D.Ghada Saad Abdelmotaleb Professor of Pediatrics Tuberculosis D.Ghada Saad Abdelmotaleb Professor of Pediatrics

Caused by mycobacterium tuberculosis , M Caused by mycobacterium tuberculosis , M. bovis [milk], mycobacterium africanum…etc **One case →infect 10-13 new case. In developing countries WHO record >8 million case appeared each year and 3 million die. About 1/6 of them are children . 2 billion over the world infected cases due to [↓ resources-HIV/AIDS infection –crowded ] It is acid fast bacilli→ need special stain and media to grow .

Tuberculosis May be : T.B. infection or tuberculosis disease ↓ ↓ (+ve) tuberculin test (+ve) symptoms No signs or radiological and findings Signs or radiological

** Intra-thoracic or ** Extra-thoracic Tuberculosis either ** Intra-thoracic or ** Extra-thoracic ↓ 1-1ry pulmonary T.B. { the common } 2-Reactive T.B. {adult} [no L.N.- has cavity- →infectious - may lead to sinus formation] 3-Tuberculous pleural effusion (need aspiration to diagnose).

1ry pulmonary T.B. In >98% lung is the portal entry It =(1ry pulmonary complex) consisted of: 1-Ghron’s focus 2-lymphagenitis 3-lymphadenitis - Usually asymptomatic or - Non specific manifestations [low grade fever- mild cough – malaise] ** In infant may lead to failure to thrive.

Fate → Resolve (the majority) by fibrosis or calcification Progressive pulmonary T.B.(rare but serious) give full blond picture with cavity . It may give : 1-Epi –tuberculosis→ direct spread to others lung parts. 2-Endo-trachial spread. 3-Lymphatic- hematogenous spread (disseminated disease) to liver- spleen- skin- joint-bones- kidney or meninges .

Extra-thoracic T.B. **L.N. either→(partial) obstruction →hyperinflation ↓ (complete) atelectasis. the most common form. { L.N. are firm, discrete, not tender, fixed to under-laying tissue, usually unilateral .If progress it will matted together (mass) ,with low grade fever. It need excision biopsy}. **Miliary T.B. :{ 2 or more organs affected} more in infant and young children. But Tubercline test ( –ve) in 40% of cases.

**T.B. abdomen. **C.N.S. the most serious - common in age 6m: 4years . ↓ Inflammation →obstruction (late) Or tuberculoma (mass) **Bone (Pott’s disease). **Others.

MRI spine (Pott’s disease)

Tuberculosis of the spine in an Egyptian mummy Pott disease, also known as tuberculous spondylitis. Is one of the oldest demonstrated diseases of humankind,

Pediatric T.B. Is different from adult in several points: 1- The diagnosis is more difficult in children due to non specific or complete absence of symptoms . 2- Young children suffer more extra pulmonary and disseminated T.B. than adult.

3-Treatment of T.B. in children is challenging due to lack of pediatric drug formulations . 4- Young children are not contagious with active T.B. and acquired their disease from shared air space with adults with pulmonary T.B.

Diagnosis

1- History : * Unexplained cough>3 weeks. *Haemoptysis. *Unexplained weight loss and fatigue. 2- Examination. 3- Very high ESR 4- Tuberculin test {delayed type hypersensitivity reaction}: Intra-dermal 0.1ml (5 tubercline unit) of purified protein derivative (PPD). **(+ve) ≥10mm. **False (–ve) in : - Malnutrition. - Poor technique or reading . - Immune- suppressive

Tuberculin test

5-X-ray. ……… 6- Bacterial examination: *Zeil Nelson stain for sputum. *Gastric lavage and stain. * BACTEC ( 1:3 week use radiolabelad nutrients.) 7- Nucleic acid amplification ( NAA) e.g. PCR (polymerase chain reaction) . *Restriction fragment length polymorphism.

Prevention : 1-Control of known cases. 2-Early diagnosis. 3- Increase resistance of population . 4-Chemoprophylaxis for contact.

Treatment

Drug Form Dose/kg/day Adverse reactions Isoniazid INH(bactericidal) 50 mg tab. 10-15 up to 300mg I N H Rifampicine (bactericidal) 150-300mg cap or syrup 10-20mg single dose fasting Discolouration of urine Hepatotoxicity GIT upset Pyrazinamide 500mg tab 20-40mg once Hyper-urecemia (rare)

Streptomycine Injection I.M. 20-40mg up to 1gm 8th nerve toxicity Less renal Ethambutol 100-200mg tab. 15-25mg Optic neuritis Ethionamide 250 cap. 15-20mg GIT Hepatic

Other anti T.B. : Cyclosporine Kanamycine (IM) Amikacin (IV) bacteriostatic to prevent drug resistance Steroids :1 mg / kg / day oral for 4 – 6 weeks. In :1-T.B. meningitis . 2-Endo-tracheal . 3-Pericarditis .

+ Supportive treatment Duration ( regimen ) : INH + RIF → 6 or 9 months + PZA 2 months 12 months in CNS – BONES – disseminated disease 4th drug SIM or EMP if INH resistance is present

DOT ( Direct Observed Therapy ) Twice / week by medical health care workers . After two weeks with daily treatment .

Thanks