Paediatric aspects of Tuberculosis

1
Paediatric aspects of Tuberculosis

• Patricia Fenton
• Sheffield Childrens Hospital
• BSMT 12th May 2006

2
Challenges

• Rare disease
• Children susceptible
• Variable presentation
• Dissemination common
• Rarely smear positive
• Drug treatment difficult
• Must locate source adult

3
Paediatric TB is rare

• We know this because.
• In Sheffield Childrens Hospital we dont see
  very much

4
Children are susceptible

• Smear positive adult
• plus
• Child in same house
• equals
• 50 chance
• Geuns et al 1975

5
Swimming is good for you

• Smear positive life guard
• 3,764 children traced
• 108 infected non-swimmersgtswimmers
• Rao et al 1980

CHILDREN ARE SUSCEPTIBLE
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Dangerous times

• Up to 5 years
• Dissemination
• Meningitis
• 5 to puberty
• LN and skeleton
• Adolescence
• Pneumonitis
• Hilar adenitis

VARIABLE PRESENTATION
7
Variable presentation

• Stage 1 primary complex
• Stage 2 haematogenous dissemination
• Stage 3 pleurisy
• Stage 4 bones and joints
• May just have a fever

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BCG bile and glycerol flavour

• Bovine mastitis strain
• Passaged 230 times
• 1921 oral
• Lubeck disaster 1930 (73 died)
• WWII freeze dried

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Prevents dissemination?

• 1950 UK schools
• 1960 selected neonates
• Efficacy 0 to 80
• Prevents meningitis
• JCVI weighed evidence
• CMO letter July 05

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Bacille Calmette-Guérin

• Improved programme
• Targeted
• Neonatal
• Others at risk

NO MORE SCHOOL PROGRAMME
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New arrangements

• Local arrangements (logistics and training)
• No more Heaf mantoux
• All infants living where TB gt 40/100,000
• Parents or grandparents born where
• Unvaccinated new immigrants from areas..
• School children screened for risk factors

12
Challenge

• PCTs HAVE A HUGE RESPONSIBILITY
• To ensue new arrangements are robust

13
Rarely smear positive

• ADULT
• Pulmonary
• Productive
• Sputum

• CHILD
• Different sites
• Not productive
• Gastric washings?
• Induced sputum?
• BAL?
• LN biopsy?
• Bone marrow?

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Gastric washings

• Single room
• 3 nights
• Pass NG tube
• Starve overnight

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Induced sputum

• Negative pressure
• Masks FFP3
• Gloves
• Apron
• Nebulised saline
• FRIGHTENING

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Tissue

• General anaesthetic

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Treatment

• Start on suspicion
• Cannot swallow tablets
• Four drugs
• Taste
• Volume
• Long course of treatment

18
Contact tracing

• Household
• Close relatives
• School
• Social groupings
• Abroad
• The unexpected

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Tuberculous meningitis

• Symptoms gt6 days
• Optic atrophy
• Focal neurology
• Abnormal movements
• Neutrophils lt half

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MPS Casebook February 2006

• Term baby
• Mum European
• Dad N African
• Triple/polio
• BCG section blank
• Noted to visit N Africa for 2 months no BCG
  given

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Seven months old

• Visit to GP
• Noted smokers in home
• Scattered coarse transmitted chest sounds
• Salbutamol ? Asthma
• Mum felt salbutamol helped
• Letter to local housing authority

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Nine months old

• Vomiting
• High temperature
• Listlessness
• Coarse transmitted sound at lung bases
• 3 GP visits in as many days
• CXR and abdo XR abroad not repeated

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Five days later

• Still vomiting
• Staring blankly
• Not moving right arm
• Blurred disc margin on fundoscopy
• Urgent neuro opinion

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Neurosurgical assessment

• Cavitating lesion
• Left cerebrum
• Hydrocephalus
• Tuberculous meningitis
• Limited motor ability and unintelligible speech

25
This case illustrates

• Non-specific symptoms
• Irreversible damage
• Missed opportunity to follow BCG guidance

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Challenges

• Rare disease
• Children susceptible
• Variable presentation
• Dissemination common
• Rarely smear positive
• Drug treatment difficult
• Must locate source adult

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Conclusion