TB in Children The diagnostic challenge Ralph Diedericks Red Cross Hospital
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