TB Intensive :: Childhood Tuberculosis :: San Antonio, TX :: … · 11/24/2015 1 EXCELLENCE EXPERTISE INNOVATION Childhood Tuberculosis Andrea T. Cruz, MD, MPH November 19, 2015 Tuberculosis
Post on 31-Jan-2020
0 Views
Preview:
Transcript
11/24/2015
1
EXCELLENCE EXPERTISE INNOVATION
ChildhoodTuberculosisAndreaT.Cruz,MD,MPHNovember19,2015
Tuberculosis IntensiveNovember 17‐20, 2015
San Antonio, TX
• No conflict of interests
• No relevant financial relationships with any commercial companies pertaining to this educational activity
AndreaT.Cruz,MD,MPHhasthefollowingdisclosurestomake:
11/24/2015
2
Pediatrics
Childhood Tuberculosis
Andrea T. Cruz, MD/MPH
Associate Professor of Pediatrics
Sections of Infectious Diseases & Emergency Medicine
November 19, 2015
Page 3
xxx00.#####.ppt 11/24/2015 5:07:45 PMPediatrics
Objectives
•To understand the definitions we use for childhood TB
•To know the common clinical and radiographic manifestations of childhood TB
•To understand the utility and limitations of available TB diagnostics
•To map out a plan of care (and know how to get help) for children with TB exposure, infection, and disease
11/24/2015
3
Page 4
xxx00.#####.ppt 11/24/2015 5:07:45 PMPediatrics
Definitions we use for TB
Category Age Exam PPD/IGRA
CXR Contagious Treatment
Exposure < 5 ‐ ‐ ‐ Never 1 drug, usually for 2‐3 months (given by health department)
Infection All ‐ + ‐ Never Usually 1 drug, given 6‐9 months (given by family or health department)
Disease All ‐/+ +/‐ +/‐ Rarely Multiple drugs (3‐4), given 6‐12 months (always given by health department)
No patient with nontuberculous mycobacteria is contagious
Page 5
xxx00.#####.ppt 11/24/2015 5:07:45 PMPediatrics 2014: http://www.who.int/tb/publications/global_report/en/
11/24/2015
4
Page 6
xxx00.#####.ppt 11/24/2015 5:07:45 PMPediatrics 2014: http://www.who.int/tb/publications/global_report/en/
Page 7
xxx00.#####.ppt 11/24/2015 5:07:45 PMPediatrics
MDR: resistant to at least INH and rifampicin
2014: http://www.who.int/tb/publications/global_report/en/
11/24/2015
5
Page 8
xxx00.#####.ppt 11/24/2015 5:07:46 PMPediatrics
MMWR 2014;64:265
US TB Epidemiology: 2014
•9412 cases
•3/100,000
•67% in the foreign-born
•Compared to whites:
‐Asians: 29x higher
‐Hispanics, Blacks: 8x higher
•4 states (CA, FL, TX, NY): 50% of US cases
Page 9
xxx00.#####.ppt 11/24/2015 5:07:46 PMPediatrics 9November 24, 2015 Baylor College of Medicine
11/24/2015
6
Page 10
xxx00.#####.ppt 11/24/2015 5:07:46 PMPediatrics MMWR 2013;62:201
Page 11
xxx00.#####.ppt 11/24/2015 5:07:46 PMPediatrics
http://www.dshs.state.tx.us/idcu/disease/tb/statistics
TB Epidemiology: Texas (1269 in ’14)
Harris County: •2009 – 393 cases•2010 – 339 cases•2011 – 318 cases•2012 – 267 cases•2013 – 287 cases•2014 – 320 cases
•4-5 times the average national incidence
11/24/2015
7
Page 12
xxx00.#####.ppt 11/24/2015 5:07:46 PMPediatrics
TB Risk Factors, Texas
Page 13
xxx00.#####.ppt 11/24/2015 5:07:46 PMPediatrics
TB Disease
Adult TB Disease Pediatric TB Disease
11/24/2015
8
Page 14
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
Page 15
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
11/24/2015
9
Page 16
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
Childhood TB Disease Sites
Site* % of cases Median Age (years)
Pulmonary 77.5 6
Lymphatic 13.3 5
Pleural 3.1 16
Meningeal 1.9 2
Bone/joint 1.2 8
Miliary 0.9 1
GU 0.8 16
Peritoneal 0.3 13*: United States (almost all are normal hosts)
Page 17
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
Risk of Progression from TB Infection to Disease by Age
Peds in Review 2010;31:13
Age at infection (y) No disease (%) Pulmonary TB(%)
CNS TB (%)
<1 50 30‐40 10‐20
1‐2 75‐80 10‐20 2.5
2‐5 95 5 0.5
5‐10 98 2 <0.5
>10 80‐90 10‐20 <0.5
11/24/2015
10
Page 18
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
CXR Findings in Pediatric TB
•Hilar or mediastinal adenopathy
•Segmental/lobar infiltrates
•Calcifications (seen in 75-80% of children with pulmonary TB)
•Miliary disease
•Pleural effusions
15% of patients with TB disease will have normal CXRs
Page 19
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
Intrathoracic Lymphadenopathy
N.O. 2008
11/24/2015
11
Page 20
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
Lobar Infiltrates
D.T. 2011
9mo M presents to TB clinic with 23mm PPD done after grandfather diagnosed with smear‐positive pulmonary TB. Baby is asymptomatic, normal vital signs, growing well. Admitted for LP (normal), gastric aspirates (smear‐negative), started on multidrug therapy for TB disease
Page 21
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
Collapse/Consolidation Pattern
Lymph node collapses a bronchus, leading to distal atelectasis M.A. 2009
11/24/2015
12
Page 22
xxx00.#####.ppt 11/24/2015 5:07:47 PMPediatrics
Calcifications
Usually indicates disease present for 2‐6 months W.C. 2005
Page 23
xxx00.#####.ppt 11/24/2015 5:07:48 PMPediatrics
Isolated Calcification
•Calcifications <2cm in diameter can be treated the same way as a normal CXR
•Represent old granulomatous disease, not active disease
Red Book 2012
11/24/2015
13
Page 24
xxx00.#####.ppt 11/24/2015 5:07:48 PMPediatrics
Cavitary Lesions
W.C. 2005
Page 25
xxx00.#####.ppt 11/24/2015 5:07:48 PMPediatrics
Cavitary Lesions
Uncommon in children, but if see cavities, treat the child as contagious and take appropriate infection control precautions M.N. 2007
11/24/2015
14
Page 26
xxx00.#####.ppt 11/24/2015 5:07:48 PMPediatrics
Cavitary Lesion
•16yo M with very poorly controlled IDDM
•2 months of productive cough, weight loss
• Smear-positive TB
Int J Tuberc Lung Dis 2011;15:179
* DM is single most common predisposing medical condition in TX adults with TB disease
J.A. 2010
Page 27
xxx00.#####.ppt 11/24/2015 5:07:48 PMPediatrics
Miliary Disease
P.K. 2008
11/24/2015
15
Page 28
xxx00.#####.ppt 11/24/2015 5:07:48 PMPediatrics
2003: 17yo WM with Crohn’s, on anti‐TNFα therapy, negative baseline TST, developed miliary TB after 2 months
C.A. 2004
Page 29
xxx00.#####.ppt 11/24/2015 5:07:49 PMPediatrics
Miliary TB with Tension Pneumothorax
D.M. 2008
11/24/2015
16
Page 30
xxx00.#####.ppt 11/24/2015 5:07:49 PMPediatrics
Miliary TB in Spleen, Liver
D.M. 2008
Page 31
xxx00.#####.ppt 11/24/2015 5:07:49 PMPediatrics
Pleural Effusions
Often, children are very well‐appearing (vs. Staph empyemas) J.G. 2007
11/24/2015
17
Page 32
xxx00.#####.ppt 11/24/2015 5:07:49 PMPediatrics
Tuberculomas
At initiation of therapyAfter 2 months of therapy
W.C. 2005
Page 33
xxx00.#####.ppt 11/24/2015 5:07:50 PMPediatrics
Tuberculous Pericarditis
11/24/2015
18
Page 34
xxx00.#####.ppt 11/24/2015 5:07:50 PMPediatrics
Lymphadenopathy + Scrofuloderma
Paed Resp Rev 2007;8:107
Page 35
xxx00.#####.ppt 11/24/2015 5:07:50 PMPediatrics
Initial Presentation
11/24/2015
19
Page 36
xxx00.#####.ppt 11/24/2015 5:07:50 PMPediatrics Pediatrics
Page 37
xxx00.#####.ppt 11/24/2015 5:07:50 PMPediatrics Pediatrics
11/24/2015
20
Page 38
xxx00.#####.ppt 11/24/2015 5:07:50 PMPediatrics
Pre/Immediately post drainage
Page 39
xxx00.#####.ppt 11/24/2015 5:07:50 PMPediatrics
Comparison: Nontuberculous Mycobacterial lymphadenopathy
T.O. 2010A.J. 2009
11/24/2015
21
Page 40
xxx00.#####.ppt 11/24/2015 5:07:51 PMPediatrics
Cutaneous TB: Lupus vulgaris
M.R. 2010
Page 41
xxx00.#####.ppt 11/24/2015 5:07:51 PMPediatrics
Skeletal TB
11/24/2015
22
Page 42
xxx00.#####.ppt 11/24/2015 5:07:51 PMPediatrics
Pott’s Disease
Clin Infect Dis 2005;41:515
J.M. 1/2011. 3yo F with 1yr of worsening ‘hunchback’ (gibbous deformity). T5 destruction. Culture: M. bovis
Page 43
xxx00.#####.ppt 11/24/2015 5:07:51 PMPediatrics
Immune System Recognition
•Tuberculin skin tests (PPD)
•Interferon gamma release assays (IGRA)
11/24/2015
23
Page 44
xxx00.#####.ppt 11/24/2015 5:07:51 PMPediatrics
Positive PPDs
Generally, skin test conversion occurs within 2 months of contact
Measure only induration, and record millimeters of induration (never record “+” or “‐”)
Any induration seen only in the first 24 hours should be ignored
Induration after 72 hours counts; blistering also counts
Page 45
xxx00.#####.ppt 11/24/2015 5:07:51 PMPediatrics
What is a Positive PPD?
2012 Red Book
≥ 5mm ≥ 10mm ≥15mm
HIV‐infected Children < 4 years of age Anyone, even without risk factors
Contact to a TB case Children exposed to high‐risk adults†
Child in whom you suspect TB disease
Immigrants from high‐prevalence regions*
Children with diabetes or other immunocompromising conditions
† HIV‐infected, incarcerated, IV drug use*Low prevalence regions: US, Canada, Scandinavia, Western Europe, Australia, New Zealand
11/24/2015
24
Page 46
xxx00.#####.ppt 11/24/2015 5:07:51 PMPediatrics
PPD Limitations
False positives:
•Exposure to mycobacteria other than TB
•BCG vaccine
False negatives:
•Corticosteroid usage
•Other immunocompromise
•Viral suppression: measles, mumps, influenza
•Inter-observer variability
•Sliding scale for what is considered positive can be confusing
•Until very recently, lack of any confirmatory tests
Page 47
xxx00.#####.ppt 11/24/2015 5:07:51 PMPediatrics
IGRAs•Interferon-γ release assays (IGRAs) detect host response to Mycobacterium tuberculosis-specific antigens
•Two main tests currently FDA-approved:
‐T-SPOT.TB
‐QuantiFERON Gold In-Tube
•Offer several potential advantages over the tuberculin skin test (TST)
MMWR 2010;59(No.RR‐5):1‐14
11/24/2015
25
Page 48
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
Comparison of Skin Test & IGRA
Characteristic TST IGRA
Antigens studied Many -PPD ESAT-6, CFP-10, (TB-7.7)
Cross-reactivity with BCG Yes Unlikely
Cross-reactivity with NTM Yes Less Likely
Estimated sensitivity, TB in immunocompetent adults
75-90% 75-95%
Estimated specificity, TB inimmunocompetent adults
70-95% 90-100%
Distinguish between TB infectionand TB disease
No No
Boosting Yes No
Patient visits required Two One
Pediatr Infect Dis J 2006;25:941
Page 49
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
IGRAs: Advantages
•One visit: optimal if adherence issues
•Decreased confusion about interpretation: one cut-off irrespective of age, immune status, and TB risk factors
•Enhanced specificity: optimal for BCG-immunized persons
11/24/2015
26
Page 50
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
IGRA: Limitations
•Indeterminate results: decrease the utility of a screening tool
•One cut-off: is this appropriate across risk strata?
•Unknown dynamics of when assays become positive
•Discordance: interpretation if TST and IGRA provide different results
•Limited pediatric data: especially for the most vulnerable risk groups
Page 51
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
TB Risk Questionnaire
positive?
Age < 5 years?
BCG Vaccinated?
Screening Complete
TST Preferred
IGRA Preferred
TST or IGRA Acceptable
No
No
Yes
No
Yes
Yes
Algorithm for TB Testing in Children
Consider•Cost•Confidence in test •Ability to return
11/24/2015
27
Page 52
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
What to do with discordant results?
•In patients in whom disease is suspected or at high risk for progression from infection, treat if any test positive
•For patients without risk factors, treat if the more specific test is positive
Page 53
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
Acid-Fast Culture Yield
Specimen Culture Yield
Sputum/gastric aspirate 30-40%
Lymphatic tissue 75%
Pleural fluid 20-40%
Cerebrospinal fluid 20-50%
Pericardial fluid 0-42%
Ascitic fluid 30%
Skin biopsy 20-50%
Skeletal biopsy 75%
Paed Resp Rev 2007;8:107
11/24/2015
28
Page 54
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
So, Our Culture Yield is Horrible; Now What?
•Great contact investigations to identify source cases for our patients (cultures by proxy)
•Try new methods of obtaining cultures
Page 55
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
Gastric Aspirates
•Inpatient procedure
•Overnight fasting
•Lavage with NS if volume < 20cc
•Generally done qAM x3
•Inpatient costs substantial
•AFB smear yield: minimal
•AFB Culture yield: 20-30%
11/24/2015
29
Page 56
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
Induced Sputum
•Outpatient procedure•2-3h fasting period•Pretreated with salmeterol; nebulized saline, then CPT given
•Nasopharynx suctioned
•One specimen sufficient•Minimal costs•AFB smear yield: 50%•AFB Culture yield: 25-30%
Lancet. 2005;365:130
Page 57
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
TB Infection Control
•In the mid-1990s, TCH began to require that adults and adolescents accompanying inpatient children with suspected tuberculosis undergo chest radiography to rule-out infectious pulmonary TB
•A previous report from TCH [Muñoz et al. Infect Control Hosp Epidemiol 2002;23:568-572.] demonstrated that 15% of the adults accompanying hospitalized children with suspected tuberculosis had previously undiagnosed pulmonary TB
•Results from this study also showed that no healthcare worker who cared for a child with tuberculosis became infected [conversion of the TST]
Infect Control Hosp Epidemiol 2002;23:568 and 2011;32:188
11/24/2015
30
Page 58
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
When do we worry about it?
•Older adolescents
•Children with certain findings on CXR
•Producing sputum
•Any draining skin lesions
Infect Control Hosp Epidemiol 2011;32:188
Page 59
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
If we are worried, what do we do?
•N95 respirator for you
•Simple facemask (not N95) for patient
•Keep patient in room
11/24/2015
31
Page 60
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
Treatment
•TB exposure
•TB infection
•TB disease
Page 61
xxx00.#####.ppt 11/24/2015 5:07:52 PMPediatrics
TB Exposure
•Children < 5 years of age with a negative PPD, normal CXR and examination exposed to contact with suspected TB
•Provide chemoprophylaxis in the window period (8-10 weeks) pending repeat skin testing
•Children > 4 yrs of age also need sequential skin testing, but no window chemoprophylaxis
11/24/2015
32
Page 62
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Why Do We Do This?To Prevent This:
E.Q. 2009
Page 63
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Why do we treat TB infection?
•Risk of developing TB disease with untreated + PPD:
‐5-10% lifetime risk in most patients
‐40% risk in infants
‐5-10% annual risk in HIV-infected patients
•½ of lifetime risk in 1st 1-2 yrs after PPD conversion
•Remainder of risk evenly spread over lifetime
•We can reduce risk by 90-95% with INH
11/24/2015
33
Page 64
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Red Book Statement on TB Infection
•“All infants, children, and adolescents who have a positive PPD result but no evidence of TB disease and who have never received antituberculosis therapy should be considered for INH unless resistance to INH is suspected or a specific contraindication exists”
Red Book 2009, p691
Page 65
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Treatment: LTBIRegimen Pros Cons
INH x9m ~20% benefit over INHx 6m
Adherence (<50% completion)
INH x 6m Adherence better than 9m
Slightly reduced benefit compared with 9m (assuming both taken as indicated)
RIF x 4m Adherence, availability Cost if uninsured; drug interactions
INH/Rifapentine x 12 doses
Adherence Availability; requirement for DOPT
INH/RIF x 3-4m Adherence Slightly increased risk of side effects compared to monotherapy
RIF/PZA x 2m Adherence Hepatotoxicity; recommended for patients initially suspected of having disease
Curr Opin Pediatr 2014;26:106
11/24/2015
34
Page 66
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
LTBI Treatment Pearls•Use INH suspension only in children < 5 kg
‐Otherwise, give tablets that can be crushed & mixed with food
•Compliance with 9 months of INH averages a bit over 50%; be skeptical
•Use health department to administer medications to high-risk patients: infants, immunocompromised children, recent contacts
•When children aren’t tolerating INH, the problem is more often with the parent than the child
•Routine LFTs not indicated unless: concomitant administration of other hepatotoxic drugs; pre-existing liver disease; or signs/symptoms of hepatitis
Page 67
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Notes on TB DrugsDrug Side Effects Other notes
INH Peripheral neuropathy; seizures in overdose
B6 helps prevent neuropathy and is only treatment for INH seizures, but doesn’t prevent hepatotoxicity
RIF Orange discoloration of secretions; inactivates oral contraceptives; many drug interactions
Please warn of Longhorn‐orange urine!
PZA Can increase uric acid gout symptoms; rash
Of 1st‐line drugs, greatest association with hepatotoxicity
EMB Optic neuritis, red‐green color blindness
Despite side effects, has very poor CNS penetrance and not used for meningitis
*All primarily hepatically metabolized, except EMB, which is also renally excreted
Peds in Review 2010;31:13
11/24/2015
35
Page 68
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
CNS PenetranceDrug CNS Penetrance
Isoniazid Good
Rifampin Inflamed meninges only
Pyrazinamide Good
Ethambutol Inflamed meninges only
Ethionamide Good
Aminoglycosides Inflamed meninges only
Fluoroquinolones Good except for ciprofloxacin
My routine empiric treatment of TB meningitis (in addition to steroids):• Inpatient: INH, RIF, PZA, amikacin• Outpatient: INH, RIF, PZA, ethionamide (need to transition kids to this
while they are still hospitalized to make sure they don’t start vomiting with addition of ethionamide)
Page 69
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Expected Clinical Course for TB Disease in ChildrenSite Course
Pulmonary TB (parenchymal) 60‐70% abnormal CXR at conclusion of therapy
Intrathoracic adenopathy Takes > 1 year to resolve radiographically in many cases
Cervical lymphadenitis Often paradoxically worsen with onset of therapy; can see spontaneous fistulae formation. Resolution over months
TB meningitis Inflammation and symptoms often increase initially with therapy (hence use of systemic corticosteroids)
11/24/2015
36
Page 70
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Monitoring on Treatment
•Risk of drug toxicity very low
•Monitor clinically, as opposed to with laboratories
•Monitor/reinforce adherence
•Pulmonary TB and getting CXRs:
‐Baseline
‐At 2 months (before stopping EMB/PZA)
‐At end of therapy (if 2m CXR still abnormal)
Page 71
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Ethambutol in Children
Adults:
•Risk of optic neuritis:‐Visual acuity
‐Color perception
‐Dose related
‐Usually reversible
‐Risk around 1-3% in adults
Children:
•Metabolize EMB far faster than adults
‐Need higher mg/kg dose to achieve same serum levels
•Risk of optic neuritis far less than for adults
•There is no child too young to get EMB
•Can use even in the pre-verbal child
11/24/2015
37
Page 72
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Ethambutol in Children
SM Graham. Arch Dis Child 1998;79:274‐278.
Age # Method of evaluation Length of f/u (months)
# with toxicity
3‐13y 47 Visual evoked responses 15‐18 0
4m‐16y 36 Acuity/field/color perception 24‐48 0
1‐15y 45 Acuity/field/color perception 9‐18 0
4‐5y 30 Acuity/field/color perception 6 0
5‐15y 27 Acuity/field/color perception 12‐36 0
9‐16y 6 Computerized visual field examination 9 0
Page 73
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Fluoroquinolones in Children
•Initial clinical trials in children: not done
•Data from off-label use: cystic fibrosis, UTI, shigellosis, TB
•Most consider safe in children
‐Germany study, 1997: 2030 children treated, 1.5% had self-resolving arthralgia
•Consider risk/benefit:
‐Clearly beneficial for MDR-TB
‐Monitor for joint/tendon problems
Hampel et al. Pediatr Infect Dis J 1997;16:127
11/24/2015
38
Pediatrics
Pediatric TB Cases
Page 75
xxx00.#####.ppt 11/24/2015 5:07:53 PMPediatrics
Lymphadenopathy
11/24/2015
39
Page 76
xxx00.#####.ppt 11/24/2015 5:07:54 PMPediatrics
Clinical CaseCervical Lymphadenopathy
•8 yr old with cervical lymphadenopathy
•History:• LAN for 3 months•PMHx: Healthy
• BCG vaccine at birth•TB skin test 10 mm
•Physical Exam:• 3 cm anterior cervical LAN•1.5 cm supraclavicular lymphadenopathy
•CXR:•Hilar LAN, no infiltrates
•Is this TB disease?•What else could it be?
Page 77
xxx00.#####.ppt 11/24/2015 5:07:54 PMPediatrics
Hilar & Cervical Lymphadenopathy
•Differential Dx•Tuberculosis•Non TB mycobacteria (NTM)•Lymphoma/Leukemia•HIV•Other causes
•Diagnostic tests•Biopsy (FNA or surgical for culture and path)
•Interferon blood test for TB infection
11/24/2015
40
Page 78
xxx00.#####.ppt 11/24/2015 5:07:54 PMPediatrics
Results
•Fine needle aspirate of node:•Pathology: lymphoma, no TB by culture or microscopy
•Interferon Blood test for TB•Positive•Diagnostic for latent TB infection or disease
•Diagnoses:•LTBI• AND•Hodgkin’s Lymphoma
•Treatment:•Chemotherapy for lymphoma AND•INH daily for 9 months for LTBI
• consider prolonged treatment during immunosuppression
Page 79
xxx00.#####.ppt 11/24/2015 5:07:54 PMPediatrics
Skin Test in Foreign Born
11/24/2015
41
Page 80
xxx00.#####.ppt 11/24/2015 5:07:54 PMPediatrics
Skin Test in Foreign Born
•6-year-old with positive TST for school entry
•Born in Taiwan
•BCG documented on vaccination records at birth and BCG scar present
•TST measures 12mm
Page 81
xxx00.#####.ppt 11/24/2015 5:07:54 PMPediatrics
CXR normal
•How do you interpret the 12 mm skin test?
•Is this BCG effect or LTBI?
•Are there any other tests that may help?
11/24/2015
42
Page 82
xxx00.#####.ppt 11/24/2015 5:07:54 PMPediatrics
TB in Newborn Nursery
Pediatrics
11/24/2015
43
Page 84
xxx00.#####.ppt 11/24/2015 5:07:54 PMPediatrics
New Mother with Positive TST
•Newborn infant in hospital nursery•Mother with 15 mm TST•CXR: calcified granuloma no active disease•Not on treatment
‐What is mother’s diagnosis?‐Do mother or baby need isolation?‐May baby breast feed and room with mother?
Page 85
xxx00.#####.ppt 11/24/2015 5:07:55 PMPediatrics
Maternal TB disease or LTBI during pregnancy
Is mother contagious?
Exposure to contagious household TB contact:• Window prophylaxis for
baby• Multivitamin for baby• Okay to breastfeed
If no exposure to contagious household TB contacts:• No treatment for baby• Okay to breastfeed
No Yes
top related