Tuberculosis in Children II

TUBERCULOSIS OF SUPERFICIAL LYMPH NODES

Occurs within 3-9 months of primary infection

Can affect any group of nodes
May be unilateral or bilateral
Glands are usually discrete, mobile, firm and non-tender
but later become matted together if there is periadenitis
May form a discharging sinus
There may or may not be associated constitutional
symptoms.

Investigations
- Tuberculin skin test
- CXR
- Fine needle aspiration biopsy or excision of nodes for
histological exam.
 Differential Diagnosis

• Pyogenic lymphadenitis
• Hodgkin’s lymphoma
• Acute lymphocytic leukemia
• Fungal infection of lymph
nodes
• Infection with atypical
mycobacteria
• HIV/AIDS
 ABDOMINAL TUBERCULOSIS

Comprises
Tb of the gastrointestinal tract
Tb of the abdominal lymph nodes
Tb of the peritoneum

Tuberculous enteritis
- Occurs as a result of haematogenous spread from a
primary focus or by swallowing tubercle bacilli which
have been coughed up.
- Jejunum and ileum near the payers patches are the
most common sites
- Shallow ulcers occur in these areas.

CLINICAL FEATURES
Abdominal pain
Diarrhoea or constipation
Weight loss
Fever
 TUBERCULOUS MESENTERIC
ADENITIS
- Arises as a result of spread from tuberculous enteritis
- The lymph nodes become enlarged and matted
together with omentum and peritoneum
- May become palpable as a firm mass

Clinical Features
Diarrhoea or constipation
Weight loss
Abdominal mass
+ Features of sub acute intestinal obstruction
 TUBERCULOUS PERITONITIS

May arise from haematogenous spread or

from direct extension from an abdominal
lymph node infection or intestinal focus.

Clinical Features
Fever
Abdominal swelling due to ascites
Mild tenderness
 Investigations

Tuberculin skin test

CXR
Plain abdominal xray
Ascitic tap for bacteriological studies
Abdominal ultrasound
Differential Diagnosis
Abdominal Malignancies
 TUBERCULSIS OF THE SPINE
The vertebrae are the commonest and most important
Bones affected by tuberculosis in children.
May arise by:
 Lymphatic spread from an adjacent area
 Haematogenous spread from a primary focus

Clinical Features
Pain in the back
Spinal rigidity and limitation of spinal movement
Kyphosis
Scoliosis with or without gibbus
Increased muscle tone
Decreased muscle power which may progress to paralysis
There may be quadriplegia if the cervical vertebrae are affected
or paraplegia
if the other vertebrae are affected.
There may be loss of voluntary bladder control
 Investigations

Tuberculin skin test

CXR
Radiograph of the affected part of the vertebral column

Complications
Paraspinal abscess
Psoas abscess
Retropharyngeal abscess

Differential Diagnosis
• Idiopathic scoliosis or kyphosis
• Acute non-tuberculous osteomyelitis of the spine
• Rickets
• Secondary malignancies affecting the CNS e.g. Burkitt
lymphoma ‫واحد‬
• Histoplasmosis Duboisii of the spine
 TREATMENT

Mainstay of treatment is combination

chemotherapy
Treatment is divided into 2 phases
- Intensive phase – 1st 2 months
- Continuation phase – 6 months
To improve compliance directly observed
therapy (DOT) is desirable at least during the
intensive phase.
 CURRENTLY USED REGIMEN

Short course therapy:

INTENSIVE PHASE : 2 MONTHS
1. STREPTOMYCIN OR ETHAMBUTOL
2. PYRAZINAMIDE
3. ISONIAZID
4. RIFAMPICIN
CONTINUATION PHASE : 6 MONTHS
1. RIFAMPICIN
2. ISONIAZID
OR
1. ETHAMBUTOL
2. ISONIAZID
 Dosages and Side Effects of Anti Tb
drugs
Drug Dosages
Side-effects

Streptomycin 20-40mg/kg/day
-Toxicity to 8th nerve

- Rash
- Renal damage

7. Isoniazid 10-15mg/kg/day - Peripheral

neuritis
- Hepatotoxicity
- Psychosis

3. Rifampicin 10-20mg/kg/day - Orange

discoloration of
urine and tears
- Gastrointestinal
disturbance
- Hepatotoxicity
-
Thrombocytopenia
 Dosages and Side Effects of Anti Tb drugs
Contd.
Drug Dosages Side-effects

3. Thiacetazone 3-5mg/kg/day - Skin

rash
- Hepatotoxity
- Haemolytic
anaemia
- Steven-
Johnson’s
syndrome in

patients with

HIV/AIDS

11. Ethambutol 15-20mg/kg/day

- Optic neuritis
 Indication for corticosteroid

• Large pleural effusion

3. Endobronchial tuberculosis

5. Pericardial effusion

4. Tuberculous meningitis
 Supportive Therapy

Improved Nutrition
Screening of immediate family
members
Surgical intervention where
necessary
Prevention of TB in a community

• Case-finding and effective treatment.

• Contact tracing and INH
chemoprophylaxis.
• BCG vaccination.
• Improvement in the general standard
of living.
 Newborn Infant of a mother with
Tuberculosis:

Mother’s treatment should be commenced

or continued if already started.
Baby should start INH soon after delivery
and continued till mother’s sputum has
been negative thrice.
After this, the infant should have mantoux
test:
- If mantoux is negative, INH should be
discontinued and child vaccinated with
BCG
- If mantoux is positive, infant should
have CXR.
– If CXR is normal, continue INH for 12
 DRUG RESISTANCE

There are three types

Natural:
- Wild strain which is resistant to a particular
drug without ever being in contact with the drug.
Acquired or secondary:
- The strain develops resistance to a drug to
which it was initially sensitive.
Primary:
- When a patient with acquired resistance is the
source of the infection.
Multi drug resistance:
- Mycobacterium resistant to a number of
antituberculous drugs
including INH and rifampicin.
 TB AND HIV/AIDS

Children who acquire HIV by MTCT are also likely to be

exposed to TB
HIV Infection:
– Increase the severity of TB in children
– Morbidity is more prolonged
– Mortality is high
– Treatment may take longer to be effective.
HIV and TB increase the side effect from anti- TB drugs
especially thiacetazone.
Antiretroviral drugs affect the blood levels of anti -TB
drugs