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 with 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
spectrum of childhood TB
TB disease: child is TB symptomatic, (+) TST and/or positive
radiologic or lab findings suggestive of TB

TB inactive: CXR calcified TB, (+) TST, asymptomatic, with or

without hx of previous TB, with or without hx of previous Rx
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