Pulmonary tuberculosis

primary infection
progressive primary infection
Chronic pulmonary TB
multidrug resistant pulmonary tuberculosis
miliary tuberculosis

TB: Airborne infection

TRANSMISSION
person to person, generally from adult to
child and not vice-versa nor from child to child
Transmission rarely occurs by direct contact
with an infected discharge or a contaminated
fomite
The lung is the portal of entry in >98% of
cases.

Factors that would ENHANCE

transmission
1. when the patient has a positive acid-fast
smear of sputum
2. an extensive upper lobe infiltrate or
cavity
3. copious production of thin sputum
4. severe and forceful cough
5. Environmental factors such as poor air
circulation

Stages of Tuberculosis
1. Primary infection
2. Progressive primary TB
3. chronic pulmonary TB

Primary Infection
First infection with tubercle bacilli
Found in children
Clinical course depends on the childs health
status
If malnourished widespread (post primary
or progressive primary stage)

Pathogenesis
Inhaled Tb bacilli reaches alveoli
nonspecific inflammatory reaction
Ghons tubercle or primary
focus(initial tissue infection)

GHONS COMPLEX
(Primary complex)
1.Ghons focus subpleural focus in
the upper part of lower lobe/
lower part of upper lobe
2. lymphangitis
3. regional (hilar) lymphadenopathy
Develops within 2-8 weeks from
onset of infection

PRIMARY INFECTION

Insiduous onset
Incubation period: 2-10 wks
No symptoms as a rule
But if (+) : Easy fatigability, low grade
fever
NOT contagious
Cell mediated immunity is responsible

Primary Pulmonary TB
BUT if the immune system is weak , there
can be disseminated TB
In 3-6 months , it can reach the brain
(meningitis, tuberculoma, TB abscess)
In 1 year: bones
In 5-25 yrs : kidneys

Only Adults Transmit TB

Number of bacilli in sputum
Adult
Child
108
104
Need about 105 organisms/ml for positive smear

Key features suggestive of TB

The presence of three or more of the following
should strongly suggest a diagnosis of TB:
Chronic symptoms suggestive of TB
Physical signs highly of suggestive of TB
A positive tuberculin skin test
Chest X-ray suggestive of TB
History of contact with a source

RISK for DISSEMINATION

Conditions that adversely affect cellmediated immunity predispose to

progression from tuberculosis
infection to disease (HIV, AIDS)

BCG VACCINE
Used as a diagnostic test for TB
If the child is previously sensitized to
tuberculo protein accelerated local
response

BCG VACCINE
Dose: 0.05ml for NB up to 1 month
0.1ml for >1month
Route: intradermal
Within 2-3 weeks induration
4-6 weeks pustule
Healing in 8-12 weeks time

Efficacy: >50-80%

BCG VACCINE
Cannot prevent people from getting primary
TB
BUT it can prevent people from getting
extrapulmonary TB ( meningitis, diseminated
TB, etc)

Tuberculin Skin Test (Mantoux test)

Intradermal
injection of 0.1ml of
PPD
amount of
induration is
measured in 72 hr
Once positive, a PPD
will always be
positive.

Mantoux test
Sensitized lymphocytes
(CD4 and CD8) recognize
the antigen local
inflammation

False positive results

Prevalence of non-tuberculous mycobacteria

Prior BCG vaccination
Repeated TST resulting in sensitization
Incorrect interpretation of the result

False negative results

Severe tuberculosis
Previous viral disease
Very young age (<3 months)
Malnutrition
immunocompromised states
Incorrect administration or interpretation of
result

Interpretation of TST
size of induration

interpretation
(regardless of BCG status)

>15 mm
> 10mm
> 5mm

strongly POSITIVE
POSITIVE
Positive if any of the ff is present:
immunocompromised state, history of
contact with source-case, signs and
symptoms suggestive of TB, CXR
findings suggestive of TB

<5mm

NEGATIVE

LAB
Sputum exam
traditional culture specimen in young children
is the early morning gastric acid obtained
before the child has arisen and peristalsis has
emptied the stomach of the pooled secretions
that have been swallowed overnight.

Interferon Gamma Release Assay (IGRA)

Involves measurement of interferon-gamma
(IFN-) released by T cells that have been
sensitized by a prior exposure to M.
tuberculosis
Response is measured after 1-24 hrs of
incubation using ELISA or enzyme-linked
immunospot (ELISPOT)

Interferon Gamma Release Assay (IGRA)

Expensive
Excellent specificity and good sensitivity
Do not distinguish LTBI from active TB disease

Nucleic acid amplification methods

(NAATs)
Uses polymerase chain reaction
Positive NAATs support the diagnosis of TB but
a negative result does not rule it out
Hence, they are not a replacement for
conventional lab methods like AFB smear and
culture

How is TB cured?
TB can be cured.
DOTS (Directly-Observed Treatment Short
Course) is the recommended strategy to cure
TB.
It ensures the right combination and
dosage of anti-TB drugs.
It ensures regular and complete intake of
anti-TB drugs.
Patient takes drugs every day with the help
of a treatment partner.

CHEMOPROPHYLAXIS
Primary chemoprophylaxis
Given to tuberculin negative neonates, infants and
children <5 years exposed to active TB

Secondary chemoprophylaxis
Tuberculin (+) individuals but NO clinical or
radiologic evidence of disease

TREATMENT
6 month regimen of Isoniazid (H),
rifampicin (R) and 2 months of
pyrazinamide (Z)

 Ethambutol used in children with lifethreatening TB or who are at

risk for drug resistant
tuberculosis
Streptomycin used to replace
Ethambutol for children below 6 yrs and
in the treatment of TB meningitis;
reserved for multi-drug resistant TB

2 Phases of treatment:
The intensive phase

usually covers the first 2 months of

treatment.

During this phase, most of the bacilli will be

killed.

The sputum converts from positive to

negative in more than 80 % of the new
patients within the first 2 months of
treatment.

Phases of treatment:
The continuation phase

usually lasts 4-6 months, depending on the

treatment regimen.

intended to eliminate the remaining dormant

bacilli.

Since it is not possible to identify which

patients still have dormant bacilli, all patients
should continue their treatment until the end
of the prescribed period, to limit the number
of relapses.

 Common side effects:

Ethambutol : optic neuritis
INH : peripheral neuropathy
Rifampicin : Hepatotoxicity
Streptomycin: ototoxicity and
vestibular dysfunction
Pyrazinamide - hepatotoxicity

Evaluation of response to TB

(-) Anorexia 3-6 months

(-) pulmonary infiltrates 2-9 months
(-) Hilar adenopathy 2-3 years
(-) Pleural effusion 6-12 wks

2. Progressive Primary Pulmonary Disease

A rare but serious complication of TB in a child
occurs when the primary focus enlarges
steadily and develops a large caseous center.
Liquefaction can cause formation of a primary
cavity associated with large numbers of
tubercle bacilli.

2. Progressive Primary Pulmonary Disease

s/s: child looks ill; distressing cough
sputum positive
Dx: CXR bronchopneumonic foci

3. Chronic Pulmonary TB
Aka Reactivation TB, Phthisis
usually represents endogenous reactivation of
a site of tuberculosis infection established
previously in the body.
Occurs in older children >10 years of age

3. Chronic Pulmonary TB
Children with a healed tuberculosis infection
acquired at <2 yr of age rarely develop chronic
reactivation pulmonary disease
more common in those who acquire the
initial infection at >7 yr of age.
Usually happens in malnourished children

3. Chronic Pulmonary TB
Now with the apical seedings (Simon foci)
established during the hematogenous phase of
the early infection.
usually remains localized to the lungs, because
the established immune response prevents
further extrapulmonary spread.
CXR: infiltrates or thick-walled cavities in the apex
of the upper lobes, where oxygen tension is high
and poor lymphatic drainage

Miliary Tuberculosis
A serious post primary complication due to
massive invasion of the blood stream by
tubercle bacilli
result in dissemination of the bacilli and a
miliary pattern, with small nodules evenly
distributed on the chest radiograph
Involves 2 or more non-contiguous anatomic
sites (disseminated)

Miliary Tuberculosis

3 clinical forms of Miliary TB

1. typhoidal
2. pulmonary
3. meningeal

Extrapulmonary Tuberculosis
Disease involving anatomic structures other
than the lung parenchyma
Most common form Tuberculous
lymphadenitis (scrofula)
Results from lymphohematogenous spread

Drug - resistant TB

is a laboratory diagnosis
Features of a child suspected of having drugresistant TB:
contact with a known case of drug-resistant TB
not responding to the anti-TB treatment
regimen
recurrence of TB after adherence to treatment

 All mono-therapeutic regimens (real or

masked by combination with drugs to which
bacilli are resistant) lead to treatment failure
and to the development of resistance.

When three or more drugs are administered,

the risk of resistance is practically zero.

spectrum of childhood TB
TB exposure: child with close contact
a
source case, no s/sx, (-) TST, no
radiologic
or lab findings for TB
TB infection: child with (+) TST, no radiologic
or lab findings for TB
TB disease: child is TB symptomatic,
(+)
TST and/or positive radiologic or lab findings
suggestive of TB

TUBERCULOSIS
Clinical manifestations in pediatric TB may be
non-specific
TB is much more difficult to diagnose in
children
Undiagnosed or untreated TB in a child is
potentially serious,
More likely to develop severe or disseminated
disease

Knowing how to administer and read PPDs,

and to contextually interpret PPDs and CXRs is
vital