Upload
others
View
8
Download
0
Embed Size (px)
Citation preview
Pediatric Tuberculosis Page 1 of 18
PEDIATRIC TUBERCULOSIS
Ann M. Loeffler, M.D.
Faculty ConsultantCurry International TB Center
Objectives
At the end of this session, participants will be ableto describe:
• how pediatric patients differ from adults in p ppresentation of tuberculosis (TB) disease
• the treatment regimens for latent TB infection (LTBI) and TB disease in children
Children are not just small adults
Pediatric TB and LTBI are sentinel events
Screening for LTBI
Likelihood of TB disease Likelihood of TB disease
Class 1 exposure
Signs and symptoms
Radiographic findings
Pediatric Tuberculosis Page 2 of 18
Children are not just small adults (2)
Pulmonary vs. extrapulmonary
Contagion
B i l i di i Bacteriologic diagnosis
Treatment regimens
Dosing difficulties
Pediatric tuberculosis
TST conversion and TB disease in a young child represent recentchild represent recent infection and therefore active transmission within the community:
“Sentinel event”
Screening for LTBIScreening for LTBI
Pediatric Tuberculosis Page 3 of 18
Why is screening for LTBI different for adults than kids?
1. Kids have fewer side effects from INH treatment than do adults
2. Most positive TSTs in adults are caused by previous BCG vaccinationBCG vaccination
3. Adults are more likely to get TB disease if they are infected
4. Adults don’t mind when we place a TST
Screening for latent TB infection
Adults
Screen only those at high risk of developing TB disease
Children
Screen those likely to have LTBI
Treat all LTBI identified
• INH less toxic
• Children more likely to be infected recently
Screening for latent TB infection (2)
Adults
www.thoracic.org
Statements
1999 − Targeted tuberculin testingand treatment of LTBI
Children – AAP guidelines http://pediatrics.aappublications.org/content/114/Supplement_4/1175.full.pdf
Pediatric Tuberculosis Page 4 of 18
IGRA in children Limited data in youngest children
National guidelines support use in children 5 years and older
IGRAs appear to have improved specificity vs. TSTIGRAs appear to have improved specificity vs. TST
Just like TST, may have decreased sensitivity in TB disease, immune compromise/young age
Rare false positives; indeterminates may be more likely in children
Use with caveats
Which children are most likely to developmost likely to develop
TB disease once infected?
Which children are NOT at increased risk of TB disease?
1. Infants
2. School-aged kids
3. HIV-infected
4. Malnourished children
Pediatric Tuberculosis Page 5 of 18
Host factors predisposing to disease
Young age
• 40% of infected babies <1 year develop TB disease
• higher risk continues until school-aged
Adolescence
Malnutrition
Underlying conditions/intercurrent illnesses: HIV, measles, pertussis, DM, immunosuppression
How do we evaluate and treat children exposed to adolescents
and adults with potentiallyand adults with potentially contagious TB?
Class 1 exposure
Exposure to an adult with TB disease:
• TST placement
• chest radiograph (PA and c es ad og ap ( a dlateral)
• physical exam to rule out extrapulmonary TB
• if no evidence of TB disease, initiate “window prophylaxis”
Pediatric Tuberculosis Page 6 of 18
Window prophylaxis
The practice of treating high-risk individuals
• with negative TST
• no evidence of TB disease
• exposed to a likely contagious case of TB
• with INH (unless source case resistant)
Window prophylaxis (2)
Repeat TST 8-10 weeks • after source case non-
contagiouscontact with source case• contact with source case broken
• if TST reliable (6-12 months of age/immunocompetent)
Stop prophylaxis if TST negative and no other source case!!
What kinds of findings
do we expect for a child
with TB disease?
Pediatric Tuberculosis Page 7 of 18
All children with TB disease have symptoms (cough, fever, or weight loss)
1. TRUE
2. FALSE
Signs and symptoms of tuberculosis
Most US children with TB are asymptomatic
The chest x-ray findingsThe chest x ray findings have NO correlation with signs and symptoms
Infants and adolescents are most likely to have signs and symptoms
Which chest X-ray finding is more common in children than adults?
1. Enlarged lymph nodes (intrathoracic lymphadenopathy)
2 Pleural effusion2. Pleural effusion
3. Apical disease
4. Cavitary disease
Pediatric Tuberculosis Page 8 of 18
Chest radiographs
Characteristic: Adults Children
Location Apical Anywhere(25% multilobar)
Adenopathy Rare Usual (30-90%)(except HIV)
Cavitation Common Rare (except adolescents)
Signs and symptoms Consistent Relative paucity
Extrapulmonary tuberculosis
>25% of children have extrapulmonary TB
• 67% lymphatic – mediastinal and scrofula• 13% meningeal• 6% pleural• 6% pleural• 5% miliary• 4% bone and joint• 5% others
intra-abdominal ears and mastoids skin, laryngeal, kidneys, etc.
Scrofula
Enlarging nodes
Not particularly painful
Skin becomes dusky and thin over time Skin becomes dusky and thin over time
May eventually suppurate and drain
Differential diagnosis: bacterial; cat scratch disease, non-tuberculous mycobacteria
Pediatric Tuberculosis Page 9 of 18
Scrofula (2)
More likely to be TB:
• cervical chain
• slightly older child
• exposure to TB
• consistent demographics
• larger TST reaction
• (in my experience) responds beautifully to TB therapy
Scrofula management
Skin test child and family
If most likely TB – treat empirically if you have culture material from elsewherematerial from elsewhere
If most likely non-tuberculous mycobacteria or diagnosis not clear – seek complete excision with AFB culture and path
AFB culture should be collected into syringe or cup without formalin – NOT ON SWAB!
How do we
bacteriologically confirmbacteriologically confirm
TB disease in a child?
Pediatric Tuberculosis Page 10 of 18
What specimens may grow M. tuberculosis in children with TB?
1. Gastric aspirates
2. Induced sputum
3. Cerebrospinal fluid
4. Lymph node biopsy
5. All of the above
Bacteriologic diagnosis
Sputum can rarely be collected from children
Can try sputum induction in older children
Bronchoalveolar lavage is invasive, expensive and should be reserved for situations where the diagnosis is in question
Bacteriologic diagnosis (2)
Gastric aspirates
• people swallow mucus in their sleep
• collect gastric contents before the stomach• collect gastric contents before the stomach empties
• http://www.currytbcenter.ucsf.edu/pediatric_tb/
Pediatric on-line course: resources
Pediatric Tuberculosis Page 11 of 18
Gastric aspirate collection
Have everything ready
Have helper if possible
Restrain the child wellRestrain the child well
• mark tube length to stomach with pen
• insert at least 10 French catheter through nose
• stay away from septum
• aim straight at the bed
Pediatric Tuberculosis Page 12 of 18
Gastric aspirate collection (2)
If insignificant yield:
• put any yield in sterile container
• check tube position in stomach by instilling air and listening with stethoscopelistening with stethoscope
• instill 20 ml sterile water
• re-aspirate
• if no good mucous – advance and withdraw tube, roll the child, etc. looking for mucous
• continue to aspirate syringe as you withdraw tube
Gastric aspirate collection (3)
Put all yield in sterile cup or tube
Immediately transport to lab for neutralize OR Neutralize at bedsideNeutralize at bedside
Order AFB smear and culture
(Bicarbonate for neutralization − 2.5 grams NaHCO3 dissolved in 100 cc deionized water. Filter the solution through a 45um filter. Use 1.5 cc for each specimen. Lab should monitor and correct the pH)
Gastric aspirate yield
A negative culture does not rule out TB
First specimen is the very highest yield
Nearly 100% yield for <3-month-olds
• smear rarely positive after 3 months
Literature for 3 gastric aspirates: 40%
Pediatric Tuberculosis Page 13 of 18
How do we treat LTBI and TB diseaseLTBI and TB disease
in children?
Which LTBI treatment regimen is not recommended for children?
1. INH for 9 months
2. Rifampin for 6 months
3 Rifampin and pyrazinamide for 2 months3. Rifampin and pyrazinamide for 2 months
4. INH for 6 months
5. 3 and 4
Treatment of latent TB infection270 doses of INH in a one year period
Regimen Adults Children
Isoniazid 9 months 9 months
Isoniazid 6 months ---------
Rifampin 4 months 6 months
Rifampin/
pyrazinamide
-------------- -----------
Pediatric Tuberculosis Page 14 of 18
Latent TB infection drug doses
Drug/regimen Adults Children
Isoniazid – daily 300 mg or 5 mg/kg/dose 10-20 mg/kg/dose up to 300 mg
Isoniazid – twice weekly DOPT
900 mg or 15 mg/kg/dose 20-40 mg/kg/dose up to 900 mg
Rifampin – daily or
twice weekly DOPT
600 mg or 10 mg/kg/dose 10-20 mg/kg/dose up to 600 mg
Pyrazinamide
Vitamin B6 25 mg for medical risks only only for breastfed; malnourished, sx
Child’s weight INH daily dose (10-15mg/kg/d)
Kilograms Pounds Milligrams 100mg tabs
300 mg tabs
3-5 kg 6.6-11 # 50 mg ½
Isoniazid (INH) dosing
3 5 kg 6.6 11 # 50 mg ½
5-7.5 11-16.4 75 ¾
7.5-10 16.5-22 100 1
10-15 22-33 150 ½
15-20 33-44 200 2
Over 20 Over 44 300 1
Maximum dose 300 mg !!
Pediatric TB:
• A decision to treat is a decision to treat
• Most often, once TB treatment is begun, it must be completedbe co p eted
• Unlike adults – positive cultures rarely available
• Clinical or radiographic improvement on treatment may be attribute to TB treatment or spontaneous resolution of another process
Pediatric Tuberculosis Page 15 of 18
Clinically and radiographically
Normal AbnormalConsistent with TB More consistent with other
diagnosis
P ti t t bl ?
Positive TB skin test
Treat for LTBI
C ll t lt d Patient very stable?Collect cultures andstart 4 drug TB therapy NO
YES
Consider culture collection
(NO INH!!!)Treat otherdiagnosis
Reassess weekly
Other diagnosis confirmed,Course inconsistent with TB
TB still possible?
*** Cultures only help if they are positive*
Treatment regimens
TB disease
• four drugs for two months
• if chest radiograph is not worse compliance• if chest radiograph is not worse, compliance good, and isolate presumed sensitive, two drugs for four more months
• miliary or CNS disease – one year
Dosing difficulties
Avoid liquid suspensions
• INH is only commercially available. High osmotic gload, stomach upset
• others custom made─
poor stability, poor homogeneity
Pediatric Tuberculosis Page 16 of 18
Dosing difficulties (2)
Crush or fragment tablets, open capsules onto vehicle and layer with aand layer with a topping of the food
Dosing difficulties (3)
Use thick, strong flavored vehicles:• jelly
• NutellaNutella
• chocolate whipped cream
• syrup
• chocolate sauce
• baby foods
Give a spoonful of vehicle before and after drug dose
Dosing difficulties (4)
Small amounts of non-sugary liquids
Rarely, dose infants in their sleep
Pediatric Tuberculosis Page 17 of 18
Conclusions – pediatric TB
Large global problem
Focal U.S. problem
Higher rates of progression to TB – requires aggressive evaluation for exposureaggressive evaluation for exposure
Children have:
• fewer signs and symptoms
• different radiographic findings
• more extrapulmonary TB
• less contagion
Conclusions – pediatric TB (2)
Gastric aspirates insensitive, but best culture method
Treatment regimens limited for LTBI, similar toTreatment regimens limited for LTBI, similar to adult TB regimens
Children are difficult to dose with TB meds; require patience and positive creativity
10 year old Ethiopian adoptee MDR-TB
Pediatric Tuberculosis Page 18 of 18
KH head CT