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Paediatric aspects of Tuberculosis

Paediatric aspects of Tuberculosis. Patricia Fenton Sheffield Children’s Hospital BSMT 12 th May 2006. Challenges. Rare disease Children susceptible Variable presentation Dissemination common Rarely “smear positive” Drug treatment difficult Must locate source adult .

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Paediatric aspects of Tuberculosis

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  1. Paediatric aspects of Tuberculosis Patricia Fenton Sheffield Children’s Hospital BSMT 12th May 2006

  2. Challenges • Rare disease • Children susceptible • Variable presentation • Dissemination common • Rarely “smear positive” • Drug treatment difficult • Must locate source adult

  3. Paediatric TB is rare • We know this because…. • In Sheffield Children’s Hospital we don’t see very much

  4. Children are susceptible Smear positive adult plus Child in same house equals 50% chance Geuns et al 1975

  5. Swimming is good for you • Smear positive life guard • 3,764 children traced • 108 infected non-swimmers>swimmers Rao et al 1980 CHILDREN ARE SUSCEPTIBLE

  6. Dangerous times Up to 5 years • Dissemination • Meningitis 5 to puberty • LN and skeleton Adolescence • Pneumonitis • Hilar adenitis VARIABLE PRESENTATION

  7. Variable presentation • Stage 1 – primary complex • Stage 2 – haematogenous dissemination • Stage 3 – pleurisy • Stage 4 – bones and joints May just have a fever

  8. BCG – bile and glycerol flavour • Bovine mastitis strain • Passaged 230 times • 1921 oral • Lubeck disaster 1930 (73 died) • WWII freeze dried

  9. Prevents dissemination? • 1950 UK schools • 1960 selected neonates • Efficacy 0 to 80% • Prevents meningitis • JCVI weighed evidence • CMO letter July 05

  10. Bacille Calmette-Guérin • Improved programme • Targeted • Neonatal • Others at risk NO MORE SCHOOL PROGRAMME

  11. New arrangements • Local arrangements (logistics and training) • No more Heaf – mantoux • All infants living where TB > 40/100,000 • Parents or grandparents born where… • Unvaccinated new immigrants from areas.. • School children screened for risk factors

  12. Challenge PCTs HAVE A HUGE RESPONSIBILITY To ensue new arrangements are robust

  13. ADULT Pulmonary Productive Sputum CHILD Different sites Not productive Gastric washings? Induced sputum? BAL? LN biopsy? Bone marrow? Rarely “smear positive”

  14. Gastric washings • Single room • 3 nights • Pass NG tube • Starve overnight

  15. Induced sputum • Negative pressure • Masks FFP3 • Gloves • Apron • Nebulised saline FRIGHTENING

  16. Tissue • General anaesthetic

  17. Treatment • Start on suspicion • Cannot swallow tablets • Four drugs • Taste • Volume • Long course of treatment

  18. Contact tracing • Household • Close relatives • School • Social groupings • Abroad • The unexpected

  19. Tuberculous meningitis • Symptoms >6 days • Optic atrophy • Focal neurology • Abnormal movements • Neutrophils < half

  20. MPS Casebook February 2006 • Term baby • Mum European • Dad N African • Triple/polio • BCG section blank • Noted to visit N Africa for 2 months – no BCG given

  21. Seven months old • Visit to GP • Noted smokers in home • Scattered coarse transmitted chest sounds • Salbutamol ? Asthma • Mum felt salbutamol helped • Letter to local housing authority

  22. Nine months old • Vomiting • High temperature • Listlessness • Coarse transmitted sound at lung bases • 3 GP visits in as many days • CXR and abdo XR abroad – not repeated

  23. Five days later • Still vomiting • Staring blankly • Not moving right arm • Blurred disc margin on fundoscopy • Urgent neuro opinion

  24. Neurosurgical assessment • Cavitating lesion • Left cerebrum • Hydrocephalus • Tuberculous meningitis • Limited motor ability and unintelligible speech

  25. This case illustrates • Non-specific symptoms • Irreversible damage • Missed opportunity to follow BCG guidance

  26. Challenges • Rare disease • Children susceptible • Variable presentation • Dissemination common • Rarely “smear positive” • Drug treatment difficult • Must locate source adult

  27. Conclusion

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