TB in Children. The diagnostic challenge. Ralph Diedericks Red Cross Hospital

Transcription

1 TB in Children The diagnostic challenge Ralph Diedericks Red Cross Hospital

2 TB in children Brief epidemiology Clinical issues in primary TB Cases

3 Rates of TB infection 2005 TST survey reported a TB prevalence of 26.2% in 5 8 yr olds Incr to 52.5% in yr olds Positive TST ( > 10mm) among primary school children 37.5% ( 2005) High rates of TB transmission predate HIV epidemic

4 Epidemiology Foll prolonged contact 60-80% children infected 60-80% childrn < 2 infected by household source Older children > 2 mostly no household contact

5 Infection vs Disease 60-80% children < 2 with primary infection will develop disease Children > 10 yrs at increased risk of disease - increased risk of cavitation

6 TB prophylaxis INH prophylaxis in children under 5

7 Incidence Paediatric Tb new cases / new cases ( < 15 yrs ) notified in 2010

8 Primary TB Young children Paucibacillary disease Sputum sampling is a challenge CXR : LN enlargement ( Ghon Complex )

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10 Primary TB Allergic manifestations: - Phlyctenular conjunctivtis - Erythema nodosum - Polyarticular arthritis ( Poncet s ) - Effusions?

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12 Erythema nodosum

13 Erythema nodosum

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16 Case yr referred from PHC PH: Inguinal hernia, Impetigo and submental LN Checked for TB Now LOW, night sweats UWA, pale, Axillary LN, hepar 2cm HIV neg, Hb 10 MCV 58, WCC 13.1, ESR 44

17 Mantoux test : large ulcerating reaction Enrolled in TB study for sputum collection and genexpert CXR

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20 Abdominal US : intra abdom LN Rx Started on 4 drug anti TB Rx with Ethambutol added Good response to Rx and wt gain

21 10 yr no contact CXR typical hilar adenopathy Extensive TB Value of US in diagnosis 4 drug Rx NB Hilar adenopathy and primary TB

22 Mantoux test Detects TB in > 80% HIV Neg patients Valuable test in children even at 10 yrs Technique important

23 Inhibition of Tuberculin response Wasting/severe malnutition Corticosteroids, immunosuppression Viral infection measles, Influenza Severe disease

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25 Case 2. 7 yr 2 weeks axillary LN, LOW Wt on 10 th centile, no fall off Enlarged axillary nodes on left, largest 2x2cm Chest exam no tachypnoea, dull on L., crackles with reduced B/S

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28 Mantoux 20 X 22mm ESR 65 Sputum neg PCR FNAB : MTB complex detected on PCR. Sens to RIF FNAB value. Technique.

29 Fine needle aspiration of LN Technique well established, not new Good yield for granulomas with/out caseation( 80% ) AFBs n 40 % Caseation present ( acellular necrotic material ) AFBs in > 60%

30 Case 3. Anathi 26 m Foster care Poor weight gain No known TB contact Wt chart

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32 Temp 38,2 Pale, apathetic Clinical features of kwashiorkor with skin lesions Cervical adenopathy RR 40 with i/c recession, crackles left chest Hepar 2cm No enlargement of spleen

33 Investigations CXR Mantoux Induced Sputum - genexpert - culture FBC, ESR, CRP, Se Alb

34 Hb 7.4 MCV 69 WCC 13.2 (N49 L38 Bands 8) Platelets 721 ESR 58 CRP 141 Se Alb 19

35 Mantoux reacting after 24 hrs Measured 28 X 15 mm Sputum genexpert neg CULTURE POSITIVE for MTB

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38 Treatment Extensive complicated Pulmonary TB - 4 drug anti TB ( Ethambutol added ) - PREDNISONE for airway compression

39 Case 4 Mona 5yrs 2011 investigated for TB after contact identified HIV infected. Not on ARVs CXR done No TB prophylaxis given

40 Subsequent ID consult Not on TB prophylaxis Started on ARVs Seen at FU in IDC and doing well

41 yrs Defaulted ARVs Acutely ill Malnourished Chest: tachypnoeic, dull on left with reduced breath sounds

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43 Investigations Hb 6.7 MCV 58 WCC 23.1 Bands 49% CRP 180 Mantoux done: was never read ( forgot to read) Gastric washings neg for AFBs CXR

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45 ICD inserted - 50ml pus drained immed - sent for MC/S, TB, Cytology - Smear positive for AFBs - Culture positive for MTb

46 Treatment ARVs - Started on ABC/3TC/EFV Anti TB Rx 4 drugs ICD developed broncho pleural fistula

47 Follow up Signs of chronic lung disease Poor resolution of L. lung Pulmonary cutaneous fistula Poor PFTs

48 Expansile pneumonia in TB

49 Diagnosing TB Clinical History symptoms - contact Evidence of FTT Allergic manifestations TST CXR add LODOX, CT scan Induced sputum FNAsp Pleural samples

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