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NTB ppt-1
NTB ppt-1
NTB ppt-1
Approach in Children
Dr Zulfiqar Ali
PG FCPS Paediatrics
EMW
TUBERCULOSIS
Failure to thrive
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DIAGNOSTIC TOOLS FOR TUBERCULOSIS
Careful history
Clinical examination
Investigations
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Index Case (Index Patient): The initially identified case of new or recurrent
TB in a person of any age in a specific household or other comparable
setting in which others may have been exposed.
Close Contact: A person who is not in the household but who shared an
enclosed space, such as a social gathering place, workplace, or facility, with
the index case for extended daytime periods during the 3 months before the
start of the current treatment episode.
Household Contact: A person who shared the same enclosed living space as
the index case for one or more nights or for frequent or extended daytime
periods during the 3 months before the start of the current treatment
episode.
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HISTORY AND EXAMINATION
Chest
Cough > 2 weeks (unremitting and not improving)
Sputum
Shortness of breath
Unilateral wheeze, dullness
Constitutional symptoms:
Loss of appetite
Weight loss
Fever
Night sweats
Fatigue
SYSTEMIC
Malnutrition or failure to gain weight (PCM Grade 3), has not responded to 02 month
dietary plan
Lymph nodes: Cervical lymph nodes (enlarged, painless, matted, or there is an abscess
with or without discharge)
Abdomen
Chronic diarrhea, distended abdomen, any mass, or ascitieS
Bones and joints
Backache, stiffness, lump, deformity, limp
Unilateral swelling of joint, any tenderness(slow onset)
Weakness in lower limbs when there is gibbous
INVESTIGATIONS
AFB SMEAR MICROSCOPY
BUT
Diagnostic yield: induced sputum has high yield as compared to gastric aspirates .
Smear sensitivity is further reduced in patients with extra-pulmonary TB
TUBERCULIN / MANTOUX TEST
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TUBERCULIN / MANTOUX TEST
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FALSE NEG AND POSITIVE
False negative
Recent TB infection (less than 8–10 weeks)
Corticosteroid therapy/steroid use
Malnutrition Immunological compromise
Detect MTB even when present in very small numbers detection limit is 136 (MTB/Ml of
sputum).
Sensitivity of a single X-pert MTB/RIF test is reported to be 72.5% and increased to 90.2%
when three samples are tested.
X-pert MTB/RIF specificity is 99 %.
CONT…
It can detect far lower numbers of AFB, the detection limit being
around 100 organisms/ ml.
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Specimen Brief description Reco Reco Optimal Comments
of sample mmen mmen Collection
collection ded ded Time
procedure Age min.
Group vol.
for
studie
s
HISTOLOGY (CERVICAL LYMPH NODE OR
GRANULOMA)
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PAKISTAN PEDIATRIC ASSOCIATION SCORING
CHART FOR DIAGNOSIS OF TB IN CHILDREN
INTERPRETATION
0-2 points TB unlikely
3-4 points Keep under observation for possible TB
for three months
5-6 points TB probable, investigations may justify
therapy
7 or more points TB “confirmed”
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TB CASE DEFINITIONS
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TB CASE DEFINITIONS
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TREATMENT OF
TUBERCULOSIS
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CATEGORIES OF TB PATIENTS
Category -1:
This includes: New cases
a) Of smear + ve / -ve pulmonary TB
b) New extra-pulmonary TB and HIV positive
Category-2:
(Re-treatment) this includes
Relapses,
Treatment after failure,
Treatment after loss to follow
,others previously treated and patients with unknown TB treatment
history
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PRINCIPLE OF CHEMOTHERAPY
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DOSAGES OF ANTI-TB MEDICINES
:
Isoniazid (H) : 10 mg/kg (range 7–15 mg/kg)
Rifampicin (R): 15 mg/kg (range 10–20 mg/kg)
Pyrazinamide (Z): 35 mg/kg (range 30–40 mg/kg)
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TREATMENT OF CHILDHOOD TB
TREATMENT REGIMENS
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•
TREATMENT
06 MONTHS 08 MONTHS 12 MONTHS
Relapses Tuberculous Meningitis
Smear negative pulmonary TB Treatment after failure Osteoarticular
Intrathoracic lymph node TB Treatment after loss to follow T.B Spine
Tuberculosis peripheral lymphadenitis Previously treated patients TB + HIV +VE
HRZ— 02 months (intensive phase) HRZE --- 03 months (intensive phase) HRZE – 02 months (intensive phase)
HRE --- 05 months (continuation) HR --- 10 months (continuation )
HR --- 04 months (continuation phase )
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SPUTUM SMEAR EXAMINATION SCHEDULE ACCORDING TO CATEGORY OF TB
PATIENT
Month Result
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CLASSIFICATION BASED ON HISTORY OF PREVIOUS
TB TREATMENT
CAT-II
Previously Treated Patients: Have received 1 month or more of anti-TB drugs in the past
Relapse A patient previously treated for TB and declared cured or treatment completed by the
program, and now diagnosed with a recurrent episode of TB
Treatment after A patient who is started on a retreatment regimen after having failed previous (CAT-I)
failure treatment
Treatment after Patients who have previously been treated for TB and were declared lost to follow-up
loss to follow-up at the end of their most recent course of treatment.
Others The patients who have previously been treated for TB but whose outcome after their
most recent course of treatment is unknown or undocumented.
Unknown Patients with unknown previous TB treatment history do not fit into any of the
previous TB categories listed above.
treatment history
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TREATMENT REGIMEN FOR CAT-II
.
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SPUTUM SMEAR EXAMINATION SCHEDULE ACCORDING TO CATEGORY OF TB
PATIENT
Month Result
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DEFAULTERS
Rx given for more then 01 month and stopped.
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Steroids…… 06-08 weeks
1. TBM
2. Pericarditis
3. Miliary TB
4. Endobronchial TB
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MONITORING
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ADVERSE EFFECTS
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Type of Adverse Likely Culprit Identification Management
Event Drugs
Hepatotoxity INH, PZA, RIF
ADVERSE
jaundice EFFECTS
Tender liver, visible Stop all drugs;
Wait for liver function to return to normal;
Re-introduce drugs one-by-one sequentially, every
2 days with monitoring of liver function before
introducing the next drug
Visual Problems EMB Regular testing with Stop EMB or substitute for alternative drug
Ishihara Chart
Severe Rash (SJS) Any Drug Severe rash, peeling Stop all drugs;
mucus membranes, Wait until clinical condition has improved;
child unwell Re-introduce drugs one-by-one sequentially every 2
days, monitoring clinically
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HEPATOTOXICITY: IN ACTIVE TB
DISEASE
The incidences of hepatotoxicity are ranged as the following (from high to
low): INH>PZA>RIF.
Ethambutol (EMB) can be used safely in patients with hepatic disease.
Symptoms:
unexplained anorexia, nausea, vomiting, dark urine,
yellow skin or eyes, fever, persistent fatigue,
abdominal tenderness especially right upper quadrant discomfort.
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HEPATOTOXICITY: IN ACTIVE TB
DISEASE
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HEPATOTOXITY: MANAGEMENT
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HEPATOTOXITY: MANAGEMENT
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TREATMENT
OUTCOME
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TREATMENT OUTCOMES
Lost to follow up A patient whose treatment was interrupted for 2 consecutive months after
registration
Not evaluated A TB patient for whom,no treatment outcome is assigned (includes “Transfer
out” to another treatment unit and whose treatment outcome is unknown).
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MANAGE THE HOUSEHOLD CONTACTS
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CANDIDATES FOR IPT (INH
PROPHYLAXIS) TREATMENT)
The children below 5 year of age and are close contact of
Bacteriologically Positive (B+ive) TB patient, give
dosage of 10 mg/kg and is given for a period of 6 months.
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CONCLUSION
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MULTI DRUG RESISTANT
TUBERCULOSIS
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DEFINITIONS
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TREATMENT…
REGIMEN DESIGN
Children with MDR-TB should be managed according
to the same principles that guide adult therapy.
These include:
• Use of any first-line medication to which susceptibility is
documented or likely.
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REGIMEN DESIGN
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REGIMEN DESIGN
1) Use any Group 1 first-line oral drugs that have certain, or
almost certain, efficacy, for example, drugs showing
susceptibility in DST. These drugs should be administered
for the duration of therapy.
2) Add one Group 2 injectable agent based on DST results
and treatment history. This agent is normally given for a
minimum of 6 months and for 4 months after culture
conversion. Preferably, it should be an aminoglycoside such
as amikacin. Do not use streptomycin (unless other Group 2
drugs are unavailable) because of high rates of resistance
with DR-TB strains and higher incidence of ototoxicity.
3) Add one Group 3 fluoroquinolone based on DST results
and treatment history, for the duration of therapy.
Levofloxacin and moxifloxacin are preferred to ofloxacin.
Note that ciprofloxacin is not recommended. 71
REGIMEN DESIGN
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KEY POINTS
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KEY POINTS
In children, doses of all drugs, including the fluoroquinolones,
should be at the higher end of the recommended ranges
wherever possible, except ethambutol. Ethambutol should be
dosed at 15 mg/kg, and not at 25 mg/kg as sometimes used in
adults with DR-TB, as monitoring for optic neuritis is more
difficult in children.
.
Choose one drug in each of 2nd groups; amikacin is preferred to
kanamycin in children. Intramuscular injection of amikacin is
very painful -intravenous infusion should be preferred
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TREATMENT PHASES
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THANKYOU
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