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Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

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Page 1: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...
Page 2: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Pediatric TB Intensive Houston, Texas

October 14, 2013

Extrapulmonary TB in Children Kim Connelly Smith, MD, MPH

October 14, 2013

Page 3: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Kim Connelly Smith, MD, MPH has the following disclosures to make:

• No conflict of interests

• No relevant financial relationships with any commercial companies pertaining to this educational activity

Page 4: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Extrapulmonary TB the Great Imitator

• Nonspecific symptoms

• Location: anywhere in body

• Mimics other more common diseases

• Broad differential diagnosis

• TB diagnostic tests not very sensitive – Lab tests often negative due to paucibacilary disease

• Obtaining specimens may require: – Hospitalization

– Invasive procedures

• When laboratory tests negative, diagnosis is made on clinical grounds

Page 5: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Extrapulmonary TB Disease Sites

• Lymphadenitis • Central nervous system • Miliary • Pleural • Bone and joint • Abdominal TB in lymph

nodes or solid organs • Genitourinary • Otitis media and mastoiditis • Pericardial • Ocular • Cutaneous

Page 6: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Common Symptoms

• Fever

• Enlarged peripheral lymph nodes

• Neurologic or central nervous system symptoms

• Cough

• Weight loss

• Palpable mass

• Night sweats

Page 7: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

TB Disease

Pulmonary

Extrapulm

15% 85%

Pulmonary

Extrapulmonary

25% 75%

• Adult TB Disease • Pediatric TB Disease

Page 8: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Lymphatic 25%

Pleural 23%

GU 16%

Meningeal 4%

Bone/Joint 10%

Miliary 9%

Other 13%

Adult Extrapulmonary TB Disease (15%)

Lymphatic

Pleural

GU

Meningeal

Bone/Joint

Miliary

Other

Page 9: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Lymphatic 65%

Meningeal 14%

Pleural 6%

Miliary 5%

Other 5%

Bone/Joint 5%

Extrapulmonary TB Disease in Children (25%)

Lymphatic

Meningeal

Pleural

Miliary

Other

Bone/Joint

Page 10: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Diagnosis of TB Disease

• Culture is the gold standard for TB diagnosis – Collect tissue or fluid for culture – 2-8 weeks for results – Low sensitivity in children and extrapulmonary TB

• Combination of findings important – Risk factors – Contact testing/exposure history – Skin testing and/or IGRA blood test may help – Radiographic findings suggestive of TB – Pathology from tissue biopsies may suggest TB – Rule out other diseases

Page 11: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

TB Cultures and AFB Smears • Sensitivity poor due to low number of bacteria

• Lymph nodes

Biopsy or FNA for path and culture AFB smears: usually negative Culture sensitivity: 30-70%

• TB meningitis

High volume sample (>6 ml CSF) improves culture yield

AFB smears negative 98% Culture sensitivity: 12-50% (Ave 20%)

• Nucleic acid amplification tests (NAAT) -

Future new tool for extrapulmonary TB

• Negative test does not rule out TB

Page 12: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

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TB Meningitis

Page 13: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Case • 15 month old

– Fever, irritability and cough for 7 days – Treated for otitis media – Developed ataxia 2 days prior to admission – Admitted with acute seizure

• History – Past medical history, healthy – Traveled to India to visit GM at 8 months – Grandmother with cough, later found to

have TB

• Labs – CSF WBC 223, 70% Lymphs – CSF Protein 178

• MRI – Hydrocephalus, leptomeningeal

enhancement

Page 14: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

Initial MRI at Diagnosis Follow up MRI in 2 months

Page 15: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Diagnosis of TB Meningitis

• Clinical criteria including exposure history

• CSF findings

• CNS imaging

• Evidence of TB elsewhere

• Exclusion of other causes

Page 16: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

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Clinical Criteria

Principi. Tuberculosis 92 (2012) 377-383

Page 17: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

TB Meningitis

Youssef FG, et al. Diagn Microbiol Infect Dis 2006;55(4):275-8

Page 18: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

TBM Clinical and CSF findings

British Infectious Disease Society. Jr of Infection (2009) 59, 167-187

Page 19: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

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Diagnostic Evidence of TB Meningitis

• Basal meningeal enhancement

• Hydrocephalus

• Tuberculoma

• Infarcts

• Radiographic evidence of TB outside CNS

– CXR/CT suggestive of TB

• Miliary

• Hilar LAN

• TB Cx + from another site

– Sputum, GA, Bx, urine, blood

• Positive NAAT

• Brain MRI or CT Suggestive of TBM

• Evidence of TB Disease Elsewhere

Page 20: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Comparison of CT findings in children with TB meningitis

Study Total

Patients

Children # Hydrocephalus

(%)

Basal enhancement

(%)

Infarcts (%) Tuberculoma

(%)

Artopoulos 9 9 100 11 44 56

Bhargava 60 36 83 82 28 10

Farinha 33 33 94 93 33 15

Kingsley 25 12 72 67

Kumar 94 94 81 83 19 24

Leiguarda 65 65 89 69 38 27

Patwari 136 136 32 13 27

Waeker 30 30 100 37 37

Andronikou 37 37 68 89 62 13.5

Altunbasak 52 52 98 52 25

De 21 21 76 67 50 10

Kemaloglu 156 156 46 22 4

Ozates 289 214 80 15 14 4

Tung 7 7 100 14 29

Upadhyaya 59 59 100 6 8

Schoeman 198 198 83 75 38 11

[

Adapted from Andronikou S. Pediatr Radiol. 2004 34(11):876-85

Brain CT Findings in TB Meningitis

Page 21: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...
Page 22: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

TB Meningitis Treatment and Clinical Course

9-12 months RIPE therapy Better CNS penetration with ethionamide

Steroids for 1-2 month with 2-3 week taper Decreases CNS inflammation

Repeat brain imaging recommended 1-2 months after treatment started

Possible complications Prolonged fever and/or worsening symptoms common initially

Seizures

Hydrocephalus

CNS tuberculoma, stroke, mental disabilities, CP

Mortality high (>90%) if not diagnosed and treated

Page 23: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

TB Meningitis Outcome

Doerr, Starke, Ong. J Pediatr. 1995 Jul;127(1):27-33. Clinical and public health aspects of tuberculous meningitis in children.

Page 24: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Extrapulmonary Cases

Page 25: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...
Page 26: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Congenital TB Case o Mother

o Pneumonia diagnosed at 34 wks of pregnancy

o TST Omm, no known exposure

o Treated with azithromycin & pneumonia resolved

o Baby

o Became ill 4 weeks after birth

o Developed extensive pneumonia and hilar LAN

o Progressed to respiratory failure

o Required ECMO

o AFB smear positive from tracheal aspirate grew MTB, pan susceptible

Page 27: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...
Page 28: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Outcome • Mother

– Repeat TST after baby diagnosed, 15mm

– CXR normal, no other source identified

– Uterine biopsy showed granulomas consistent with TB endometritis

– Treated for uterine TB disease

• Baby – Treated 12 months for miliary and TB meningitis

– Required home oxygen and NG tube feedings for 8 months

– Healed with complete recovery and no sequella

Page 29: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...
Page 30: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Tuberculosis, In Remington JS, Klein JO (eds): Infectious Diseases of the Fetus and

Newborn Infant. Philadelphia, WB Saunders, 1983, p576.)

Page 31: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Congenital Tuberculosis

• Congenital TB disease very rare

– Only 200-300 cases reported

– Higher risk if mother has primary or disseminated TB during pregnancy

• Postnatal transmission via exposure to pulmonary TB disease more common

Page 32: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Teen Case • 17 year old Hispanic female

Abdominal pain and fever for 10 days

• Past Medical Hx: Healthy

US born, no history of BCG vaccination

• Social:

High school student

No drugs or alcohol, is sexually active

Lives with her 15 mo baby, her boyfriend and his parents

No known TB exposure, parents from Mexico

• Physical exam: Lungs normal

Nodes: no lymphadenopathy

Abdomen: tender with guarding

Pelvic exam: + cervical motion tenderness

Page 33: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Differential Diagnosis

• Pelvic inflammatory disease

• Appendicitis or ruptured appendix

• Ovarian abscess or torsion

• Ectopic pregnancy

• Lower lobe pneumonia causing acute abdomen symptoms

• Mesenteric lymphadenitis

Page 34: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Teen Case Labs and Radiographs

• STD testing

• HIV, GC, Chlamydia, RPR – all negative

• Pregnancy test negative

• Abdominal CT

– nonspecific inflammation

– large peritoneal effusion

– normal appendix

– no lymphadenopathy or masses

Page 35: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...
Page 36: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

T2-weighted MRI shows the high signal intensity peritoneal fluid (F).

Enhancement of the peritoneal surface indicates peritonitis (arrow).

Abdominal CT and MRI

Page 37: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Teen Case, cont

• Exploratory laparotomy by GYN

“Caseous material” from fallopian tubes

• Culture from laparotomy specimen

AFB smear negative

M. tuberculosis identified on culture

• Contact investigation of household

Patient TST negative, O mm

Household Members:

5/7 with LTBI, TST positive & CXRs normal

2/7 TB Disease:

Father-in-law, TST negative, chronic cough, CXR with cavitary disease, AFB smear and culture positive

Page 38: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Teen Case

• Diagnosis based on Clinical picture

Pneumonia

Caseous surgical material

Other diagnoses ruled out

Contagious adult source case identified

MTB on Culture (2-8 weeks later)

Page 39: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

TB Lymphadenitis

Page 40: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Cervical Lymphadenitis • 4 year old girl with acute 4 cm anterior cervical LAN • PMH

– Strep throat treated 1 week prior – Severe head lice and scalp dermatitis – Otherwise healthy

• TST 11 mm • CXR normal • Social

– US born, no BCG – Grandparents from Mexico – Uncle with cough

Page 41: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Cervical Lymphadenitis, cont

• Differential diagnosis – Reactive LAN from strep throat and/or head lice

– Tuberculosis or nontuberculous cervical LAN

– Other causes

• Management options – Treat common/acute diseases first

– Gather more information, contact investigation

– +/- RIPE, now or later

– +/- Biopsy

Page 42: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Cervical LAN • Outcome

– LAN treated with clindamycin

– Head lice and scalp dermatitis treated

– TB treatment held until follow up

– LAN resolved in 2 weeks

– Patient treated for LTBI

• Contact investigation

– Uncle diagnosed with pulmonary disease

– Multiple family members with LTBI

Page 43: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Teen Case

• 15 year old AA boy with 5 week history Abdominal pain

Cough, fever, 20 lb weight loss

Denies high risk behavior

No foreign travel or known TB exposure

• Physical 220 lb, football player

Cervical LAN

Abdomen normal, no HSM

Lungs clear

• TST: negative, O mm

• CXR normal

Page 44: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Teen Case, cont

Laboratory: • CBC –

H/H 9.6/29, WBC 16, PLT normal

Peripheral smear negative for cancer

• ESR – 83 (normal < 20)

• HIV – negative, x 2

• CT of neck and abdomen Lymphadenopathy

Page 45: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

Abdominal CT shows multiple lymph nodes with low attenuation centers and prominent rim enhancement (arrow).

Page 46: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

Neck CT

Page 47: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Teen Case of Lymphadenopathy Case, cont

• Differential diagnosis Lymphoma, leukemia HIV, EBV, other disseminated infections Tuberculosis

• Laboratory IGRA - positive Node biopsy:

AFB smear negative TB culture positive at 5 weeks for MTB Susceptible to all drugs

• Treatment RIPE, 9 months total for disseminated disease

Page 48: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Bone Disease

• 3 year old Hispanic boy

• 2 months of knee pain and limping

• Physical exam: knee with swelling and tenderness

• Knee x-ray with mass in femur

• Seen at MD Anderson Hospital for suspected cancer

Page 49: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Bone Disease

• X-ray

– Mass vs chronic osteomyelitis

• ESR 67

• Biopsy

– Path: + granuloma

– No evidence of cancer

– AFB negative

Page 50: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Bone Disease

• Patient’s PPD 20 mm

• Contact Investigation: Mother, father and father’s girl friend PPD positive

• Source case identified

– Father’s girl friend with pulmonary disease

• Bone biopsy grew MTB on culture

• Treatment: RIPE for 12 months

Page 51: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Bone Disease

• 15 year old female

• Headache, back pain, fever and paresthesias

Page 52: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

Potts Disease or TB Spondylitis

Page 53: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

9 year old boy-TB Exposed

• Child with 5 mm TST

• Father with pulmonary TB disease

Page 54: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

9 year old exposed to dad with TB

TST 5 mm

Initial CXR

No treatment started

Page 55: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

6 weeks later Fever and respiratory difficulty

Page 56: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

TB Pleural Effusions

• Uncommon in children

– 1-2% cases in US

• More common in boys and adolescents

• Usually unilateral

• 70% associated with parenchymal disease

• Cultures

– Pleural fluid often culture negative

– Pleural biopsy and/or sputum best specimens for culture

Page 57: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Treatment of Extrapulmonary TB

• Medications

– RIPE therapy standard

– Isoniazid, rifampin, PZA and ethambutol

• Duration

– 6 months for lymph node disease

– 9 months recommended for multisite disease

– 9-12 months for bone and joint and TB meningitis

• Steroids standard for 1-2 months for TB meningitis followed by 2-3 week taper

Page 58: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Expected Clinical Course for Extrapulmonary TB Disease

• Hilar Lymphadenopathy – Months, sometimes years for regression on x-ray

• Lymphadenitis – Swelling may obstruct airways or GI tract

– Often gets worse before improves

– May rupture and drain

– Months, rarely years for regression

• Meningitis – Inflammation increases initially with treatment

– Fever common for 2-3 weeks but may persist for months

– Tuberculoma, infarcts and/or hydrocephalus may develop weeks after diagnosis and treatment started

Page 59: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

EXCELLENCE EXPERTISE INNOVATION

Summary Extrapulmonary TB

• Children at higher risk for extrapulmonary TB especially TB meningitis

• Diagnostic dilemma common • Consider and rule out other diseases • Tissue diagnosis and/or culture important

– FNA or surgical biopsy if indicated – Low sensitivity due to paucibacilary disease

• Full resolution is a long process • Paradoxical reactions may occur

– Symptoms may worsen initially before gradual improvement

Page 60: Pediatric TB Intensive :: Extrapulmonary TB in Children ... TB in Children Kim Connelly Smith, MD, ... Steroids for 1-2 month with 2-3 week taper ... no HSM Lungs clear •TST: ...

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