Pulmonary tuberculosis

primary infection
progressive primary infection
Chronic pulmonary TB
multidrug resistant pulmonary tuberculosis
miliary tuberculosis
TB: Airborne infection
 TRANSMISSION

person to person, generally from adult to

child and not vice-versa nor from child to
child
Transmission rarely occurs by direct
contact with an infected discharge or a
contaminated fomite
The lung is the portal of entry in >98% of
cases.
 Factors that would ENHANCE
transmission
1. when the patient has a positive acid-fast
smear of sputum
2. an extensive upper lobe infiltrate or
cavity
3. copious production of thin sputum
4. severe and forceful cough
5. Environmental factors such as poor air
circulation
 Stages of Tuberculosis

1. Primary infection
2. Progressive primary TB
3. chronic pulmonary TB
 Primary Infection
First infection with tubercle bacilli
Found in children
Clinical course depends on the childs
health status
If malnourished widespread (post
primary or progressive primary stage)
 Pathogenesis
Inhaled Tb bacilli reaches
alveoli nonspecific
inflammatory reaction Ghons
tubercle or primary focus(initial
tissue infection)
 GHONS COMPLEX
(Primary complex)
1.Ghons focus subpleural focus
in the upper part of lower lobe/
lower part of upper lobe
2. lymphangitis
3. regional (hilar) lymphadenopathy
Develops within 2-8 weeks from
onset of infection
 PRIMARY INFECTION
Insiduous onset
Incubation period: 2-10 wks
No symptoms as a rule
But if (+) : Easy fatigability, low grade
fever
NOT contagious
Cell mediated immunity is responsible
 Primary Pulmonary TB
BUT if the immune system is weak ,
there can be disseminated TB
In 3-6 months , it can reach the
brain (meningitis, tuberculoma, TB
abscess)
In 1 year: bones
In 5-25 yrs : kidneys
 Only Adults Transmit TB

Number of bacilli in sputum

Adult Child
108 104

Need about 105 organisms/ml for positive smear

Key features suggestive of TB
The presence of three or more of the following
should strongly suggest a diagnosis of TB:
Chronic symptoms suggestive of TB
Physical signs highly of suggestive of
TB
A positive tuberculin skin test
Chest X-ray suggestive of TB
History of contact with a source
 RISK for DISSEMINATION

Conditions that adversely affect

cell-mediated immunity
predispose to progression from
tuberculosis infection to disease
(HIV, AIDS)
 BCG VACCINE
Used as a diagnostic test for TB
If the child is previously sensitized to
tuberculo protein accelerated local
response
 BCG VACCINE

Dose: 0.05ml for NB up to 1 month

0.1ml for >1month
Route: intradermal
Within 2-3 weeks induration
4-6 weeks pustule
Healing in 8-12 weeks time
Efficacy: >50-80%
 BCG VACCINE
Cannot prevent people from getting
primary TB
BUT it can prevent people from getting
extrapulmonary TB ( meningitis,
diseminated TB, etc)
 Tuberculin Skin Test (Mantoux test)
Intradermal
injection of 0.1ml
of PPD
amount of
induration is
measured in 72 hr
Once positive, a
PPD will always be
positive.
 Mantoux test
Sensitized lymphocytes
(CD4 and CD8)
recognize the antigen
local inflammation
False positive results
Prevalence of non-tuberculous
mycobacteria
Prior BCG vaccination
Repeated TST resulting in sensitization
Incorrect interpretation of the result
False negative results
Severe tuberculosis
Previous viral disease
Very young age (<3 months)
Malnutrition
immunocompromised states
Incorrect administration or interpretation of
result
 Interpretation of TST
size of induration interpretation
(regardless of BCG status)
>15 mm strongly POSITIVE
> 10mm POSITIVE
> 5mm Positive if any of the ff is
present: immunocompromised
state, history of contact with
source-case, signs and
symptoms suggestive of TB,
CXR findings suggestive of TB

<5mm NEGATIVE
 LAB
Sputum exam
traditional culture specimen in young
children is the early morning gastric acid
obtained before the child has arisen and
peristalsis has emptied the stomach of the
pooled secretions that have been
swallowed overnight.
 Interferon Gamma Release Assay
(IGRA)
Involves measurement of interferon-
gamma (IFN-) released by T cells that
have been sensitized by a prior exposure
to M. tuberculosis
Response is measured after 1-24 hrs of
incubation using ELISA or enzyme-linked
immunospot (ELISPOT)
 Interferon Gamma Release Assay
(IGRA)
Expensive
Excellent specificity and good sensitivity
Do not distinguish LTBI from active TB
disease
 Nucleic acid amplification
methods (NAATs)
Uses polymerase chain reaction
Positive NAATs support the diagnosis of
TB but a negative result does not rule it
out
Hence, they are not a replacement for
conventional lab methods like AFB smear
and culture
 How is TB cured?
TB can be cured.
DOTS (Directly-Observed Treatment Short
Course) is the recommended strategy to cure
TB.
It ensures the right combination and
dosage of anti-TB drugs.
It ensures regular and complete intake of
anti-TB drugs.
Patient takes drugs every day with the help
of a treatment partner.
 CHEMOPROPHYLAXIS
Primary chemoprophylaxis
Given to tuberculin negative neonates, infants
and children <5 years exposed to active TB

Secondary chemoprophylaxis
Tuberculin (+) individuals but NO clinical or
radiologic evidence of disease
 TREATMENT
6 month regimen of Isoniazid
(H), rifampicin (R) and 2 months
of pyrazinamide (Z)
 Ethambutol used in children with life-
threatening TB or who are at
risk for drug resistant
tuberculosis

Streptomycin used to replace

Ethambutol for children below 6 yrs and
in the treatment of TB meningitis;
reserved for multi-drug resistant TB
 2 Phases of treatment:
The intensive phase
usually covers the first 2 months of
treatment.
During this phase, most of the bacilli will
be killed.
The sputum converts from positive to
negative in more than 80 % of the new
patients within the first 2 months of
treatment.
 Phases of treatment:
The continuation phase
usually lasts 4-6 months, depending on the
treatment regimen.
intended to eliminate the remaining
dormant bacilli.
Since it is not possible to identify which
patients still have dormant bacilli, all
patients should continue their treatment
until the end of the prescribed period, to
limit the number of relapses.
 Common side effects:
Ethambutol : optic neuritis
INH : peripheral neuropathy
Rifampicin : Hepatotoxicity
Streptomycin: ototoxicity and
vestibular dysfunction
Pyrazinamide - hepatotoxicity
 Evaluation of response to TB
(-) Anorexia 3-6 months
(-) pulmonary infiltrates 2-9 months
(-) Hilar adenopathy 2-3 years
(-) Pleural effusion 6-12 wks
 2. Progressive Primary Pulmonary
Disease
A rare but serious complication of TB in a
child occurs when the primary focus
enlarges steadily and develops a large
caseous center.
Liquefaction can cause formation of a
primary cavity associated with large
numbers of tubercle bacilli.
 2. Progressive Primary Pulmonary
Disease
s/s: child looks ill; distressing cough
sputum positive
Dx: CXR bronchopneumonic foci
 3. Chronic Pulmonary TB
Aka Reactivation TB, Phthisis
usually represents endogenous
reactivation of a site of tuberculosis
infection established previously in the
body.
Occurs in older children >10 years of age
 3. Chronic Pulmonary TB
Children with a healed tuberculosis
infection acquired at <2 yr of age rarely
develop chronic reactivation pulmonary
disease
more common in those who acquire
the initial infection at >7 yr of age.
Usually happens in malnourished children
 3. Chronic Pulmonary TB
Now with the apical seedings (Simon foci)
established during the hematogenous phase
of the early infection.
usually remains localized to the lungs,
because the established immune response
prevents further extrapulmonary spread.
CXR: infiltrates or thick-walled cavities in the
apex of the upper lobes, where oxygen
tension is high and poor lymphatic drainage
 Miliary Tuberculosis
A serious post primary complication due
to massive invasion of the blood stream by
tubercle bacilli
result in dissemination of the bacilli and a
miliary pattern, with small nodules evenly
distributed on the chest radiograph
Involves 2 or more non-contiguous
anatomic sites (disseminated)
Miliary Tuberculosis
3 clinical forms of Miliary TB
1. typhoidal
2. pulmonary
3. meningeal
Extrapulmonary Tuberculosis
Disease involving anatomic structures
other than the lung parenchyma
Most common form Tuberculous
lymphadenitis (scrofula)
Results from lymphohematogenous
spread
 Drug - resistant TB

is a laboratory diagnosis
Features of a child suspected of having drug-
resistant TB:
contact with a known case of drug-resistant TB
not responding to the anti-TB treatment regimen
recurrence of TB after adherence to treatment
 All mono-therapeutic regimens (real or
masked by combination with drugs to
which bacilli are resistant) lead to
treatment failure and to the development
of resistance.

When three or more drugs are

administered, the risk of resistance is
practically zero.
 spectrum of childhood TB
TB exposure: child with close contact
a source case, no s/sx, (-) TST, no
radiologic or lab findings for TB
TB infection: child with (+) TST, no
radiologic or lab findings for TB
TB disease: child is TB symptomatic,
(+) TST and/or positive radiologic or lab
findings suggestive of TB
 TUBERCULOSIS
Clinical manifestations in pediatric TB may
be non-specific
TB is much more difficult to diagnose in
children
Undiagnosed or untreated TB in a child is
potentially serious,
More likely to develop severe or disseminated
disease
Knowing how to administer and read
PPDs, and to contextually interpret PPDs
and CXRs is vital
Questions?