1. Pediatric Tuberculosis

2. Tuberculosis 411
 Caused by mycobacterium tuberculosis
 Can cause latent TB or primary TB
 Primary TB can be pulmonary or extrapulmonary TB
 Spread by aerosolized particles during coughing,
sneezing, or speaking

Children less likely to spread
 Extrapulmonary TB is not transmitted
 Incubation period is 2-12 weeks
 Time from infection to identification of a primary lesion on
TST

3. Worldwide TB Epidemiology
 8.7 million NEW cases per year
 490,000 pediatric cases
 Low burden countries – 5% pediatric cases
 High burden countries- 20% pediatric cases
 Infants and young children are more prone to
develop life threatening forms
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
Disseminated TB
TB meningitis
 1.4 million deaths
 64,000 pediatric deaths
 Top ten cause of pediatric death

4. Worldwide

5. US Incidence

6. Clinical Features
 Bimodal presentation

Children < 5 y/o and adolescents >10 y/o
 Most children asymptomatic
 Most common symptoms:
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Chronic cough (>21 days)
+/- wheezing
Dyspnea
Hemoptysis
Fever (>14 days)
Weight loss/FTT
Weakness/lethargy
Night sweats

7. Pulmonary TB
 Pulmonary parenchymal disease and intrathoracic
adenopathy
 Most common: 60-80% of cases

8. Extrapulmonary TB
 Harder to diagnose
 Symptoms highly suggestive of extrapulmonary TB
 Gibbus from vertebral body
 Enlarged or painless joints
 Cervical lymphadenopathy with fistula
 Meningitis or pleural effusion not responsive to antibiotics
 Pericardial effusion
 Abdominal ascites

9. TB meningitis
 CNS involvement is common
 Symptoms include:
 Headache
 Neck stiffness
 Coma
 Hemiplegia
 Seizures
 LP to diagnose
 SIADH is common

10. Latent TB
 Do not show any symptoms of the disease
 Not infectious
 Can transition from LTBI to active TB more
frequently and faster (within weeks)
 Conversion rate is 5% in 2 years

11. Diagnosis
 Must distinguish between latent TB (LTBI) or TB
 Diagnostic tests include
 TST/QFT-GIT
 CXR
 AFB/Sputum culture
 Majority of case ( < 12y/o) are paucibacillary
 Microscopically negative for AFB
 Culture negative
 Smear positive TB only 20-40% of pediatric cases

12. Diagnosis
 TST- Mantoux method: 0.1ml dermal injection of
PPD into volar surface of forearm
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
Positive can mean current or future active TB
False positive in BCG vaccine and non tuberculosis
mycobacteria
 Interferon-gamma release assays (IGRAs)
 IGRAs can not distinguish between current or past
 QuantiFERON-TB Gold in Tube (QFT- GIT) ELISA test
QFT- GIT and TST sensitivity: 38% and 35%
 QFT- GIT and TST specificity: 81% and 84%
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 Nucleic acid amplification tests (NAATs)
 Used in neg. AFB microscopy and to detect drug resistance

13. TST Guidelines

14. Laboratory tests
 TST- Mantoux method: 0.1ml dermal injection into
volar surface of forearm


Positive can mean current or future active TB
False positive in BCG vaccine and non tuberculosis
mycobacteria
 Interferon-gamma release assays (IGRAs)
 IGRAs can not distinguish between current or past
 QuantiFERON-TB Gold in Tube (QFT- GIT) ELISA test
QFT- GIT and TST sensitivity: 38% and 35%
 QFT- GIT and TST specificity: 81% and 84%

 Nucleic acid amplification tests (NAATs)
 Used in neg. AFB microscopy and to detect drug resistance

15. Pulmonary TB on CXR
 Primary TB- infiltrate usually in middle or lower lobe
 Ipsilateral hilar adenopathy
 Any lobe can be affected
 25% multilobar
 Endogenous TB- develops from LTBI
 Infiltrate in upper lobes
 Cavitation and collapse
 Both can have atelectasis, pleural effusions,
pericardial effusion, or lymphadenopathy

17. Primary TB Treatment
 Initial phase for 2 months then continuation phase for 4
months
 Isoniazid (INH) and rifampicin (RIF)

Bactericidal, decrease microbial loads
 RIF and pyrazinamide (PZA)
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Sterilizing drugs that eradicate slow- replicating organism
 Ethambutol (EMB)
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Protects against the emergence of drug resistant TB
Not used in <8 y/o’s due to concerns for optic neuritis
 Disseminated TB and TB meningitis treatment is 12
months
 LTBI treatment:
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INH daily for 6-9 months or RIF for 4 months