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Background
Tuberculosis (TB) is the most common
cause of infection-related death worldwide
Mycobacterium tuberculosis is the most
common cause of TB
Very rare causes are Mycobacterium bovis
and Mycobacterium africanum
It is a very hardy bacillus that can survive
under adverse environmental conditions
Pathophysiology
The main determinant of the pathogenicity
of TB is its ability to escape host defense
mechanisms
The infective droplet nucleus is very small,
measuring 5 micrometers or less, and may
contain approximately 1-10 bacilli.
5-200 inhaled bacilli are usually necessary
for infection
Pathophysiology
The small size of the droplets allows them to
remain suspended in the air for a prolonged
period of time
The risk of infection is increased in small
enclosed areas and in areas with poor
ventilation
the alveolar macrophages phagocytose the
inhaled bacilli. However, these are unable to kill
the mycobacteria, and the bacilli continue to
multiply unimpeded.
Pathophysiology
A cell-mediated immune (CMI) response
terminates the unimpeded growth of the M
tuberculosis 2-3 weeks after initial
infection
Most persons infected with M tuberculosis
do not develop active disease
In individuals who are immunocompetent,
the lifetime risk of developing disease is 5-
10%
Frequency
to the WHO, more than 8 million new
cases of TB occur each year
Currently, 19-43.5% of the world's
population is infected with M tuberculosis
TB occurs disproportionately among
disadvantaged populations, such as
homeless individuals, malnourished
individuals, and those living in crowded
areas
Frequency
According to the WHO, developing
countries including India, China, Pakistan,
Philippines, Thailand, Indonesia,
Bangladesh, and the Democratic Republic
of Congo account for nearly 75% of all
cases of TB.
Mortality/Morbidity
. In 1953, the mortality rate was 12.5 per
100,000 individuals
MDR-TB cases have a reported fatality
rate of greater than 70%.
Worldwide, deaths due to TB are
estimated at 3 million per year
Stage 1
Exposure has occurred, implying that the child has
had recent contact with an adult who has contagious
TB
The child has no physical signs or symptoms and has
a negative TST result
Not all patients who are exposed become infected,
and it may take 3 months for the TST result to
become positive
o children younger than 5 years may develop disseminated TB
in the form of miliary disease or tubercular meningitis before
the TST result becomes positive. Thus, a very high index of
suspicion is required when a young patient has a history of
contact.
Stage 2
o : This stage is heralded by a positive TST result.
No signs and symptoms occur, although an
incidental CXR may show the primary complex.
Stage 3
o Tuberculous disease occurs and is characterized
by the appearance of signs and symptoms
depending on the location of the disease.
Radiographic abnormalities also may be seen.
Stage 4
TB with no current disease
This implies that the patient has a history of
previous episodes of TB
stable radiographic findings with a significant
reaction to the TST and negative bacteriologic
studies. No clinical findings suggesting current
disease are present.
Pulmonary TB
Pulmonary TB may manifest itself in several
forms
endobronchial TB with focal lymphadenopathy
progressive pulmonary disease
pleural involvement
reactivated pulmonary disease
Symptoms of primary pulmonary disease in the
pediatric population often are meager
Fever, night sweats, anorexia, nonproductive cough,
failure to thrive, and difficulty gaining weight may
occur
Extrapulmonary TB
Extrapulmonary TB includes
peripheral lymphadenopathy,
tubercular meningitis,
miliary TB,
skeletal TB,
and other organ involvement.
Congenital TB
Congenital TB is a rare entity.
Symptoms typically develop during the second
or third week of life
poor feeding
poor weight gain
cough
lethargy
irritability
Other possible symptoms include fever, ear
discharge, and skin lesions
Congenital TB
the infant should have proven TB lesions
and at least one of the following:
Lesions in the first week of life
Documentation of TB infection of the placenta
or the maternal genital tract
Presence of a primary complex in the liver
Exclusion of the possibility of postnatal
transmission
TB Disease
Defects in cell-mediated immunity
HIV
Steroid therapy, cancer chemotherapy,
and hematologic malignancies increase
the risk of TB
Malnutrition
Non-TB infections, such as measles,
varicella, and pertussis,
Lab Studies
the diagnosis of TB in children is extremely
challenging because of difficulty in isolating M
tuberculosis
initial step is to obtain appropriate specimens for
bacteriologic examination
Gastric aspirates are used in lieu of sputum in
very young children (<6 y)
An early morning sample should be obtained, before
the child has had a chance to eat or ambulate, as
these activities dilute the bronchial secretions
accumulated during the night
Lab Studies
Initially, the stomach contents should be aspirated,
and then a small amount of sterile water should be
injected through the orogastric tube. This aspirate
also should be added to the specimen
Since gastric acidity is poorly tolerated by the tubercle
bacilli, neutralization of the specimen should be
performed immediately with 10% sodium carbonate.
Even with careful attention to detail and meticulous
technique, the tubercle bacilli can be detected in only
70% of infants and in 30-40% of children with
disease.
Lab Studies
Staining of the specimen
Conventional growth techniques
Nucleic acid probes
Polymerase chain reaction (PCR)
TST
Immediate skin testing is indicated for the
following children
Those who have been in contact with persons with active
or suspected TB
Immigrants from countries in which TB is endemic (eg,
Asia, Middle East, Africa, Latin America) or children with
travel histories to these countries
Those who have radiographic or clinical findings
suggestive of TB
TST
Annual TST is indicated for the following
children
Children who are infected with HIV or those living in a
household with persons infected with HIV