( Poncet’s )

- Effusions ?

Erythema nodosum

Erythema nodosum

Case 1.

10 yr referred from PHC

PH: Inguinal hernia, Impetigo and submental LN

Checked for TB

Now LOW, night sweats

UWA, pale, Axillary LN, hepar 2cm

HIV neg, Hb 10 MCV 58 , WCC 13.1, ESR 44

Mantoux test : large ulcerating reaction

Enrolled in TB study for sputum collection

and geneXpert

CXR

Abdominal US : intra abdom LN

Rx Started on 4 drug anti TB Rx with

Ethambutol added

Good response to Rx and wt gain

10 yr no contact

CXR typical hilar adenopathy

Extensive TB

Value of US in diagnosis

4 drug Rx

NB Hilar adenopathy and primary TB

Mantoux test

Detects TB in > 80% HIV Neg patients

Valuable test in children even at 10 yrs

Technique important

Inhibition of Tuberculin response

Wasting/severe malnutition

Corticosteroids, immunosuppression

Viral infection – measles, Influenza

Severe disease

Case 2.

7 yr

2 weeks axillary LN , LOW

Wt on 10th centile, no fall off

Enlarged axillary nodes on left, largest

2x2cm

Chest exam – no tachypnoea, dull on L.,

crackles with reduced B/S

Mantoux 20 X 22mm

ESR 65

Sputum neg PCR

FNAB : MTB complex detected on PCR.

Sens to RIF

FNAB value. Technique.

Fine needle aspiration of LN

Technique well established , not new

Good yield for granulomas with/out

caseation( 80% )

AFBs n 40 %

Caseation present ( acellular necrotic

material ) AFBs in > 60%

Case 3.

Anathi 26 m

Foster care

Poor weight gain

No known TB contact

Wt chart

Temp 38,2

Pale, apathetic

Clinical features of kwashiorkor with skin

lesions

Cervical adenopathy

RR 40 with i/c recession, crackles left chest

Hepar 2cm

No enlargement of spleen

Investigations

CXR

Mantoux

Induced Sputum

- geneXpert

- culture

FBC, ESR, CRP, Se Alb

Hb 7.4 MCV 69

WCC 13.2 (N49 L38 Bands 8)

Platelets 721

ESR 58

CRP 141

Se Alb 19

Mantoux reacting after 24 hrs

Measured 28 X 15 mm

Sputum geneXpert neg

CULTURE POSITIVE for MTB

Treatment

Extensive complicated Pulmonary TB

- 4 drug anti TB ( Ethambutol added )

- PREDNISONE for airway compression

Case 4

Mona

5yrs

2011 investigated for TB after contact

identified

HIV infected. Not on ARVs

CXR done

No TB prophylaxis given

Subsequent ID consult

10.11.2011

Not on TB prophylaxis

Started on ARVs

Seen at FU in IDC and doing well

31.05.2013

5yrs

Defaulted ARVs

Acutely ill

Malnourished

Chest: tachypnoeic, dull on left with reduced

breath sounds

Investigations

Hb 6.7 MCV 58

WCC 23.1 Bands 49%

CRP 180

Mantoux done: was never read ( forgot to

read)

Gastric washings neg for AFBs

CXR

ICD inserted

- 50ml pus drained immed

- sent for MC/S, TB, Cytology

- Smear positive for AFBs

- Culture positive for MTb

Treatment

ARVs

- Started on ABC/3TC/EFV

Anti TB Rx 4 drugs

ICD – developed broncho pleural fistula

Follow up

Signs of chronic lung disease

Poor resolution of L. lung

Pulmonary cutaneous fistula

Poor PFTs

Expansile pneumonia in TB

Diagnosing TB

Clinical

History – symptoms

- contact

Evidence of FTT

Allergic manifestations

TST

CXR – add LODOX, CT scan

Induced sputum

FNAsp

Pleural samples