Picture of

CPG Cover
Case Discussion 2 -
TB IN CHILDREN

by
Dr. Jeyaseelan P. Nachiappan
&
Dr. Suryati Adnan

1
Extended Family
 History
• Father is a lorry driver

• Mother is a factory worker

• Grandmother
– is the primary caregiver for the children
– sleeps in the same room with the children

3
 About the Grandmother
• Prolonged cough – 2 month

• Haemoptysis – 3 days

• CXR – right upper lobe opacity

• Sputum smear AFB – strongly positive

• Diagnosed as PTB – treatment started

4
 Q1
• What else would you need to do for the
children in the household?

5
 A1
Consultation with a doctor:

• History
– presence of cough, loss of weight & fever

• Examination
– focusing on the respiratory system
– presence of lymphadenopathy

6
 Management of Tuberculosis
(3rd Edition)
• Screening of TB contacts is important among
those exposed to patients with PTB for early
detection of TB & to reduce its transmission

7
 History (cont.)
• 11 year-old boy
– has mild cough on & off
– known asthmatic (intermittent mild)
– requires salbutamol MDI 4 times in a month
– no fever, no loss of weight , no loss of appetite
– physical examination – normal
– BCG scar present

• Q2. What would you do for this child?

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 A2
• Mantoux test

• CXR

• Sputum smear & culture

9
 History (cont.)
• Mantoux test – 15 mm

• CXR – normal

• Sputum smear – negative

• Q3. What is your diagnosis & management?

10
 A3

• Diagnosis – Latent TB

• Follow-up to review for asthma

• Follow-up for
• 2 years at 3 - 6 monthly
• Parents explained on features of TB – fever, loss
of weight, prolonged cough, haemoptysis

• RISK SITUATION
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 Management of Tuberculosis
(3rd Edition)

Latent TB

Not treated
for Latent
TB
 Management of Tuberculosis
(3rd Edition)
• Risk of progression to disease is increased
when primary infection occurs before
adolescence, particularly in the very young (0
- 4 years old) & in immunocompromised
children

• Active TB usually develops within 2 years of

infection but the time-lag can be as short as a
few weeks in infants
WHO, 2006

13
 Terminology
• TB infection = Latent TB

• TB disease = Active TB

14
 History (cont.)
8 year-old girl
• Cough 1 month
• Not known to be asthmatic
• No fever
• Loss of weight, loss of appetite
• Air entry decreased right upper zone

• Q4. What would you do?

15
 A4
• Mantoux test

• CXR

• Sputum for AFB smear & culture

• ESR

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 Management of Tuberculosis
(3rd Edition)
RECOMMENDATION 18

• Children suspected of PTB should have

sputum examination, CXR & TST performed.
(Grade C)

17
 History (cont.)
• ESR – 117
• Sputum AFB taken
• Mantoux test done

• CXR – scattered consolidation bilaterally

– Imp: Pneumonia/PTB

18
 History (cont.)
• I/V amoxicillin & oral erythromycin
• Isolation room

• Mantoux test – 17 mm
• Sputum AFB smear – negative

• Q5. What is the diagnosis & management?

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 A5
• Pulmonary TB

• Need to start on antiTB treatment

20
 Management of Tuberculosis
(3rd Edition)
• Active TB usually develops within TWO years
of infection but the time-lag can be as short as
a few weeks in infants
WHO, 2006

21
 History (cont.)
• TB treatment started – HRZ regimen

• AFB culture results 1 month latter

– positive for M. tuberculosis
– sensitivity not ready

• Diagnosis – Pulmonary TB

22
Management of Tuberculosis
(3rd Edition)

WHO, 2006
WHO, 2005 23
 Management of Tuberculosis
(3rd Edition)

Pyridoxine 5 - 10 mg daily needs to be added if isoniazid is

prescribed.
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 History (cont.)
4 year-old boy
• Asymptomatic
• BCG scar present

• Q6. What would you do?

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 A6
• Mantoux test

• CXR

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 History (cont.)
• Mantoux test – 0 mm

• CXR – normal

• Q7. What is the diagnosis & management?

27
 A7
• Normal child – no infection

• No need for sputum AFB smear

• Follow-up – 3 - 6 monthly for 2 years

28
Management of Tuberculosis
(3rd Edition)

29
 But…..
• Grandmother is
– primary caregiver
– CLOSE contact
– smear AFB positive

• Q8. Why is the Mantoux only 0 mm?

30
 A8
• Has there been an error in the test due to…
– solution expired?
– technique of dilution?
– administration?
– reading?

31
 Management plan for
the 4 year-old should be:
• Treat as Latent TB isoniazid – 10 mg/kg daily
for 6 months

• No need for sputum AFB smear

• Follow-up at 2 weeks with LFT

• Follow up at 3 - 6 monthly for 2 years

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 Why a CXR?
• Mantoux test is not specific & sensitive for
LTBI or active TB

• History taking (exposure & s/s of active TB) &

physical examination may be done poorly &
may result in missing active TB

• Some areas have high TB burden e.g. OA

villages

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 Why a CXR?
• CXR can be omitted if adequate history &
physical examination are done after factoring
in:-  
– severity of exposure
– age of the child
– disease burden in community
– logistics for follow-up for 2years

• CXR IS DONE ONLY TO EXCLUDE ACTIVE PTB

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Management of Tuberculosis
(3rd Edition)

35
 Management of Tuberculosis
(3rd Edition)

ay
ly m
ac t
t ex
g i T B
w in tive
ollo & ac
e . F BI
u id L T
a g me
t is s o
a r is s
Ch m

36
Management of Tuberculosis
(3rd Edition)

37
 History (cont.)
2 year-old boy
• Asymptomatic
• Examination is normal

• Q9. What would you do?

38
 A9
• Mantoux test

• CXR

39
 History (cont.)
• Mantoux test – 15 mm

• CXR – normal

• Q10. What is the diagnosis & management?

40
 A10
• No need for sputum AFB smear

• Treat as Latent TB

• Follow-up at 2 weeks with LFT

• Follow-up at 3 - 6 monthly for 2 years

41
Management of Tuberculosis
(3rd Edition)

42
 Management of Tuberculosis
(3rd Edition)
• The risk of developing disease after infection
is much greater for infants & young children
under 5 years. Active TB usually develops
within 2 years of infection but the time-lag
can be as short as a few weeks in infants.
WHO, 2006

43
 Take Home Messages
• Adult with PTB is potential source of infection
to a child

• The closer the contact, the higher the risk of

transmission

• Risk of disease (infection to disease) is highest

for the younger child & in first 2 years of
transmission
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 Take Home Messages
• If symptomatic
– investigate & treat as active TB

• If asymptomatic
– investigate
– if no signs/symptoms of TB but significant
Mantoux test
• Diagnosis - Latent TB (Tx depends on age)

Exclude Active TB before treating for Latent TB

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 THANK YOU

drsuryati_adnan@phg.moh.gov.my
jaynachi@gmail.com

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