Tuberculosis in children

Bone tuberculosis: a case report on child

The authors report a case of a 12-year-old child with a complaint of pain and deformity in the lower thoracic region that had lasted for two years. Clinical, epidemiological and laboratory characteristics associated with images of apparent damage in the T9-T10 and T11-T12 vertebrae taken by radiography of the thoracic spine and nuclear magnetic resonance in addition to the positivity of the molecular test based on the polymerase chain reaction, led to tuberculous spondylitis being diagnosed and specific therapy was started. Culture of vertebral biopsy was positive for Mycobacterium tuberculosis after thirty days.

Tuberculosis in childhood

There has been a recent global resurgence of tuberculosis (TB) fuelled by HIV infection and migration. Childhood TB represents a sentinel event in the community, suggesting recent transmission from an infectious adult. The diagnosis of TB in children is based on chest X-ray, tuberculin skin testing and mycobacterial staining/culture, although the diagnostic yield from these investigations is often lower than in adults. Newer diagnostic tests are being developed and may improve the diagnostic yield in childhood TB. Treatment of TB in children is similar to adults in that short-course multidrug treatment has been adopted as standard therapy in many national TB programmes. Compliance is a major determinant of the success of drug treatment and directly observed therapy has been adopted as a key component of TB treatment programmes. Although uncommon in children, multidrug-resistant TB is also increasing and treatment often involves longer courses of therapy with second-line drugs.

Granulysin-expressing CD4+ T cells as candidate immune marker for tuberculosis during childhood and adolescence

Background

Granulysin produced by cytolytic T cells directly contributes to immune defense against tuberculosis (TB). We investigated granulysin as a candidate immune marker for childhood and adolescent TB.

Methods

Peripheral blood mononuclear cells (PBMC) from children and adolescents (1–17 years) with active TB, latent TB infection (LTBI), nontuberculous mycobacteria (NTM) infection and from uninfected controls were isolated and restimulated in a 7-day restimulation assay. Intracellular staining was then performed to analyze antigen-specific induction of activation markers and cytotoxic proteins, notably, granulysin in CD4⁺ CD45RO⁺ memory T cells.

Results

CD4⁺ CD45RO⁺ T cells co-expressing granulysin with specificity for Mycobacterium tuberculosis (Mtb) were present in high frequency in TB-experienced children and adolescents. Proliferating memory T cells (CFSE_lowCD4⁺CD45RO⁺) were identified as main source of granulysin and these cells expressed both central and effector memory phenotype. PBMC from study participants after TB drug therapy revealed that granulysin-expressing CD4⁺ T cells are long-lived, and express several activation and cytotoxicity markers with a proportion of cells being interferon-gamma-positive. In addition, granulysin-expressing T cell lines showed cytolytic activity against Mtb-infected target cells.

Conclusions

Our data suggest granulysin expression by CD4⁺ memory T cells as candidate immune marker for TB infection, notably, in childhood and adolescence.

[Diagnosis of tuberculosis in pediatrics. Consensus document of the Spanish Society of Pediatric Infectology (SEIP) and the Spanish Society of Pediatric Pneumology (SENP)]

Tuberculosis is one of the most important health problems worldwide. There are an increased number of cases, including children, due to different reasons in developed countries. The most likely determining cause is immigration coming from high endemic areas. Measures to optimize early and appropriate diagnosis of the different forms of tuberculosis in children are a real priority. Two Societies of the Spanish Pediatric Association (Spanish Society of Pediatric Infectology and Spanish Society of Pediatric Pneumology) have agreed this Consensus Document in order to homogenize diagnostic criteria in pediatric patients.

Paediatric tuberculosis

Tuberculosis continues to cause an unacceptably high toll of disease and death among children worldwide, particularly in the wake of the HIV epidemic. Increased international travel and immigration have led to a rise in childhood tuberculosis rates even in traditionally low burden, industrialised settings, and threaten to promote the emergence and spread of multidrug-resistant strains. Whereas intense scientific and clinical research efforts into novel diagnostic, therapeutic, and preventive interventions have focused on tuberculosis in adults, childhood tuberculosis has been relatively neglected. However, children are particularly vulnerable to severe disease and death following infection, and those with latent infection become the reservoir for future transmission following disease reactivation in adulthood, fuelling future epidemics. Further research into the epidemiology, immune mechanisms, diagnosis, treatment, and prevention of childhood tuberculosis is urgently needed. Advances in our understanding of tuberculosis in children would provide insights and opportunities to enhance efforts to control this disease.

An unusual case of craniovertebral junction tuberculosis in an infant

STUDY DESIGN

We present, to the best of our knowledge, the first reported case of craniovertebral junction tuberculosis with complete quadriplegia in an infant.

OBJECTIVE

To describe report of an unusual case and discuss the difficulties and peculiarities of diagnosis, management, and follow-up of craniovertebral tuberculosis in an infant.

SUMMARY OF BACKGROUND DATA

Spinal tuberculosis is prevalent in areas where tuberculosis is endemic, and its incidence is on the rise in developed nations with the rising incidence of HIV/AIDS. Although common in children and young adults, spinal tuberculosis is rare in infants. Again, craniovertebral tuberculosis is one of the rarest forms of spinal tuberculosis.

METHODS

The infant presented to us at the age of 9 months with Grade IV quadriplegia. Among many of the clinical differential diagnoses, craniovertebral tuberculosis was suspected only on MRI and proved after fine needle aspiration cytology demonstrated granulomas. The patient was subjected to transoral debridement, immobilized with help of a pair of pillows by either side of the head and multidrug antitubercular treatment was started, which continued for duration of 12 months.

RESULTS

At the last follow-up of 1 year, the patient had recovered fully and caught up with the milestones suitable for her age.

CONCLUSION

Craniovertebral tuberculosis is difficult to diagnose and treat in infants. A high index of suspicion is essential for a prompt diagnosis and treatment, which is all the more crucial in this age group.

Tuberculosis of the Thyroid Gland: Review of the Literature

OBJECTIVE

Thyroid tuberculosis (TTB) is a very rare condition, even in countries with a high prevalence of tuberculosis. The aim of this article is to review and retrieve data about thyroid tuberculosis from the English-language literature in order to gain a better understanding of the clinical characteristics of TTB.

STUDY DESIGN

We performed Medline, PubMed, and library searches using the key words "thyroid tuberculosis," "throid disease," "tuberculosis and thyroid." Reference lists of the articles obtained and previous reviews were also examined.

RESULTS

We retrieved 76 cases matching our selection criteria from the search. Review of the cases with TTB revealed a slight female preponderance. The patients reported in the literature ranged in age from 9 to 83 years, with a median age of 40+/-16 years for men and 44+/-17 years for women. In the articles surveyed, TTB presented with a broad spectrum of manifestations, ranging from an isolated nodule to thyrotoxicosis. It seems that diagnosis of thyroid tuberculosis has recently been increasing, perhaps because of the growing incidence of tuberculosis and the diagnostic use of fine-needle aspiration cytology in the diagnosis. Although, in the past, the diagnosis was generally made by the examination of the specimens, at present, fine-needle aspiration cytology seems to be a useful method in diagnosis tuberculous thyroiditis. The role of surgery is limited after the diagnosis. The choice of treatment should be medical antituberculous therapy.

CONCLUSIONS

Preoperative diagnosis of thyroid tuberculosis is important because of the availability of medical treatment and the limited role of surgery. This condition should be kept in mind in evaluating patients with a thyroid nodule, in communities where the prevalence of tuberculosis is high.

Congenital tuberculosis requiring extracorporeal membrane oxygenation

We describe a 6-week-old infant with congenital tuberculosis with cardiorespiratory failure. She was successfully treated with ECMO initiated after worsening hypoxemia despite mechanical ventilation.

Diagnosis and treatment of tuberculosis in children

There has been a recent global resurgence of tuberculosis in both resource-limited and some resource-rich countries. Several factors have contributed to this resurgence, including HIV infection, overcrowding, and immigration. Childhood tuberculosis represents a sentinel event in the community suggesting recent transmission from an infectious adult. The diagnosis of tuberculosis in children is traditionally based on chest radiography, tuberculin skin testing, and mycobacterial staining/culture although these investigations may not always be positive in children with tuberculosis. Newer diagnostic methods, such as PCR and immune-based methods, are increasingly being used although they are not widely available and have a limited role in routine clinical practice. Diagnostic approaches have been developed for use in resource-limited settings; however, these diagnostic methods have not been standardised and few have been validated. Short-course, multidrug treatment has been adopted as standard therapy for adults and children with tuberculosis, with or without directly observed therapy. Compliance is a major determinant of the success of drug treatment. Although uncommon in children, multidrug-resistant tuberculosis is also increasing and treatment will often involve longer courses of therapy with second-line antituberculosis drugs. Treatment of latent infection and chemoprophylaxis of young household contacts is also recommended for tuberculosis prevention, although this may not always be carried out, particularly in high incidence areas.

Primary tuberculosis of the thyroid gland: report of three cases

We report on three cases with rapidly increasing thyroid masses who were referred with the provisional diagnosis of thyroid carcinoma. In the two cases, the diagnosis of tuberculosis was established after thyroidectomy, but in the third case diagnosis was made pre-operatively with acid fast bacilli (AFB) staining and culture from fine needle aspiration (FNA) material. Although rare, tuberculosis of the thyroid gland should be included in the differential diagnosis of thyroid masses. FNA, AFB staining and culture of the aspirate are important diagnostic tools in these cases.

The role of fluoroquinolones in tuberculosis today

Tuberculosis is a growing international health concern; it is the leading infectious cause of death in the world today. The fluoroquinolones are the most recent class of drugs offering hope in the fight against this disease. Ciprofloxacin, ofloxacin, levofloxacin and sparfloxacin are currently the most commonly used agents used against Mycobacterium tuberculosis (TB), with in vitro minimum inhibitory concentrations (MICs) of 0.1 to 4 mcg/ml. Resistance in TB to fluoroquinolones may occur spontaneously or may be acquired, especially when these agents are used inappropriately. Cross-resistance among the fluoroquinolones has been shown in TB. The fluoroquinolones offer a favourable pharmacokinetic profile for the treatment of TB. Most demonstrate excellent oral bioavailability and achieve maximum (peak) serum concentrations well above the MIC. They are also distributed widely, including intracellularly. The fluoroquinolones are cleared renally and/or hepatically, with varying serum half-lives. Fluoroquinolones are most effective when the peak concentration (Cmax) to MIC ratio is maximised. Fluoroquinolones such as ciprofloxacin and ofloxacin have been used in regimens for the prevention of TB, but have been poorly tolerated when used in combination with pyrazinamide. Favourable responses with fluoroquinolones in regimens used in the treatment of clinical TB disease have been seen. They, however, are not to be considered as equal replacements for isoniazid or rifampicin (rifampin) and should be used with at least 2 other antituberculous agents. Therapeutic drug monitoring of fluoroquinolones is beneficial in assuring that maximum Cmax to MIC ratios are being achieved, especially in patients at risk for malabsorption, such as those infected with HIV. Higher, once-daily doses of most fluoroquinolones are becoming more common in treating TB. Fluoroquinolones are generally well tolerated with long term use in treating TB, but rare, serious adverse effects have been reported with general fluoroquinolone use. The most common drug interactions with fluoroquinolones in TB therapy include the malabsorption interactions associated with multivalent cations and cytochrome P450 interactions with ciprofloxacin. An increased risk of central nervous system effects with concomitant cycloserine has been reported and seen clinically. When using fluoroquinolones to treat TB, careful consideration of individual susceptibility patterns, pharmacokinetic and toxicity profiles should be taken. The aid of a TB expert may also be warranted. The exact role of the fluoroquinolones in treating TB remains to be determined.

Pulmonary manifestations of pediatric HIV infection

Vertically acquired HIV infection is becoming increasingly common in India. The main clinical manifestations of HIV in childhood are growth failure, lymphadenopathy, chronic cough and fever, recurrent pulmonary infections, and persistent diarrhoea. Pulmonary disease is the major cause of morbidity and mortality in pediatric AIDS, manifesting itself in more than 80% of cases. The most common causes are Pneumocystis carinii pneumonia (PCP), lymphocytic interstitial pneumonitis (LIP), recurrent bacterial infections which include bacterial pneumonia and tuberculosis. The commonest AIDS diagnosis in infancy is PCP, presenting in infancy with tachypnea, hypoxia, and bilateral opacification on chest-X-ray (CXR). Treatment is with cotrimoxazole. LIP presents with bilateral reticulonodular shadows on CXR. It may be asymptomatic in the earlier stages, but children develop recurrent bacterial super infections, and can progress to bronchiectasis. LIP is a good prognostic sign in children with HIV infection in comparison to PCP. HIV should be considered in children with recurrent bacterial pneumonia, particularly with a prolonged or atypical course, or a recurrence after standard treatment. Pulmonary TB is common in children with HIV, but little data is available to guide treatment decisions. Much can be done to prevent PCP and bacterial infections with cotrimoxazole prophylaxis and appropriate immunisations, which may reduce hospital admissions and health care costs.

Tuberculosis in children and adolescents: California, 1985 to 1995

OBJECTIVES

To describe the epidemiology and clinical characteristics of tuberculosis (TB) among children and adolescents and to define children at risk for TB.

SETTING

4607 children 0 to 14 years of age and 1615 adolescents 15 to 19 years of age reported with TB in California.

METHODS

We analyzed surveillance data reported to the California Department of Health Services TB Control Branch from 1985 through 1995.

RESULTS

TB cases increased 22% among children 0 to 4 years of age and 66% among children 5 to 14 from 1985 through 1995. Case rates were highest among children 0 to 4 years of age (13/ 100000 children), but declined from 1993 to 1995, except for black children 0 to 4 years of age. Minority children 0 to 14 years of age had case rates 6- to 34-fold higher than did white children. Pulmonary TB was the most common site of disease in all age groups (71 to 82%). TB meningitis was most common in children 0 to 4 years of age (5%). Most children (64%) did not have cultures done; however, among culture-proved cases isoniazid-resistant Mycobacterium tuberculosis was isolated in 7%. Adolescents were more likely to have cavitary pulmonary disease (24%), to be foreign-born (78%) or homeless (4%) and to have an isoniazid-resistant strain isolated (13%) than were children 0 to 14 years of age (P < 0.05).

CONCLUSIONS

TB in children and adolescents increased substantially in the mid-1980s and early 1990s. Pediatric TB remains a serious health problem, especially among minority children and adolescents. Our findings indicate that TB control programs need improved strategies to prevent infection and detect disease in this population.

Isoniazid dose adjustment in a pediatric population

This retrospective analysis was designed to evaluate the inactivation index (I3) method used to adjust the isoniazid dose during long-term administration in a pediatric population. Before starting on antituberculosis therapy, sixty-one children received one 10 mg.kg-1 isoniazid test-dose (D). The isoniazid and acetyl isoniazid concentrations were measured by high-performance liquid chromatography on a plasma sample collected 3 hours (C3h) after administration. The patients were separated into slow and fast acetylator groups according to the metabolic ratio. The dose adjustment method using the I3 is based on the assumption that there is a linear correlation between C3h and D [C3h = (I3 x D) - 0.6] in which the slope is I3 and the Y intercept is equal to -0.6 mg.l-1. I3 was determined from a single plasma concentration determination and used to calculate the dose recommended to obtain a desired C3h equal to 1.5 micrograms.ml-1: recommended dose (mg.kg-1) = (1.5 + 0.6)/I3.I3 was significantly higher in the slow acetylator group (0.55 +/- 0.16) than in the fast one (0.26 +/- 0.13), which leads us to recommend a significantly lower dose in the slow acetylator group (4.2 +/- 1.5 mg.kg-1) than in the fast one (10.3 +/- 4.6 mg.kg-1). The data obtained in a subgroup of 21 patients who had at least three consecutive determinations of C3h after different dosages allowed us to verify that there was a linear correlation between C3h and the dose. The mean slope of the correlation lines in that subgroup was 0.61 +/- 0.25 and the 95% confidence interval of the estimated Y-intercept include the theoretical value of -0.60, which shows that our data are consistent with those previously reported in adults. The percentage of patients with a C3h plasma concentration within the expected range (1.5 +/- 0.5 micrograms.ml-1) was significantly higher (69%) in those whose dose was derived from the calculation than in the others (25%). Within each acetylator group, the range of the recommended dose varied widely, and these results emphasize the usefulness of individual dose adjustment based on the inactivation index method.

Tuberculous anterior neck mass simulating goitre

A 13-year-old Saudi boy was referred to the paediatric endocrinology clinic for evaluation of rapidly progressive goitre with weight loss of 6 months duration. A clinical diagnosis of possible thyroid malignancy was made. On exploration the mass was found to be tuberculous in origin, attached to the thyroid gland, and responded to partial excision and anti-tuberculous chemotherapy. Tuberculosis should be considered in the differential diagnosis of anterior midline neck masses.

Immunological aspects of pulmonary tuberculosis in children

In recent years new information has been collected about the immunological responses to pathogenic mycobacteria. More information on cellular and molecular responses of cells in murine and human tuberculosis has been produced and T cells' role in the production of selected cytokines has been clarified. Studies in mice have provided insight into the phases of the T cell response to virulent M. tuberculosis, the role of various T cell subsets, and the repertoire of antigens recognized by these cells. However, despite this new information, some of which has been confirmed in humans, large gaps remain in our knowledge about the immune response to this infection, particularly concerning cellular or molecular mechanisms involved in acquired protection. Even if some extrapolations from adult data can be made, large gaps in our knowledge exist on the potential immune defects in young infants who are prone to develop tuberculosis soon after infection.