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The Pediatric Infectious Disease Journal • Volume 28, Number 11, November 2009 www.pidj.com | 981
Cruz et al The Pediatric Infectious Disease Journal • Volume 28, Number 11, November 2009
⫹ ⫹ ⫹ ⫹ 4 (8.9)
⫹ ⫹ ⫹ 12 (26.7)
⫹ ⫹ ⫹ 5 (11.1)
⫹ ⫹ 19 (42.2)
⫹ ⫹ ⫹ 1 (2.2)
⫹ ⫹ 2 (4.4)
⫹ ⫹ 1 (2.2)
⫹ ⫹ 1 (2.2)
Totals 40 (88.9%) 43 (95.6%) 20 (44.4%) 12 (26.7%) 100%
AFB indicates acid-fast bacilli.
DISCUSSION
TABLE 3. Radiographic Findings Seen in 45 Children
Several differences were noted between this study popula-
With Pleural Tuberculosis
tion and previously reported data in terms of prevalence, age
No. Children Abnormalities distribution, radiographic findings, and culture yield. Pleural TB
Finding With Present at End was less commonly seen in this patient population than has been
Finding (%)* of Therapy (%)* previously reported in other pediatric series: 5% versus 22% of all
All cases
cases of TB disease.4 This might reflect our referral population,
Total 45/45 (100%) 28/45 (62.2%) which is heavily skewed toward preschool-aged children identified
Right 24 (53.3%) 14/24 (58.3%) in the course of health department contact investigations. Many of
Left 18 (40%) 11/18 (61.1%) the children diagnosed with TB disease in our clinic are asymp-
Bilateral 3 (6.7%) 3/3 (100%)
Isolated pleural tomatic (often with isolated hilar or mediastinal lymphadenopathy)
Total 12 5/12 (41.7%) or are identified early in their clinical course as a result of active
Right 7 2/7 (28.6%) surveillance. Whereas pleural TB has been more frequently re-
Left 4 2/4 (50%) ported in adolescents,3,4 in this series 7 of 45 (15.6%) of children
Bilateral 1 1/1 (100%)
Effusion ⫹ adenopathy were younger than 5 years of age and 28 of 45 (62.2%) were
Isolated effusion ⫹ adenopathy 5 3/5 (60%) prepubertal. This finding also may be a phenomenon of our
Parenchymal
†
involvement relatively young patient population. Most of the children diag-
Total 27 19/27 (70.4%)
Right upper lobe 4 3/4 (75%)
nosed with TB disease in our clinic population are children in the
Right middle lobe 9 5/9 (55.6%) first 5 years of life. Although a relatively smaller proportion of
Right lower lobe 11 8/11 (72.7%) these young children might have TB disease, the absolute number
Left upper lobe 6 5/6 (83.3%) of pleural TB cases is greatest in the youngest children.
Left lower lobe 8 6/8 (75%)
Cavity 3 3/3 (100%)
Chest radiographic findings showed parenchymal involve-
Pericardial effusion 2 0 ment in more children (73%) than have been reported in prior
Miliary disease 1 0 studies (56%).4 Few children had bilateral pleural effusions. Ef-
*The numbers do not sum to 45 because some children had ⬎1 radiographic abnor- fusions were somewhat more common on the right, perhaps
mality.
†
reflecting intrathoracic lymphatic drainage patterns. The majority
Eleven children (24%) had multi-lobar involvement with TB. of children continued to have abnormal chest radiographs at the
end of therapy, though no child had recurrence of disease after
termination of therapy.
In this series, the culture yield of pleural fluid and pleural
children were diagnosed by histopathologic findings of caseat- biopsy culture were not significantly different, but other studies
ing granulomas or visualized acid-fast bacilli in the absence of have found that the latter is more sensitive in terms of culture5
culture confirmation. One child’s isolate was isoniazid monore- and histopathology.6 Gastric aspirates or sputum samples were
sistant; the remaining isolates were susceptible to all first-line culture-positive in 33% of patients who had no evidence of
TB medications. parenchymal involvement by plain radiographs. This indicates
the possible utility of obtaining sputum or gastric aspirate
Treatment
cultures even in children with apparently isolated pleural dis-
Mean duration of therapy was 7.9 months (median: 6 ease, especially in circumstances in which sampling the pleural
months; range: 6 –13 months). Therapy was extended beyond 9
fluid itself is not feasible.
months in 10 children: 5 for nonadherence with initial regimens
There are several limitations to this study. Given the
(before directly observed therapy became available), 3 children
retrospective nature of the study, not all data were available for
with other extrapulmonary disease (2 pericarditis, 1 meningitis), 1
each patient. It was difficult to assess the utility of diagnostic
child with endobronchial disease, and 1 child with acute lympho-
assays such as PCR and adenosine deaminase in this study, as
blastic leukemia. Steroids were administered to 5 patients for a
they were performed in few children. For some children, this
mean of 6.4 weeks. Three children receiving steroids had extrapul-
might have been because TB was not suspected at the time the
monary disease (2 pericarditis, 1 meningitis), 1 had endobronchial
procedure was performed. In other instances, assays were not
TB, and 1 child had extensive bilateral pleural effusions.
available at the time the child was being evaluated. Diagnostic
Prognosis evaluation may have been less aggressively pursued for children
End-of-therapy chest radiographs were abnormal in 28 of 45 with identifiable source cases for whom TB susceptibility infor-
patients (62.2%) (Table 3). The most common abnormalities were mation was known. Finally, for some children, pleural biopsies
residual pleural effusion or thickening (13/28, 46.4%), pulmonary might not have been obtained because they were deemed higher
infiltrate or scarring (8/28, 28.6%), and hilar adenopathy (7/28, risk than thoracentesis. The rationale for diagnostic decision-
25%). All children had complete symptomatic resolution of dis- making was not always entirely evident from the medical record.
ease. The 2 children with TB pericarditis had no evidence of It is unclear why cultures were not attempted in all patients.
constrictive pericarditis on serial echocardiograms during fol- Although cultures obtained from patient specimens were positive
low-up evaluations up to 3 years after the acute episode. The only for 44% of children in this study, cultures of pleural fluid were
child with sequelae was a 10-year-old boy with TB meningitis who attempted for only a minority of patients (9/45, 20%). For some
had hemiparesis and visual loss. Children who had radiographic patients, concomitant parenchymal disease led clinicians to at-
abnormalities at the end of therapy had repeated imaging after 6 to tempt less invasive methods of obtaining cultures, such as sputum
12 months, with approximately 50% having residual abnormalities collection or gastric aspiration. For other children, small pleural
after this time. The most common radiographic anomalies seen effusions and/or identifiable links with a case of infectious tuber-
after 6 to 12 months were pleural thickening (7/14, 50%) and culosis might have led to more conservative diagnostic ap-
pulmonary parenchymal scarring (5/14, 35.7%). No child devel- proaches. In the last decade, more attempts were made to secure a
oped relapse or recrudescence after therapy was discontinued. microbiologic diagnosis by surgical and medical methods. This
was likely driven at least in part by increasing rates of drug- directly observed therapy. The index of suspicion for tuberculosis
resistant tuberculosis. should remain high in children with pleural effusions, with TST
The diagnosis of TB in a child is a sentinel event in a and the presence of epidemiological risk factors facilitating the
community, serving as a marker for recent transmission. This was diagnosis of tuberculosis in the majority of children.
also noted in this series, where 60% of the source cases were
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