Childhood TB was written to enable healthcare workers to learn about the primary care of children with tuberculosis. It covers: introduction to TB infection, the clinical presentation, diagnosis, management and prevention of tuberculosis in children

1. 2
Clinical
presentation
of childhood
tuberculosis
Before you begin this unit, please take the EARLY PRESENTATION
corresponding test at the end of the book to
assess your knowledge of the subject matter. OF TUBERCULOSIS
You should redo the test after you’ve worked
through the unit, to evaluate what you have
learned. 2-1 How is the clinical diagnosis
of tuberculosis made?
The clinical diagnosis of tuberculosis depends
Objectives on the following five steps:
1. Having a high index of suspicion.
When you have completed this unit you 2. The patient being in contact with an adult
should be able to: with pulmonary tuberculosis.
3. Taking a careful history.
• Recognise the general symptoms and
4. Completing a full general examination.
signs of tuberculosis. 5. Requesting special investigations.
• List the symptoms and signs of
pulmonary tuberculosis. 2-2 What would make you suspect that
• Describe the appearance of tuberculous the child may have tuberculosis?
lymph node enlargement. Always suspect tuberculosis if one or more of
• Clinically diagnose tuberculous the following are present:
meningitis.
• A history of close contact with someone
• Clinically diagnose abdominal suffering from tuberculosis in the family or
tuberculosis. household, especially if recently diagnosed.
• Clinically diagnose spinal tuberculosis. • Poor, overcrowded living conditions.
• Clinically diagnose disseminated • The child has HIV infection.
tuberculosis. • The child is losing weight or is severely
malnourished.
• The child has a chronic, persistent cough.

2. CLINICAL PRESENTATION OF CHILDHOOD TUBERCULOSIS 25
• The child has pneumonia which does not symptoms. In young children the parents
respond to antibiotics. complain that the child is not as playful
• The child has fever for more than 14 days as usual. Older children may complain of
and is not responding to antibiotics. feeling weak and tired.
• The child is unwell with vomiting and a • A fever for more then two weeks when
decreased level of consciousness, with or no other cause of fever can be found and
without convulsions. there is no response to antibiotics. Fever
due to viral infections usually lasts less
Having a high index of suspicion that the child
than seven days.
has been in close contact with someone with
• Nights sweats, especially if the child
tuberculosis in a community, especially if they
is so wet that their clothes need to be
live in the same household, is often the most
changed. However severe night sweats
important step in making the diagnosis. A high
are not common in young children with
index of suspicion is very important in the
tuberculosis.
early diagnosis of tuberculosis, as tuberculosis
• Children with tuberculosis have usually
may present in many different ways and may be
been unwell for a few weeks when they first
confused with a wide range of other diseases.
present. Unlike the sudden onset in acute
bacterial or viral infections, the symptoms
Suspecting tuberculosis is important in making and signs of tuberculosis usually develop
the diagnosis. over a number of days or weeks.
• There are often no clinical signs on
examination in the early stages of
2-3 What are the symptoms and
tuberculosis.
clinical signs of tuberculosis?
A detailed history is very important when
• The early symptoms and signs of
considering a diagnosis of tuberculosis as the
tuberculosis are often vague and non-
history is often the most important clue to the
specific, making the diagnosis difficult.
correct diagnosis. Therefore always consider
These general symptoms and signs are
tuberculosis in a child with a chronic cough,
caused by tuberculosis at any site in the
weight loss, failure to thrive or unexplained
body. Children are usually asymptomatic
fever for more than two weeks, especially
in the early stages of tuberculosis.
if there is an adult with a chronic cough or
• The later signs of tuberculosis usually
known pulmonary tuberculosis in the family.
depend on which organ or organs are
infected. The organ most commonly
affected is the lung (pulmonary A careful history is very important in the
tuberculosis). diagnosis of tuberculosis.
Symptoms are what the child or parent
complains of, while signs are what you observe.
PULMONARY
2-4 What are the early general TUBERCULOSIS
symptoms and signs of tuberculosis?
• Failure to thrive with poor weight gain or
weight loss. Children with tuberculosis are 2-5 What are the symptoms of
often thin and undernourished. This may pulmonary tuberculosis?
first be noticed when the child’s weight is These symptoms and signs are important as
plotted on the Road-to-Health card. pulmonary tuberculosis is the commonest
• Feeling generally unwell with loss of form of tuberculosis in children and adults.
appetite, apathy and fatigue, are common

3. 26 CHILDHOOD TB
• In addition to the early general symptoms
Commonly there are no clinical signs on chest
and signs, the most important sign of
examination in children with pulmonary
pulmonary tuberculosis is a persistent
cough lasting more than two weeks. The tuberculosis.
cough may be dry or productive and shows
no signs of improving. Children with tuberculosis may also have
• The enlarged hilar nodes may press on symptoms and signs of HIV infection.
a bronchus (airway) causing wheezing,
cough or stridor. The wheeze does not
respond to inhaled bronchodilators. EXTRAPULMONARY
• Shortness of breath and fast breathing
are not common in children with
TUBERCULOSIS
tuberculosis. Chest pain and blood-stained
sputum (haemoptysis) may be present in 2-7 What is the clinical presentation
adolescents, but are rare in children. of extrapulmonary tuberculosis?
This depends on whether TB bacilli spread to
A persistent cough lasting longer than two only one organ (e.g. the meninges), or to two
weeks is an important symptom of pulmonary or more organs at the same time.
tuberculosis.
2-6 What are the clinical signs of ENLARGED TUBERCULOUS
pulmonary tuberculosis? LYMPH NODES
• Usually there are no abnormal clinical
signs on examination of the chest.
Therefore, a lack of signs does not exclude 2-8 What is the common site of
the diagnosis of tuberculosis. enlarged tuberculous lymph nodes?
• There may be signs of pneumonia (fast Enlarged lymph nodes (lymphadenopathy)
breathing, crackles and decreased air due to tuberculosis occur most commonly in
entry). the neck (cervical nodes).
• There may be wheezing due to airway
compression by enlarged hilar lymph
nodes. The wheeze does not respond to Enlarged cervical lymph nodes may be due to
bronchodilators. tuberculosis.
• There may be signs of a pleural effusion
(dullness over one side of the chest with 2-9 What are important signs of
poor air entry and possibly shortness of enlarged cervical lymph nodes?
breath), especially in older children and
adolescents. Often the mother first notices that the child
• Often children with extensive tuberculosis has lumps in the neck. At first the nodes are
are not acutely ill, do not require typically firm and non-tender on examination.
supplementary oxygen and have very few Later they may feel matted (stuck together).
clinical signs on chest examination but Enlarged tuberculous lymph nodes may lead
have extensive changes on chest X-ray. to complications.

4. CLINICAL PRESENTATION OF CHILDHOOD TUBERCULOSIS 27
2-10 What are the complications of Depressed level of consciousness is an important
enlarged cervical lymph nodes?
sign of tuberculous meningitis.
The lymph nodes may become tender and soft
due to inflammation and the breakdown of It is important to suspect tuberculous
tissue in the node (lymphadenitis) to form a meningitis in any child with drowsiness,
lymph node abscess. Later lymph nodes may headache and vomiting. The onset of symptoms
become attached to the skin and discharge and signs are often slow over a number of days.
the soft (caseous) material onto the skin. This A depressed level of consciousness, convulsions
results in a fistula. With healing, tuberculous and paralysis are late and dangerous signs.
fistulas leave scars.
2-14 Do children with tuberculous
2-11 What is a common cause of meningitis always die?
enlarged lymph nodes in the axilla?
It depends on whether the diagnosis is made
Enlarged lymph nodes in the axilla (arm pit) early or late. Full recovery is possible after an
are common a few weeks or months after a early diagnosis. However children who present
BCG immunisation on the upper arm on the late with depressed level of consciousness and
right side. This is not caused by tuberculosis signs of a stroke often die despite treatment.
but results from the BCG immunisation in Children who survive after the development
young children. Complications of enlarged of late signs may survive with permanent
axillary lymph nodes due to BCG are common disability (blindness, deafness, cerebral palsy,
in children with HIV infection. mental retardation and hydrocephalus).
It is very important to suspect TB meningitis
TUBERCULOUS in any child with unexplained drowsiness,
headache or vomiting so that an early diagnosis
MENINGITIS can be made and immediate treatment started.
2-12 What is tuberculous meningitis? ABDOMINAL
Infection of the membranes which cover the TUBERCULOSIS
brain (the meninges) by TB bacilli.
2-13 What is the clinical presentation 2-15 What is abdominal tuberculosis?
of tuberculous meningitis?
Tuberculosis of one or more organs in the
The symptoms and signs of tuberculous abdomen. It is usually due to the spread of TB
meningitis are: bacilli from the lungs. Newborn infants may
• Drowsiness, irritability and vomiting in a have abdominal tuberculosis as a result of TB
child who has been unwell for a few days. bacilli spreading from the infected placenta.
• Depressed level of consciousness.
• Older children may complain of headaches. 2-16 What are the clinical signs
• Convulsions. of abdominal tuberculosis?
• The fontanelle may be full with a rapidly The most common presentation of abdominal
increasing head circumference. tuberculosis is:
• Muscle weakness progressing to one-sided
paralysis (hemiplegia) due to a stroke. • Abdominal distension (swelling). This may
be due to fluid (ascites) or enlarged lymph
On examination there may be neck stiffness.

5. 28 CHILDHOOD TB
nodes. The liver and spleen may also be DISSEMINATED
enlarged.
• Abdominal pain may be present. TUBERCULOSIS
• Weight loss.
• Fever with no obvious cause.
2-20 What is disseminated tuberculosis?
Disseminated tuberculosis occurs when TB
TUBERCULOUS BONE bacilli spread throughout the body via the
AND JOINT DISEASE bloodstream as the immune system cannot
contain them in the lung. This leads to
tuberculosis in a number of organs other than
2-17 What bones and joints may the lungs, such as the meninges, abdominal
be infected with TB bacilli? lymph nodes, liver, spleen, bones and joints.
The most common sites are the spine (spinal
tuberculosis) and large joints such as the hip, 2-21 Which children are at high risk
knee or ankle. However, any bone or joint can of disseminated tuberculosis?
be infected. • Children under the age of one year
• Children who have not had BCG
2-18 When do children develop immunisation
bone tuberculosis? • Children with severe malnutrition
Bone tuberculosis (tuberculous osteitis) • Children with HIV infection
usually develops months to years after the
primary TB infection. It is due to reactivation Disseminated tuberculosis is most often seen in
of TB bacilli that have been dormant in the infants.
bone ever since they were first carried there
by blood spread from the lungs. Therefore it
is uncommon in young children and usually 2-22 What is the clinical presentation
seen in older children and adolescents. of disseminated tuberculosis?
• At first the child becomes generally
2-19 What is the presentation unwell with loss of appetite, failure to
of spinal tuberculosis? thrive and fever.
• There may be a history of cough.
Tuberculous osteitis of the spine usually
• The liver and spleen may be enlarged.
occurs in the lower thoracic or upper lumbar
• There may be features of tuberculous
vertebrae with:
meningitis.
• Local pain and tenderness
• Local deformity (gibbus) 2-23 Why is it important to
• Spinal cord compression (difficulty diagnose disseminated tuberculosis
walking and passing urine) as soon as possible?
Any child with local pain and tenderness over Because these children become extremely
the spine must be suspected of having spinal ill and may die if not diagnosed and treated
tuberculosis. A rapid onset of a gibbus (‘hump rapidly and correctly.
back’) is almost always due to tuberculosis.
2-24 What is miliary tuberculosis?
Spinal tuberculosis presents with local pain and Miliary tuberculosis is the spread of TB bacilli
tenderness. throughout both lungs. It is seen in some

6. CLINICAL PRESENTATION OF CHILDHOOD TUBERCULOSIS 29
cases of disseminated tuberculosis and can be tuberculosis. You should also ask about
diagnosed on chest X-ray. overcrowding and poverty.
NOTE The word ‘miliary’ comes from the
Latin for millet seed as the X-ray in a 3. Why is the history of the
child with miliary tuberculosis shows mother’s death important?
small spots throughout both lungs.
She might have died of tuberculosis
complicating HIV infection. If the child is
HIV positive this would greatly increase the
SCORING SYSTEMS TO risk of tuberculosis.
IDENTIFY TUBERCULOSIS
4. What clinical signs would
you expect to find?
2-25 Can a scoring system be used to help
make a clinical diagnosis of tuberculosis? Often there are very few clinical signs early in
tuberculosis. It would be important to weigh
Scoring methods are available, but they are the child and plot the weight on the Road-
not very accurate in children, especially if to-Health chart to assess weight loss. Signs of
HIV infection is also present. However, they malnutrition and HIV infection should also be
are useful in identifying children who are at looked for.
high risk of having tuberculosis and need to be
referred for further evaluation and special tests. 5. Do children with tuberculosis
often have night sweats?
CASE STUDY 1 No.
A grandmother presents at a primary-care 6. Would a scoring system be useful
clinic with her three-year-old granddaughter. in diagnosing tuberculosis?
She gives a history that the child has a poor It would be more accurate to identify children
appetite, weight loss and fever for the past who are at high risk of tuberculosis and need
three weeks. The local general practitioner further investigation.
prescribed amoxicillin for a respiratory tract
infection but this has not helped. The mother
died of HIV infection a few months ago. CASE STUDY 2
1. Why should you suspect tuberculosis? A four-year-old child presents with a chronic
Because the child has a number of the general cough for the past month, together with
symptoms which suggest tuberculosis (poor feeling weak and tired. As the examination
appetite with weight loss and prolonged fever). of the chest is normal, the medical officer
Failure to respond to the antibiotic treatment assures the parents that the child does not have
given for a bacterial respiratory tract infection pulmonary tuberculosis.
also suggests tuberculosis.
1. Could this child have
2. What social history would be important? pulmonary tuberculosis?
It would be important to know if anyone Yes. A chronic cough, especially if not
in the home has tuberculosis or a chronic improving, should always suggest tuberculosis.
cough which may be due to undiagnosed There is not enough information to exclude
tuberculosis.

7. 30 CHILDHOOD TB
2. Would a normal chest examination 3. What complication can occur in
exclude pulmonary tuberculosis? tuberculous lymph node enlargement?
No, as children with pulmonary tuberculosis The nodes may become painful and soft
often do not have abnormal chest signs on (lymphadenitis) and form an abscess or fistula
examination. which drains onto the skin.
3. What would be the likely cause 4. What may cause enlarged
if a wheeze was present? axillary (arm pit) lymph nodes?
If the child had no previous history of BCG immunisation on that side.
wheezing, it would be important to think of an
enlarged hilar lymph node pressing on a large 5. How do TB bacilli reach
airway. If this were correct, the wheeze would the cervical nodes?
not respond to an inhaled bronchodilator.
By lymphatic spread from lymph nodes in the
chest.
4. What would the likely diagnosis be if
there was poor air entry and dullness to
percussion on one side of the chest?
CASE STUDY 4
A pleural effusion. This might also cause
shortness of breath. An ill six-month-old child presents with
a two-week history of fever, poor feeding,
5. How should this child be managed? drowsiness and irritability. A few hours back
Further investigations are indicated to confirm the child had a convulsion. The father started
or exclude a clinical diagnosis of tuberculosis. on TB treatment a month before.
1. What is the likely clinical diagnosis?
CASE STUDY 3 Tuberculous meningitis. The father is almost
certainly the source of the infection.
A ten-year-old girl is seen in the outpatient
department of a district hospital with a 2. How do TB bacilli reach the meninges?
swelling in her neck. Examination suggests
enlarged cervical lymph nodes. There is no They get there via the bloodstream.
history of tuberculosis in the home. Tuberculous meningitis is usually seen in
infants and young children, and occurs soon
after the primary infection.
1. How common are enlarged cervical
lymph nodes in tuberculosis?
3. Is it important that this child has had a fit?
Cervical lymph node enlargement is common
in children with tuberculosis. Yes, as this is a late and serious sign of
tuberculous meningitis and increases the risk
of death or permanent disability. Therefore it
2. What are the typical clinical findings?
is important to make the diagnosis as soon as
Usually the lymph nodes are firm and painless, possible.
but may feel matted (stuck together).

8. CLINICAL PRESENTATION OF CHILDHOOD TUBERCULOSIS 31
4. What is miliary tuberculosis? 2. Children who are unwell with a chronic
cough or weight loss should be investigated
Disseminated tuberculosis with widespread
for tuberculosis
involvement of both lungs. These children are
3. A normal clinical examination does not
seriously ill.
exclude tuberculosis in a child.
4. Tuberculous meningitis is a very serious
5. What are important local signs form of tuberculosis and should be
of abdominal tuberculosis? suspected in any child with lethargy,
Abdominal pain and distension. Sometimes an headache and vomiting.
enlarged liver and spleen may be palpated. 5. Disseminated tuberculosis is most
commonly seen in young infants
and children with HIV infection or
THE FIVE MOST malnutrition.
IMPORTANT ‘TAKE-
HOME’ MESSAGES
1. Close contact with a person with untreated
tuberculosis in the household is the most
important clue to suspecting tuberculosis
in a child.