Tuberculosis, Pulmonary In Children
Description Diagnostic criteria General and supportive measures Medicine treatment Referral ICD-10 code: A16.9 *Notifiable condition. DESCRIPTION A chronic, granulomatous disease of the lungs caused by M. tuberculosis. Most children acquire tuberculosis from infected adults by inhalation. Malnourished, immunosuppressed (HIV-infected) and children < 3 years of age with pulmonary tuberculo
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
Referral
ICD-10 code: A16.9
*Notifiable condition.
DESCRIPTION
A chronic, granulomatous disease of the lungs caused by M. tuberculosis.
Most children acquire tuberculosis from infected adults by inhalation. Malnourished, immunosuppressed (HIV-infected) and children < 3 years of age with pulmonary tuberculosis (PTB) are always regarded as having serious disease.
Complications include:
- enlarged hilar and mediastinal lymphadenopathy with obstruction, e.g. tracheal or bronchial airway compression or occlusion with secondary atelectasis or hyperinflation;
- local spread of infection, e.g. TB bronchopneumonia, pleural effusion or cavitation;
- disseminated disease, e.g. miliary TB, TB meningitis and metastatic extrapulmonary involvement.
DIAGNOSTIC CRITERIA
|
Any child presenting with symptoms and signs suggestive of pulmonary TB is regarded as a child with TB if there is: - A chest X-ray suggestive of TB. AND/OR - History of exposure to a person with infectious TB. The diagnosis is supported by a positive rapid TB molecular test (e.g. GeneXpert®) if a specimen can be obtained. Culture, usually on gastric aspirates, induced sputum or other appropriate sample, is a confirmatory test. |
- Signs and symptoms include (not an exhaustive list):
- unexplained weight loss or failure to thrive,
- lack of energy, child is less playful,
- unexplained fever for ≥ 2 weeks,
- chronic, unremitting cough for > 14 days,
- lymphadenopathy (especially cervical, often matted),
- hepatosplenomegaly,
- consolidation and pleural effusion on chest examination.
- The following may be evident on chest X-ray:
- Direct or indirect evidence of hilar or mediastinal adenopathy with or without parenchymal opacification and/or bronchopneumonia, miliary changes, or pleural effusions.
Note:
Miliary pattern on chest X-rays of HIV-infected children may also be suggestive of a diagnosis of lymphoid interstitial pneumonitis (LIP). (The miliary pattern of TB extends into the periphery of the lungs whereas LIP usually does not).
- Exposure to an adult with symptoms of TB or known pulmonary tuberculosis.
- Tuberculin skin test (TST), e.g. Mantoux
- A positive TST has an induration of ≥ 10 mm.
- A TST may be falsely negative in the presence of:
- malnutrition,
- immunodeficiency, e.g. HIV,
- immunosuppression, e.g. steroid therapy, cancer chemotherapy,
- following overwhelming viral infection, e.g. measles or post vaccination.
In these circumstances a TST induration of ≥ 5 mm may be regarded as positive. Frequently, the TST will be non-reactive in these cases and a decision not to start TB treatment should not be based on a negative TST test.
- M. tuberculosis is suggested by a positive rapid TB molecular test (e.g. GeneXpert®) and confirmed by culture on the following specimens, noting that most children will not have microbiological confirmation of TB:
- early morning gastric aspirate (empty stomach, no oral food intake for ≥ 4 hours),
- sputum (older children),
- induced sputum,
- stool (if testing is available),
- CSF,
- pleural and ascitic fluids,
- fine needle aspirate biopsies of lymph nodes,
- ear swabs for tuberculosis culture in chronic otorrhoea.
GENERAL AND SUPPORTIVE MEASURES
- Identify and treat persons considered to be the TB source.
- In case of known contact with a person with DR TB, the child requires referral for appropriate DR TB prophylaxis or treatment.
- Screen all close contacts for symptoms and signs of TB disease.
- Provide TPT to child and high-risk adult contacts (HIV-infected) once TB disease excluded.
- Monitor the nutritional status of the child to assess response to treatment.
- Only symptomatic pleural effusions should be drained via pleural aspiration (in such cases consider adjunctive steroid therapy).
- Ensure household infection control practices.
- Refer for nutrition support.
MEDICINE TREATMENT
Tuberculosis control programme drug regimens (2013) and Circulars
Directly observed therapy (DOT), short-course, using fixed medicine combinations is used to avoid the development of antimicrobial resistance.
Give treatment daily in both the intensive (initial) and the continuation phase.
HIV-infected children with tuberculosis should be treated according to the standard treatment protocol with clinical, radiologic and microbiologic followup to determine response to treatment.
| Recommended dose ranges in mg/kg | ||
| Daily | Max. daily | |
| Isoniazid (H) | 10–15 | 300 mg |
| Rifampicin (R) | 10–20 | 600 mg |
| Pyrazinamide (PZA/Z) | 30–40 | 2 g |
| Ethambutol (EMB/E) | 15–25 | 1200 mg |
Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 10: Tuberculosis, 10.2 Tuberculosis, Pulmonary In Children
Click here for 10.2.1 Non-severe Tuberculosis Disease
Click here for 10.2.2 Severe Tuberculosis Disease