Tuberculosis In Children Ii

Tuberculosis in Children II

TUBERCULOSIS OF SUPERFICIAL LYMPH NODES

Occurs within 3-9 months of primary infection Can affect any group of nodes May be unilateral or bilateral Glands are usually discrete, mobile, firm and non-tender but later become matted together if there is periadenitis May form a discharging sinus There may or may not be associated constitutional symptoms. Investigations - Tuberculin skin test - CXR - Fine needle aspiration biopsy or excision of nodes for histological exam.

Differential Diagnosis • • • •

Pyogenic lymphadenitis Hodgkin’s lymphoma Acute lymphocytic leukemia Fungal infection of lymph nodes • Infection with atypical mycobacteria • HIV/AIDS

ABDOMINAL TUBERCULOSIS Comprises Tb of the gastrointestinal tract Tb of the abdominal lymph nodes Tb of the peritoneum Tuberculous enteritis - Occurs as a result of haematogenous spread from a primary focus or by swallowing tubercle bacilli which have been coughed up. - Jejunum and ileum near the payers patches are the most common sites - Shallow ulcers occur in these areas. CLINICAL FEATURES Abdominal pain Diarrhoea or constipation Weight loss Fever

TUBERCULOUS MESENTERIC ADENITIS - Arises as a result of spread from tuberculous enteritis - The lymph nodes become enlarged and matted together with omentum and peritoneum - May become palpable as a firm mass Clinical Features Diarrhoea or constipation Weight loss Abdominal mass + Features of sub acute intestinal obstruction

TUBERCULOUS PERITONITIS May arise from haematogenous spread or from direct extension from an abdominal lymph node infection or intestinal focus. Clinical Features Fever Abdominal swelling due to ascites Mild tenderness

Investigations Tuberculin skin test CXR Plain abdominal xray Ascitic tap for bacteriological studies Abdominal ultrasound Differential Diagnosis Abdominal Malignancies

TUBERCULSIS OF THE SPINE The vertebrae are the commonest and most important Bones affected by tuberculosis in children. May arise by:  Lymphatic spread from an adjacent area  Haematogenous spread from a primary focus Clinical Features Pain in the back Spinal rigidity and limitation of spinal movement Kyphosis Scoliosis with or without gibbus Increased muscle tone Decreased muscle power which may progress to paralysis There may be quadriplegia if the cervical vertebrae are affected or paraplegia if the other vertebrae are affected. There may be loss of voluntary bladder control

Investigations Tuberculin skin test CXR Radiograph of the affected part of the vertebral column Complications Paraspinal abscess Psoas abscess Retropharyngeal abscess Differential Diagnosis • Idiopathic scoliosis or kyphosis • Acute non-tuberculous osteomyelitis of the spine • Rickets • Secondary malignancies affecting the CNS e.g. Burkitt lymphoma ‫واحد‬ • Histoplasmosis Duboisii of the spine

TREATMENT Mainstay of treatment is combination chemotherapy Treatment is divided into 2 phases Intensive phase – 1st 2 months Continuation phase – 6 months To improve compliance directly observed therapy (DOT) is desirable at least during the intensive phase.

CURRENTLY USED REGIMEN Short course therapy: INTENSIVE PHASE : 2 MONTHS 1. STREPTOMYCIN OR ETHAMBUTOL 2. PYRAZINAMIDE 3. ISONIAZID 4. RIFAMPICIN CONTINUATION PHASE : 6 MONTHS 1. RIFAMPICIN 2. ISONIAZID OR 1. ETHAMBUTOL 2. ISONIAZID

Dosages and Side Effects of Anti Tb drugs Drug Side-effects

Dosages

Streptomycin -Toxicity to 8th nerve

20-40mg/kg/day

- Rash - Renal damage 7.

Isoniazid neuritis

10-15mg/kg/day

- Peripheral - Hepatotoxicity - Psychosis

3.

Rifampicin discoloration urine and tears

10-20mg/kg/day

- Orange - Gastrointestinal

disturbance Thrombocytopenia

- Hepatotoxicity -

of

Dosages and Side Effects of Anti Tb drugs Contd. Drug 3.

Thiacetazone rash

Dosages

Side-effects

3-5mg/kg/day

- Skin - Hepatotoxity - Haemolytic

anaemia - StevenJohnson’s syndrome in patients with HIV/AIDS 11. Ethambutol - Optic neuritis

15-20mg/kg/day

Indication for corticosteroid •

Large pleural effusion

3.

Endobronchial tuberculosis

5.

Pericardial effusion

4.

Tuberculous meningitis

Supportive Therapy

Improved Nutrition Screening of immediate family members Surgical intervention where necessary

Prevention of TB in a community • • • •

Case-finding and effective treatment. Contact tracing and INH chemoprophylaxis. BCG vaccination. Improvement in the general standard of living.

Newborn Infant of a mother with Tuberculosis: Mother’s treatment should be commenced or continued if already started. Baby should start INH soon after delivery and continued till mother’s sputum has been negative thrice. After this, the infant should have mantoux test: If mantoux is negative, INH should be discontinued and child vaccinated with BCG If mantoux is positive, infant should have CXR. –

If CXR is normal, continue INH for 12

DRUG RESISTANCE There are three types Natural: - Wild strain which is resistant to a particular drug without ever being in contact with the drug. Acquired or secondary: - The strain develops resistance to a drug to which it was initially sensitive. Primary: - When a patient with acquired resistance is the source of the infection. Multi drug resistance: - Mycobacterium resistant to a number of antituberculous drugs including INH and rifampicin.

TB AND HIV/AIDS Children who acquire HIV by MTCT are also likely to be exposed to TB HIV Infection: – – – –

Increase the severity of TB in children Morbidity is more prolonged Mortality is high Treatment may take longer to be effective.

HIV and TB increase the side effect from anti- TB drugs especially thiacetazone. Antiretroviral drugs affect the blood levels of anti -TB drugs