PEDIATRICS 2

TUBERCULOSIS IN CHILDREN / DR. TEVES / AUG 15, 2017

Reading the TST

OBJECTIVES
 To review the diagnosis and management of childhood TB
 To address common issues on TB
TUBERCULOSIS
What is the burden of illness?
 Major public health problem in the Philippines
 In 2010, TB was the 6th leading cause of mortality
 NTP survey 2007: annual risk of TB infection – 2.1%
 More than 80% of these active TB will be contagious
 Transmit TB infection – perpetuating TB cycle
Age group for contagiousness is 15 years old and above
What happens after exposure to TB?
Innate immune system can clear the infection immediately  No
evidence of TB exposure
Growth of organisms can be controlled/contained but not stopped by
immune response  Latent infection(Exposed and positive to skin test)
 Should be read between 48-72 hours after administration
 (+) TSTs can be measured accurately for up to 7 days
 (-) TSTs can be read accurately up to 72 hours only
 Interpretation of result is the same for persons with BCG
 A TST that was not measured and recorded must be repeated
Repeat 6 weeks or 3 months after
Cut-off points
10 mm or >
 Regardless of BCG status
5mm or >
 In any of the ff:
- History of close contact with a known/suspected
infectious TB case
- Suggestive clinical findings of TB
- Suggestive Chest Xray findings of TB
- Immunocompromised condition(HIV positive)

MTB organisms can begin to proliferate immediately  Primary TB Limitations of the TST

DIAGNOSIS  Intradermal injection must be administered properly

 Patient must return for the reading 48-72 hours later
 Measurement of the induration must be done correctly
LTBI TB DISEASE
No symptoms of TB With Symptoms of TB Detecting a test to detect LTBI
(+) TST or IGRA TST or IGRA usually
(+) IGRAs preferred for
Normal Chest Xray Chest X-ray usually
abnormal; may be  People with poor rates of returning for TST reading, those
normal in with BCG vaccine
immunosuppressed - TST and IGRAs should not be used at the same time
or extra pulmonary
disease
TST preferred for
Respiratory Respiratory
specimens are specimens are
smear/culture usually  Children <5 years
negative smear/culture(+);  Either TST or IGRA may be used without preference for other
may be (-) in groups
early/minimal  Routine testing with both TST and IGRAs is NOT recommended
pulmonary/extra-
disease THE OTHER TESTS- IGRAs
Exposure usually Exposure usually
uncertain uncertain
Who do we test?
 Interferon-Gamma Release Assays
- Immunocompromised, active exposure, those with clinical o Quantiferon TB Gold in-Tube test (QFT-GIT)
manifestations o T-SPOT-TB
 Blood test that measures a person’s immune reactivity to
How do we test? specific myobacterial antigens
 If infected with MTB, the WBC’s recognize the stimulated
The tuberculin Skin test antigens and release IFN-y.
 Results are based on the amount of IFN-y released.
 Intradermal injection of 0.1 ml of 5TU PPD-S or 0.1 ml of 2TU
PPD-RT 23
 Evident pale wheal of 6-10 mm diameter
 Otherwise, repeat test 2 inches away from original site

Trans Group: PASCUA, TINTE, VILLAR

Edited By: MLP
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TOPIC: TUBERCULOSIS

KEY POINTS- IGRAs other preventive treatments are not considered as previous TB
treatment.
b.) Retreatment case: A px who has previously been treated
Advantages Limitations with anti-TB treatment for at least 1 month in the past.
Requires a single patient visit Blood sample must be
processed within 8-16 hrs 4.) Classification based on Drug Susceptibility Testing
No booster phenomenon* Limited data exist in use in: a.) Monoresistant TB: resistance to 1 first-line anti-TB drug
Less reader bias than TST <5 yrs, recent exposure to TB, only.
Unaffected by BCG and most Immunocompromised, serial
b.) Poly-drug resistant TB: resistance to more than 1 first-
environmental mycobacteria testing
line anti-TB drug (other than both INH and R)
*If you do PPD skin test, the more you do PPD skin test..nagkakaroon
c) MDR-TB: resistance to at least both INH and R.
ng so-called “Booster phenomenon”, nagkakaroon ng false-positive
d.) XDR-TB: resistance to any flouroquinolone and to at least
reaction.
one of the three second-line injectable drugs (capreomycin,
Kanamycin, and Amikacin), in addition to multidrug resistance.
DIRECT SPUTUM SMEAR MICROSCOPY
e.) Rifampicin-resistant/ RR-TB: resistance to Rifampicin
 DSSM- recommended for case finding among patients who
detected using phenotypic and genotypic methods, with or without
can expectorate.
resistance to other anti-TB drugs. It includes any resistance to
 Provides a definite diagnosis of active TB; simple,
Rifampicin, whether monoresistance, PDR or XDR.
economical; microscopy center easy to put up
 Can monitor progress of TB patients; confirm cure and at end
CASE FINDING
of treatment.
*The limitations of this test is that, nagkakaroon ka ng positive result in
Procedures
DSSM kapag advanced na yung TB. In pediatrics, marami pa sa 10
 Identification of Presumptive TB
ang nakita ko na nag-positive for DSSM. This is not a basis if you have
o via clinical signs and symptoms
a negative result for this one.
o 15 yrs old and above, a presumptive TB has any
XPERT MTB-RIF ASSAY
of the ff symptoms:
 Rapid diagnosis of TB and drug resistance (R) in <2 hrs with
 Cough of at least 2 weeks duration with or
minimal technical training
without the ff symptoms:
 A nucleic acid amplification test
 significant and unintentional wt
 Sputum sample is collected and mixed with reagent loss.
 Does not replace cultures  fever
 hemoptysis
PATIENT CLASSIFICATION
 chest/ back pain not referable to
Classiification of TB Diseases
any musculoskeletal d/o
 easy fatigability
1.) Classification based on Bacteriological status
 night sweats
a.) Bacteriologically-confirmed: A TB patient from whom a
 dyspnea
biological specimen is positive by smear microscopy, culture or rapid
diagnostic tests (XPERT MTB/RIF)
o Below 15 years old: *night sweats and fever are not
b.) Clinically-diagnosed: A PTB patient who does not fulfil
common presentation
the criteria for bacteriological confirmation but has been diagnosed
o At least 3 of the ff criteria:
with active TB by a clinician who has decided to give the px a full
 coughing/ wheezing of 2 weeks or more,
course of TB treatment; based on CXR abnormalities or suggestive
especially if unexplained
histology, and extra-pulmonary cases without laboratory confirmation.
 Unexplained fever of 2 weeks or more
 loss of wt/ failure to gain wt/ loss of appetite
2.) Classification based on Anatomic site
 failure to respond to 2 weeks antibiotics
a.) PTB: refers to a case of TB involving the lung
therapy for lower respi. tract infection
parenchyma. A px with both pulmonary and extra-pulmonary TB
 failure to regain previous state of health 2
should be classified as a case of PTB. *TB confined within the lung
weeks after a viral infection or exanthema
b.) EPTB: refers to cases of TB involving organs other than
 fatigue, reduced playfulness, lethargy
the lung (larynx, pleura, LN, abdomen, genitor-urinary tract, skin,
bones, joint, meninges). Histologically diagnosed TB. Laryngeal TB,
o Any one (1) of the above signs and symptoms in a
though likely sputum-smear positive, is considered an exta-pulmonary
child who is a close contact of a known TB case.
case in the absence of lung infiltrates on CXR.

o Below 15 yrs old who are smear-negative but can

3.) Classification based on History of Previous Treatment
expectorate, refer to an Xpert MTB/RIF site if
a.) New Case: A px who has never had treatment for TB, or
accessible. If px has no access to an Xpert MTB/RIF
who has taken anti-TB drugs for <1 month; INH-preventive therapy or

“I have told you these things, so that in me you may have peace. In this world you will have trouble. But
take heart! I have overcome the world.”- John 16:33 (NIV)
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 PEDIATRICS 2
TUBERCULOSIS IN CHILDREN / DR. TEVES / AUG 15, 2017

site or cannot expectorate, perform TST. If TST is negative, request for HOW DO WE TREAT LTBI?
CXR.  What does LTBi means?
Positive in TST only, with or whithout exposure, without
A. Decide to treat as active TB if the child has any 3 of the
symptoms, and negative xray findings. We need to give INH
following criteria:
for 6 months. It used to be for 9 months. That is the new TB
guidline of 2016. Unfortunately, not all pulmonologists follow
I. Positive exposure to an adult/ adolescent with active TB disease
this.
II. Positive Tuberculin Test (a positive TST confirms TB infection after
exposure) CLINICAL FORM REGIMEN REMARKS
PPD conversion 6H If primary H
III. Positive signs and symptoms suggestive of TB within past 1-2 resistance, give 6R
years, (-) CXR
IV. Abnormal chest radiograph suggestive of TB *MC: Hilar PPD (+) not due to 6H 6H for <5yrs
BCG, (-) CXR (-)
lymphadenopathy
previous TX
PPD (+) with stable/ 6H -
V. Laboratory findings suggestive or indicative of TB
healed lesion (-)
previous Tx
B. If patient fulfils 3 out of 5 criteria, classify as clinically- PPD (+) with stable - -
diagnosed PTB. healed lesion,(+)
previous Tx at risk
C. If patient does not fulfil at least 3 out of 5 criteria, investigate of reactivation due
further or refer to specialist. to

D. CXR findings suggestive of PTB, with or without symptoms, -Measles, pertussis

regardless of age etc.
-Conditions
E. Presumptive EPTB may have any of the ff: including
immunosuppression
HIV infection, or at - -
o Gibbus, recent onset (vertebral TB)
risk but status
o Non-painful enlarged cervical lymphadenopathy with or unknown
without fistula formation *what will cause cervical
lymphadenopathy? Viral, Bacterial, Dental carries, current
cold/cough
o Neck stiffness/ Nuchal rigidity and/ or drowsiness suggestive
Table 11.5 Recommended treatment regimens for adults and
of meningitis that is not responding to antibiotic treatment, children
with a subacute or raised ICP
o Pleural effusion Category of Classification and Treatment
o Pericardial effusion Treatment Registration Group Regimen
o Distended abdomen with ascites Category I Pulmonary TB, new 2HRZE/4HR
(whether 2 months
o Non-painful enlarged joint bacteriologically Intensive phase
o Signs of tuberculin hypersensitivity confirmed or clinically- isoniazid,
diagnosed) rifampicin/ 4
HOW DO WE TREAT TB EXPOSURE? Extrapulmonary TB, new months
(whether Maintenance
Clinical Regimen Remarks bacteriologically- phase
TB Exposure 3H -For >5 years, confirmed or clinically-
recommend diagnosed) except
specifically if with risk CNS/bones or joints.
factors Category Ia Extra-pulmonary TB, new 2HRZE/10HR
-For both groups, re- (CNS/Bones or joints)
evaluate after 3 longer treatment
months, re-classify
Category II Pulmonary or 2HRZES/1HRZE
and treat accordingly
extrapulmonary, /5HRE
-6 H IPT for <5 years; previously treated
assess q 2 mths drug- susceptible TB
-for 5-18 years: bacteriologically-
observe confirmed or clinically-
-NTCP MOP 2014 diagnosed)
 Relapse
 Treatment after failure
 Treatment after Lost to
Follow up (TALF)
Trans Group: PASCUA, TINTE, VILLAR
Edited By: MLP
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TOPIC: TUBERCULOSIS

 Previous treatment  Hyperaeration/EBTB- 3 weeks

outcome unknown
 Other
Category IIa Extrapulmonary, 2HRZE/1HRZE/9
previously treated drug HRE
susceptible TB
(whether
bacteriologically
confirmed or clinically-
diagnosed)
SIDE EFFECTS
 INH
 Peripheral neuropathy because INH interferes with
pyridoxine metabolism
 routine use of pyridoxine in
children is NOT recommended except if
child is symptomatic, breastfeeding or
on a pyridoxine-deficient diet
 Hepatotoxicity; monthly clinical monitoring; D/C
INH if transaminase levels are >3xULN in
symptomatic patients, or 5x ULN in asymptomatic
patients (drug induced liver injury)
 Restart after AST returns to <2x
ULN (THZ in weekly intervals)
 RIF
 Gastrointestinal upset most comon; skin rash
and thrombocytopenia less often; orange
discoloration of body fluid.
All medications should be given 1 hour before
meal or at least, breakfast. More effective if taken
wihout meal. Or at least, two hours after dinner.
That’s why they have GI upset or stomach pain.
This is causing problem with TB treatment in
pediatrics because patients take them with meal to
lessen the GI effects but it also lessens its
therapeutic effect or the effectivity
compromised.
 All anti-TB drugs may cause rashes. All patients who develop
rashes, all the medications should be stopped. Then start
again all the meds after 2 weeks.
Is post treatment Xray needed? Not Mandatory.
 After 6 months of treatment or after 6 mo
of INH tx alone, or after 4 drug-regimen,
yes you may, BUT repeat xray should only
be the basis.
 If Xray is positive for primary TB, it is not
an indication to repeat the management.
The literature says SIX months is enough.
You have to correlate your xray findings
with clinical (?).
 In their practice, If after 6 months, the
patient is non-compliant, symptomatic, no
weight gain, xray is still abnormal and still
with cough, YOU MAY EXTEND
TREATMENT for another 3 months. But in
literature, in 6 months, stop.
 Normal Chest xray is not an indication to
discontinue treatment.
 Chest Xray is only a baseline for
comparison for diagnosis and assessment
not basis of treatment. For future
references
CLINICAL APPROACH TO TB
First diagram, if there is risk factors LTBI, exposureor progression to
TB, skin test is mandatory.
If there’s no risk factor, or exposure, no need to do the skin test.
DIAGRAM 1.1
is

 Severity determines management

 MINOR: Affects a limited area; give oral anti-histamine;
continue anti-TB meds
 MAJOR: petechial rash with thrombocytopenia suggest
hypersensitivity, stop R
 Generalized erythematous rash with fever and
mucuos membrane involvement-stop all drugs;
rash subsided, restart one by one; R- H-E-Z-S with
2-3 days interval
POST TREATMET CXRAYS

 Consider resolution of radiologic findings:

 Hilar lymph nodes- 2-3 years
 Miliary TB- 7-22 months
Miliary systemic or hematogenous spread
of TB in all organs. The presence of millet
seeds in TB is an outright indications, will
not need TST or sputum. Consider it TB!
 Pulmonary infiltrates- 2-9 months
 Pleural Effusion- 6-12 weeks

“I have told you these things, so that in me you may have peace. In this world you will have trouble. But
take heart! I have overcome the world.”- John 16:33 (NIV)
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TOPIC: TUBERCULOSIS

In summary, Exposure (+) then give INH and do PPD. If PPD is

positive, you may continue that patient’s treatment for 6 months and
DIAGRAM 1.2 consider as LTBI. If PPD is (-) then repeat the PPD after 3 months.
Then if the PPD became (+) positive after 3 months, then do CXRAY.If
CXRAY is negative, then consider as LTBI and treat for 6 months INH.
If CXRAY if positive, treatment for TB new patient.

RECOGNITION OF CP FAILURE
 Cardiopulmonary arrest in infants and children is rarely a
sudden event.
 Most cardiopulmonary emergencies in children are primarily
respiratory not cardiac in origin.
 It is often the end result of progressive deterioration in
respiratory and circulatory function.
 Regardless of the initiating event or disease process, the
final pathway is the development of cardiopulmonary failure
and possible cardiopulmonary arrest.
 Early recognition and effective management of the problems
are critical to the survival of the patient.
 Normal vital functions are maintain (ABC’s)
By To provide
Airway Ventilation
Breathing Oxygenation
Circulation Perfusion

RAPID CARDIOPULMONARY ASSESSMENT- physical

examination

 RESPIRATORY ASSESSMENT
Airway patency
 If negative in skin test/TST (-) and no exposure (-)= no need
- maintanable
for tx.
- unmaintanable
 Exposure (+), TST (-) = repeat skin test after 3 months. - requires adjuncts/ assistance
 Exposure (+), TST (-) = you can give INH, and repeat skin Breathing
test after 3 months. - Rate
 On repeat PPD, TST (-) = stop INH. - Mechanics/effort
 On repeat PPD, TST (+) from previously negative= you need - Air entry
- color
to xray. Evaluate the patient if the patient is having
symptoms. Then, consider as TB disease and give  CIRCULATORY ASSESSMENT
appropriate treatment. - Heart rate
 (+) TST, (-) x-ray= LTBI, give INH for 6 months. Rifampicin - Blood pressure- central pulses
for INH-resistant-Mtb. - Peripheral pulses
- Skin perfusion- CRT, T< color
DIAGRAM 1.3 - CNS perfusion- level of consciousness or
responsiveness

“I have told you these things, so that in me you may have peace. In this world you will have trouble. But
take heart! I have overcome the world.”- John 16:33 (NIV)
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