Managing Pediatric tuberculosis

05/01/23 Aklilu Endalamaw 1

Seminar Presentation: Managing of Pediatric Tuberculosis 2016.

By: Aklilu Endalamaw (Department of pediatrics and child health nursing)

Seminar Presentation outline

• Epidemiology• Clinical features• Diagnosis modality• Differential diagnosis• Management• Key points• References


Objectives

• At the end of this session, you will be able to:• Describe the epidemiology of tuberculosis• Explain clinical features• Verify diagnosis modalities• List differential diagnosis• Manage pediatrics tuberculosis


Case study: Didimos, 5 year-old male, HIV+, returns

for follow-up complaining of dyspnea and dry cough

for 4 weeks. Work-up 2 weeks ago revealed normal

CXR and sputum AFB smear negative. Patient

reports no improvement after 10 day course of

doxycycline.

A.What additional information is needed to diagnose

and manage this patient?

B.What is the differential diagnosis?


Differential diagnosis

A. Additional information to be asked: that would support pericardial TB includes fever (often worse in the afternoon), wt loss, night-sweats, anorexia, orthopnea, and dyspnea on exertion & P/E( related with heart signs). repeat CXR and sputum examination.B. DDX: Pulmonary infections, such as TB, PCP, or possibly cryptococcus and a cardiomyopathy.


Repeated X-ray

•Current CXR shows an enlarged cardiac silhouette with clear lung fields; ddx includes pericardial effusion 2ndary to TB or cardiomyopathy

So, How can you manage it?


Cont…

• Adjuvant steroids (Anti-TB therapy plus prednisolone) are recommended for treatment of pericardial TB.

Let us check the correctness of our management, Move forward a slide & get the answer- Management of Pediatric Tuberculosis


why we are interested on tuberculosis?

1. Two billion people latently infected with TB in the

globe (WHO,2012).

2. HIV has contributed to a substantial increase in the

incidence of TB worldwide.3. TB is the 2nd leading cause of death following HIV

(WHO,2012).4. Each person with active TB will infect 10 to 15

people each year (WHO, 2002).


Cont…

5. TB is the most common cause of death among

AIDS patients worldwide -Kills 1 of every 3 AIDS

patients (WHO, 2014).

6. Rifampin resistance is also found among HIV-

infected patients with tuberculosis.


Cont…7. Primary PTB is most common in infants and children and has the highest prevalence in children under 5 years of age (Burrill J et.al, 2007) .8. Ethiopia ranks third in Africa and eighth among the 22 highest tuberculosis (TB) burdened countries in the world (HDP IV,2011). 9. Emergent of MDR/XDR TB10. High prevalence but preventable.


Mycobacterium

• M TB complex (M bovis, M africanus, M microti, M Tb).

Primary TB infection can be primary active or secondary active or latent Tb


Characteristics: Latent TB Infection Active TB Disease

M. tuberculosis in the body Yes Yes

Tuberculin skin test reaction Positive Positive

Symptoms No Yes

Chest x-ray Normal Abnormal if pulmonary

Sputum smears and cultures Negative *Positive/negative

Infectiousness Not Pulmonary TB is infectious

* May not be true in immuno-compromised individuals.

Latent TB Infection versus Active TB Disease:


How it can be diagnosed?

1. Clinical characteristics ( hemoptysis, cough

>2wks, fever>2 weeks, failure to thrive,

fatigue, night sweating, asymmetrical

wheeze, other non-specific, Based on site for

EPTB.)2. Smear sputum test. Below 6yr-Gastric aspiration

smear test.3. Chest X-ray05/01/23 Aklilu Endalamaw 13

Cont…4. Culture

5. Biopsy for extra-pulmonary TB

5. Interferon gamma release assay

6. Purified Protein Derivative (PPD) test-After initial

infection, it takes 2-10 wks to develop hypersensitivity

to the PPD test. Once positive, a PPD will always be

positive. Minimum recommended age for PPD: 3

months. ≥5mm in size- +PPD.Red Book 2009 ,p 68105/01/23 Aklilu Endalamaw 14

Negative PPD No need for CXR

-If recent close-contact exposure, repeat PPD in 8-10 weeks -To make sure you haven’t missed a new conversion

No TB infection


Variations of +PPD

Blisters, granulomas, local necrosis may occur05/01/23 Aklilu Endalamaw 16

Positive PPD Negative CXR

+

=Latent TB Infection05/01/23 Aklilu Endalamaw 17

Positive PPD TB-Positive CXR

+

= active TB05/01/23 Aklilu Endalamaw 18

TB: adults vs children• Compared to adults, children:

1.Tend to develop primary active TB more often

after initial infection (0-4yrs)

2.Are more likely to have extra-pulmonary

disease, especially TB meningitis (0-4yrs)

3.Are less contagious

4.Are more difficult to diagnose05/01/23 Aklilu Endalamaw 19

(Abhijit Mukherjee, et.al, 2014)

Cont…

6. A child with active TB is an indicator of an

unidentified contagious adult/adolescent with TB.

7. A child suspected of having active TB may not

yield any positive cultures/smears.

8. Need the adult contact’s culture results for drug

sensitivities and to determine treatment regimen

for the child.


(Abhijit Mukherjee, et.al, 2014)

TB Treatment• No differences in regimens: adult =child

1.Latent tuberculosis infection

A.Isoniazid susceptible: 9 months of

isoniazid/day. If daily therapy is not possible,

DOT twice a week can be used for 9 months.

B. Isoniazid resistant: 6 months of rifampin/

day. If daily therapy is not possible, DOT twice

a week can be used for 6 months.(Nelson, 2015)05/01/23 Aklilu Endalamaw 21

Cont…2. Pulmonary & EPTB: Active TB

•Except meningitis: 2 months of IRPE daily,

followed by 4 months of IR by DOT§ for drug-

susceptible Mycobacterium tuberculosis. 9-12

months of IR for drug susceptible

Mycobacterium bovis.(Nelson, 2015, MOH,2012)


Cont…TB meningitis : 9-12months

•2 months of IRPE/ day, followed by 7-10

months of IR/day or twice a week (9-12 months

total) for drug-susceptible M. tuberculosis. ≥12

months of therapy without pyrazinamide for

drug-susceptible M. bovis.

(Nelson, 2015, MOH,2012)


Cont…

• MDR and XDR TB: second line drug

– 4-6 drugs for 18-24 months.• HIV co-infection:

– ≥ 3 drugs for ≥ 9 months recommendedTb prevention:BCG vaccineProphylaxis: IsoniazidEarly treatmentHealth education

(Nelson, 2015, MOH,2012)


TB Medication issues

05/01/23 Aklilu Endalamaw 25(Drugs.com,2015)

Cont…• Food interactions:

INH & R: taken 1-2 hr before a meal

Ethambutal, PZA, ethioamide, amikacin,

capriomycin, para-aminosalicylic(PAS): taken with

food

Amikacin, streptomycin, capreomycin, PAS :

require increased fluid intake .


(Drugs.com,2015)

Key points• Any person with cough of two weeks or more is a

“Pulmonary TB suspect”.

• Treating TB takes priority over initiating ART:

Anti-TB treatment should be started immediately

after diagnosis whereas, ART could be delayed to

2-8 weeks after or as soon as TB therapy is

tolerated WHO,2013).

• Rifampicin have significant drug-drug interactions

with ARV.05/01/23 Aklilu Endalamaw 27

References• WHO. Global tuberculosis report 2012.• Global report: UNAIDS report on the global AIDS epidemic 2013.• Health Sector Development Programme IV. Annual performance

report. Addis Ababa, Government of Ethiopia, Ministry of Health, 2011.

• Burrill J, Williams CJ, Bain G et-al. Tuberculosis: a radiologic review. Radiographics. 27 (5): 1255-73. doi:10.1148/rg.275065176 - Pubmed citation

• Red Book 2009. Tuberculosis.• Pediatric practice: Infectious Disease. Ed: Shah,S. Chapter 36:

Childhood tuberculosis.• Nelson text book of pediatrics. 2015• MOH. Tuberculosis training manual. 2012.• CDC. Decrease in reported TB cases, 2009. MMWR March 19, 2010.

59(10); 289-294.• paediatric desk guideline for diagnosis TB in children, 2010, IUATLD


አመሰግናለሁ!!05/01/23 Aklilu Endalamaw 29

Managing Pediatric tuberculosis

Health & Medicine