Tuberculosis in children: Difference between revisions

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! style="background: #4479BA;" colspan=2| {{fontcolor|#FFF|Diagnostic Approach for Extrapulmonary Tuberculosis}}
! style="background: #4479BA;" colspan=2| {{fontcolor|#FFF|Diagnostic Approach for Extrapulmonary Tuberculosis}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; width: 200px;" |  
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; width: 200px;" | Peripheral Adenopathy
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" | Fine needle aspiration or biopsy of the lymphnode
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |  
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" | Miliary Tuberculosis
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" | Order a chest X-ray and a lumbar puncture in suspicion of meningeal involvement.
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |  
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" | Tuberculous Meningitis
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" | Lumbar puncture, head CT.
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" | Pleural Effusion
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" | Order a chest X-ray, perform an analysis of the pleural fluid
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |  
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" | Tuberculous Peritonitis
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" | Order an abdominal ultrasound, consider abdominal fluid aspiration for analysis.
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |  
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" | Bone or Joint Infection
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" | X-ray of the affected limb, joint fluid aspiration and analysis
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" | Tuberculous Pericarditis
| style="padding: 5px 5px; background: #F5F5F5;" | Echocardiography, consider pericardiocentesis for fluid analysis.
|-
|-
| style="padding: 5px 5px; background: #F5F5F5;" colspan=2 |<small> Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}}</ref></small>
| style="padding: 5px 5px; background: #F5F5F5;" colspan=2 |<small> Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children<ref name="WHO TB Children"> {{cite web |url=http://apps.who.int/iris/bitstream/10665/112360/1/9789241548748_eng.pdf| title=WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014}}</ref></small>

Revision as of 19:15, 23 September 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Tuberculosis Microchapters

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Children

HIV Coinfection

Diagnosis

History and Symptoms

Physical Examination

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Electrocardiogram

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CT

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Overview

Screening for Tuberculosis

Symptom-based Screening Approach

Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1]

 
 
 
 
 
 
 
 
 
Child in close contact with confirmed tuberculosis case
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
< 5 yrs old
 
 
 
 
 
 
 
 
 
> 5 yrs old
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic
 
 
 
Symptomatic
 
 
 
Symptomatic
 
 
 
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer INH 10 mg/kg/d x 6 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No preventive treatment is recommended.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the child develops symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the child develops symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirm the diagnosis of TB with:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Screening in Children with HIV

Algorithm adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1]
IPT: Isoniazid preventive therapy (INH 10 mg/kg/d x 6 months)

 
 
 
 
 
 
 
 
 
Child with HIV and older than 1 year
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient has any of the following symptoms?
  • Weight loss or poor weight gain
  • Cough
  • Fever
  • History of close contact with a TB case
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess for the diagnosis of TB (TST, chest X-ray, sputum studies) and rule out other diseases
 
 
 
 
 
 
 
 
 
Does the patient has any of the following contraindications for IPT?
  • Active hepatitis
  • Peripheral neuropathy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
TB confirmed
 
 
 
TB ruled out, other diagnosis confirmed
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer 2HRZE/4HR regimen
 
 
 
Give appropriate treatment for the disease and consider IPT
 
 
 
Do not administer IPT
 
 
 
Administer IPT
 
 
 
 
 

Diagnosis

  • Children must be evaluated with a complete assessment, which includes a meticulous medical history, physical examination, TST, chest X-ray, sputum or gastric aspirate studies (microscopy and culture), and HIV testing.
  • Bacteriological testing might be difficult among children, but it should be performed whenever possible.
  • Adolescents usually have the adult clinical presentation, but may also present with symptoms and findings seen in smaller children.
  • Even though a scoring system has been developed in some countries[2][3][4][5][6], the WHO does not recommend this system for the evaluation of children with suspected TB.
Diagnostic Approach in Children with Suspected Tuberculosis
History and Symptoms
Physical Examination
  • The physical examination might be unremarkable in children.
  • Extrapulmonary tuberculosis presents with abnormal physical findings.
Tuberculin Skin Test
  • Important for evaluate children with no history of close contact and to screen for TB infection.
  • In immunocompetent children, > 10 mm is considered positive.
  • In immunosupressed children, > 5mm is considered positive.
Chest X-ray
  • Common findings include consolidation associated with an enlarged lymph node in the hilium.
Bacteriological Tests
  • Sputum or gastric aspirates should be assessed for the presence of M. tuberculosis.
  • Microscopy and culture should be done in every case possible to confirm the diagnosis.
HIV Test
  • In children with suspected TB, HIV testing should be offered.
Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1]
Diagnostic Approach for Extrapulmonary Tuberculosis
Peripheral Adenopathy Fine needle aspiration or biopsy of the lymphnode
Miliary Tuberculosis Order a chest X-ray and a lumbar puncture in suspicion of meningeal involvement.
Tuberculous Meningitis Lumbar puncture, head CT.
Pleural Effusion Order a chest X-ray, perform an analysis of the pleural fluid
Tuberculous Peritonitis Order an abdominal ultrasound, consider abdominal fluid aspiration for analysis.
Bone or Joint Infection X-ray of the affected limb, joint fluid aspiration and analysis
Tuberculous Pericarditis Echocardiography, consider pericardiocentesis for fluid analysis.
Adapted from Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children[1]

Treatment

Tuberculosis in Children

  ▸  Drug Susceptible TB

  ▸  MDR-TB

  ▸  XDR-TB

Drug Susceptible TB Regimen
Table adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed.[7]
MDR-TB Regimen
Standard Regimen
Group 1: First-line oral drugs

Pyrazinamide 20-30 mg/kg (Max: 600 mg)
OR
Ethambutol 15-20 mg/kg
OR
Rifabutin 5 mg/kg

PLUS
Group 2: Injectable drugs

Capreomycin 15-30 mg/kg (Max: 1000 mg)
OR
Kanamycin 15-30 mg/kg (Max: 1000 mg)
OR
Amikacin 15-22.5 mg/kg (Max: 1000 mg)
OR
Streptomycin 12-18 mg/kg

PLUS
Group 3: Fluoroquinolones

Levofloxacin 7.5-10 mg/kg
OR
Moxifloxacin 7.5-10 mg/kg
OR
Ofloxacin 15-20 mg/kg divided q12h (Max:800 mg)

PLUS
Group 4:Oral bacteriostatic second-line drugs

Ethionamide 15-20 mg/kg divided q12h (Max: 1000 mg)
OR
Protionamide 15-20 mg/kg divided q12h (Max: 1000 mg)
OR
Cycloserine 10-20 mg/kg (Max: 1000 mg)
OR
Terizidone 10-20 mg/kg (Max: 1000 mg)
OR
Para-aminosalicylic acid 150 mg/kg divided q8-12h(Max: 12 000 mg)

Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.[7] and Guidance for national tuberculosis programmes on the management of tuberculosis in children [1]
XDR-TB Regimen
Standard Regimen
Group 1: First-line oral drugs

Pyrazinamide 20-30 mg/kg (Max: 600 mg)
OR
Ethambutol 15 mg/kg
OR
Rifabutin 5 mg/kg

PLUS
Group 4:Oral bacteriostatic second-line drugs

Ethionamide 15-20 mg/kg (Max: 1000 mg)
OR
Protionamide 15-20 mg/kg (Max: 1000 mg)
OR
Cycloserine 10-20 mg/kg (Max: 1000 mg)
OR
Terizidone 10-20 mg/kg (Max: 1000 mg)
OR
Para-aminosalicylic acid 150 mg/kg/d divided q8-12h

PLUS
Group 5
Use at least 2 of the following:

Clofazimine 50 mg/d AND 300 mg once a month
OR
Amoxicillin/clavulanate
OR
Linezolid 300-600 mg
OR
Imipenem 500mg q6h
OR
Clarithromycin 500-1000 mg q12h
OR
Thioacetazone 2.5 mg/kg
OR
Isoniazid (high-dose) 16–20 mg/kg

Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.[7] and WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children [1]


References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 "WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014" (PDF).
  2. Isabella Coimbra, Magda Maruza, Maria de Fatima Pessoa Militao Albuquerque, Joanna D.'Arc Lyra Batista, Maria Cynthia Braga, Libia Vilela Moura, Democrito Barros Miranda-Filho, Ulisses Ramos Montarroyos, Heloisa Ramos Lacerda, Laura Cunha Rodrigues & Ricardo Arraes de Alencar Ximenes (2014). "Validating a scoring system for the diagnosis of smear-negative pulmonary tuberculosis in HIV-infected adults". PloS one. 9 (4): e95828. doi:10.1371/journal.pone.0095828. PMID 24755628.
  3. Constantino Giovani Braga Cartaxo, Laura C. Rodrigues, Carolina Pinheiro Braga & Ricardo Arraes de Alencar Ximenes (2014). "Measuring the accuracy of a point system to diagnose tuberculosis in children with a negative smear or with no smear or culture". Journal of epidemiology and global health. 4 (1): 29–34. doi:10.1016/j.jegh.2013.10.002. PMID 24534333. Unknown parameter |month= ignored (help)
  4. Sandra Christo dos Santos, Ana Maria Campos Marques, Roselene Lopes de Oliveira & Rivaldo Venancio da Cunha (2013). "Scoring system for the diagnosis of tuberculosis in indigenous children and adolescents under 15 years of age in the state of Mato Grosso do Sul, Brazil". Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 39 (1): 84–91. PMID 23503490. Unknown parameter |month= ignored (help)
  5. Stephen M. Graham (2011). "The use of diagnostic systems for tuberculosis in children". Indian journal of pediatrics. 78 (3): 334–339. doi:10.1007/s12098-010-0307-7. PMID 21165720. Unknown parameter |month= ignored (help)
  6. Emily C. Pearce, Jason F. Woodward, Winstone M. Nyandiko, Rachel C. Vreeman & Samuel O. Ayaya (2012). "A systematic review of clinical diagnostic systems used in the diagnosis of tuberculosis in children". AIDS research and treatment. 2012: 401896. doi:10.1155/2012/401896. PMID 22848799.
  7. 7.0 7.1 7.2 "2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition)".

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