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Clinical
Infection (2 class): TST (+), clinical (-), radiographic (-) Disease (3rd class):
primary pulmonary TB milliary TB pleuritis TB progr primary pulm TB: pneumonia, endobr TB lymph nodes brain & meninges bone & joint gastrointestinal other organs
Extrapulmonary:
Clinical manifestation
vary, wide spectrum factors:
TB bacilli: numbers, virulence host: age, immune state
clinical manifestation
general manifestation organ specific manifestation
General manifestation
chronic fever, subfebrile anorexia weight loss malnutrition malaise chronic recurrent cough, think asthma! chronic recurrent diarrhea others
Organ specific
Respiratory Neurology : cough, wheezing, dyspnea : convulsion, neck stiffness, SOL manifestation Orthopedic : gibbus, crippled Lymph node : enlarge, scrofuloderma Gastrointestinal: chronic diarrhea Others
3
Resistance reduced : 1. Early infection (esp. in first year) 2. Malnutrition 3. Repeated infections : measles, whooping cough streptococcal infections 4. Steroid therapy
infection
4-8 weeks
12 months
24 months
DIMINISHING RISK
But still possible 90% in first 2 years
Tuberculin test
TB infection cellular immunity delayed type hypersensitivity
tuberculin reaction
Tuberculin
Strength first intermediate
(standard dose)
second
Tuberculin delivery
1. Mantoux : intradermal injection 2. Multiple puncture :
Heaf, special apparatus with 6 needles Tine, disposable, 4 needles
3. Patch test
Tuberculin
Mantoux 0.1 ml PPD intermediate strength location : volar lower arm reading time : 48-72 h post injection measurement : palpation, marked, measure report : in millimeter, even 0 mm Induration diameter : 0 - 5 mm : negative 5 - 9 mm : doubt > 10 mm : positive
Tuberculin positive
1. TB infection :
infection without disease / latent TB infection infection AND disease disease, post therapy
Anergy
Patient with primary complex do not give reaction to TST due to supression of CMI : Severe TB: miliary TB, TB meningitis Severe malnutrition Steroid, long term use Certain viral infection: morbili, varicella Severe bacterial infection: typhus abdominalis, diphteria, pertussis Viral vaccination: morbili, polio Malignancy: Hodgkin, leukemia, ...
TB disease: CMI failed to control TB infection TB infection + clinical and/or radiological manifestation
TB classification
modified)
Class
(ATS/CDC
0 1 2 3
+ + +
+ +
Microbiology
Microbiology
culture (Lowenstein Jensen) confirm the diagnosis negative result do not rule out TB positive result : 10 - 62 % (old method) methods:
old method radiometric (Bactec) PCR
Radiology
Imaging diagnostic
routine : chest X ray on indication : bone, joint, abdomen majority of CXR non suggestive TB pitfall in TB diagnostic
Radiographic picture
primary complex: lymph node enlargement milliary atelectasis cavity tuberculoma pneumonia air trapping - hyperinflation pleural effusion honeycombs bronchiectasis calcification, fibrosis
Radiographic picture
do not always help, particularly in small children at times can be confusing some cases: extensive disease from radiography clinical exam revealed little or nothing more confusingsuperadded bacterial pneumonia
Osborne CM et.al. Arch Dis Child 1995;72:369-74
Radiographic picture
No radiographic picture is typical of TB Many lung diseases have similar radiographic appearances mimicking PTB Cannot distinguish active pulmonary TB inactive PTB previously treated TB May not detect early stages of TB disease
under-reading Vijayan VK. Indian J Clin Biochem 2002;17(2):96-100.
Radiographic picture
Commonly found: enlargement of hilar/ paratracheal nodes sometimes difficult to interpret requires thorax CT with contrast Thorax CT reveals enlargement of lymph node in 60% children with TB infection and normal Chest rntgenogram
Delacourt C et.al. Arch Dis Child 1993;69:430-2.
Overdiagnosis
32
Serology
Serology
Sensitivity: 19 68% Specificity: 40 98%
Depends on: Type of antigen used Type of infection
Disadvantages results affected by factors such as - age - history of BCG vaccination - exposure to atypical Mycobacteria - unable to differentiate between infection and disease
Khan EA and Starke JR. Emerg Infect Dis 1995;1:115-23 .
Interferon
Detection of interferon- (QuantiFERON TB)
comparable with TST to detect latent TB infection Advantages - less affected by BCG vaccination - can discriminates responses due to nontuberculous mycobacteria - avoids variability and subjectivity associated with placing and reading TST The utility of QFT in predicting the progression to active TB has not been evaluated
Mazurek GH et.al. MMWR Dispatch 2002;51.
Diagnosis
Adherence / compliance
Drug discontinuation treatment failure
Diagnosis
1. 2. 3. 4. 5. 6. 7. 8. Clinical manifestation Tuberculin skin test Chest X ray Microbiology Pathology Hematology Known infection source Others : serologic, lung function, bronchoscopy
Algorithm
IDAI: 1998, 2002
If > 3 positive
Next page
Considered TB Give anti-TB therapy Observation in 2 months Clinical response (+) TB Continue anti-TB therapy
ATTENTION Presence of any dangerous signs: Seizure Decreased level of consciousness Neck stiffness Or signs such as: Spinal tumor/lump Limping Dam board phenomenon Send to hospital
Refer to hospital
Reevaluation in Referral Hospital: Clinical signs Tuberculin test Radiological findings Microbiology and serology examination Histopatology examination Diagnostic procedure and therapy according to each hospitals protocol
UKK Pulmonologi IDAI.
Encountered problem
Increasing demands of TB drugs for Pediatric TB Increasing diagnosis of Pediatric TB using the IDAI algorhitm Over diagnosis !? Need improvement IDAI scoring system
0
not clear -
1
reported, AFB(-) <red line, BW unexplained >3weeks >1 node, >1cm,painle ss swelling sugestive
2
severe malnutritio n -
3
AFB(+ ) positiv e -
Score
<3week s -
normal
Diagnosis by doctor BW assessement at present Fever & cough no respons to standard tx CXR is NOT a main diagnostic tool in children All accelerated BCG reaction should be evaluated with scoring system TB diagnosis total score >5 Score 4 in under5 child or strong suspicion, refer to hospital INH prophylaxis for AFB(+) contact with score <5
Diagnosis of TB in children
If you find the diagnosis of TB in children easy, you probably overdiagnosing TB If you find the diagnosis of TB in children difficult, you are not alone It is easy to over-diagnose TB in children It is also easy to miss TB in children Carefully assess all the evidence, before making the diagnosis
Anthony Harries & Dermot Maher, 1997
Thank you