Pneumonia, Severe acute malnutrition, Tuberculosis, Xpert MTB/RIF assay
DOI: 10.5005/jp-journals-10081-1101 |
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S S, Ratageri VH, Shivananda I, C S, Wari P. Pulmonary Tuberculosis in Children with Severe Acute Malnutrition: A Prospective Hospital-based Study. Pediatr Inf Dis 2019; 1 (1):1-3.
Background: Tuberculosis is one of the common infectious diseases in under-five children especially with severe acute malnutrition (SAM). Pulmonary tuberculosis (PTB) presenting as pneumonia in undernourished children especially in communities where TB is highly endemic is still a less recognized entity.
Objective: To study the prevalence of pulmonary tuberculosis in severe acute malnourished children with acute pneumonia.
Materials and methods: Prospective hospital-based observational study done at Nutritional Rehabilitation Centre (NRC), Department of Pediatrics, Karnataka Institute of Medical Sciences (KIMS), Hubli, Karnataka, India from January 2016 to December 2016.
Inclusion criteria: Severe acute malnourished children of 1 month to 59 months of age with acute pneumonia with/without HIV infection.
Exclusion criteria: Children with severe acute malnutrition already diagnosed to have any form of tuberculosis and on ATT. All enrolled children's detailed history and examination was taken in a predesigned Proforma. A detailed history, examination and investigations like complete hemogram, Mantoux test, chest X-ray, gastric lavage for AFB, Xpert MTB/RIF, was done in all enrolled children.
Results: Total of 152 SAM children admitted during the study period, of these 29 (19.07%) fulfilled inclusion/exclusion criteria, with a mean age of 14.29 ± 9.63 months and male (14) to female (15) ratio of 0.9:1. The prevalence of pulmonary tuberculosis in SAM with acute pneumonia was 10.34% (3/29). All three were males, 2 cases were ≤12 months. Clinical symptoms/signs in order of frequency were fever (100%), respiratory distress (100%) and cough (66.66%). Risk factors for the development of tuberculosis were (i) presence of contact history (2/3) (p = 0.007) and (ii) positive Mantoux test (2/3) (p = 0.02), respectively. Though tuberculosis was more in children with absent BCG scar however it was statistically not significant (2/3). All three were bacteriologically confirmed (Xpert MTB/RIF assay) and rifampicin sensitive. Smear for AFB was positive in only one child.
Conclusion: Pulmonary tuberculosis should be considered in SAM children with acute pneumonia. Family history of contact with tuberculosis and positive Mantoux test was significant risk factors. XpertMTB/RIF was found superior in isolating TB bacilli as compared to smear for AFB
Tuberculosis is a scourge of mankind. The prechemotherapeutic era has given insights into the much needed natural history of tuberculosis. Once the TB bacilli enter the system, many factors including the age, nutritional status, the host immunity, bacillary load, pathogenicity of TB bacilli and HIV status tilt the balance between infection and disease. A clear understanding of the natural history helps us understand the various presentations in both pulmonary and extrapulmonary tuberculosis.
Tuberculosis (TB) in India accounts for about a quarter of the world's TB cases and children are at high risk of tuberculous infection and TB disease. TB diagnosis in children continues to be a challenge due to difficulty in getting appropriate samples and paucibacillary disease. In recently revised recommendations a major emphasis has been made on microbial diagnosis and more liberal use of molecular diagnostic modalities like cartridge-based nucleic acid amplification test (CBNAAT) and line probe assay. Cartridge based nucleic acid amplification test (CB-NAAT, GeneXpert,) is now considered as a World Health Organization (WHO)-recommended rapid diagnostic (WRD) and is a very simple test, with a well-established role in the diagnosis of pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) cases in comparison to AFB smear. CBNAAT should be offered upfront whereever TB is suspected. Drug sensitivity tests (DST) should always be attempted in all positive cases. For latent TB infection diagnosis intradermal TST is widely used however interferon-gamma release assays is also an equivalent option.
India has the highest burden of tuberculosis (TB). This article presents a review of the diagnostic utility and various limitations of the Mantoux and the interferon-gamma release assays (IGRA) tests in this high TB endemic setting. While both the tests cannot differentiate between latent and active TB, recent guidelines from WHO strongly recommends against the use of IGRA as an alternative to Mantoux test for India.
Abdominal tuberculosis is a common form of extrapulmonary tuberculosis constituting 11% of the cases; Ileocaecal region is the most commonly affected area followed by ascending colon, jejunum, appendix, duodenum, stomach, esophagus, sigmoid colon, and rectum. Diagnosis is a challenge which involves basic work up like computed tomography (CT) scan, esophageal ultrasonography (USG), ascitic fluid adenosine deaminase (ADA) and special investigations like capsule endoscopy, balloon enteroscopy, TB-PCR, GeneXpert, diagnostic laparoscopy are being increasingly used. Standard antitubercular drugs are the first line of treatment, and they are usually highly effective for intestinal TB. Six-months therapy is as effective as 9 months of therapy. Surgery is usually reserved for patients who have developed complications or obstruction not responding to medical management. Multidrug resistance (MDR) has been observed in 13% of MTB isolates in abdominal tuberculosis.
The emergence of multidrug-resistant and extensively drug-resistant tuberculosis (TB) and the advent of acquired immunodeficiency syndrome (AIDS) have complicated the diagnosis and treatment of central nervous system tuberculosis in children. Manifestations of central nervous system (CNS) TB varies from meningeal involvement to compressive myelopathy from vertebral TB. Rapid recognition of tuberculous meningitis (TBM) is essential as delays in initiating treatment are associated with poor outcome. Delayed diagnosis and treatment of TBM heralds’ poor neurological outcomes. The laboratory diagnosis of TBM is hampered by the low yield from CSF and the slow growth of M. tuberculosis. The current schedule of treatment of TBM has undergone a considerable change and is now aimed at the elimination of TB by 2030. In this review, we examine the recent advances in the understanding of TBM, its diagnosis, and the treatment.
Tuberculosis (TB) is a major contributor to disease burden globally. Congenital tuberculosis is a life-threatening disease in neonates with higher mortality rate. Perinatal transmission of infection occurs in utero or during delivery. It is difficult to differentiate congenital infection from postnatal. Cantwell criteria is used for the diagnosis of congenital infection. As symptoms are nonspecific congenital tuberculosis has to be actively considered as a possibility to diagnose it. Isolation of Mycobacterium tuberculosis organism either in culture or acid-fast bacilli (AFB) smear is very essential for the diagnosis. After the diagnosis of congenital tuberculosis treatment has to be initiated without delay. Breastfeeding should be encouraged among mothers on treatment for latent tuberculosis and after two weeks of treatment for active TB.
Mendelian susceptibility to mycobacterial disease (MSMD) is a group of rare genetic disorders characterized by increased susceptibility to infections with low-virulent mycobacteria like the Bacillus Calmette-Guérin (BCG) vaccines and the nontubercular environmental mycobacteria. These patients are also at increased risk of infections with non-typhoidal Salmonella, Candida, and Mycobacterium tuberculosis. In this article, we provide a clinical and laboratory approach to the diagnosis of MSMD. Various genetic defects causing MSMD and their treatment have been discussed.
The RNTCP guidelines for management of pediatric tuberculosis is continuously evolving and this article highlights the 2019 recommendations:
• The treatment categories have been simplified to two; new and previously treated.
• The definitions of the types of drug resistance have been elucidated.
• Daily therapy is recommended as the treatment of choice.
• The continuation phase now includes three drugs; isoniazid, rifampicin and ethambutol as isoniazid monoresistance is around 13%.
• The antituberculous therapy (ATT) dosing in children is higher as the pharmacokinetic studies have shown that children traditionally achieve lower serum levels than adults.
• Empiric category 2 regimen with extension of IP by 2 months has been withdrawn. It is now recommended to investigate for drug resistant TB (DR TB) in such cases.
• The indications for steroid usage and dosage in pediatric TB have been clearly defined. The evidence for the routine use of steroids in tuberculomas is unclear as of date.
• Pyridoxine supplementation is routinely recommended in children isoniazid is higher for both prophylaxis and treatment.
DOI: 10.5005/jp-journals-10081-1110 |
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Dhanalakshmi K, Sumanth A, Deshpande S, Agrawal S. An Adolescent with Jaundice and Respiratory Distress from the Case Records of Kanchi Kamakoti CHILDS Trust Hospital. Pediatr Inf Dis 2019; 1 (1):39-41.