Tuberculosis in Children and Young Adults

1. Tuberculosis in Children and Young Adults FARHAD SALEHZADEH MD. 2009 ARUMS

2. TB in PEDIATRIC

3. TB in PEDIATRIC

4. Transmission and Pathogenesis

5. TB

7. TB in PEDIATRIC • Primary infection • Reactivated TB • Progressive post primary TB • Miliary TB • Lymphohematogenesis TB

8. Evaluation for TB • Medical history • Physical examination • Mantoux tuberculin skin test • Chest radiograph • Bacteriologic or histologic exam “Clinical judgement” Tuberculosis is one of the great imitator.

9. Common Sites of TB Disease • Lungs • Pleura • Central nervous system • Lymphatic system • Genitourinary systems • Bones and joints • Disseminated (miliary TB)

10. Conditions That Increase the Risk of Progression to TB Disease • HIV infection • Substance abuse • Recent infection • Chest radiograph findings suggestive of previous • Diabetes mellitus • Immunosuppressed • End-stage renal disease • Chronic malabsorption syndromes • Low body weight (10% or more below the ideal)

11. Systemic Symptoms of TB • Fever • Chills • Night sweats • Appetite loss • Weight loss • Easy fatigability

12. Extrapulmonary TB • In most cases, treat with same regimens • used for pulmonary TB Bone and Joint TB, Miliary TB, or TB Meningitis in Children • Treat for a minimum of 12 months

13. TB in Children • WHO estimate of TB in children • 1.3 million annual cases • 450,000 deaths • 15% of TB in low-income countries children vs. 6% in United States

14. Risk of Progression to Disease • Age • 43% in infants (children < 1year) • 25% in children aged one to five years • 15% in adolescents • 10% in adults • Recent Infection • Malnutrition • Immunosuppression, particularly HIV Miller, 1963

15. Childhood TB diagnosed by: • Combination of : • Contact with infectious adult case • Symptoms and signs • Positive tuberculin skin test • Suspicious CXR • Bacteriological confirmation • Serology

16. Childhood TB • Retrospective study of 43 hospitals using National TB Data from 1998 • 2739 cases in children (11.9%) • 1.3% smear-positive, 21.3% smear-negative, 15.9% extrapulmonary • Poor outcomes • 45% completed treatment • 17% died • 13% default • 21% unknown Harries AD et al. Int J Tuberc Lung Dis. 2002; 6: 424-31.

17. TB and BCG Vaccination • Efficacy for adult pulmonary TB 0-80% in randomized clinical trials • Best efficacy against serious childhood disease • 64% protection against TB meningitis • 78% protection effect against disseminated TB • BCG important for young children, inadequate as single strategy Colditz GA et al. JAMA 1994; 271: 698-702.

21. TB PEDIATRIC

22. In older children and adults the distinction between TB infection and disease is usually clear and often separated by a period of years before the onset of reactivation-type disease. A major reason for making the distinction between infection and disease is because each is treated differently. Infection is treated with one medication, whereas disease is treated with at least three or more anti-TB drugs.

23. A diagnosis of latent TB infection (LTBI) can bemade solely on clinical grounds and a positive TST orINF--releasing assay (IGRA).

25. The IGRAsresults are unaffected by prior BCG vaccination. IGRAs are highly specific and correlate well with known exposure history. IGRAs appear to be sensitive, at least in children over 2 years of age. It is reasonable to hold off on treatment in a TST, IGRA asymptomatic child who is over age 2 years and has a normal CXR.

27. Worldwide the most common symptoms of pediatric TB disease are a chronic cough for more than 21 days, a fever 38°C for 14 days (after common causes such as malaria and pneumonia have been excluded), and weight loss or failure to thrive.1 Any child with any of these symptoms for a shorter duration than described above and a history of contact to an index case should have a TST planted and diagnostic workup for TB,