1. Diagnosis and Management of Pediatric
TB – Recent Developments
Dr. Pratik Kumar
1

2. • The National guidelines on Pediatric TB
diagnosis and management were updated
based on the recent evidence and advances in
pediatric TB diagnosis and treatment in
consultation with Indian Academy Pediatrics
during January- February 2012.
2

3. DIAGNOSIS OF PEDIATRIC TB
• All efforts should be made to demonstrate
bacteriological evidence in the diagnosis of
pediatric TB.
• Alternative specimens : (Gastric lavage,
Induced sputum, broncho-alveolar lavage).
3

4. • Optimal strength of tuberculin : 2 TU (RT 23
or equivalent) to be used for diagnosis in
children.
• A positive Tuberculin skin test / Mantoux
positive >=10 mm induration.
4

5. • No role for inaccurate/inconsistent diagnostics
like serology (IgM, IgG, IgA antibodies against
MTB antigens), various in-house or non-
validated commercial PCR tests and BCG test.
• Loss of weight was defined as a loss of > 5% of
the highest weight recorded in the past three
months.
5

6. • Persistent Fever or Cough > 2 weeks …….And / Or
• Loss of weight / No weight gain …… And / Or
• History of Contact with Infectious TB Case
DIAGNOSTIC ALGORITHM FOR PTB (page 1)
SPUTUM EXAMINATION
Sputum Smear +ve Sputum Smear negative /
Sputum Not Available for
Examination
• Smear Positive
Pulmonary TB
• Treat according to
Guidelines
• Already received a complete course
of antibiotics or
• Sick Look or
• Severe Respiratory Distress or
• Any other reason for X-ray Chest
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7. DIAGNOSTIC ALGORITHM FOR PTB (page 2)
• Smear Positive Pulmonary
TB
• Treat according to
Guidelines
• Already received a complete course of antibiotics or
• Sick Look or
• Severe Respiratory Distress or
• Any other reason for X-ray Chest (XRC)
Yes No
XRC & TST A 7 day course using antibiotic which has
no anti TB activity eg Amoxicillin. (Do not
use Quinolones)
No Response
XRC suggestive of TB and TST
positive
GL / IS / BALSmear +ve
Smear negative
Either or both negative
• Smear Negative Pulm. TB
• Treat according to Guidelines
Smear negative
Follow Flow Chart TWO
7

8. Further investigations in Pediatric pulmonary TB suspect who HAS PERSISTENT
SYMPTOMS and does not have highly suggestive Chest skiagram (page 1)
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XRC Normal
TST Negative
XRC – Nonspecific
Shadows
TST Positive/ Negative
XRC Normal
TST positive
Review for an alternative
diagnosis
Repeat X-Ray Chest after
a course of
Antibiotic (if not already
received)
Review for alternate
diagnosis
• XRC – persistent
nonspecific shadows
• TST positive/ Negative
Alternate Diagnosis
Established
YES, Give Specific
therapy
NO

9. Further investigations in Pediatric pulmonary TB suspect who HAS PERSISTENT
SYMPTOMS and does not have highly suggestive Chest skiagram (page 2)
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GL/ IS/ BAL
• Look for extra pulmonary
site TB,
• If no then: Seek Expert
help, CT Chest & other
investigations may be
needed
Smear positive Smear negative
Smear positive Pulmonary TB
Treat according to Guidelines
• Look for alternative diagnosis
• If no alternative diagnosis found -Treat
as Smear negative Pulmonary TB

10. Diagnostic Algorithm for Lymph Node TB
Enlarged lymph node - Matted, cold abscess with
or without a discharging Sinus
Lymph node enlargement of > 2 cm in one or
more sites
• Prescribe a course of antibiotics for 7
days(Do not use Quinolones).
• Review after 2 weeks
In case of non-response, suspect TB as the
cause for lymphadenitis
• Smear examination for AFB by ZN Staining of the pus from discharging sinus / aspirate
from lymph node
• Aspirate for fine needle aspiration for cytology (FNAC), where facilities exist.
Diagnosis confirmed if the pus /aspirate from
FNAC show: (i) ZN stain +ve for AFB, and/or (ii)
granulomatous changes
• If no granulomatous changes and no
AFB, consider alternative diagnosis;
• Go for lymph node biopsy.
• Isolated Mantoux test positivity without
suggestive findings on FNAC should not
be treated with ATTTreat as Case
10

11. Intermittent versus Daily Regimen:
• The intermittent therapy will remain the mainstay
of T/t
• However, Among seriously ill, severe disseminated
disease or neurotuberculosis, the chances of
vomiting or non-tolerance of oral drugs is high in
the initial phase.
- should be given daily supervised therapy
during hospital stay.
11

12. Daily doses (mg per kg/day)
• Rifampicin : 10-12 mg/kg (max 600 mg/day)
• Isoniazid :10 mg/kg (max 300 mg/day)
• Ethambutol :20-25mg/kg (max 1500mg/day)
• PZA :30-35mg/kg (max 2000 mg/day)
• Streptomycin: 15 mg/kg (max 1gm/day).
12

13. • After discharge :
- thrice weekly DOT regimen
13

14. Newer Case definitions for pediatric TB
patients
A. Failure to respond:
• Who fails to have bacteriological conversion to
negative status or fails to respond clinically or
deteriorates after 12 weeks of compliant
intensive phase.
• Alternative diagnoses/ reasons for non-
responsiveness should be ruled out.
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15. B .Relapse :
- A case of pediatric TB declared cured or
completed therapy in past and now has (clinical
or bacteriological) evidence of recurrence.
C. Treatment after default :
- A case of pediatric TB who has taken
treatment for at least 4 weeks and comes after
interruption of treatment for 2 months or more
and has active disease (clinical or
bacteriological).
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16. D. Others :
- For programmatic purposes of reporting, all
types of retreatment cases where
bacteriological evidence could not be
demonstrated but decision to treat again was
taken on clinical grounds would continue to be
recorded and reported as “OTHERS” for
surveillance purposes.
16

17. TREATMENT CATEGORIES:
• There will be only two treatment categories –
1. For treating ‘new’ cases
2. For treating ‘previously treated cases’.
17

18. TREATMENT CATEGORIES AND REGIMENS
Treatment
Groups
Type of Patient Regimen
Intensive
Phase (IP)
Continuation
Phase (CP)
New
(78 doses)
1.Sputum smear positive
2.Sputum smear negative
3.Extra-pulmonary
2 H³ R³ Z³ E³
(24 doses)
4 H³ R³ (54
doses)
Previously
Treated
(102
doses)
1.Sputum positive relapses
2.Sputum positive failure
3.Sputum positive treatment
after default
4.Others
2 H³ R³ Z³ E³ S³
+
1 H³ R³ Z³ E³
(24+12 doses)
5 H³ R³ E³
(66 doses)
18

19. Till , the newer drugs are procured programme will continue using the existing drugs for at
least two years 19

20. 20

21. Product Code 13
Treatment box for Pediatric TB
Anti - TB Schedule 5 (24 blisters of IP
each containing)
Pyrazinamide Tablet 250 mg 1 Tablet
Ethambutol Tablet 200 mg 1 Tablet
Isoniazid Tablet 75 mg 1 Tablet
Rifampicin Tablet 75 mg 1 Tablet
Each box containing 24 Combi-packs of Schedule-5 in the Intensive
Phase and 18 multi-blister calendar Combi-pack of Schedule-6 in the
Continuation Phase
Anti TB Schedule 6 (18 blisters of
CP containing)
Isoniazid Tablet 75 mg 3 Tablets
Rifampicin Tablet 75 mg 3 Tablets
Pyridoxine Tablet 5 mg 4 Tablets
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22. Product Code 14
Treatment box for Pediatric TB
Anti-TB Schedule 7 (24 blisters of IP
each containing)
Pyrazinamide Tablet 500 mg 1 Tablet
Ethambutol Tablet 400 mg 1 Tablet
Isoniazid Tablet 150 mg 1 Tablet
Rifampicin Tablet 150 mg 1 Tablet
Each box containing 24 Combi-packs of Schedule-7 in Intensive
Phase and 18 multi-blister calendar Combi-pack of Schedule-8 in
Continuation Phase
Anti-TB Schedule 8 (18 blisters of
CP each containing)
Isoniazid Tablet 150 mg 3 Tablets
Rifampicin Tablet 150 mg 3 Tablets
Pyridoxine Tablet 5 mg 4 Tablets22

23. • Smear positive: Any sample (sputum, induced
sputum, gastric lavage, broncho‐alveolar
lavage) positive for acid fast bacilli.
• New Case: A patient who has had no previous
ATT or for less than 4 weeks.
• Relapse: Patient declared cured/completed
therapy in past and has evidence of recurrence.
23

24. • Treatment after Default: A patient who has
taken treatment for at least 4 weeks and comes
after interruption of treatment for 2months
and has active disease.
• Failure to respond: A case of pediatric TB who
fails to have bacteriological conversion to
negative status or fails to respond
• Default : which do not fit the above definitions.
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25. • TB Meningitis: During intensive phase of TB
Meningitis, Injection Streptomycin is to be
replaced byTab. Ethambutol
• Extending intensive and continuation phase:
Children who show poor or no response at 8
weeks of intensive phase should be given
extension of IP for one more month.
.
25

26. - In patients with TB Meningitis, spinal TB,
miliary/disseminated TB and osteoarticular TB,
the continuation phase shall be extended by 3
months making the total duration of treatment to
a total of 9 months.
- A further extension may be done for 3 more
months in continuation phase (making the total
duration of treatment to 12 months) on a case to
case basis in case of delayed response and as per
the discretion of the treating physician/
pediatrician
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27. • TB preventive therapy: The dose of INH for
chemoprophylaxis is 10 mg/kg (instead of
currently recommended dosage of 5 mg/kg)
administered daily for 6 months.
• TB preventive therapy should be provided to:
a. All asymptomatic contacts (under 6 years of
age) of a smear positive case, after ruling out
active disease and irrespective of their BCG
or nutritional status.
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28. b. Chemoprophylaxis is also recommended for
all HIV infected children who either had a
known exposure to an infectious TB case or
are Tuberculin skin test (TST) positive (>=5mm
induration) but have no active TB disease.
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29. c. All Tuberculin positive children who are
receiving immunosuppressive therapy
(e.g.Children with nephrotic syndrome, acute
leukemia, etc.)
d. A child born to mother who was diagnosed to
have TB in pregnancy should receive
prophylaxis for 6 months, provided congenital
TB has been ruled out. BCG vaccination can be
given at birth even if INH chemoprophylaxis is
planned.
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30. When to suspect pulmonary TB?
• Fever and / or cough of recent onset lasting for
> 2 weeks should arouse suspicion of
tuberculosis.
• Cough persisting beyond 2 weeks
• Recent unexplained loss of weight
• In a symptomatic child, contact with a person
with any form of active tuberculosis within last
two years.
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31. • Pneumonia not responding to antibiotic
therapy .
• Diagnosis is also more likely in presence of risk
factors such as recent history of measles or
whooping cough and immuno-compromised
state including steroid therapy.
• Significant superficial lymphadenopathy
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32. Extra-pulmonary Tuberculosis
TB lymphadenitis
• Progressive enlargement of lymph node for
more than 2 weeks, firm, minimally tender or
not tender, sometimes fluctuating, may be
matted and may have chronic sinus formation.
• Fine needle aspiration cytology (FNAC) is usually
adequate for accurate diagnosis and it correlates
well with biopsy in >90% of cases.
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33. • Histopathology typically shows necrosis and
epitheloid granuloma.
• When FNAC is inconclusive, biopsy is
necessary for confirmation of diagnosis.
• In children, lymphadenopathy is common due
to recurrent tonsillitis and URIs as well.
• Such reactive lymphadenitis may clinically
mimic tuberculosis but does not warrant anti-
TB drugs.
• Anti-TB drugs should not be given unless the
diagnosis of TB is confirmed by FNAC or
histopathology.
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34. Pleural Effusion
• If chest X-ray is suggestive of pleural
effusion, pleural aspiration should always
be performed for biochemical,
cytological and smear examination by ZN
stain to confirm the diagnosis.
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35. • Typically, a tubercular effusion fluid is straw
colored (pus, if aspirated, is very rarely due to TB
etiology) has large numbers of cells
(predominantly mononuclear), with high
proteins (>3g/dL).
• Adenosine Deaminase (ADA) levels over 60 IU/L
may be suggestive of tuberculousis.
• Pleural biopsy may be performed, where
available, particularly when the fluid aspirate
findings are inconclusive.
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36. Tubercular meningitis (TBM)
• Longer (>1 week) duration of fever, with vague
CNS symptoms such as behavior changes, irritability,
drowsiness, headache, vomiting and seizures.
• Physical examination reveals typically global
encephalopathy with focal deficits, hydrocephalus
and movement disorder.
• Risk factors for TBM include age < 5 years,
contact with an adult suffering from tuberculosis,
PEM grade III and IV, and HIV infection. 36

37. Tuberculoma
• Often seen in older children, it may present as
a focal seizure or
• Symptoms and signs of raised intracranial
tension with multiple localizing signs
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38. Abdominal tuberculosis
• Mesenteric lymphadenopathy, intestinal
disease,peritoneal involvement or systemic
disseminated disease presenting as
hepatosplenomegaly.
• Large matted lymph node mass
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39. • There are no standard guidelines for
sonography diagnosis of abdominal
tuberculosis.
• Corroborative evidence includes: echogenic
thickened mesentery with lymph nodes > 15mm
in size; dilated and matted bowel loops;
thickened omentum, and ascites.
• None of these findings, however, is specific to
TB alone.
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40. • Barium follow-through examination may be
suggestive of intestinal disease but is not
confirmatory.
• Exudative peritoneal disease presents as
ascites that is often clinically evident.
• The ascitic tap should always be done in such
situations.
• The fluid tapped is an exudate, typically
showing lymphocytic predominant cellular
response with high proteins (>3g/dL).
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41. Thank You
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