Unit 9 Diagnosis and Treatment of Unit 9 Diagnosis and Treatment of Paediatric TB: B Family CasePaediatric TB: B Family Case

Botswana National Tuberculosis Programme Manual Training for Medical Officers

Slide 2Unit 9: Case Studies

B Family BackgroundB Family Background

Remember the B Family?

• Mr. B is on TB retreatment and ART

• Because he is receiving streptomycin injections, he is not eligible for DOTS

• The B’s have 3 children: • BB (3 mos)• KB (3 yrs)• JB (7 yrs)

Slide 3Unit 9: Case Studies

B Family Case (1)B Family Case (1)

BB• Mrs. B’s 3 month-old

daughter• Mrs. B states BB is eating

well, hasn’t had a fever or cough and is active

• BB is afebrile, has age appropriate behaviour and weighs 5 kg

KB• Mrs. B’s 3 year-old son• Mrs. B states KB is playing

with children, doesn’t have a fever or cough and has a healthy appetite

• KB is afebrile, has age-appropriate behaviour and weighs 15 kg

Slide 4Unit 9: Case Studies

B Family Case (2)B Family Case (2)

• Mrs. B is HIV positive

• Mr. B has smear-positive TB• A breast-feeding child of a smear-positive mother

has a higher risk of infection (compared to a child living in the same household as a smear-positive patient).

• Both are eligible for INH (if not symptomatic for TB)

Slide 5Unit 9: Case Studies

B Family B Family Case: Question 1Case: Question 1

1. What is your management plan for BB?

2. What is your management plan for KB?

3. Would you give pyridoxine in either of these cases?

Slide 6Unit 9: Case Studies

B Family Case: Answer 1B Family Case: Answer 1

BB (3 month-old girl)• INH at 5mg/kg = 25

mg/day x 6 months• Repeat BCG if no scar

on forearm• Note that CXR and TST

are NOT necessary• HIV test

KB (3 year-old boy)• INH at 5mg/kg = 75

mg/day, but you give 100 mg/day due to drug formulation available

• Note that CXR and TST are NOT necessary

• HIV test

Neither of these cases should get pyridoxine

Slide 7Unit 9: Case Studies

B Family B Family Case: Question 2 Case: Question 2

• JB is Mrs. B’s 7 year-old daughter• Mrs. B. states that JB has had an intermittent cough

for 4 weeks• She has not been to school for 3 days because she

has been complaining of feeling tired• She has not been eating well lately• JB is short for her age, appears thin, is febrile

(38.1 C) and weighs 18 kg

Slide 8Unit 9: Case Studies

B Family Case: Question 2B Family Case: Question 2

What do you do for

Mrs. B’s daughter, JB?

Slide 9Unit 9: Case Studies

B Family Case: Answer 2B Family Case: Answer 2

TB investigations

• TST

• Sputum collection

• CXR

• HIV test

Slide 10Unit 9: Case Studies

B Family B Family Case: Question 3Case: Question 3

• JB is found to be HIV negative

• Mantoux is 12mm• Only 1 sputum was sent

and it was negative• Chest x-ray shows a

pleural effusion

Source: B. Marais, Stellenbosch University

What do you do next for JB?

Slide 11Unit 9: Case Studies

B Family B Family Case: Answer 3Case: Answer 3

• Start JB on Category III treatment:• Intensive phase: 2HRZ

• 2 tabs R60H30Z150 daily x 2 months

• Continuation phase: 4HR• 2 tabs R60H30 x 4 months

• She will likely show marked improvement after 2 weeks

• NOTE: the dose will change as JB gains weight

Unit 9 Diagnosis and Treatment of Unit 9 Diagnosis and Treatment of Paediatric TB Additional CasePaediatric TB Additional Case

Botswana National Tuberculosis Programme Manual Training for Medical Officers

Slide 13Unit 9: Case Studies

Additional Case (1)Additional Case (1)

• Agnes is 2 years old• Her mother was just diagnosed with smear-

positive pulmonary TB• Agnes is brought to the hospital by her parents• Agnes’ father says she has been ill for 3 weeks • She eats poorly, is losing weight, doesn’t play,

and feels hot most days

Slide 14Unit 9: Case Studies

Additional Case (2)Additional Case (2)

• Physical exam• T 39°C• Weight 70% of the expected weight for her age• Enlarged lymph nodes in the neck, axilla, and inguinal

areas• Swollen parotid glands, enlarged liver and spleen• Malaria smear negative

• Management• Prescribe ampicillin• Educate the parents, and ask them to return in 3 days

Slide 15Unit 9: Case Studies

Additional Case: Additional Case: Question 1 Question 1

1. What are common signs and symptoms of TB in small children?

2. What tests provide a confirmed diagnosis of tuberculosis disease in small children?

3. What tests provide supporting evidence of TB in small children?

Slide 16Unit 9: Case Studies

Additional Case: Answer 1 (1)Additional Case: Answer 1 (1)

1. Signs and symptoms in small children: • Chronic cough not improving and present for two

to three weeks• Night sweats• Fever of >38 degrees for two weeks• Weight loss or failure to thrive• Fatigue• Blood-streaked sputum

Slide 17Unit 9: Case Studies

Additional Case: Answer 1 (2)Additional Case: Answer 1 (2)

2. Confirmed TB in small children• Positive gastric aspirate smear or culture• Other positive culture• Positive acid-fast stain on lymph node aspirate• Caseous material on biopsy

• Cheesy material on visual inspection of biopsied lymph node

Slide 18Unit 9: Case Studies

Additional Case: Answer 1 (3)Additional Case: Answer 1 (3)

3. Supportive evidence of TB in small children• Positive TST

• BUT do not treat active TB in children based only on positive TST

• Suggestive x-ray images• Widened mediastinum from hilar or mediastinal

lymphadenopathy• Miliary pattern• Pleural effusion

Slide 19Unit 9: Case Studies

Additional Case: Question 2Additional Case: Question 2

What signs and symptoms are helpful in making a presumptive diagnosis of TB if microbiologic

or radiologic testing is not possible?

Slide 20Unit 9: Case Studies

Additional Case: Answer 2Additional Case: Answer 2

• Prolonged cough• Fatigue • No response to broad

spectrum antibiotic• Fever• Weight loss• Positive PPD

• A minority of patients with active TB will have a negative skin test, particularly if malnourished or otherwise debilitated

Slide 21Unit 9: Case Studies

Additional Case: Question 3Additional Case: Question 3

1. Knowing what you know now about Agnes, should she be started on treatment for tuberculosis disease?

2. If Agnes improves on ampicillin, the treatment for bacterial pneumonia, would you do anything additional for her?

Slide 22Unit 9: Case Studies

Additional Case: Answers 3 (1)Additional Case: Answers 3 (1)

1. Yes, she should receive TB treatment because:• She is the child of a smear-positive patient• She has all the symptoms of TB and did not

respond to antibiotics • There were non-specific chest X-ray changes

Slide 23Unit 9: Case Studies

Additional Case: Answers 3 (2)Additional Case: Answers 3 (2)

2. Remember that in immunosuppressed patients, more than one disease frequently exists at the same time

• Due to the presence of enlarged lymph nodes, liver, and spleen, Agnes may have HIV or pneumonia that is superimposed on TB– test her for HIV

• She needs further evaluation before starting on IPT (lymph node aspirate, etc.)