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Introduction
This guide is based on the following article:
Management of tuberculosis in children in low-income countries.
P.M.Enarson, D.A.Enarson, R.Gie
INT J TUBERC LUNG DIS 9(12):1299-1304
which essentially contains a summary of a guide of International Union Against Tuberculosis and Lung Disease. The complete guide's title is "Management of Tuberculosis. A Guide for Low Income Countries". You may download it from the Union's site using this link:
IUATLD publications

All doctors handling children with tuberculosis should know that tuberculosis presents in two stages:
  • infection: a significant percentage of children coming in contact with a contagious adult will be infected
  • disease: in a smaller percentage of children infection will not be controlled by host defense and will progress to disease

What do we mean by infection
Sputum positive adults are responsible for tuberculosis spread. When these patients cough, droplets carrying mycobacteria are formed and expelled to their environment, infecting children. The percentage of children infected depends on the duration of contact (close contact 50%, casual contact 10%), the concentration of mycobacteria in droplets, the age of the child and on whether the adult's environment is a poorly ventilated, close space.

A negative-sputum adult with pulmonary tuberculosis is less probable to be contagious. An adult with extrapulmonary tuberculosis is almost never contagious.

Infected children have a positive tuberculin skin reaction after 6 weeks - 3 months. Symptoms of infected children are usually mild or absent.

Children with a documented contact with a sputum-positive adult should be examined for symptoms and signs of tuberculosis. Children with a documented contact AND symptoms of tuberculosis should be considered to have tuberculosis until further testing confirms or not the diagnosis. Children with symptoms should be checked for tuberculosis and if positive should be treated accordingly. All other chilrdren groups (asymptomatic and those with negative xray, cultures, PCR etc.) should receive chemoprophylaxis because they are in high risk of developing disease in the future.

Most children control infection and do not progress to disease. In a small percentage of childen the immune system cannot control infection and present tuberculosis.

What do we mean by disease
A child develops tuberculosis when infection progresses to disease. The risk of tuberculosis is higher the first year after infection. The risk is also significant in children under 5 yrs of age, especially the first two years of life. The same age groups have a higher possibility of severe tuberculosis. Other high risk groups are children with AIDS or malnutrition.

The incidence of pulmonary disease in infants is 30-40% and that of tuberculous meningitis or disseminated tuberculosis is 10-20% due to the immaturity of their immune system. The second year of life the incidence falls to 10-20% and 2-5% respectively, dropping further with increasing age until they reach adult levels in adolescence.

Diagnosis
We consider that a child under 5 yrs developed tuberculosis when there are:
  • proof of infection (positive tuberculin skin reaction) or certain contact with a contagious patient
  • symptoms or signs of tuberculosis
  • radiographic findings suggestive of tuberculosis

Children meeting ALL THREE CRITERIA have tuberculosis, are recorded and treated.

Common symptoms in children are:
  • chronic cough (lasting at least 3 weeks), showing no improvement, especially if the child has already received antibiotics
  • fever higher than 38.8 C lasting more than 14 days, not attributable to other causes
  • weight loss or insufficient weight gain

Common signs in children are:
  • sudden onset of spine deformity (kyphosis)
  • non-tender lymph node swelling, especially of in the neck
  • pneumonia, unresponsive to antibiotics
  • pleural effusion
  • abdominal distention or ascites
  • meningitis presenting gradually over several days

A significantly positive TST (at least 10 mm even with prior BCG administration) is an indication of tuberculosis. By definition, a positive TST in children indicates "recent infection", and as we already said, the possibility of developing tuberculosis is greater the first year after infection and increases with decreasing age.

Immunosuppressed children may have a false negative TST and active disease because of: AIDS, severe malnutrition, after measles or other severe viral disease, in case of severe tuberculosis, when receiving steroid or other immunosuppressive drugs.

Most children developing disease have an abnormal chest xray. The following points are important:
  • The most common findings are unilateral enlarged hilar or paratracheal lymph nodes with an associated parenchymatous lesion.
  • Besides an abnormal xray, to establish the diagnosis of tuberculosis, there should be proof of infection AND symptoms or signs suggesting tuberculosis. The only exception to this rule are findings of desseminated tuberculosis: treatment should beging immediately in this case.
  • Radiologic findings may be difficult to identify and require an experienced medical officer. The Union has published a relevant guide: "Diagnostic atlas of intrathoracic tuberculosis in children. A guide for low income countries".

Sputum cultures are usually negative in children. If positive a diagnosis of tuberculosis is established beyond doubt..

Children with any of the following findings should be referred to an experienced medical professional:
  • hepatomegaly or splenomegaly (indication of disseminated tuberculosis)
  • nuchal rigidity or drowsiness (indication of meningitis)
  • respiratory distress or unilateral wheezing (enlarged lymph nodes compressing bronchus)
  • hear failure (indication of pericardial effusion)

Children with HIV infection need special consideration because:
  • the possibility of their parents developing tuberculosis and being contagious is high and so is the risk of a child being infected
  • infection progresses to disease more frequently and more rapidly
  • symptoms AND radiologic findings of tuberculosis are often the same with those of other lung diseases affecting HIV-positive patients
  • TST is often false negative



Next week: "TREATMENT OF TUBERCULOSIS"


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