Pediatric 2

Lecturer : Dr Asma Ahmed

Chapter : 3
Pulmonary Tuberculosis in Childhood
 Overview
 Aetiology
 Pathogenesis
 Natural history
 Presentation
 Diagnosis
 Treatment
 Prevention
 Introduction
Disease caused by Mycobacteria tuberculosis complex(tuberculosis,
bovis, caprae, africanum, microti, pinnipedii, canetti)

Family-Mycobacteriaceae
 Order-Actinomycetales

Non spore forming,non motile,pleomorphic,weak G+

Curved rod 0.5Um-3Um
Obligate aerobe

Slow growth-12 -24hr generation time

 Epidemiology
 2 billion of world population infected(1/3)
 8-10 million cases - children1.3m (11%) annually with 3-5million
deaths – children (0.45m)
 75% of the childhood cases occur annually in 22 high
burden countries contributing 80% global burden:
8 of which are in Africa
 Increasing incidence due to HIV/AIDs, migration, poverty,
social strife, crowding, healthcare access and inadequate
control programmes
 Highest 25-44yrs, <5yrs, elderly,
 5-15yrs lowest ‘safe school years’
 Transmission, exposure, infection

• Transmission-inhalation(>98%)
-ingestion, innoculation,vertical
• infection- risk-duration of exposure
(exogenous) -proximity to infectious source
-infectiousness of source (adult
cavitatory)
-poverty; housing/crowding,
prevalence
 Infection to disease

60-80% of <2yrs have radiological abnormalities

Influencing factors -age
(endogenous) -nutritional status
-immune status; drugs,dz-HIV
 Pathogenesis
 Transmission is primarily through inhalation (>98%) after
contact with an infectious adult
 Ingestion (M.bovis)/inoculation/congenital (rare)
 Most bacilli killed by alveolar epithelium but some persist
within the inactivated macrophages
 Spread through the lymphatic vessels to regional lymph
nodes
 Cont …………………
 Primary infection is indicated by
1. ghon focus formation with lymph node infection
2. development of cellular immune response about 4 to
6wks (up to 12wks) after primary infection
3. positive TST, which may be only evidence of infection
 Primary lesion may heal with fibrosis and calcification; or
continue to enlarge leading to focal
pneumonitis/pleuritis
 Cont ………………..
 Progression of disease occurs by:
-extension of primary focus (+/- cavitations)
-enlargement of lymph nodes
-lymphatic/hematogenous spread (lung apices, kidney,
bones/jnts, CNS etc)
 Complications may include atelectasis due to
partial/complete obstruction of bronchus by enlarging
lymph nodes; erosion of bronchial wall by caseum
leading to endobronchial TB/ fistula formation; pleural
effusion/pleuritis
 Cont ……………….
 Children who develop disease usually do so within 2yrs
following infection/exposure (i.e primary TB).
 This rapid progression is partly due to immature immune
system
 Young children (vs older children/adults) rarely infect
other children/adults as
-tubercle bacilli are sparse in endobronchial secretions
-cough absent/lacks enough force
 Cont ………………..
 Time between initial infection and clinical manifestation
of disease varies.

 Disseminated/ meningeal TB being early manifestations

(2-6mo)

 From 25-35% of children with TB develop extrapulmonary

manifestations, vs about 10% in immunocompetent
adults
 Cont …………………..
 Reactivation TB is rare in children but common in
adolescents and young adults.
 Most common form is infiltrate/cavity in upper lobes
where oxygen tension and blood flow is great
 5-14yrs appear to be resistant and have lowest rates of
TB disease-not clear why
 Cont ………………….
 TB (especially extra pulmonary) in a pregnant woman is
associated with greater risk of prematurity, IUGR, LBW,
perinatal mortality
 Congenital infection is likely to occur if mother has primary
infection just before or during pregnancy
 Can be transplacental (therefore to fetal hepatic cells,
lungs, rest of body) or by swallowing/aspirating infected
amniotic fluid
 Diagnosis
 Challenge
-mimic other childhood diseases eg.malnutrition,
pneumonia, generalised bacterial/viral infection
-small sputum volume which is usually swallowed
 Bacteriological dx10-15% sputum +ve and up to 70%
culture negative
 Treatment usually on clinical grounds aided by
-exposure history
-clinical features
-immunological evidence
-radiological findings
 Diagnosis of PTB in children
 Careful history including history of contact/symptoms
consistent with TB
 Clinical examination (including growth assessment)
 Tuberculin skin testing
 Bacteriological confirmation, where possible
 Relevant investigations
 HIV testing
 Remember to assess for the risk factors
 Key features suggestive of TB
If 3 or more of the following are present, they strongly
suggest a diagnosis of TB
 Chronic symptoms suggestive of TB
 Physical signs suggestive of TB
 Positive tuberculin skin test
 CXR suggestive
 Examination
 Physical signs highly suggestive of extrapulmonary TB
-gibbus (esp recent onset)
-non painful LN (+ fistula formation)
 Physical signs requiring investigations to r/o
extrapulmonary TB
-Pleural/pericardial effusion
-non painful LN (- fistula formation)
-non painful enlarged joint
-ascites
-signs of tuberculin hypersensitivity
 TST
• Mantoux test most commonly used
• Can be an adjunct to diagnosis (with clinical features/
investigations)
• Useful for screening, but a neg test doesn’t mean no
disease
• In high risk children : >5mm induration
• all other children >10mm considered positive
 Anti TB Treatment
• Main aims
-cure the patient of TB by rapidly eliminating most of
bacilli
-prevent death from active TB/complications
-prevent relapse
-prevent development of drug resistance
-decrease transmission to others
 Prevention
 Early detection and treatment of adult infectious cases

 Preventive treatment for children under 5 years of age

who are in contact with cases of sputum smear positive
PTB

 Universal use of BCG