Transcript 3rd CPG on Management of Tuberculosis

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CPG Cover
Case Discussion 2 TB IN CHILDREN
by
Dr. Jeyaseelan P. Nachiappan
&
Dr. Suryati Adnan
1
Extended Family
Father
Girl
2 yrs
Mother
Grandmother
Boy
4 yrs
Boy
11yrs
Girl
8 yrs
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
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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
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Q1
• What else would you need to do for the
children in the household?
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A1
Consultation with a doctor:
• History
– presence of cough, loss of weight & fever
• Examination
– focusing on the respiratory system
– presence of lymphadenopathy
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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
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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
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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
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Terminology
• TB infection = Latent TB
• TB disease = Active TB
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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?
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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)
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History (cont.)
• ESR – 117
• Sputum AFB taken
• Mantoux test done
• CXR – scattered consolidation bilaterally
– Imp: Pneumonia/PTB
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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
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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
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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
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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?
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A7
• Normal child – no infection
• No need for sputum AFB smear
• Follow-up – 3 - 6 monthly for 2 years
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Management of Tuberculosis
(3rd Edition)
29
But…..
• Grandmother is
– primary caregiver
– CLOSE contact
– smear AFB positive
• Q8. Why is the Mantoux only 0 mm?
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A8
• Has there been an error in the test due to…
– solution expired?
– technique of dilution?
– administration?
– reading?
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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)
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Management of Tuberculosis
(3rd Edition)
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Management of Tuberculosis
(3rd Edition)
37
History (cont.)
2 year-old boy
• Asymptomatic
• Examination is normal
• Q9. What would you do?
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A9
• Mantoux test
• CXR
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History (cont.)
• Mantoux test – 15 mm
• CXR – normal
• Q10. What is the diagnosis & management?
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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
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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
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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
[email protected]
[email protected]
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