Paediatric aspects of Tuberculosis

Patricia Fenton Sheffield Children’s Hospital BSMT 12th May 2006

Challenges
 Rare disease  Children susceptible  Variable presentation  Dissemination common  Rarely “smear positive”  Drug treatment difficult  Must locate source adult

 In Sheffield Children’s Hospital we don’t see very much .Paediatric TB is rare  We know this because….

Children are susceptible Smear positive adult plus Child in same house equals 50% chance Geuns et al 1975 .

Swimming is good for you  Smear positive life guard  3.764 children traced  108 infected nonswimmers>swimmers Rao et al 1980 CHILDREN ARE SUSCEPTIBLE .

Dangerous times Up to 5 years  Dissemination  Meningitis 5 to puberty  LN and skeleton Adolescence  Pneumonitis  Hilar adenitis VARIABLE PRESENTATION .

Variable presentation  Stage 1 – primary complex  Stage 2 – haematogenous dissemination  Stage 3 – pleurisy  Stage 4 – bones and joints May just have a fever .

BCG – bile and glycerol flavour  Bovine mastitis strain  Passaged 230 times  1921 oral  Lubeck disaster 1930 (73 died)  WWII freeze dried .

Prevents dissemination?  1950 UK schools  1960 selected neonates  Efficacy 0 to 80%  Prevents meningitis  JCVI weighed evidence  CMO letter July 05 .

Bacille Calmette-Guérin  Improved programme  Targeted  Neonatal  Others at risk NO MORE SCHOOL PROGRAMME .

000  Parents or grandparents born where…  Unvaccinated new immigrants from areas.  School children screened for risk factors .New arrangements  Local arrangements (logistics and training)  No more Heaf – mantoux  All infants living where TB > 40/100..

Challenge PCTs HAVE A HUGE RESPONSIBILITY To ensue new arrangements are robust .

Rarely “smear positive” ADULT  Pulmonary  Productive  Sputum CHILD  Different sites  Not productive  Gastric washings?  Induced sputum?  BAL?  LN biopsy?  Bone marrow? .

Gastric washings  Single room  3 nights  Pass NG tube  Starve overnight .

Induced sputum  Negative pressure  Masks FFP3  Gloves  Apron  Nebulised saline FRIGHTENING .

Tissue  General anaesthetic .

Treatment  Start on suspicion  Cannot swallow tablets  Four drugs  Taste  Volume  Long course of treatment .

Contact tracing  Household  Close relatives  School  Social groupings  Abroad  The unexpected .

Tuberculous meningitis  Symptoms >6 days  Optic atrophy  Focal neurology  Abnormal movements  Neutrophils < half .

MPS Casebook February 2006  Term baby  Mum European  Dad N African  Triple/polio  BCG section blank  Noted to visit N Africa for 2 months – no BCG given .

Seven months old  Visit to GP  Noted smokers in home  Scattered coarse transmitted chest sounds  Salbutamol ? Asthma  Mum felt salbutamol helped  Letter to local housing authority .

Nine months old  Vomiting  High temperature  Listlessness  Coarse transmitted sound at lung bases  3 GP visits in as many days  CXR and abdo XR abroad – not repeated .

Five days later  Still vomiting  Staring blankly  Not moving right arm  Blurred disc margin on fundoscopy  Urgent neuro opinion .

Neurosurgical assessment  Cavitating lesion  Left cerebrum  Hydrocephalus  Tuberculous meningitis  Limited motor ability and unintelligible speech .

This case illustrates  Non-specific symptoms  Irreversible damage  Missed opportunity to follow BCG guidance .

Challenges  Rare disease  Children susceptible  Variable presentation  Dissemination common  Rarely “smear positive”  Drug treatment difficult  Must locate source adult .

Conclusion .