Download - Tuberculosis in children
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Tuberculosis in children
Zhi-min Chen
Dept. Pediatric Pulmonology
Email: [email protected]
Pediatrics
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Etiology: Tubercle bacillus
Oder Actinomycetales
Family mycobacteriaceae
Genus Mycobacterium(M.)
Species M. tuberculosis M. bovis Non-TB M.
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Characteristics
Acid-fastness
Slow-growing
Unusual resistance
Multi-Drug Resistance strain(MDR)
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Source of infection
Open Pulmonary Tuberculosis (adult)
acid-fast smear of sputum(+)
copious production of thin sputum
severe and forceful cough
extensive upper lobe infiltrate or cavity
Young children with TB rarely infect others
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Route of transmission
By respiratory tract:
airbone mucus droplet nuclei
contaminated dustBy alimentary tract
raw milk
contaminated foodBy others: (Placenta,skin)
Transmission rarely occurs by direct contact with an infected discharge or contaminated fomite!
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High-risk population
Genetic background:
twin
racial difference
HLA BW35Environmental factors:
socioeconomic status
overcrowding
poor nutrition
inadequate health care
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TB infection and TB disease
TB infection:
inhalation of infective droplet nuclei containing
TB
A reactive tuberculin skin test and the absence
of clinical and radiographic manifestations
TB disease:
Signs and symptoms, or radiographic changes
become apparent
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Infection, disease or not
Virulence of the TB strain
The size of inoculin
The hypersensitivity of the individual tissues
Nutritional or social status
Immunologic status
Genetic background
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Primary Pulmonary Tuberculosis
Pediatrics
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Spreading of M.tuberculosis
Initial focus (local infection at the portal of entry)
Draining lymphatic vessles
Regional lymph nodes
Blood
Other tissues of the body
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Primary pulmonary tuberculosis
Clinical types Initial focus
Primary complex lymphangitis
Lymphadenitis
Bronchial lymph node tuberculosis
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Primary pulmonary tuberculosis
Clinical manifestation
Surprisingly meager(subclinical)
Infants more likely to develop signs and
symptoms
Nonproductive cough and mild dyspnea as the
most common symptoms
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Primary pulmonary tuberculosis
Less common symptoms
Systemic complaints
fever, night sweats, failure-to-thrive,
anorexia, etc.
Bronchial irritation or obstruction
localized wheezing
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Prognosis
Improve or dissolve
Completely resolution
Induration
Calcification
Local progress
Exacerbation
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Tuberculous meningitis
Most common in children of 6mo~4yr
Usually develops during the lymphohematogenous
dissemination of the primary infection
High mortality and high morbidity
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Tuberculous meningitis: Clinical manifestation
Stage 1: Prodromal stage
Stage 2: Transitional stage
Stage 3: Terminal stage
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Stage 1: Prodromal stage
Lasts 1~2wk
Nonspecific symptoms: character
alteration, fever, headache, malaise,
irritability, drowsiness
Focal neurologic signs absent
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Stage 2: Transitional stage
Increased intracranial pressure: headache,
projectile vomiting, papilledema
Meningeal irritation: nuchal rigidity, Kernig’s
sign, Brudzinski’s sign
Toxic appearance: fever, anorexia, nausea
Others: cranial nerve palsies, convulsion
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Stage 3: Terminal stage
1~3wk
Exacerbation of neurologic symptoms
Very thin with scaphoid abdomen
Electrolyte imbalance
SIADH
Cerebral salt losing syndrome
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Diagnosis
Laboratory study
Clinical diagnosis
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Diagnosis
Laboratory study
detection of M. tuberculosis
• Smear acid-fast staining
• Culture (BACTEC, liquid, coloricmetric)
• PCR and Gene probe
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Diagnosis
Laboratory study
Isolation of M. tuberculosis
Serology: limited value
• LAM antibody
• 38kDa antibody
• 16kDa antibody
• … …
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Diagnosis
Laboratory study
Isolation of M. tuberculosis
Serology
Pathology: biopsy and histology
• Caseous necrosis and encapsulation
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Diagnosis
Laboratory study
Others
• INF-γ Releasing Assays( IGRAs)- promising
– INF-γ produced by T-cell responses to
M.tb-special antigens called early secreted
antigenic target 6 (ESAT-6) and culture
filtrate protein10.
– Commercial kits: Quantiferon-TB Gold In-
tube (QFT) and The T-Spot TB (T-Spot) test
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Typical CSF picture of tuberculous meningitis, but NOT specific
Pressure
Appearance ground-glass
Cell counts 50~500×106/L, L. predominates
Protein
Glucose <40mg/dl , or CSF/blood <50%
Chloride
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Diagnosis
Laboratory Study
Clinical diagnosis
History
Clinical manifestation
Tuberculin test
Roentgenographic examination
Therapeutic trial
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Diagnosis
Laboratory Study
Clinical diagnosis
History: usually need chest film or CT of her parents or family members
Clinical manifestation
Tuberculin test
Roentgenographic examination
Therapeutic trial
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Diagnosis
Laboratory Study
Clinical diagnosis
History
Clinical manifestation: Not specific
Tuberculin test
Roentgenographic examination
Therapeutic trial
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Diagnosis
Laboratory Study
Clinical diagnosis
History
Clinical manifestation
Tuberculin test: more valuable
Roentgenographic examination
Therapeutic trial
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Tuberculin test : principle & method
Based on delayed type hypersensitivity( type IV)
Two antigen preparations:
Old tuberculin, OT
Protein purified derivative, PPD
Intradermal injection of 0.1ml containing 5
tuberculin units of PPD (Mantoux test)
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Tuberculin skin test:
result evaluation
The amount of induration should be measured by a trained person 48~72hours after administration
Intensity:
– or ±: <5mm negative or doubtful
+ : 5~9mm suspicious
++ : 10~19mm positive
+++ : >=20mm strong-positive
++++ : blister,ulcer,lymphangitis,double rings
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What does it mean: Positive result
Previous infection with TB
Previous vaccination with BCG
Active tuberculosis
<=3 year without prior vaccination
> = 15mm
conversion occurring within 2 years
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What does it mean: Negative result
Not infected with TB
False-negative :
incubation period
immunosuppression or immunodeficiency
technical error or improper reagents
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Diagnosis
Laboratory Study
Clinical diagnosis
History
Clinical manifestation
Tuberculin test
Roentgenographic examination
Therapeutic trial
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Diagnosis
Laboratory Study
Clinical diagnosis
History
Clinical manifestation
Tuberculin test
Roentgenographic examination
Therapeutic trial
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Prevention of TB
Avoiding contact with those with open
pulmonary tuberculosis
BCG (Bacillus Calmette-Guerin)
vaccination
Chemoprophylaxis
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Treatment
Antituberculosis therapy:
early, dosage, combination, regular, whole course
intensification stage and consolidate stage
directly observing therapy shortcourse (DOTS)
Corticosteroids
Symptomatic management
Supportive care