Value of bronchoalveolar lavage and gastric lavage in the diagnosis of pulmonary tuberculosis in children

Interventional bronchoscopy in pediatric pulmonary tuberculosis

INTRODUCTION

Lymphobronchial tuberculosis (TB) is common in children with primary TB and enlarged lymph nodes can cause airway compression of the large airways. If not treated correctly, airway compression can result in persistent and permanent parenchymal pathology, as well as irreversible lung destruction. Bronchoscopy was originally used to collect diagnostic samples; however, its role has evolved, and it is now used as an interventional tool in the diagnosis and management of complicated airway disease. Endoscopic treatment guidelines for children with TB are scarce.

AREAS COVERED

The role of interventional bronchoscopy in the diagnosis and management of complicated pulmonary TB will be discussed. This review will provide practical insights into how and when to perform interventional procedures in children with complicated TB for both diagnostic and therapeutic purposes. This discussion incorporates current scientific evidence and refers to adult literature, as some of the interventions have only been done in adults but may have a role in children. Limitations and future perspectives will be examined.

EXPERT OPINION

Pediatric pulmonary TB lends itself to endoscopic interventions as it is a disease with a good outcome if treated correctly. However, interventions must be limited to safeguard the parenchyma and prevent permanent damage.

Effect of time, temperature and pH on Mycobacterium tuberculosis culture positivity of gastric aspirate: An experimental study

BACKGROUND

The culture of gastric aspirate (GA) has been used for bacteriological confirmation of pulmonary tuberculosis in children and patients who are unable to expectorate. Sodium bicarbonate neutralization of gastric aspirates is commonly recommended to increase culture positivity. We aim to study Mycobacterium tuberculosis (MTB) culture positivity of GA collected from confirmed case of pulmonary tuberculosis after storing it at different temperature, pH & time.

METHODS

GA specimens from 865 patients of either sex predominately non-expectorating children/adults with suspected pulmonary TB were collected. Gastric lavage was performed in the morning after an overnight fasting (at least 6hrs fasting). The GA specimens were tested by CBNAAT (GeneXpert) and AFB microscopy & those who were positive on CBNAAT were further processed with MTB culture on Growth Indicator Tube (MGIT™) culture. pH neutralized and non-neutralized CBNAAT positive GA specimens were culture within 2 hours of collection and 24 hours after storage at 4 °C & room temperature.

RESULTS

MTB was detected in 6.8% of collected GA specimens by CBNAAT. Culture positivity of neutralized GA specimens when processed within 2 hours of collection, was higher compared to paired non-neutralized GA specimens. Neutralized GA specimens had higher contamination rate than non-neutralized GA specimens. Storage of GA specimens at $Deg C had better culture yield than those stored at room temperature.

CONCLUSION

Early neutralization of acid in Gastric aspirate (GA) is essential for better culture positivity of M. tuberculosis (MTB). If there is a delay in processing GA, it should be kept at 4 °C after neutralization; however, positivity decreases with time.

Intrathoracic tuberculosis: Role of interventional bronchoscopy in diagnosis

Tuberculosis (TB) is the leading cause of death from a single infectious agent globally. Mortality is related to the delay in diagnosis and starting treatment. According to new guidelines it is very important to classify pulmonary tuberculosis (PTB) as severe or not severe disease due to the difference in treatment duration. Bronchoscopy is the gold standard for assessing the degree of airway compression and obstruction in paediatric PTB. Paediatric bronchoscopy has evolved from a primarily diagnostic procedure to include interventional bronchoscopy for diagnostic purposes. Endobronchial ultrasound (EBUS) has increased the potential of sampling mediastinal lymph nodes both for histological diagnosis and microbiological confirmation.

The role of bronchoscopy in the diagnosis and management of pediatric pulmonary tuberculosis

Bronchoscopy is useful as a diagnostic and therapeutic procedure in children with Tuberculosis (TB) disease complicated by airway obstruction. It is needed in children when surgical intervention may be required for airway compression, when drug resistance is suspected, and to rule out an alternative diagnosis for airway obstruction. Bronchoscopy with bronchoalveolar lavage (BAL) should be performed when other, less invasive samples cannot be collected, or when they fail to provide useful diagnostic information. BAL specimens collected at bronchoscopy can be tested using molecular TB assays and mycobacterial culture. The aim of this review is to evaluate the role of bronchoscopy in the diagnosis and management of pulmonary TB in children, and, specifically, to review the role of interventional bronchoscopy. A search of electronic databases was undertaken using the online databases PubMed, Ovid MEDLINE, EMBASE, Google Advanced Scholar, and Web of Science to identify relevant literature. The search was limited to pediatrics, pulmonology, bronchoscopy, and pediatric pulmonary tuberculosis for all articles published in English on pediatric bronchoscopy between 2010 and 2020. Recent advances in pediatric bronchoscopy was included, as well as recent research on improving the diagnosis with the use of interventional bronchoscopy. The role of bronchoscopy in pediatric pulmonary tuberculosis has changed during the last decade, from a simple method of collecting samples for bacteriological conformation to an more sophisticate procedure. New methods are available for collecting samples, which includes the use of Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and also better methods of bacteriological conformation. Interventions are now possible; not only to improve the diagnostic abilities of bronchoscopy but also to diagnose, manage, and follow-up upon airway-related complications. Bronchoscopy services remain limited in resource-limited countries due to the high cost of equipment.

Biopsy and Tracheobronchial Aspirates as Additional Tools for the Diagnosis of Bovine Tuberculosis in Living European Bison (Bison bonasus)

Simple Summary

In this study, additional methods of collecting material for bovine tuberculosis diagnosis in living European bison were introduced. We showed a potential usage of tracheobronchial aspirates and ultrasound-guided biopsies from lateral retropharyngeal lymph nodes in living animals for diagnostics. We confirmed that the isolation of Mycobacterium caprae in living European bison is possible, as is the respiratory shedding of viable M. caprae in this host. This study is important as tuberculosis is a real threat for European bison which is an endangered species and the improvement of diagnostics can help with better health monitoring and further restitution.

Abstract

The diagnosis of bovine tuberculosis (BTB) in living wildlife remains a complex problem, and one of particular importance in endangered species like European bison (Bison bonasus). To identify infection and avoid the unnecessary culling of such valuable individuals, current best practice requires the collection and culture of material from living animals, as mycobacteria isolation remains the gold standard in BTB diagnosis. However, such isolation is challenging due to the need for the immobilization and collection of appropriate clinical material, and because of the sporadic shedding of mycobacteria. In the present study, we evaluated the potential of sampling for the detection of BTB in a group of seven living European bison suspected of being infected with Mycobacterium caprae. The specimens were collected both as swabs from the nasal and pharyngeal cavities, tracheobronchial aspirates (TBA), ultrasound-guided biopsies from lateral retropharyngeal lymph nodes, and post mortem, from mandibular, retropharyngeal and mediastinal lymph nodes. Clinical samples were tested for mycobacterial species via mycobacteriological culture and PCR. M. caprae was isolated from collected material in two out of four living infected individuals (TBA, biopsy) and mycobacterial DNA was detected in three out of four (TBA, pharyngeal swab) bison. This is the first report of isolation of M. caprae in living European bison. Our findings demonstrate the value of diagnostic tests based on both molecular testing and culture in European bison and confirm the respiratory shedding of viable M. caprae in this host species.

Alternative sputum collection methods for diagnosis of childhood intrathoracic tuberculosis: a systematic literature review

BACKGROUND

Diagnosis of intrathoracic tuberculosis (ITB) is limited in children partly by their difficulty to produce sputum specimen.

OBJECTIVE

To systematically review the detection yields of mycobacterial culture and Xpert MTB/RIF from induced sputum (IS), nasopharyngeal aspirate (NPA) and gastric aspirate (GA) in children with presumptive ITB.

DESIGN

Pubmed, Embase and Biosis databases and grey literature were searched. Randomised controlled trials, cohort, cross-sectional or case control studies using IS, GA and NPA for diagnosis of ITB published between January 1990 and January 2018 were included. Data were extracted on study design, case definition of presumptive ITB, sample collection methods, outcome measures and results.

RESULTS

30 studies were selected, including 11 554 children. Detection yields for culture ranged between 1% and 30% for IS, 1% and 45% for GA and 4% and 24% for NPA. For Xpert MTB/RIF, it was between 2% and 17% for IS, 5% and 51% for GA and 3% and 8% for NPA. There was a tendency of better yields with IS when the pretest probability of ITB was low to moderate and with GA when it was high. Sampling a second specimen contributed for 6%-33% of the cumulative yield and combination of different methods significantly increase the detection yields.

CONCLUSIONS

Despite the important study heterogeneity, any of the specimen collection methods offers good potential to confirm childhood ITB. However, their operational challenges were poorly evaluated. In the absence of a sensitive non-sputum based test, only a minority of children with ITB can be confirmed.

Managing latent tuberculosis infection and tuberculosis in children

Tuberculosis (TB) is a major cause of childhood morbidity and mortality worldwide. The aim of this review is to describe the management of the child with TB and latent tuberculosis infection (LTBI). To develop this article, a working group reviewed relevant epidemiological and other scientific studies and established practices in conducting LBTI and TB in children. The article describes how to manage the child with LTBI, considering transmission and infectiousness of tuberculosis, contact screening and prioritization of contacts and recommendations on treatment of children with LTBI and how to manage the child with TB considering the susceptibility of children to developing tuberculosis, epidemiology and classification of tuberculosis in children, diagnosis and treatment.

A systematic approach to diagnosing intra-thoracic tuberculosis in children

Children suffer a huge and often underappreciated burden of disease in tuberculosis (TB) endemic countries. Major hurdles include limited awareness among health care workers, poor integration of TB into maternal and child health approaches, diagnostic difficulties and a lack of child-friendly treatment options. Accurate disease diagnosis is particularly difficult in young and vulnerable children who tend to develop paucibacillary disease and are unable to produce an expectorated sputum sample. In addition, access to chest radiography is problematic in resource-limited settings. Differentiating between TB exposure and M. tuberculosis infection, and especially between M. tuberculosis infection and TB disease is crucial to guide clinical management. TB represents a dynamic continuum from well-contained "latent" infection to incipient and ultimately severe disease. The clinical spectrum of disease in children is broad and can be confused with a myriad of common infections. We provide a pragmatic 4-step approach to diagnose intra-thoracic TB in children and demonstrate how classifying clinical, radiological and laboratory findings into recognised clinical syndromes may provide a more refined diagnostic approach, even in resource-limited settings.

Tuberculosis exposure, infection and disease in children: a systematic diagnostic approach

The accurate diagnosis of tuberculosis (TB) in children remains challenging. A myriad of common childhood diseases can present with similar symptoms and signs, and differentiating between exposure and infection, as well as infection and disease can be problematic. The paucibacillary nature of childhood TB complicates bacteriological confirmation and specimen collection is difficult. In most instances intrathoracic TB remains a clinical diagnosis. TB infection and disease represent a dynamic continuum from TB exposure with/without infection, to subclinical/incipient disease, to non-severe and severe disease. The clinical spectrum of intrathoracic TB in children is broad, and the classification of clinical, radiological, endoscopic, and laboratory findings into recognized clinical syndromes allows a more refined diagnostic approach in order to minimize both under- and over-diagnosis. Bacteriological confirmation can be improved significantly by collecting multiple, high-quality specimens from the most appropriate source. Mycobacterial testing should include traditional smear microscopy and culture, as well as nucleic acid amplification testing. A systematic approach to the child with recent exposure to TB, or with clinical and radiological findings compatible with this diagnosis, should allow pragmatic classification as TB exposure, infection, or disease to facilitate timely and appropriate management. It is important to also assess risk factors for TB disease progression and to undertake follow-up evaluations to monitor treatment response and ongoing evidence supporting a TB, or alternative, diagnosis.

Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis

The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.

Mycobacterium bovis infection in the lion (Panthera leo): Current knowledge, conundrums and research challenges

Mycobacterium bovis has global public-health and socio-economic significance and can infect a wide range of species including the lion (Panthera leo) resulting in tuberculosis. Lions are classified as vulnerable under the IUCN Red List of Threatened Species and have experienced a 30% population decline in the past two decades. However, no attempt has been made to collate and critically evaluate the available knowledge of M. bovis infections in lions and potential effects on population. In this review we set out to redress this. Arguments suggesting that ingestion of infected prey animals are the main route of infection for lions have not been scientifically proven and research is needed into other possible sources and routes of infection. The paucity of knowledge on host susceptibility, transmission directions and therefore host status, manifestation of pathology, and epidemiology of the disease in lions also needs to be addressed. Advances have been made in diagnosing the presence of M. bovis in lions. However, these diagnostic tests are unable to differentiate between exposure, presence of infection, or stage of disease. Furthermore, there are contradictory reports on the effects of M. bovis on lion populations with more data needed on disease dynamics versus the lion population's reproductive dynamics. Knowledge on disease effects on the lion reproduction and how additional stressors such as drought or co-morbidities may interact with tuberculosis is also lacking. Filling these knowledge gaps will contribute to the understanding of mycobacterial infections and disease in captive and wild lions and assist in lion conservation endeavours.

Utility of gastric aspirates for diagnosing tuberculosis in children in a low prevalence area: predictors of positive cultures and significance of non-tuberculous mycobacteria

BACKGROUND

In countries with low rates of tuberculosis (TB), yields of gastric aspirates (GAs) for Mycobacterium tuberculosis (MTB) culture are low. The significance of non-tuberculous mycobacteria (NTM) isolated from GA is uncertain.

METHODS

We reviewed clinical, microbiologic and radiologic data for children who underwent GA between 1999 and 2011 at Sick Kids, Toronto. Radiologic features of cases were compared with those of age matched controls.

RESULTS

785 GAs were obtained from 285 patients of whom 20 (7%) had positive MTB cultures: in 15 patients the GA was the only positive culture for MTB. Of 15 culture-positive patients who underwent exactly 3 GAs, MTB was isolated from the first lavage in 10 (67%), only from the second in 3 (20%) and only from the third in 2 (13%). On univariate analysis, miliary disease and intrathoracic lymphadenopathy were associated with a positive GA MTB culture. On multiple conditional logistic regression analysis, adenopathy remained significant (OR 10.2 [95% CI 2.0-51.4] p =0.005). Twelve patients had NTM isolated, most commonly M. avium complex: none had evidence of invasive NTM disease during a median duration of 12 months of follow-up. Causal pathogens different from the GA NTM culture were isolated from biopsies or bronchoalveolar lavage in 3.

CONCLUSIONS

GAs continue to be important for TB diagnosis in children. Three GAs have a yield better than 1. Those with miliary or disseminated TB and intrathoracic lymphadenopathy have highest yields. NTM isolates from GA are likely unimportant and can be clinically misleading.

GeneXpert MTB/RIF on bronchoalveolar lavage samples in children with suspected complicated intrathoracic tuberculosis: a pilot study

BACKGROUND

Children with complicated intrathoracic tuberculosis (TB) require rapid confirmation of TB diagnosis and of drug susceptibility to institute appropriate therapy. In a pilot study, we evaluated the feasibility and potential utility of GeneXpert (Xpert) on bronchoalveolar lavage (BAL) samples in children undergoing routine diagnostic bronchoscopy.

METHODS

We included children <13 years of age undergoing bronchoscopy for suspected complicated intrathoracic TB at Tygerberg Children's Hospital, October 1, 2012-May 15, 2013. A minimum of two respiratory specimens in addition to BAL were obtained from each child. In addition to fluorescent smear microscopy and automated liquid culture performed on all samples, BAL samples were analyzed by Xpert. Drug susceptibility was confirmed by GenoType(®) MTBDRplus.

RESULTS

Fourteen children (2 HIV positive, median age 16 months) were included. The Mantoux tuberculin skin test was positive in 11. On chest radiograph, six children had expansile pneumonia and nine had airway compression (one had both). The median duration of TB treatment before bronchoscopy was 8 days. TB was confirmed by either culture or Xpert from any sample in 11 (78%) children. Among 9/14 (64%) cases confirmed by culture, BAL Xpert was positive in 7 (78% sensitivity); in addition, Xpert confirmed 2 cases who had negative culture (14% additional diagnostic yield). Two drug resistant cases were identified: one by BAL Xpert and one from genotypic testing of a culture from gastric aspirate. All children were initiated on anti-TB treatment and responded well to therapy.

CONCLUSION

BAL Xpert resulted in additional diagnostic yield and also in the rapid detection of drug resistance in children with complicated intrathoracic TB. The clinical impact of this modality should be further evaluated in children.

Ambulatory gastric lavages provide better yields of Mycobacterium tuberculosis than induced sputum in children with intrathoracic tuberculosis

OBJECTIVE

To compare mycobacterial yield by induced sputum (IS) and gastric lavage (GL), performed on an ambulatory basis in children with probable intrathoracic tuberculosis.

DESIGN

Diagnostic accuracy study.

SETTING

Two tertiary care hospitals in Delhi, India.

PATIENTS

Children aged 6 months to 15 years with newly diagnosed intrathoracic tuberculosis.

METHODS

GL and IS were performed in children on 2 consecutive days on ambulatory basis. Samples were examined by Ziehl-Neelsen staining and cultured on an automated BACTEC-MGIT 960 system.

OUTCOME MEASURE

Mycobacterial yields (smear and culture) for the 2 sample types (IS and GL) were compared.

RESULTS

Four hundred three children (56.6% girls), median age 111 months (interquartile range: 68, 144) were enrolled. Overall yield for acid-fast bacilli and/or Mycobacterium tuberculosis (MTB) by either IS and/or GL was 152 (37.7%). Acid-fast bacilli positivity from IS and GL were 5.7% (23) and 10.4% (42), respectively. Confirmed MTB on culture from IS and GL were 17.9% (72) and 32.5% (127), respectively (P < 0.001). IS and GL identified 17 (4.2%) and 73 (18.1%) additional cases respectively when the other method failed to identify MTB. The combined yields (acid-fast bacilli positivity/MTB) with GL and IS on day 1 (115, 28.5%) were less than that obtained from 2 consecutive GL (135, 33.5%), but better than 2 consecutive IS samples (79, 19.6%; P < 0.001).

CONCLUSION

It is feasible to collect induced sputum and gastric lavage on an ambulatory basis. The yield of MTB obtained by GL is superior to that obtained by IS.

Are we missing opportunities to confirm the diagnosis of tuberculosis by microbial culture?

SETTING

Tuberculosis (TB) incidence is rising globally, with drug resistance becoming increasingly problematic. Microbiological confirmation ensures correct anti-tuberculous chemotherapy.

OBJECTIVE/DESIGN

We retrospectively analysed all TB cases diagnosed in Central Manchester in 2009 investigating how often we are not achieving microbiological diagnosis, factors influencing this and whether opportunities to obtain microbiological samples are missed.

RESULTS

128/156 (82%) cases had samples sent for microbiology. Factors affecting this included disease site, with ocular disease least likely to be sampled (p < 0.0001), and patient age (with children less likely to be sampled p = 0.002). Ethnicity did not affect sampling (n.s.). Overall, 92/156 (59%) cases were culture positive. Negative culture was related to specimen type (p < 0.0001) and patient age (p = 0.019), with children significantly less likely to have a positive culture. Ethnicity and disease site did not affect culture results. There was a trend towards culture positivity being more common in pulmonary (75%) than non-pulmonary (46%) disease (n.s.). In only 7 (4%), could samples have been sent where they were originally absent (3) or further samples obtained where the cultures proved to be negative (4).

CONCLUSION

Despite an overall culture positive rate of 59%, opportunities to achieve microbiological confirmation are seldom missed. In our centre, which is typical of UK practice, this lack of capacity to increase microbiological confirmation, particularly in an era of increasing importance of extra-pulmonary TB, is concerning. Improvements in sample acquisition and laboratory methods are urgently required.

Bronchoscopic evaluation in childhood pulmonary tuberculosis: risk factors of airway involvement and contribution to the bacteriologic diagnosis

We aimed to describe the risk factors of airway involvement and to investigate the contribution of bronchoscopy in the bacteriologic diagnosis of tuberculosis. Airway involvement was more often present in patients with resistance to tuberculosis therapy than in the patients having bronchoscopy performed at initial presentation. Addition of bronchoalveolar lavage to the diagnostic workup increased the mycobacteriologic yield statistically.

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.

A prospective assessment of the role of bronchoscopy and bronchoalveolar lavage in evaluation of children with pulmonary tuberculosis

OBJECTIVE

To assess the diagnostic yield of fibreoptic bronchoscopy and bronchoalveolar lavage (BAL) compared to gastric aspiration (GA) in children with probable pulmonary tuberculosis (TB).

METHODS

Children with probable pulmonary TB were subjected to bronchoscopy, BAL and gastric aspiration. The samples were examined for acid fast bacilli (AFB) on smear.

RESULTS

A total of 52 children underwent bronchoscopy with BAL and GA. AFB on smear was identified in 19 (36.5%); BAL was positive in 16 (30.8%) and GA was positive in 11 (21.15%). GA alone was positive in 3 (5.67%) while BAL alone was positive in 8 (15.38%). Bronchoscopy detected airways' abnormality in 29 (56%) of patients. One GA and BAL detected AFB in majority of patients.

CONCLUSION

The diagnostic yield for AFB from BAL was better than that from GA in children with probable pulmonary TB. Combining one GA and bronchoscopy may improve AFB yield in children with pulmonary TB.

[Specific features of tuberculosis in childhood]

Primary infection with Mycobacterium tuberculosis usually occurs during childhood. The source of infection is most often an adult. The risk of infection in exposed children is modulated by various factors related to the infectiousness of the index case, exposure conditions, and the child himself. This review aims to describe the specific diagnostic and therapeutic features of latent TB infection and TB disease in childhood.

How to optimize current (available) diagnostic tests

Isolation of mycobacterium tuberculosis is the gold standard in the diagnosis of childhood tuberculosis. However, it has inherent limitations due to paucibacillary nature of the disease in children and technical difficulties encountered in collection of appropriate sample. Thus, diagnosis is dependent on circumstantial evidence at best supported by conventional tests such as tuberculin test and chest radiograph. Several new tests are being developed but they lack ideal sensitivity and specificity. Hence, it is important to optimise use of current diagnostic tests. Clinical suspicion based on protocol developed by IAP is a pre-requisite of ordering tests and it is only then that proper interpretation is possible. Tuberculin skin test is still a useful screening test. It does help in establishing presence of infection though not necessarily disease. Attention must be paid to ideal test solution, proper technique and cautious interpretation. BCG test is not recommended. Miliary shadows and fibrocaseious cavitary lesions in chest radiograph are highly suggestive of tuberculosis in our epidemiology. CT scan is rarely necessary and is not cost and radiation-effective. It is ideal to attempt bacteriological examination in every suspected case of childhood tuberculosis. Most practical method is collection of gastric aspirate for smear and culture. It is possible to carry out this procedure in out-patient clinic. Better yield is likely with increasing expertise especially in extensive disease. Bronchoalveolar lavage is an invasive test and bacterial yield is comparable to that of gastric aspirate. Tissue collected for histopathological examination must be submitted for bacteriological tests. PCR is not easily available. It has high sensitivity but lower specificity and thus, is not routinely recommended. Serology has no place in diagnosis of tuberculosis. Interferon gamma release assays are also now available. Sensitivity and specificity of Quantiferon Gold and T-spot tests have not been studied in children and hence are not recommended in routine practice. Instead of trying newer tests, it may be best to avail an expert advice in difficult cases.

The diagnostic value and safety of transbronchial needle aspiration biopsy in children with mediastinal lymphadenopathy

INTRODUCTION

Anterior mediastinal masses in children can have different causes which includes, Mycobacterium tuberculosis (MTB) or malignant lymphadenopathy. Transbronchial needle aspiration (TBNA) has been described as a safe and effective diagnostic procedure in adult patients with lung cancer.

AIM

To describe the use of TBNA as a diagnostic test in children with large subcarinal lymphadenopathy and to determine the safety of the procedure in children.

PATIENTS AND METHODS

Prospective descriptive study of children with subcarinal mediastinal lymph nodes who underwent TBNA. The majority of the children were referred due to treatment failure. Children were enrolled if the diagnosis remained unclear after computer tomography of the chest.

RESULTS

Thirty patients were enrolled in this study; TBNA was done in 28 patients. A definitive diagnosis was made by TBNA in 54% (n = 15) of patients; MTB lymphadenopathy (n = 13), metastatic nephroblastoma (n = 1), and fibrosing mediastinitis (n = 1). In seven (25%) cases the TBNA was the sole source of the specimens from which the definitive diagnosis was made. No serious complications were encountered during or after the procedure.

CONCLUSION

TBNA is a safe procedure in children with mediastinal lymphadenopathy of unknown cause resulting in a definitive diagnosis in 57% of cases. TBNA adds additional value to flexible bronchoscopy in the diagnosis of mediastinal lymphadenopathy in children.

Saline nebulization before gastric lavage in the diagnosis of pulmonary tuberculosis in children and adolescents

The main objective is to assess whether nebulization before gastric lavage (GL) improves its sensitivity for the diagnosis of childhood tuberculosis (TB). Children and adolescents suspected of pulmonary TB were randomly assigned (1 : 2) to nebulization with hypertonic saline 30 min before GL (Neb group; n = 36) or GL without prior nebulization (controls; n = 68). The proportion of positive GL smears was greater in Neb group than in the control group; however, no statistical significance was observed (36.3% vs. 22.2%; p = 0.4). Inhalation of nebulized hypertonic saline before GL did not improve TB diagnosis in this study. Nevertheless, the validation of our data will require large longitudinal studies.

Gastric lavage in the diagnosis of pulmonary tuberculosis in children: a systematic review

OBJECTIVE

To analyze standardization of gastric lavage protocols in the diagnosis of pulmonary tuberculosis in children.

METHODS

A systematic review was conducted for the period between 1968 and 2008 in the following databases: LILACS, SCIELO and MEDLINE. The search strategy included the following terms: "gastric lavage and tuberculosis" or "gastric washing and tuberculosis" with the restriction of "children aged up to 15 years;" "gastric lavage and tuberculosis and childhood" or "gastric washing and tuberculosis and childhood." There were retrieved 80 articles and their analysis was based on information on the gastric lavage protocol for the diagnosis of pulmonary tuberculosis in children: preparation of children and fasting; time of gastric aspiration; aspiration of gastric residues; total volume of aspirate; solution used for aspiration of gastric contents; decontaminant solution; buffer solution; and time for forwarding samples to the laboratory. After a thorough analysis, 14 articles were selected.

RESULTS

No article detailed the whole procedure. Some articles had missing information on: amount of gastric aspirate; aspiration before or after solution injection; solution used for gastric aspiration; buffer solution used; and waiting time between specimen collection and laboratory processing. These results showed inconsistencies of gastric lavage protocols.

CONCLUSIONS

Although gastric lavage is a secondary diagnostic approach used only in special cases that did not reach the diagnostic scoring as recommended by the Brazilian Ministry of Health, there is a need to standardize gastric lavage protocols for the diagnosis of pulmonary tuberculosis in children.

Consensus statement on childhood tuberculosis

JUSTIFICATION

Revised National Tuberculosis Control Program (RNTCP) has focused on adults with smear positivity a tool not so well used in children with tuberculosis. There is a need to redefine standardization of diagnosis and management protocols for childhood tuberculosis.

PROCESS

Indian Academy of Pediatrics constituted a Working Group to develop consensus statement on childhood tuberculosis (TB). Members of the Group were given individual responsibilities to review the existing literature on different aspects of the childhood TB. The group deliberated and developed a consensus which was circulated to all the members for review. Efforts were made to ensure that the recommendations are standardized.

OBJECTIVES

To produce recommendations and standard protocols for reasonably accurate diagnosis and rational treatment of tuberculosis in children.

RECOMMENDATIONS

Fever and or cough > 2 weeks with loss of weight and recent contact with infectious case should arouse suspicion of TB. Chest Xray and trial with broad-spectrum antibiotic for 7-10 days is justified. In case of clinical and radiological non-response, Mantoux test and sputum or gastric aspirate for AFB is recommended. If AFB is positive, diagnosis is confirmed. If AFB is negative but chest Xray is suggestive and Mantoux test is positive, it is a probable case and if these tests are negative, alternate diagnosis must be sought and referral made to an expert. Ideally it is recommended to use 1TU of PPD for Mantoux test but 2 or 5 TU may be acceptable (but less preferred). Cut-off point of 10 mms for natural infection may be used for test done with 1, 2 or 5 TU. There is no linear relation of reaction to tuberculin strength and so no more than 5 TU should be used. BCG test is not recommended. Diagnosis must not be made without an attempt to look for AFB in gastric aspirate or sputum, as it is possible to get AFB even in primary complex. Elisa and PCR tests for TB are not recommended. There is no place for trial of anti tubercular therapy. Lymphnode enlargement > 2 cm with or without typical findings suggestive of TB and failure of antibiotic response demands FNAC for histopathology and bacteriology. Clinical suspicion of tubercular meningitis (TBM) should be confirmed by CSF examination and CT scan though none of these investigations are confirmatory and hence should not be considered in isolation. CSF tests for TB antibody and PCR are not recommended for routine use. Diagnosis of abdominal TB is made on circumstantial evidence and there are no standard guidelines. For treatment, disease is divided into three categories. The Category I and III are recommended for different types of new cases i.e. those who have received treatment for not more than 4 weeks. Category III includes primary pulmonary complex, one site peripheral lymphadenitis and pleural effusion, while all other forms of TB are included in Category I, that corresponds to smear positive TB in adults. This is because AFB is often found in many Category I disease in children. Category II includes defaulters, relapses and failure cases irrespective of the site of disease. Standard protocol is followed for each of these categories. Intermittent thrice weekly therapy with higher dose has been found to be equally effective as daily therapy and so is recommended in DOTS Direct Observed Therapy Short term. Compliance of treatment must be ensured. Repeat chest X-ray is ideal at the end of therapy. Liver function tests are not routinely recommended. Recommendations are also made for special situations such as MDRTB, TB and HIV and neonate born to mother suffering from TB.

Comparison of bronchoscopic washing and gastric lavage in the diagnosis of smear-negative pulmonary tuberculosis

OBJECTIVE

To evaluate the diagnostic contribution and utility of bacteriologic surveys using bronchoscopic washing and gastric lavage in cases of radiologically suspected tuberculosis with no detectable acid-fast bacilli (AFB) in the sputum.

MATERIAL AND METHODS

This prospective study performed bronchoscopic lavage following gastric washing in suspected pulmonary tuberculosis patients. The presence of AFB was determined via direct microscopy and materials were cultured in Löwenstein-Jensen medium.

RESULTS

Thirty-eight consecutive patients were enrolled in the study (30 males and 8 females; mean age, 33.8 +/- 10.9 years). Three patients could not give sputum. In 23 of 35 cases (66%), sputum cultures (SC) were positive. In 17 cases (49%), gastric lavage cultures (GLC) were positive. Eighteen cases (55%) had positive bronchoscopic washing cultures (BWC). No statistically significant difference was observed when SC positivity was compared to GLC and BWC, and no difference was observed when the GLC results were compared with BWC. Tuberculosis was confirmed in 30 of 38 (79%) patients when SC and GLC were evaluated together, in 33 of 38 patients (87%) when SC and BWC were evaluated together, and in 36 of 38 (95%) when SC, GLC, and BWC were evaluated together (P = 0.016, P = 0.002, and P = 0.0001, respectively). The increase in positive cultures was statistically significant when gastric lavage was evaluated together with bronchoscopic washing (P = 0.004).

CONCLUSION

Adding gastric lavage and bronchial washing to sputum culture could increase culture positivity for M tuberculosis bacilli in suspected pulmonary tuberculosis patients with AFB-negative sputum smears.

Flexible bronchoscopy for diagnosis and follow up of childhood endobronchial tuberculosis

BACKGROUND

In this study, our aim was to determine the clinical and bronchoscopic outcome of the endobronchial tuberculosis (ETB).

METHODS

Patients with suspected tuberculosis (TB) or TB patients with an inadequate response to 8 weeks of antituberculosis treatment were enrolled in the study.

RESULTS

Seventy patients were included to the study and 118 flexible bronchoscopies were performed. ETB was present in 33 (47%) patients. There was isolated compression in 14 cases, caseous lesions in 13, granuloma formation in 6, polypoid lesions in 2, adenopathy protrusion in 1, and mucosal erosion in 1 case. The mean duration of bronchoscopic resolution of endobronchial lesions was 5.50 +/- 2.74 months. Mycobacterium tuberculosis was isolated from gastric lavage in 10% and from bronchoalveolar lavage in 12.8% of 70 cases. When both of the procedures were performed concurrently, the isolation rate increased to 20%. Transient hypoxia resolving with nasal O2 was observed in 3 patients as a complication of bronchoscopy.

CONCLUSIONS

Bronchoscopy offered a safe and rapid means of confirming the diagnosis of ETB.

Acurácia do lavado gástrico realizado em ambiente hospitalar e ambulatorial no diagnóstico da tuberculose pulmonar em crianças

OBJETIVO: Comparar a acurácia do lavado gástrico (LG) realizado em ambiente hospitalar e ambulatorial no diagnóstico da tuberculose (TB) pulmonar em crianças. MÉTODOS: Estudo prospectivo realizado no Estado do Espírito Santo, Brasil, de 1999 a 2003. Um total de 230 crianças com suspeita de TB foi selecionado para realizar exame de LG em ambiente hospitalar (n = 103) ou em ambiente ambulatorial (n = 127). Desse total, 53 foram diagnosticadas como casos de TB e divididas em dois grupos: LG hospitalar (n = 30) e LG ambulatorial (n = 23). Todas as 53 crianças foram monitoradas por 6 meses para avaliação da acurácia do diagnóstico. A acurácia foi determinada com base na mudança do diagnóstico, na taxa de cura e no percentual de culturas positivas nos dois grupos estudados. RESULTADOS: A taxa de cura foi de 100% nos dois grupos, e não houve mudança de diagnóstico nas 53 crianças estudadas. Nenhuma diferença significativa foi encontrada entre os dois grupos estudados em relação ao achado do Mycobacterium tuberculosis (RR = 1,47; IC95%: 0,95-2,27; p = 0,095), apesar de o grupo LG ambulatorial ter apresentado o maior índice de cultura positivas. CONCLUSÕES: Nossos resultados mostram que a acurácia do LG realizado em ambiente hospitalar é semelhante à do realizado em ambiente ambulatorial, o que indica que a internação é necessária apenas em casos mais graves nos quais não se pode realizar o procedimento em ambiente ambulatorial.

Avaliação do sistema de pontuação para o diagnóstico da tuberculose na infância preconizado pelo Ministério da Saúde, Brasil

A tuberculose é conhecida como uma das mais importantes causas de mortalidade no mundo. O diagnóstico da tuberculose na infância tem entre suas muitas dificuldades o achado bacteriológico do Mycobacterium tuberculosis. Este foi um estudo de caso-controle aninhado em uma coorte prospectiva com crianças que coletaram lavado gástrico em nível ambulatorial e hospitalar, com o objetivo de identificar se o sistema de pontuação para o diagnóstico de tuberculose em crianças negativas à baciloscopia, proposto pelo Ministério da Saúde, poderia ser utilizado como instrumento inicial de identificação do diagnóstico da tuberculose na infância. Um total de 108 crianças foi submetido ao lavado gástrico, sendo que 53 tiveram diagnóstico de tuberculose e 55 com diagnóstico descartado. O sistema de pontuação proposto pelo Ministério da Saúde para o diagnóstico de tuberculose em crianças com baciloscopia negativa apresentou uma boa sensibilidade em ambos os grupos estudados, sendo o melhor ponto de corte o critério 1 (possível diagnóstico de tuberculose) com sensibilidade de 92% podendo, então, ser usado como um auxiliar na investigação diagnóstica de crianças que se submeterão ao lavado gástrico. Nossa recomendação é que o sistema de pontuação do Ministério da Saúde seja utilizado nos serviços de saúde para auxiliar o médico a decidir sobre continuar ou não a investigação da tuberculose infantil, e não somente em crianças que já foram submetidas ao procedimento e tiveram suas amostras com resultado negativo.

Microbiological diagnostic procedures in respiratory infections: mycobacterial infections

This article will review traditional and newer microbiological techniques for the diagnosis of mycobacterial respiratory infections. It will concentrate on the diagnosis of infections due to Mycobacterium tuberculosis, the main mycobacterium causing respiratory infections of clinical and public health importance. The diagnosis of respiratory disease associated with non-tuberculous mycobacteria (NTM), particularly in children with underlying airway pathology such as cystic fibrosis (CF) or bronchiectasis, will be briefly discussed. With respect to the diagnosis of tuberculosis (TB), the review will concentrate on the diagnosis of patients with symptoms and/or signs of clinical disease, rather than the detection of exposure or asymptomatic infection. It will not specifically address the assessment of pre-test probability based on clinical or epidemiological factors, the use of radiological investigations or the investigation of extrathoracic lymph node disease or chest wall disease. The role of newer diagnostic modalities including nucleic acid detection (NAD) and gamma-interferon assays in paediatric practice will be reviewed, and suggestions made as to how they may fit into contemporary diagnostic algorithms.

Airway involvement in pulmonary tuberculosis

Lymph gland involvement of the airways is common in young children with pulmonary tuberculosis. This lymph gland involvement leads to lymphobronchial tuberculosis, which presents with varying degrees of airway obstruction. These children are best assessed by fibreoptic bronchoscopy and are treated with the normal anti-tuberculosis regimens to which corticosteroids are added for a month and then weaned off over the next month. If, after a month, the children remain symptomatic, they must be re-evaluated by bronchoscopy and chest computed tomography. Surgery must be considered in children with severe airway obstruction still present at the time of the second evaluation. Surgical intervention consists of endoscopic or transthoracic enucleation of the lymph nodes. Only a small percentage of those with lymphobronchial tuberculosis will require surgery to relieve their airway obstruction.

PCR amplification of the IS6110 insertion element of Mycobacterium tuberculosis in fecal samples from patients with intestinal tuberculosis

PCR amplification of insertion element IS6110 of Mycobacterium tuberculosis in fecal samples was evaluated in the diagnosis of intestinal tuberculosis (ITB). The numbers of samples that tested positive by PCR with SalI digestion were 16/18 untreated-ITB samples, 0/8 treated-ITB samples, 12/14 smear-positive pulmonary tuberculosis samples, and 0/30 control samples. The sensitivity, specificity, positive predictive value, and negative predictive value of fecal PCR were 88.8%, 100%, 100%, and 93.7%, respectively.

Primary pulmonary Hodgkin's disease and tuberculosis in an 11-year-old boy: case report and review of the literature

Tuberculosis (TB) has been described in association with different malignancies including Hodgkin's disease. However, the association with primary pulmonary Hodgkin's disease (PPHD) is hardly reported in literature and in teenage is quite exceptional. We report a case of an 11 years old boy in whom the diagnosis of tuberculosis preceded and delayed the diagnosis of PPHL.

La cuerda dulce--a tolerability and acceptability study of a novel approach to specimen collection for diagnosis of paediatric pulmonary tuberculosis

Background

Recent data demonstrate the utility of the string test for the diagnosis of sputum-scarce HIV-associated TB in adults. We hypothesized that, if well-tolerated by children, this simple tool might offer a breakthrough in paediatric TB diagnosis. Thus the objective of this study, undertaken in the paediatric service of the Hospital Nacional Dos de Mayo, Lima, Perú, was to determine the tolerability and acceptability of the string test to paediatric TB suspects, their parents and nursing staff.

Methods

22 paediatric subjects aged 3–14 years (median 8) under investigation for TB were invited to undergo 2 string tests (four-hour downtime each). Subjective and objective pain and discomfort rating scales were used to assess the perception of the subject, parent and attending nurse.

Results

Patients as young as 4 years tolerated the procedure extremely well with 84% willing to undergo a second procedure. Peak discomfort at the time of swallowing and of string retrieval was mild (30% of maximum possible score) and brief as judged by visual analogue ratings and objective indicators. Good concordance of parent/child and objective/subjective ratings strengthened the validity of these findings.

Conclusion

The string test is well tolerated and achievable for most paediatric TB suspects as young as 4 years. A formal prospective paediatric efficacy study is now needed.

Increased reported cases of tuberculosis among children younger than 5 years of age, Maricopa County, Arizona, 2002-2003

OBJECTIVES

Although tuberculosis (TB) rates in the United States among children younger than 5 years old (2.8/100,000 in 2003) have been declining, Maricopa County, Arizona, reported an increase from 4.1/100,000 in 2002 to 9.0/100,000 in 2003. We investigated factors associated with this increase.

METHODS

We reviewed county TB clinic records of pediatric patients (younger than 5 years old) and their probable adult sources, interviewed parents or guardians of pediatric TB patients and examined changes in clinic procedures.

RESULTS

We verified 11 pediatric TB cases in 2002 and 25 in 2003 (n = 36). A total of 31 (86%) patients were born in the United States, and 28 (78%) had at least 1 foreign-born parent. There were 19 children (53%) identified from an adult TB contact investigation. Of children with identified sources (n = 24, 67%), 23 (96%) had probable household transmission; 20 (83%) had a foreign-born relative from a TB-endemic country as the probable source. Seven (50%) of 14 adult sources investigated had a delayed TB diagnosis. In 2003, increased TB clinic staffing, more frequent pediatric TB clinics and on-site gastric aspirates for TB diagnosis contributed to 55% more children being evaluated for TB.

CONCLUSIONS

Close interaction with family members and delayed diagnoses were the primary means of TB transmission to children. The increase in pediatric TB likely reflects improved clinic diagnostic capacity and may indicate a more accurate baseline rate for Maricopa County. Programmatic improvements in TB control and targeted outreach to high-risk immigrant populations may increase pediatric and adult source case detection and reduce Mycobacterium tuberculosis transmission.

Endoscopie bronchique et tuberculose de l'enfant

Bronchoscopy can be helpful for microbiological diagnosis in children with primary tuberculosis and its yield is clearly enhanced by PCR detection. However,endoscopic sampling has a lower sensitivity rate than repeated gastric washings and probably sputum induction. Bronchoscopy is indicated in case of clinically and/or radiologically suspected endobronchial involvement, helps for restoration of normal airway diameter and bronchial wall injury follow-up. A few series on endoscopic findings according to the mode of presentation have been published in pediatric patients. In these studies endobronchial tuberculosis occurrence is described irrespective of clinical or radiological symptoms.

Tuberculosis in children

The epidemiology of pediatric tuberculosis (TB) is shaped by risk factors such as age, race, immigration, poverty, overcrowding, and HIV/AIDS. Once infected, young children are at increased risk of TB disease and progression to extrapulmonary disease. Primary disease and its complications are more common in children than in adults, leading to differences in clinical and radiographic manifestations. Difficulties in diagnosing children stem from the low yield of mycobacteriology cultures and the subsequent reliance on clinical case definitions. Inadequately treated TB infection and TB disease in children today is the future source of disease in adults.

[Fiberoptic bronchoscopy in childhood endobronchial tuberculosis]

BACKGROUND

Endobronchial tuberculosis is a classical manifestation of primary tuberculosis in childhood. Fiberoptic bronchoscopy (FB) is an ancillary diagnostic tool, but its utility and indications are not well established.

OBJECTIVES

To analyze the FB performed over 11 years (1992-2003) in children with a diagnosis of tuberculosis and to review the literature. A further aim was to establish the current usefulness of FB in children with tuberculosis and propose criteria to determine the indications for FB in this population.

METHODS

We report a retrospective series (n 5 16). FB was indicated in children who showed any of the following findings in chest roentgenogram: a) persistent parenchymal consolidation; b) lymphadenopathy and consolidation; c) hyperinsufflation (emphysema); d) atelectasias, and e) airway narrowing caused by lymphadenopathies. Published series on the topic were reviewed and six studies were suitable for comparison with our own.

RESULTS

Endobronchial tuberculosis was found in seven children (43 %) and extrinsic compression was found in three (18 %). The microbiological results obtained from FB samples were not superior to those obtained from classical diagnostic methods. The sensitivity of the proposed criteria for suspicion of endobronchial tuberculosis was 71 %. Endoscopic findings justified a change in therapy in 50 % of the children (addition of corticoids or surgery) and this percentage was similar to that reported in other series.

CONCLUSIONS

FB does not usually improve microbiological diagnosis of tuberculosis but can be useful when choosing the most appropriate therapy in children with suspected endobronchial tuberculosis. In some cases, computed tomography may make FB unnecessary, but in others this procedure can be therapeutic (obstruction due to caseum, atelectasias). Establishing the indications for FB in childhood tuberculosis is difficult, but the proposed criteria may be an acceptable guide to identifying which patients could benefit most from this procedure. Not all children with endobronchial tuberculosis require corticoids.

Diagnostic value of certain methods for isolation of Mycobacterium tuberculosis in children with suspected pulmonary tuberculosis

Introduction The aim of this study was to find out if bronchoalveolar lavage (BL) is better than gastric lavage (GL) or sputum (SP) examination for isolation of Mycobacterium tuberculosis in childhood pulmonary tuberculosis. Material and methods The study included a group of 30 children with suspected pulmonary tuberculosis, aged 6 months to 18 years. Gastric lavage was done on 4 consecutive mornings after overnight fast. Sputum was examined in 12 patients older than 10 years, (4 consecutive samples). BL was performed on the same day as the last GL and SP, using a rigid bronchoscope. Specimens were examined for the existence of BL acid fast bacilli (AFB) and culture for Mycobacterium tb. Results Out of 30 cases, Mycobacterium tb was grown in 13 BL samples (43.33%), and in 10 GL samples from the same patients (33.33%). Comparative analysis of microbiological samples of sputum and bronchoalveolar lavage fluid in 12 children showed that 6 patients had SP+ cultures and 6 patients had SP-cultures of Mycobacterium tb. All SP+ patients where also BL+, but 1 SP- patient was BL+. Smear examination of BL fluid samples was positive for AFB in 10 patients with positive cultures for Mycobacterium tb. Conclusion The results of our study indicate that BL examination is better than GL and SP examination for bacteriological diagnosis of childhood tuberculosis. .

Tuberculosis in children: considerations for children from developing countries

Although accurate data are scarce for children, tuberculosis (TB) represents one of the most common infectious causes of morbidity and mortality worldwide. TB case rates have declined among children in the United States in the last decade, but they remain high among children from low-income countries and racial or ethnic minorities. Establishing the definitive diagnosis of TB in a child remains difficult and frequently relies on a constellation of history, clinical findings, and bacteriology. Recently, updated national and international treatment recommendations have been published. Contact investigation and treatment using directly observed therapy are important components of the optimal case detection and management of TB in children.

Epidemiology of childhood tuberculosis in the United States, 1993-2001: the need for continued vigilance

OBJECTIVE

To describe trends and highlight epidemiologic and clinical characteristics of childhood tuberculosis (TB) in the United States.

METHODS

All verified TB cases reported to the national TB surveillance system from 1993 to 2001 were included. A child was defined as a person younger than 15 years.

RESULTS

A total of 11,480 childhood TB cases were reported. Case rates (TB cases/100,000 population) in all children declined from 2.9 (n = 1663) in 1993 to 1.5 (n = 931) in 2001. Among children, those who were younger than 5 years had the highest rate. California, Texas, and New York accounted for 48% of all childhood TB cases. In 2001, TB case rates were higher for foreign-born (12.2) than US-born children (1.1). Hispanic and non-Hispanic black children accounted for nearly three quarters of all cases. Twenty-four percent of children with TB were foreign-born children, with the largest number originating from Mexico (39.8%), the Philippines (8.6%), and Vietnam (5.7%). Most children had evidence of pulmonary TB disease (78.9%). Among culture-positive cases without previous TB, drug resistance to at least isoniazid was 7.3% and to isoniazid and rifampin was 1.6%. In 1999, 82.9% of children received directly observed therapy for at least part of their treatment and 94.8% completed treatment.

CONCLUSIONS

Although the overall TB case number among children is declining in the United States, certain groups of children (eg, younger children, racial and ethnic minorities, foreign-born) are at higher risk for TB. As the United States moves toward the elimination of TB, future efforts should endeavor to prevent all cases of childhood TB.

Bronchoscopist talks to you

Fiberoptic bronchoscopy (FBS) is an important entry in the armamentarium of procedures listed in management of respiratory problems. It is a simple and a safe procedure. FBS has a great scope for diagnosis as well as therapy in pediatric respiratory illnesses. This article gives a practical overview of FBS in pediatric practice.

Cavitating tuberculosis in an infant: case report and literature review

Primary cavitating tuberculosis is a rare complication of primary tuberculosis in young children. In the absence of a known adult source case, the diagnosis of tuberculosis in children can be difficult. We describe an 8-month-old baby with primary cavitating tuberculosis, in whom there was considerable delay in diagnosis, and review the literature.