Tuberculosis

TB is usually suspected in the following circumstances: 

• Unexplained loss of weight or failure to thrive 
• Coughing for longer than 2 weeks 
• Unexplained fever for more then 2 weeks 
• Night sweats 
• Localised lymphadenopathy (especially cervical, often matted), hepatosplenomegaly, consolidation, pleural effusion and clubbing 
• Suggestive appearance on Chest X ray 
• Possible TB Contact 
• Should always ask, why do we not need to exclude TB? 

A history of a confirmed family or close TB contact (including drug sensitivities of contact) is very important. It is essential to define that a confirmed contact is a close or household contact with tuberculosis. Malnourished, immunosuppressed (HIV and AIDS) and children under 3 years with pulmonary tuberculosis (PTB) are always regarded as having a very serious disease. 

New TB cases per year: 

Child with positive TB contact 

• A positive history of a TB contact requires a full TB work-up: 
• If child is well: Mantoux negative and CXR normal and under 5 years: 
  • Refer to local clinic for TB prophylaxis and follow up. Refer telephonically and by letter and write the name of the clinic and contact person in the patient’s notes. 
• If child is ill: Admit for Mantoux, CXR, 2 gastric aspirates for TB MC&S. 

NB: Find out what is the TB sensitivities of the contact. 

A routine TB work-up consists of 

• Chest X ray 
• Mantoux skin test 
• Two early morning gastric washings for TB MC&S 
• Induced sputum collection for TB MC&S (can be arranged with the physiotherapist) 

Diagnoses of TB: 

• Suggestive history, clinical picture and TB contact 
• CXR: Hilar or mediastinal lymphadenopathy, alveolar shadowing, airway compression, pleural effusion or cavities. 
• Mantoux: A strongly positive tuberculin test ( 10mm or more in HIV negative child or 5mm or more in a HIV positive child). If TB is likely and the Mantoux negative consider repeating it after 4-8 weeks. 
• Gastric washings positive for AFBs or positive culture (take up to 6 weeks). 
• TB Culture can be done from: Early morning gastric aspirate, Induced sputum (younger children), Sputum (older children), CSF, Pleural and Ascitic fluids, Fine needle aspirate biopsies of lymphnodes, ear swabs in chronic otorrhoea. 
• Abdominal U/S for lymphadenopathy. 

Diagnosis and Evaluation of Extrapulmonary TB

TB TREATMENT: 

A. Uncomplicated pulmonary TB: 

Start combination treatment according to TB drug dosing chart 2013. (See Appendix back of book). Start Rifampicin/Isoniazid 60/60mg Tablets (Rimactazid) according to weight and add Pyrazinamide orally daily dose. 

B. Complicated TB (Excluding TB Meningitis): 

Start combination treatment according to TB drug dosing chart 2013. Start Rifampicin/Isoniazid 60/60mg Tablets (Rimactazid) according to weight. Add Pyrazinamide and Ethambutol orally daily dose. Refer all complicated TB children for specialist care. These include: 

Drug-susceptible or presumed drug-susceptible TB who are smear-positive 

• Cavitatory TB, mediastinal lymphadenopathy with airway compression 
• Extensive or severe TB (Extra-pulmonary TB, Disseminated disease, e.g. abdominal or military TB) 
• All HIV/TB co-infected cases 

C. TB meningitis: 

Start combination treatment according to TB drug dosing chart 2013. (See Appendix back of book). Need higher doses, with Ethionamide as 4th drug. If nausea / vomiting with daily dose, split drugs 2 drugs in morning and 2 drugs at night. Refer all TB meningitis patients for in hospital specialist care. 

D. MDR or XDR TB: 

If suspected, refer to TB specialist urgently. 

Important notes on TB treatment: 

• All children with suspected or proven TB should have an HIV test: if HIV-infected should be commenced on TB treatment and referred to the nearest HIV clinic for assessment for ARVs 
• Drug dosages should be adjusted on a monthly basis according to the current weight of the patient 
• All children with severe forms of TB (TB meningitis, miliary TB, TB peritonitis, spinal or skeletal TB) and those suspected of having multi-drug resistant (MDR) TB (in contact with MDR TB case or not responding to first-line therapy) should be referred for expert opinion and management 
• Prednisone 2-4mg/kg/dose (maximum dose 60mg) orally daily x 4 weeks then tapered over 2 weeks is added to the treatment regimen for patients with TB meningitis, pericardial TB, airway obstruction due to mediastinal lymphadenopathy and miliary TB 
• For children who experience persistent vomiting associated with taking TB medication consider dividing the dose and administering twice daily (particularly ethionamide) 
• Supplemental pyridoxine (usually 12.5mg (1/2 tablet) in children & 25mg (1 tablet) in adults once daily) is recommended particularly in malnourished patients and patients receiving ARVs 
• Complete the TB Register and make a note in the Road to Health Card 
• Ask about other children or adults in the household and screen them for TB 

On discharge 

On discharge write a script for the treating clinic, fill in triplicate referral form, notify case and complete patient summary. Refer to Sonstraal TB Hospital if parents are unreliable. Book follow-up for all complicated TB patients in IDC clinic Paarl POPD. Book with Sr Steyn in POPD Tel number: 021-860 3097. 

Drugs for the treatment of multidrug-resistant Tuberculosis (MDR TB) in children

TB Drug Formulations