Tuberculosis in Children Summarized

Tuberculosis

Evaluation

• H/O Fever > 2weeks, weight loss, cough > 2 weeks, night sweats,
• H/O contact with a case of tuberculosis (esp: family contact)
• H/O measles, whooping cough or steroid intake in recent past
• BCG vaccination status
• Examination : malnutrition, unresolved pneumonia, pleural effusion, ascites, enlarged, matted lymph nodes, signs of meningeal irritation, focal neurologic signs
• Blood complete exam, ESR
• Radiograph chest : primary complex, hilar / mediastinal lymph node enlargement, effusion, miliary shadows.
• Mantoux test 10mm or more at 72 hours
• Accelerated BCG response 10 mm or more within 72 hrs
• Pleural / abdominal aspirate : exudative with raised proteins , low sugar and cellular infiltrate with lymphocytic predominance
• Lumbar puncture with CSF proteins > 40mg/dl, low sugar (< 50% blood sugar) and cellular infiltrate (> 5 WBC/^mm3) with lymphocytic predominance
• Gastric aspirate after overnight fast / Sputum for AFB
• FNA and / or biopsy of lymph nodes
  
  
  

SCORING METHOD FOR DIAGNOSIS (Modified Kenneth Jones Criteria)

Features	1	2	3	4	5	Score
HISTORY
Age	<2 yrs	-	-	-	-	-
Close contact in last 2 years	With Sputum –ve TB patient		With sputum +ve TB patient
BCG scar	Absent	-
History of measles and whooping cough	> 3months	<3 months
Immunocompromised/ Immunosuppressant*	Yes	-
PCM grade III	Yes	-	Not improving
EXAMINATION AND INVESTIGATION
Physical examination	-	Suggestive of TB *		Strongly suggestive **
Radiological Findings	Non specific ***	Suggestive of TB ****
Tuberculin skin Test	5-10 mm		>10mm
Granuloma	Nonspecific				Specific for TB
TOTAL SCORE

INTERPRETATION :
0 – 2 TB unlikely
3 – 4 Keep under observation
5 – 6 Tuberculosis probable, investigations may justify therapy
7 or more TB unquestionable
*consolidation not responding to antibiotic therapy
**pleural effusion / gibbus etc
***ill defined opacity / bronchovascular marking
****Paratracheal / mediastinal adenitis, miliary mottling

Management

• Treat according to stage of disease
• Stage I

No symptoms, No signs, only H/O contact, Chest X-ray negative, age below 3 years and/or h/o recent Mantoux positivity

INH 10 mg/kg/d + Rifampicin 15 mg/kg/d

Give for 6 months

·         Stage II

Patient symptomatic, Mantoux +, Chest X-ray Normal

INH 10 mg/kg/d + Rifampicin 15 mg/kg/d

Give for 9 months

·         Stage III

Patient symptomatic, Mantoux test +, Chest, abdominal, lymph nodes involvement

RIF+INH as above +Pyrazinamide 30 mg/kg/d after meals

Then withdraw PZI after 2 months and continue 2 drugs for total 9 months

·         Stage IV

TBM and Miliary TB

RIF, INH+PZA as above + Ethambutol 25 mg/kg/d 

Withdraw PZA and Ethambutol after 2 months and continue rest for one year.

Add Prednisolone(deltacortil) 2 mg/kg/d for 2-3 weeks.