Basic Childhood TB including clinical presentation

TB affect lung

1. By Dr.Abdureshid Kedir ( MD,Pediatrician ) CHILDHOOD TUBERCULOSIS

2. OUTLINE Introduction Microbiology Epidemiology Major stages of tuberculosis Clinical presentation Diagnosis Treatment Prevention Reference

3. INTRODUCTION Tuberculosis caused human disease for>4,000yrs A preventable and curable disease Species of mycobacterium - M. tuberculosis the most important cause of tuberculosis (TB) M. bovis , M. africanum , M. microti M. caprae , M. canetti

4. Microbiology The tubercle bacilli Rod-shaped bacillus. Non– spore-forming, Nonmotile , pleomorphic , Weakly gram-positive curved rods 1-5 μ m long, Typically slender, and slightly bent. appear beaded or clumped under microscop Grow best at 37–41°C (98.6–105.8°f), Obligate aerobes AFB-hallmark of all mycobacteria

5. Microbiolo … Culture media containing glycerol - carbon source and a mmonium N Solid synthetic media usually takes 3-6 weeks , drug susceptibility testing requires an additional 2-4 weeks. Liquid medium takes 1-3 weeks drug susceptibilities can be determined in an additional 3-5 days.

6. Epidemiology A leading cause of death from an infectious disease worldwide. About 1/4 th of the world‘s population is estimated to be infected Approximately 95% of TB cases occur in the developing world The global burden of TB Influenced by HIV pandemic Multidrug-resistant tuberculosis development Diagnostic tests and effective medical therapy low COVID-19 pandemic

7. Epi … Tuberculosis transmitted by Inhalation - lung is the portal of entry in >98% Ingestion Direct contact with body fluid Congenital y Placenta The chance of transmission Ꙟ ses A positive acid-fast smear of sputum, An extensive upper lobe infiltrate or cavity, Copious production of sputum Cough (Severe and forceful)

8. Epi … Most children are infected their home by someone close to them(mother) Outbreaks occurre in Elementary and high schools, Nursery schools, Daycare centers and homes, Churches, School buses, Sports teams.

9. STAGES OF TUBERCULOSIS Exposure TB infection TB disease

10. Exposure Significant contact (shared the air) with infectious TB Lacks proof of infection - Ve TST or IGRA No sign and symptom Normal CXR Children at greater risk of developing TB In close contact with a newly diagnosed smear-positive TB case Age< 5 years HIV-infected children Severely malnourished children

11. Difference between TBI and TBD Person with TBI Person with TBD S mall amount of bacilli in body (inactive) Cannot spread TB to others No symptoms Usually has TB skin test or TB blood test (IGRA) reaction + Radiograph is typically normal Sputum smears and cultures are -v TPT Does not require isolation Not a TB case large bacilli in body(active spread TB to others have symptoms TB skin test or blood test reaction (IGRA) + Radiograph may be abnormal Sputum smears and cultures may + Needs treatment for TB disease Require respiratory isolation TB case

12. NATURAL HISTORY OF DISEASE In 90-95% infected with M. Tuberculosis the immune system either kills the bacilli keeps them suppressed (silent focus)( oftern ) In immunocompetent individuals, only 5-10% of infected persons develop active disease in their lifetime. People living with HIV are 16-27 times more likely to develop TB than persons without (WHO). HIV positive people with latent TB infection have a 10% annual and 50% lifetime risk of developing active TB disease.

13. NATURAL HISTORY OF DISEASE Active TB disease may arise from Progression of the primary lesion after infection Endogenous reactivation of latent foci Exogenous re-infection. Post primary TB usually affects the lungs though any body part can be affected after haematogenous and/or lymphatic spread of the bacilli.

14. Risk for progression of LTBI to TB Disease Ꙟ HIV Age <5 years Recently infected with MTB (within the past 2 years); A history of untreated or inadequately treated TB disease Receiving immunosuppressive therapy Tumor necrosis factor-alpha (TNF) antagonists, Systemic corticosteroids equivalent to/> 15 mg of prednisone per day, Immunosuppressive drug therapy Organ transplantation

15. Risk for progression of LTBI to TB Disease Ꙟ Persons with silicosis, Diabetes mellitus, Chronic renal failure, Cancer of blood the head, neck, or lung; Gastrectomy or jejunoileal bypass; Underweight -weigh <90% of their ideal body weight Cigarette smokers and abuse drugs and/or alcohol

16. Clinical presentation of tuberculosis The commonest symptoms tuberculosis Cough Fever Not eating well/anorexia failure to thrive Fatigue, Reduced playfulness, Decreased activity.

17. Presumptive tuberculosis Fever of unknown origin, Failure to thrive, Significant weight loss; Severe malnutrition Measles in the previous 3 months, Whooping cough, HIV, medication like steroids Unexplained lymphadenopathy

18. Physical signs requiring investigation to exclude EPTB Gibbous, recent onset Enlarged cervical LAP Meningitis Pleural effusion Pericardial effusion Ascites Non-painful enlarged joints. Failure to gain weight nutritional treatment

19. Diagnosis of TB in childhood Medical history Contact history Symptom complex P/E-clinical sign Growth assessment Weight and height of children presumed to have TB will be taken. underweight failing to thrive.

20. Investigations Xpert Identify genes associated with M. Tuberculosis R resistance Results are available in hours The preferred investigative modality for children with presumptive TB Zeil Nelson/ Fluorescent LED microscopy: treatment response monitoring Histopathologic examination: FNA /Tissue biopsy. caseation and granulomatous inflammation

21. CXR Enlarged hilar lymph nodes opacification in the lung tissue Miliary mottling in lung tissue Cavitation (tends to occur in older children) Pleural or pericardial effusions

22. Vertebral X-ray Spinal X-ray may be normal in early disease, bone mass must be lost 50% for changes to be visible on X-ray. Plain X-ray (PA and Lateral view) of the affected vertebra can show vertebral destruction and narrowed disc space

23. CT or MRI of the brain The most common finding Basilar enhancement Communicating hydrocephalus with signs of cerebral edema or Early focal ischemia silent tuberculomas , occurring most often in the cerebral cortex thalamic regions

24. Challenge of pediatrics TB Diagnosis of TB in childhood is difficult because: Clinical presentation variable & nonspecific Confirmation by culture < 40% Absence productive cough paucibacillary disease

25. Pulmonary tuberculosis TB involving Lung parenchyma / Tracheobronchial tree. Miliary TB with lesions in the lungs. Both pulmonary and Extrapulmonary TB

26. Extra pulmonary tuberculosis TB involving other than lungs Pleura, Lymph nodes, Abdomen, Genitourinary tract, Skin, Joints and bones, Meninges . Without CAX abnormalities in the lungs intra-thoracic LAP ( mediastinal and/or hilar ) TB pleural effusion TB

27. Disseminated TB The most clinically significant form of disseminated TB is miliary disease causing disease in 2 or more organs. The clinical manifestations of miliary TB are protean, depending on the number of organisms that disseminate and where lodge. Lesions are often larger and more numerous in Lungs Spleen Liver Bone marrow. CHOROID TUBERCLES OCCUR IN 13–87% OF PATIENTS AND ARE HIGHLY SPECIFIC FOR THE DIAGNOSIS OF MILIARY TUBERCULOSIS. Diagnosis Biopsy of the liver bone marrow biopsy

28. Classification of TB based on Drug resistance Rifampicin resistant TB (RR-TB) Multidrug-resistant TB (MDR-TB ) Pre-extensively drug resistant TB (Pre-XDR TB): MDR/RR-TB and resistant to any fluoroquinolone . Extensively drug-resistant TB (XDR-TB ) Pre-XDR TB and at least 1 additional Group A drug Bedaquiline or Linezolid Isoniazid -Resistant TB (Hr-TB )

29. TB cases New TB cases : patients who has never been treated for TB or has taken anti-TB drugs for <1 mo Previously treated TB case : patients who have received anti-TB drugs for 1 or > months in the past Relapse patients : patients that have been previously treated for TB and were declared cured or treatment completed at the end of their most recent course of treatment and now diagnosed with a recurrent episode of TB. Treatment after failure : patients who have previously been treated for TB and whose treatment have failed (smear positive results after fifth month during treatment or emergence of resistance) at the end of their most recent course of treatment.

30. Treatment Ant-TB Adjuvant Vitamin B6

31. Clinical scoring to support TB treatment decision in children

32. Clinical scoring to support TB treatment decision in children

33. The aims of TB treatment To cure the patient from TB To prevent death from TB disease and its late effects To prevent relapse of TB To prevent the development of acquired drug resistance, and To decrease TB transmission

34. Principles of management TB Chemotherapy with Anti-TB drugs Nutritional rehabilitation Screening of the family Follow up Adjuvant therapy Health education

35. Ant-TB - regimen The choice of regimen depends on The extent of TB disease, The host, The likelihood of drug resistance multidrug therapy 4 month 6-month 12 month

36. Ant-TB - regimen The initial treatment regimen Isoniazid , Rifampin , Pyrazinamide , Ethambutol . All drug administration be either directly observed electronically observed,

37. Benefit of Corticosteroids Steroid in TB meningitis decrease Mortality rates Long-term neurologic sequelae Vasculitis , Inflammation, Intracranial pressure. limits tissue damage favors circulation of antituberculosis drugs

38. Short courses of corticosteroids Endobronchial tuberculosis Acute pericardial effusion. Large pleural effusion and shift of the mediastinum . Severe miliary tuberculosis-severe that alveolocapillary block

39. Prevention Tuberculosis BCG TPT

40. One of the following is highly specific for the diagnosis of miliary TB Papulonecrotic tuberculids Choroid tubercles Tuberculous peritonitis ADA levels are elevated

41. Reference Nelson 22 nd edition Guidelines Management of TB, TB/HIV, DR-TB and Leprosy in Ethiopia 7 th edition