Pulmonary Tuberculosis in Children: Clinical Case and Viva QnA

Clinical Case: Pulmonary Tuberculosis in Children

Case Presentation

A 6-year-old boy presents with a 3-month history of persistent cough, intermittent fever, and weight loss. His mother reports night sweats and decreased appetite. The family recently immigrated from a high TB-endemic country.

Physical Examination

• Weight: Below the 5th percentile for age
• Temperature: 38.5°C
• Respiratory rate: 28 breaths/min
• Chest auscultation: Bronchial breathing in the right upper zone
• Palpable cervical lymphadenopathy

Investigations

• Chest X-ray: Right upper lobe infiltrate with hilar lymphadenopathy
• Mantoux test: 18mm induration
• IGRA (QuantiFERON-TB Gold): Positive
• Sputum microscopy: Acid-fast bacilli seen
• GeneXpert MTB/RIF: Mycobacterium tuberculosis detected, Rifampicin resistance not detected
• HIV test: Negative

Diagnosis and Management

Diagnosed with pulmonary tuberculosis. Started on standard four-drug regimen: Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol. Contact tracing initiated for family members.

Varieties of Presentation of Pulmonary Tuberculosis in Children

1. Primary Pulmonary TB

   Most common in young children. Features include persistent non-remitting cough, low-grade fever, and failure to thrive. Chest X-ray may show hilar lymphadenopathy and/or lung infiltrates.

2. Reactivation TB (Post-primary)

   More common in adolescents. Presents with chronic cough, hemoptysis, weight loss, and night sweats. Chest X-ray often shows upper lobe infiltrates and cavitations.

3. Miliary TB

   Severe form seen in young or immunocompromised children. Presents with high fever, severe weight loss, respiratory distress, and sometimes meningeal signs. Chest X-ray shows diffuse miliary nodules.

4. Endobronchial TB

   Presents with persistent wheezing, cough, and sometimes atelectasis due to bronchial obstruction. May mimic foreign body aspiration or asthma.

5. Pleural TB

   More common in older children and adolescents. Presents with chest pain, dry cough, and sometimes fever. Chest X-ray shows pleural effusion, often unilateral.

Knowledge Check: Question and Answers

This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.

What are the key differences between pediatric and adult pulmonary tuberculosis?

Key differences include: 1) Children more likely to develop primary disease rather than reactivation, 2) Higher risk of dissemination/severe disease, especially in young children, 3) Often paucibacillary disease making diagnosis challenging, 4) More frequent extrapulmonary involvement, 5) Better treatment outcomes with appropriate therapy.

How does age affect the risk and manifestations of pediatric TB?

Age-related patterns: <2 years: highest risk of dissemination/meningitis, frequent severe disease; 2-10 years: 'favorable' age with better outcomes; >10 years: adult-type disease with cavitation more common. Infants have highest mortality risk without treatment.

What is the typical natural history of primary TB infection in children?

After primary infection: 90-95% develop Ghon complex (primary focus + lymphadenopathy), most heal spontaneously. 5-10% develop progressive disease within 2 years. Risk factors for progression include age <2 years, malnutrition, immunosuppression, and HIV infection.

Describe the clinical manifestations of pulmonary TB in children.

Manifestations include: 1) Persistent cough >2 weeks, 2) Failure to thrive/weight loss, 3) Intermittent fever, 4) Night sweats, 5) Fatigue/reduced playfulness, 6) Lymphadenopathy (especially cervical), 7) Often subtle in early disease. Young children may present with non-specific symptoms.

What are the radiological patterns of pediatric pulmonary TB?

Common patterns include: 1) Hilar/mediastinal lymphadenopathy (most common), 2) Primary focus in mid/lower zones, 3) Miliary pattern in disseminated disease, 4) Pleural effusions in older children, 5) Cavitation less common than adults. Serial imaging important for monitoring.

How do you approach diagnosis of TB in children given the paucibacillary nature?

Diagnostic approach includes: 1) History of contact, 2) Clinical features, 3) TST/IGRA, 4) Chest imaging, 5) Bacteriological confirmation when possible (gastric aspirates/induced sputum), 6) Gene Xpert MTB/RIF. Clinical scoring systems may aid diagnosis.

What are the current recommendations for TB screening in children?

Screening recommended for: 1) Contacts of active TB cases, 2) HIV-infected children, 3) Children starting immunosuppressive therapy, 4) Immigrants from high-burden countries, 5) Symptomatic children with risk factors. Uses combination of symptoms, TST/IGRA, and chest X-ray.

Compare and contrast TST and IGRA tests in pediatric TB diagnosis.

TST: Affected by BCG/environmental mycobacteria, requires return visit, age-specific cutoffs. IGRA: More specific, not affected by BCG, single visit, more expensive, may be less reliable in <2 years. Both can be false negative in severe disease.

What are the principles of treating pediatric pulmonary TB?

Treatment principles: 1) Always multi-drug therapy, 2) Standard regimen: 2HRZE/4HR, 3) Weight-based dosing, 4) Directly observed therapy when possible, 5) Regular monitoring for compliance/side effects, 6) Treatment duration may extend in severe/complicated cases.

How do you monitor treatment response in children with pulmonary TB?

Monitoring includes: 1) Clinical improvement (symptoms, weight gain), 2) Serial chest X-rays, 3) Microbiological follow-up if initially positive, 4) Regular LFT monitoring, 5) Height/weight tracking, 6) Assessment of adherence. Clinical response often best indicator.

What are the indications for hospital admission in pediatric TB?

Admission indicated for: 1) Severe disease/respiratory distress, 2) Significant complications, 3) Young infants (<6 months), 4) Social concerns affecting treatment adherence, 5) Need for diagnostic procedures, 6) Suspected drug resistance requiring complex management.

How do you manage TB exposure in neonates?

Management includes: 1) Separation from infectious mother only if mother has MDR-TB or poor adherence, 2) INH prophylaxis for 3-6 months, 3) BCG delayed until prophylaxis completed, 4) Close monitoring for symptoms, 5) Treat if disease develops. Mother can breastfeed if adherent to treatment.

What are the challenges in diagnosing drug-resistant TB in children?

Challenges include: 1) Difficulty obtaining specimens, 2) Often paucibacillary disease limiting DST, 3) Need to rely on source case's DST, 4) Limited diagnostic tools, 5) Non-specific symptoms. Molecular methods (Gene Xpert) helpful when available.

Describe the approach to managing MDR-TB in children.

Management requires: 1) Confirmed DST when possible, 2) At least 4-5 effective drugs, 3) Longer treatment duration (18-24 months), 4) More intensive monitoring, 5) Management of side effects, 6) Often requires expert consultation, 7) Consider therapeutic drug monitoring.

What are the common adverse effects of anti-TB drugs in children?

Common effects include: 1) INH: hepatotoxicity, peripheral neuropathy, 2) Rifampicin: hepatotoxicity, orange secretions, 3) Pyrazinamide: arthralgia, hepatotoxicity, 4) Ethambutol: optic neuritis (rare in children at recommended doses). Regular monitoring essential.

How do you approach TB-HIV co-infection in children?

Management includes: 1) Early ART initiation (within 2-8 weeks of TB treatment), 2) Attention to drug interactions, 3) Immune reconstitution monitoring, 4) Prophylactic cotrimoxazole, 5) More frequent monitoring, 6) Longer treatment may be needed.

What are the principles of contact investigation in pediatric TB?

Key principles: 1) Prioritize young children and immunocompromised contacts, 2) Screen all household contacts <5 years, 3) Use combination of symptoms, TST/IGRA, chest X-ray, 4) Provide preventive therapy when indicated, 5) Consider source case investigation for young children.

How do nutrition and TB interact in children?

Interactions include: 1) Malnutrition increases TB risk and severity, 2) TB causes/worsens malnutrition, 3) Nutritional support essential for recovery, 4) Regular anthropometric monitoring needed, 5) Vitamin D supplementation may be beneficial, 6) Micronutrient supplementation often required.

What preventive strategies are effective for pediatric TB?

Prevention strategies: 1) BCG vaccination in high-risk areas, 2) Contact tracing/screening, 3) Preventive therapy for exposed/infected children, 4) infection control measures, 5) Addressing social determinants, 6) Treating adult source cases.

Describe the role of BCG vaccination in TB prevention.

BCG provides: 1) 80% protection against severe forms (meningitis/miliary), 2) Variable protection against pulmonary TB (0-80%), 3) Recommended at birth in endemic areas, 4) Contraindicated in HIV-positive infants, 5) Protection wanes over time. Not recommended in low-burden countries.

What are the indications for preventive therapy in children?

Preventive therapy indicated for: 1) TB contacts <5 years, 2) HIV-positive children, 3) TST/IGRA converters, 4) Children starting immunosuppressive therapy, 5) After ruling out active disease. Options include 6H, 3HR, 3HP regimens.

How do you manage TB in special situations (e.g., extrapulmonary involvement)?

Management requires: 1) Longer treatment duration often needed, 2) Additional diagnostic procedures, 3) Regular monitoring of involved sites, 4) Consideration of adjunctive treatments (e.g., steroids), 5) Expert consultation often beneficial.

What factors influence treatment adherence in pediatric TB?

Factors include: 1) Caregiver understanding/support, 2) Medication palatability/formulation, 3) Duration of therapy, 4) Side effects, 5) Socioeconomic factors, 6) Distance to health facility. DOT and family support crucial for success.

How do you approach pediatric TB in low-resource settings?

Approach includes: 1) Greater reliance on clinical diagnosis, 2) Use of scoring systems, 3) Limited diagnostic tools, 4) Focus on high-risk groups, 5) Integration with other child health services, 6) Community-based DOT when possible.

What are the long-term consequences of pediatric pulmonary TB?

Long-term effects may include: 1) Bronchiectasis, 2) Chronic lung disease, 3) Growth impairment, 4) Bronchial stenosis, 5) Psychological impact. Early diagnosis and appropriate treatment minimize sequelae.

How do you manage TB infection control in pediatric settings?

Control measures include: 1) Early identification/isolation of infectious cases, 2) Adequate ventilation, 3) Personal protective equipment for staff, 4) Separation from high-risk patients, 5) Education of staff/families, 6) Regular screening of healthcare workers.

What is the role of therapeutic drug monitoring in pediatric TB?

TDM indicated for: 1) Drug-resistant TB, 2) HIV co-infection, 3) Poor treatment response, 4) Suspected malabsorption, 5) Severe disease. Helps optimize dosing and identify absorption issues.

How do you approach TB diagnosis in resource-limited settings?

Approach focuses on: 1) Strong clinical suspicion, 2) Contact history, 3) Simple scoring systems, 4) Basic radiography when available, 5) Limited use of advanced diagnostics, 6) Empiric treatment when indicated based on strong clinical grounds.

What are the emerging diagnostic tools for pediatric TB?

New tools include: 1) GeneXpert Ultra (more sensitive), 2) Urine LAM testing, 3) Stool PCR testing, 4) Novel IGRA assays, 5) Digital chest X-ray reading systems. Still need better point-of-care tests for children.

How do you manage non-adherence to TB treatment in children?

Management includes: 1) Identifying barriers to adherence, 2) Family support/education, 3) DOT implementation, 4) Social support when needed, 5) Simplified regimens when possible, 6) Regular follow-up, 7) Child-friendly formulations.

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