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Clinical Worsening in an Adolescent With Pleural Tuberculosis. J Adolesc Health 2023; 72:480-482. [PMID: 36567181 DOI: 10.1016/j.jadohealth.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 11/12/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022]
Abstract
A 17-year-old previously healthy female presented with unilateral chest pain and dyspnea. Chest radiographs demonstrated a unilateral pleural effusion and pneumonia. Pleural fluid bacterial cultures were negative; acid-fast cultures grew Mycobacterium tuberculosis. Two months after starting appropriate therapy, she had a recrudescence of symptoms and reaccumulation of the pleural fluid. Her tuberculosis antibiotic regimen was expanded, the effusion drained, and systemic corticosteroids initiated, resulting in rapid clinical improvement. Cultures of the second pleural fluid collection were negative. Her clinical deterioration was due to immune reconstitution inflammatory syndrome (IRIS). IRIS can be seen within the first several months of starting tuberculosis therapy and can result in paradoxical worsening of symptoms or radiographic findings in adolescents who are on the appropriate therapy. IRIS is a diagnosis of exclusion after drug resistance and medication malabsorption, intolerance, and nonadherence are excluded. Therapy includes nonsteroidal anti-inflammatory agents for milder reactions and systemic corticosteroids for more severe IRIS cases.
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Liu P, Li T, Xi X, Pei N, Huang W, Liu X, Xia L, Yang Y, Lu S. Case Report: Thalidomide in the treatment of complicated central nervous system tuberculosis. FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.983635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Central nervous system tuberculosis (CNSTB) is the most fatal type of tuberculosis (TB). Early administration of glucocorticoids can improve the prognosis of CNSTB patients and reduce mortality; however, some CNSTB patients do not respond well to anti-tuberculosis drugs and glucocorticoids. As an immunomodulatory drug, Thalidomide has been used under such circumstances. We retrospectively reviewed the drug to describe its clinical characteristics, efficacy, and safety in the treatment of four complicated CNSTB patients who responded well to thalidomide. Thalidomide may be an effective and well-tolerated drug for the treatment of CNSTB, and therefore requires further study.
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3
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Palamit A, Tovichien P, Amornsitthiwat R. Tuberculosis-immune reconstitution inflammatory syndrome in HIV-negative children. Respirol Case Rep 2022; 10:e0945. [PMID: 35386580 PMCID: PMC8968164 DOI: 10.1002/rcr2.945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/14/2022] [Accepted: 03/14/2022] [Indexed: 11/08/2022] Open
Abstract
Even though tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is usually found in HIV-positive patients receiving antiviral treatment, it can also occur in HIV-negative patients especially if they have risk factors. We report a unique case of TB-IRIS in an immunocompetent child presenting with new onset of pleuritic chest pain after receiving anti-TB drugs. TB-IRIS should be considered as a differential diagnosis in case of clinical deterioration or appearance of new typical lesions despite appropriate anti-TB treatment for more than 2 weeks in the absence of persistently active TB or any other alternative causes. This will prevent physicians from misdiagnosis as superimposed infections, treatment failure or TB relapse.
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Affiliation(s)
- Apinya Palamit
- Division of Pulmonology, Department of Pediatrics, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Prakarn Tovichien
- Division of Pulmonology, Department of Pediatrics, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Ramida Amornsitthiwat
- Department of Radiology, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
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Chidambaram AC, Maya M, Sugumar K, Parameswary S, Ramamoorthy JG, Selvan T. Paradoxical upgrading reaction following treatment of disseminated tuberculosis-associated haemophagocytic lymphohistiocytosis in an infant without HIV: a case report and review of the literature. Paediatr Int Child Health 2022; 42:78-82. [PMID: 36175204 DOI: 10.1080/20469047.2022.2108673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Tuberculosis-associated haemophagocytic lymphohistiocytosis (HLH) is rare in paediatrics and can be fatal if not recognised and treated on time. A 3-month-old infant with tuberculosis and HLH is described. He was successfully treated with anti-tuberculous therapy (ATT) which comprised isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin and dexamethasone (10 mg/m2/day). On Day 28 of therapy, he developed a paradoxical upgrading reaction to ATT for which he was again treated with (oral) corticosteroids for 4 weeks. He recovered successfully and is now completely well and asymptomatic. To the best of our knowledge, this is the first case of a child having a paradoxical upgrading reaction following treatment for TB-HLH.Abbreviations ATT: anti-tuberculous therapy; CB-NAAT: cartridge-based nucleic acid amplification test; CECT: contrast-enhanced computed tomography; HLH: haemophagocytic lymphohistiocytosis; NK: natural killer, PUR: paradoxical upgrading reaction; sHLH: secondary HLH.
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Affiliation(s)
- Aakash Chandran Chidambaram
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Malini Maya
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Kiruthiga Sugumar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Singaravadivelu Parameswary
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | - Tamil Selvan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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5
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Starke JR, Erkens C, Ritz N, Kitai I. Strengthening Tuberculosis Services for Children and Adolescents in Low Endemic Settings. Pathogens 2022; 11:158. [PMID: 35215101 PMCID: PMC8877840 DOI: 10.3390/pathogens11020158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 01/22/2023] Open
Abstract
In low tuberculosis-burden countries, children and adolescents with the highest incidence of tuberculosis (TB) infection or disease are usually those who have immigrated from high-burden countries. It is, therefore, essential that low-burden countries provide healthcare services to immigrant and refugee families, to assure that their children can receive proper testing, evaluation, and treatment for TB. Active case-finding through contact tracing is a critical element of TB prevention in children and in finding TB disease at an early, easily treated stage. Passive case-finding by evaluating an ill child is often delayed, as other, more common infections and conditions are suspected initially. While high-quality laboratory services to detect Mycobacterium tuberculosis are generally available, they are often underutilized in the diagnosis of childhood TB, further delaying diagnosis in some cases. Performing research on TB disease is difficult because of the low number of cases that are spread over many locales, but critical research on the evaluation and treatment of TB infection has been an important legacy of low-burden countries. The continued education of medical providers and the involvement of educational, professional, and non-governmental organizations is a key element of maintaining awareness of the presence of TB. This article provides the perspective from North America and Western Europe but is relevant to many low-endemic settings. TB in children and adolescents will persist in low-burden countries as long as it persists throughout the rest of the world, and these wealthy countries must increase their financial commitment to end TB everywhere.
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Affiliation(s)
- Jeffrey R. Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, TX 77030, USA
| | - Connie Erkens
- KNCV Tuberculosis Foundation, 2516 AB The Hague, The Netherlands;
| | - Nicole Ritz
- Department of Paediatrics and Paediatric Infectious Diseases, Children’s Hospital, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland;
- Mycobacterial and Migrant Health Research Group, Department of Clinical Research, University of Basel Children’s Hospital, University of Basel, 4031 Basel, Switzerland
| | - Ian Kitai
- Department of Pediatrics, Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada;
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Kaba Ö, Kara M, Bayramoğlu Z, Çalışkan E, Çetin B, Karimov E, Özkuvancı Ü, Özlük Y, Hançerli Torun S, Yürük Yıldırım ZN, Ziylan HO, Somer A. An adolescent girl with obstructive uropathy requiring nephro-ureterectomy was subsequently diagnosed with renal tuberculosis: case report. Paediatr Int Child Health 2021; 41:154-157. [PMID: 32990186 DOI: 10.1080/20469047.2020.1822633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A 15-year-old girl was followed up for 2 years in a district hospital for management of vesicoureteral reflux and, subsequently, hydronephrosis of both kidneys and required bilateral ureteroneocystostomy. Despite surgery, there was continuous progression of the left hydronephrosis. Referral to a tertiary hospital because of continued sterile pyuria prompted investigation for tuberculosis (TB): she was diagnosed with bilateral pulmonary TB and urine culture confirmed Mycobacterium tuberculosis. Despite tuberculous chemotherapy and dexamethasone, she required a left nephrectomy. Histology demonstrated necrotising granulomatous pyelonephritis. She remains well with normal function of the right kidney. Despite the rarity, chronic urinary tract disorders should always prompt investigation for tuberculosis.
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Affiliation(s)
- Özge Kaba
- Department of Pediatrics, Division of Pediatric Infectious Disease, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Manolya Kara
- Department of Pediatrics, Division of Pediatric Infectious Disease, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zuhal Bayramoğlu
- Department of Radiology, Division of Pediatric Radiology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Emine Çalışkan
- Department of Radiology, Division of Pediatric Radiology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bilal Çetin
- Department of Urology, Division of Pediatric Urology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Elnur Karimov
- Department of Pediatrics, Division of Pediatric Infectious Disease, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ünsal Özkuvancı
- Department of Urology, Division of Pediatric Urology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasemin Özlük
- Department of Pathology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Selda Hançerli Torun
- Department of Pediatrics, Division of Pediatric Infectious Disease, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Zeynep Nagehan Yürük Yıldırım
- Department of Pediatrics, Division of Pediatric Nephrology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hasan Orhan Ziylan
- Department of Urology, Division of Pediatric Urology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ayper Somer
- Department of Pediatrics, Division of Pediatric Infectious Disease, Faculty of Medicine, Istanbul University, Istanbul, Turkey.,Department of Radiology, Division of Pediatric Radiology, Seyhan State Hospital, Adana, Turkey
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Goussard P, Retief F, Burke J, Malherbe A, Janson J. The role of bronchoscopy in the diagnosis and management of pediatric pulmonary tuberculosis. Ther Adv Infect Dis 2021; 8:20499361211037168. [PMID: 34422266 PMCID: PMC8377312 DOI: 10.1177/20499361211037168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Pierre Goussard
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Francois Retief
- Department of Anaesthesia and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Jonathan Burke
- Department of Anaesthesia and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Annemie Malherbe
- Department of Anaesthesia and Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - Jacques Janson
- Department of Surgical Sciences, Division of Cardiothoracic Surgery, Stellenbosch University, and Tygerberg Hospital, Tygerberg, South Africa
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Liu P, Pei N, Liu X, Huang W, Lu S. Thalidomide in the treatment of human immunodeficiency virus-negative tuberculous meningitis: A case report. Medicine (Baltimore) 2020; 99:e22639. [PMID: 33019487 PMCID: PMC7535634 DOI: 10.1097/md.0000000000022639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Tuberculous meningitis (TBM) is the most fatal type of tuberculosis in which corticosteroids are added with antitubercular therapy to prevent permanent brain damage. However, this treatment may produce paradoxical reactions. In such cases, thalidomide use might reduce central nervous system inflammation and improve the outcome. We present the case of a human immunodeficiency virus-negative patient with TBM who developed paradoxical reactions manifesting as multiple intracranial tuberculomas that were resistant to standard care (antitubercular drugs and corticosteroids) but responded well to thalidomide. PATIENT'S MAIN CONCERN AND CLINICAL FINDINGS The patient was a 40-year-old Chinese female, who was admitted with a 10-day history of headaches, night sweats, and cough. She was healthy before contracting the infection and had no history of contact with tuberculosis patients. DIAGNOSES, INTERVENTION, AND OUTCOME We diagnosed the patient with TBM complicated by the occurrence of pulmonary tuberculosis. Positive results were obtained from Gram and Ziehl-Neelsen staining of the sputum and acid-fast bacilli sputum culture. Standard treatment was initiated with antitubercular drugs (daily isoniazid, rifampicin, ethionamide, and pyrazinamide) and corticosteroids (dexamethasone). However, 3 months later the magnetic resonance imaging of the head revealed some new tuberculoma lesion. Thus, a specific therapy of antitubercular drugs and thalidomide was introduced. On completion of a 12-month course of antitubercular drugs with 2 months of thalidomide, the patient showed favorable outcomes without neurologic sequelae. Moreover, thalidomide appeared safe and well tolerated in the patient. CONCLUSION In addition to the specific anti-tubercular and adjuvant corticosteroid therapies for TBM, thalidomide can be used as a "salvage" antitubercular drug in cases that are unresponsive to corticosteroids.
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9
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Troch RL, Kochis S, Milstone AM, Jain S, Lederman H, Sick-Samuels AC. Fever and an Abdominal Mass in an 18-month-old Boy. Pediatr Rev 2020; 41:S94-S97. [PMID: 33004595 PMCID: PMC7670867 DOI: 10.1542/pir.2018-0312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Suzanne Kochis
- Department of Pediatrics.,Division of Pediatric Allergy and Immunology
| | - Aaron M Milstone
- Department of Pediatrics.,Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sanjay Jain
- Department of Pediatrics.,Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Howard Lederman
- Department of Pediatrics.,Division of Pediatric Allergy and Immunology
| | - Anna C Sick-Samuels
- Department of Pediatrics.,Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
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10
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Kassegne L, Bourgarit A, Fraisse P. [Parardoxical reaction following tuberculosis treatment in non HIV-infected patients]. Rev Mal Respir 2020; 37:399-411. [PMID: 32386802 DOI: 10.1016/j.rmr.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 12/10/2019] [Indexed: 11/17/2022]
Abstract
A paradoxical reaction is the worsening of prior existing, or the appearance of, new tuberculous lesions, following the initiation of treatment with anti-tuberculous drugs, after the exclusion of poor compliance, malabsorption, drug interaction or multiresistant mycobacteria. Well known and well managed in the context of HIV coinfection, it is not well known outside this context. An increasing number of publications have described this syndrome. This review aims to describe the pathogenic, epidemiological, clinical, prognostic and therapeutic elements of non-HIV-associated paradoxical reactions. It involves a reversal of the Mycobacterium tuberculosis-induced immunodepression along with a heightened detrimental pro-inflammatory profile caused by efficient drug treatment. Extra-thoracic locations, especially lymph nodes and neurological, malnutrition and initial lymphopenia are the principal risk factors. The median delay is 40±20 days after the onset of treatment. Corticosteroids are the mainstay of the management. Anti-TNF-α drugs show good results in corticosteroid refractory cases. The prognosis is good overall except in neurological forms. The place of preventive methods remains to be established.
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Affiliation(s)
- L Kassegne
- Service de pneumologie, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg cedex, France.
| | - A Bourgarit
- Université Paris 13, Bobigny, France; Service de médecine interne, hôpital Jean-Verdier, HUPSSD AP-HP, Bondy, France; Inserm U1135, centre d'immunologie et des maladies infectieuses, 75013 Paris, France
| | - P Fraisse
- Service de pneumologie, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'hôpital, 67000 Strasbourg cedex, France; Groupe pour l'enseignement et la recherche en pneumo-infectiologie de la SPLF, 66, boulevard Saint-Michel, 75006 Paris, France
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11
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Desai L, Shah I, Shaan M. Retropharyngeal abscess as a paradoxical reaction in a child with multi-drug-resistant tuberculosis. Paediatr Int Child Health 2019; 39:287-289. [PMID: 30284512 DOI: 10.1080/20469047.2018.1518054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Paradoxical reactions (PRs) are exaggerated inflammatory responses owing to recovery of cellular immunity following initiation of anti-tuberculous therapy (ATT). The presentation is worsening of pre-existing symptoms or development of new lesions. A 14-year-old girl with multi-drug-resistant tuberculosis developed a recurrent asymptomatic retropharyngeal abscess while on ATT. She required multiple aspirations of the abscess. Xpert MTB/RIF detected Mycobacterium tuberculosis from the aspirate which was resistant to rifampicin; culture was negative. Following aspirations of the abscess, continued ATT and a 2-month course of corticosteroids, she remains well and has gained weight. A retropharyngeal abscess presenting in the form of a PR has not been reported previously in adults or children.
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Affiliation(s)
- Lavina Desai
- Seth G. S. Medical College, KEM Hospital , Mumbai , India
| | - Ira Shah
- Department of Pediatric Infectious Diseases, Nanavati Hospital , Mumbai
| | - Manohar Shaan
- Department of ENT, Nanavati Hospital , Mumbai , India
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12
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Liu Y, Wang Z, Yao G, Lu Y, Hu Z, Yao H, Zhang Q, Zhu H, Song Z, Wang W, Liu D. Paradoxical reaction in HIV-negative tuberculous meningitis patients with spinal involvement. Int J Infect Dis 2018; 79:104-108. [PMID: 30529369 DOI: 10.1016/j.ijid.2018.11.366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the occurrence of paradoxical reaction (PR) in HIV-negative tuberculous meningitis (TBM) patients with spinal involvement, as well as its possible risk factors. METHODS Fifty TBM patients with spinal involvement were studied retrospectively and divided into a PR group and a non-PR group according to the presence of PR. Their demographic, clinical, radiological, and laboratory data, and status at follow-up were collected and compared. RESULTS PR developed in 26 patients (52%), with the median time to the development of PR being 30days (range 15-330 days) after the initiation of tuberculosis therapy. At initial diagnosis, age, documented acid-fast bacilli (AFB), and the cerebrospinal fluid protein level were found to differ significantly between the two groups. After multivariate analysis, age, documented AFB, and vertebral involvement were significantly associated with the development of PR. CONCLUSIONS PR was common in TBM patients with spinal involvement. Age, documented AFB, and musculoskeletal involvement may be predictors of PR development.
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Affiliation(s)
- Yin Liu
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zheng Wang
- Department of Neurology, Changsha Central Hospital, Changsha, Hunan, China
| | - Guang Yao
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuying Lu
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhongyang Hu
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Huan Yao
- Department of Neurology, Changsha Central Hospital, Changsha, Hunan, China
| | - Qinghua Zhang
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Haixia Zhu
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhi Song
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wei Wang
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ding Liu
- Department of Neurology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China.
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13
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Yang C, Yasseen AS, Stimec J, Rea E, Waters V, Lam R, Morris SK, Kitai I. Prevalence of tuberculosis infection and disease in children referred for tuberculosis medical surveillance in Ontario: a single-cohort study. CMAJ Open 2018; 6:E365-E371. [PMID: 30154220 PMCID: PMC6182122 DOI: 10.9778/cmajo.20180043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are few data about the utility of the Canadian tuberculosis medical surveillance system for detecting tuberculosis in children and adolescents. We sought to assess the prevalence of tuberculosis infection and disease in children and adolescents referred by the tuberculosis medical surveillance program who were evaluated at The Hospital for Sick Children (SickKids) tuberculosis program. METHODS We retrospectively studied clinical records, radiographic findings and results of interferon-γ release assays (IGRAs) of all children less than 18 years of age referred by the tuberculosis medical surveillance program and evaluated at SickKids between November 2012 and June 2016. RESULTS The median age of the 216 children was 10.0 years. Most were born in the Philippines (157 [72.7%]) or India (39 [18.0%]). Of the 216, 166 (76.8%) had a history of prior treatment for tuberculosis, and 34 (15.7%) were federal-sponsored refugees from settings with a high tuberculosis burden. Negative IGRA results were found in 110/130 (84.6%) of those with prior tuberculosis treatment. Thirty-one children (14.4%) had any chest radiographic abnormality, of whom 4 had changes thought to be due to tuberculosis. No child received a diagnosis of active tuberculosis at assessment or during follow-up; 3 (1.4%) were treated for latent tuberculosis infection following IGRA testing at SickKids. A positive IGRA result was associated with contact with infectious tuberculosis (odds ratio [OR] 5.97, 95% confidence interval [CI] 2.06-17.52) and older age at first clinic visit (OR 2.98, 95% CI 1.24-8.30) but not with radiographic abnormalities or history of prior tuberculosis treatment. INTERPRETATION Most children were referred because of a history of prior treatment for tuberculosis; few had clinical or laboratory evidence of infection or prior disease. The tuberculosis medical surveillance process did not identify any children who required treatment for active disease and requires improvement.
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Affiliation(s)
- Catherine Yang
- Faculty of Medicine (Yang), Dalla Lana School of Public Health (Yasseen, Rea), Department of Pediatrics (Waters, Morris, Kitai) and Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Yasseen), Ottawa, Ont.; Department of Diagnostic Imaging (Stimec) and Division of Infectious Diseases (Waters, Morris, Kitai), The Hospital for Sick Children; Toronto Public Health (Rea), Toronto, Ont
| | - Abdool S Yasseen
- Faculty of Medicine (Yang), Dalla Lana School of Public Health (Yasseen, Rea), Department of Pediatrics (Waters, Morris, Kitai) and Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Yasseen), Ottawa, Ont.; Department of Diagnostic Imaging (Stimec) and Division of Infectious Diseases (Waters, Morris, Kitai), The Hospital for Sick Children; Toronto Public Health (Rea), Toronto, Ont
| | - Jennifer Stimec
- Faculty of Medicine (Yang), Dalla Lana School of Public Health (Yasseen, Rea), Department of Pediatrics (Waters, Morris, Kitai) and Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Yasseen), Ottawa, Ont.; Department of Diagnostic Imaging (Stimec) and Division of Infectious Diseases (Waters, Morris, Kitai), The Hospital for Sick Children; Toronto Public Health (Rea), Toronto, Ont
| | - Elizabeth Rea
- Faculty of Medicine (Yang), Dalla Lana School of Public Health (Yasseen, Rea), Department of Pediatrics (Waters, Morris, Kitai) and Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Yasseen), Ottawa, Ont.; Department of Diagnostic Imaging (Stimec) and Division of Infectious Diseases (Waters, Morris, Kitai), The Hospital for Sick Children; Toronto Public Health (Rea), Toronto, Ont
| | - Valerie Waters
- Faculty of Medicine (Yang), Dalla Lana School of Public Health (Yasseen, Rea), Department of Pediatrics (Waters, Morris, Kitai) and Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Yasseen), Ottawa, Ont.; Department of Diagnostic Imaging (Stimec) and Division of Infectious Diseases (Waters, Morris, Kitai), The Hospital for Sick Children; Toronto Public Health (Rea), Toronto, Ont
| | - Ray Lam
- Faculty of Medicine (Yang), Dalla Lana School of Public Health (Yasseen, Rea), Department of Pediatrics (Waters, Morris, Kitai) and Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Yasseen), Ottawa, Ont.; Department of Diagnostic Imaging (Stimec) and Division of Infectious Diseases (Waters, Morris, Kitai), The Hospital for Sick Children; Toronto Public Health (Rea), Toronto, Ont
| | - Shaun K Morris
- Faculty of Medicine (Yang), Dalla Lana School of Public Health (Yasseen, Rea), Department of Pediatrics (Waters, Morris, Kitai) and Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Yasseen), Ottawa, Ont.; Department of Diagnostic Imaging (Stimec) and Division of Infectious Diseases (Waters, Morris, Kitai), The Hospital for Sick Children; Toronto Public Health (Rea), Toronto, Ont
| | - Ian Kitai
- Faculty of Medicine (Yang), Dalla Lana School of Public Health (Yasseen, Rea), Department of Pediatrics (Waters, Morris, Kitai) and Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.; Children's Hospital of Eastern Ontario Research Institute (Yasseen), Ottawa, Ont.; Department of Diagnostic Imaging (Stimec) and Division of Infectious Diseases (Waters, Morris, Kitai), The Hospital for Sick Children; Toronto Public Health (Rea), Toronto, Ont.
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14
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Kitai I, Morris SK, Kordy F, Lam R. Diagnosis and management of pediatric tuberculosis in Canada. CMAJ 2017; 189:E11-E16. [PMID: 28246254 DOI: 10.1503/cmaj.151212] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ian Kitai
- Division of Infectious Diseases (Kitai, Morris, Kordy, Lam); Centre for Global Child Health (Morris), Hospital for Sick Children; Department of Pediatrics (Kitai, Morris); Faculty of Nursing (Lam), University of Toronto, Toronto, Ont.
| | - Shaun K Morris
- Division of Infectious Diseases (Kitai, Morris, Kordy, Lam); Centre for Global Child Health (Morris), Hospital for Sick Children; Department of Pediatrics (Kitai, Morris); Faculty of Nursing (Lam), University of Toronto, Toronto, Ont
| | - Faisal Kordy
- Division of Infectious Diseases (Kitai, Morris, Kordy, Lam); Centre for Global Child Health (Morris), Hospital for Sick Children; Department of Pediatrics (Kitai, Morris); Faculty of Nursing (Lam), University of Toronto, Toronto, Ont
| | - Ray Lam
- Division of Infectious Diseases (Kitai, Morris, Kordy, Lam); Centre for Global Child Health (Morris), Hospital for Sick Children; Department of Pediatrics (Kitai, Morris); Faculty of Nursing (Lam), University of Toronto, Toronto, Ont
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15
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Abstract
Paradoxical immune reconstitution inflammatory syndrome is a well-described entity even in immunocompetent children, principally in association with Mycobacterium tuberculosis infections. Central nervous system involvement is a potential life-threatening form, sometimes refractory to standard treatment. We report the case of an HIV-negative refugee teenager, who presented with brain tuberculomas and pseudoabscesses responsive only to thalidomide.
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16
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Abstract
Peripheral lymphadenopathy (scrofula) is the second most common site for childhood tuberculosis. Paradoxical reactions are commonly seen even in immunocompetent children after therapy is initiated, and this can lead to draining sinus tracts. We describe a multimodal therapeutic option of antituberculosis therapy, corticosteroids and therapeutic ultrasound-guided nodal aspiration in an adolescent with massive cervical adenopathy.
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Carazo Gallego B, Moreno-Pérez D, Nuñez Cuadros E, Mesa Fernandez A, Martin Cantero M, Obando Pacheco P, Urda Cardona A. Paradoxical reaction in immunocompetent children with tuberculosis. Int J Infect Dis 2016; 51:15-18. [PMID: 27544714 DOI: 10.1016/j.ijid.2016.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 08/09/2016] [Accepted: 08/11/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND A paradoxical reaction (PR) during anti-tuberculosis treatment is a phenomenon that is poorly studied in immunocompetent children. It is defined as a clinical or radiological worsening of pre-existing tuberculosis (TB) disease. METHODS A retrospective descriptive study of children younger than 14 years of age was performed; these children developed PR during the years 2009 to 2014, following a diagnosis of TB. Demographic characteristics, microbiological results, treatment and outcome data were collected. RESULTS Of 51 children diagnosed with TB, five (9.8%) developed a PR; four of these children had pulmonary TB and the remaining patient had miliary TB with central nervous system involvement. The PR occurred at a median of 42 days (range 23-53 days) after initiating therapy. Corticosteroids were started when PR was suspected, at a median dose of 1mg/kg/day. Clinical and radiological improvement was noted in all cases, with a median clinical regression time of 10.5 days (range 3-15 days) and a median radiological regression time of 45 days (range 26-105 days). No sequelae were described in any patient. CONCLUSIONS PR in immunocompetent children during anti-tuberculosis treatment is not such an unusual reaction. Treatment with corticosteroids may be useful for the resolution of PR.
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Affiliation(s)
- Begoña Carazo Gallego
- Infectious Diseases and Immunodeficiencies Unit, Department of Paediatrics, Malaga Regional University Hospital, Avenida Arroyo de los Angeles, s/n, Malaga, 29011, Spain.
| | - David Moreno-Pérez
- Infectious Diseases and Immunodeficiencies Unit, Department of Paediatrics, Malaga Regional University Hospital, Avenida Arroyo de los Angeles, s/n, Malaga, 29011, Spain
| | - Esmeralda Nuñez Cuadros
- Infectious Diseases and Immunodeficiencies Unit, Department of Paediatrics, Malaga Regional University Hospital, Avenida Arroyo de los Angeles, s/n, Malaga, 29011, Spain
| | - Alba Mesa Fernandez
- Infectious Diseases and Immunodeficiencies Unit, Department of Paediatrics, Malaga Regional University Hospital, Avenida Arroyo de los Angeles, s/n, Malaga, 29011, Spain
| | - María Martin Cantero
- Infectious Diseases and Immunodeficiencies Unit, Department of Paediatrics, Malaga Regional University Hospital, Avenida Arroyo de los Angeles, s/n, Malaga, 29011, Spain
| | - Pablo Obando Pacheco
- Infectious Diseases and Immunodeficiencies Unit, Department of Paediatrics, Malaga Regional University Hospital, Avenida Arroyo de los Angeles, s/n, Malaga, 29011, Spain
| | - Antonio Urda Cardona
- Infectious Diseases and Immunodeficiencies Unit, Department of Paediatrics, Malaga Regional University Hospital, Avenida Arroyo de los Angeles, s/n, Malaga, 29011, Spain
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18
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Vecchio AL, Bocchino M, Lancella L, Gabiano C, Garazzino S, Scotto R, Raffaldi I, Assante LR, Villani A, Esposito S, Guarino A. Indications to Hospital Admission and Isolation of Children With Possible or Defined Tuberculosis: Systematic Review and Proposed Recommendations for Pediatric Patients Living in Developed Countries. [Corrected]. Medicine (Baltimore) 2015; 94:e2045. [PMID: 26683914 PMCID: PMC5058886 DOI: 10.1097/md.0000000000002045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Tuberculosis (TB) is a re-emerging health problem in developed countries. This paper is part of large guidelines on the global management of TB in children, by a group of scientific societies. It describes the indications to hospitalization of children with suspected or diagnosed TB, the isolation measures, hospital discharge, and re-admission into the community. Using the Consensus Conference method, relevant publications in English were identified by means of a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception until 31 December 2014. Available data on indications to hospitalization were mainly indirect and largely derived from observational studies. They include: (1) host-related risk factors, the main being age <12 months, immune deficiencies, and malnutrition; (2) TB-related clinical conditions that resemble those of pneumonia but also include drug-resistance; and (3) social and logistic conditions. The latter are based on opinion and depend on local conditions. Analysis of the literature showed that patients hospitalized with suspected pulmonary TB should be put in precautionary respiratory isolation regardless of their age while they await diagnosis. The general conditions for re-admission into the community are at least 14 days of effective treatment and negative microscopic tests of 3 consecutive samples in previously microscopically positive patients. This is the first paper that provides indications to hospitalization of children with TB. Most recommendations are generally applicable in all developed countries. Some might need an adaptation to local setting, epidemiological, parameters, and availability of specific health-care facilities.
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Affiliation(s)
- Andrea Lo Vecchio
- From the Section of Pediatrics, Department of Translational Medical Science, Federico II University of Naples, Naples, Italy (ALV, RS, AG); Pneumology Unit, Federico II University of Naples, Naples, Italy (MB, LRA); Unit of General Pediatrics and Pediatric Infectious Diseases, IRCCS Bambino Gesù Hospital, Rome, Italy (LL, AV); Pediatric Infectious Diseases Unit, Regina Margherita Hospital, University of Turin, Turin, Italy (CG, SG, IR); and Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (SE)
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19
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Hamzaoui A. [Childhood tuberculosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2015; 71:168-180. [PMID: 24932504 DOI: 10.1016/j.pneumo.2014.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 03/12/2014] [Accepted: 03/15/2014] [Indexed: 06/03/2023]
Abstract
Childhood TB is an indication of failing TB control in the community. It allows disease persistence in the population. Mortality and morbidity due to TB is high in children. Moreover, HIV co-infection and multidrug-resistant diseases are as frequent in children as in adults. Infection is more frequent in younger children. Disease risk after primary infection is greatest in infants younger than 2 years. In case of exposure, evidence of infection can be obtained using the tuberculin skin test (TST) or an interferon-gamma assay (IGRA). There is no evidence to support the use of IGRA over TST in young children. TB suspicion should be confirmed whenever possible, using new available tools, particularly in case of pulmonary and lymph node TB. Induced sputum, nasopharyngeal aspiration and fine needle aspiration biopsy provide a rapid and definitive diagnosis of mycobacterial infection in a large proportion of patients. Analysis of paediatric samples revealed higher sensitivity and specificity values of molecular techniques in comparison with the ones originated from adults. Children require higher drugs dosages than adults. Short courses of steroids are associated with TB treatment in case of respiratory distress, bronchoscopic desobstruction is proposed for severe airways involvement and antiretroviral therapy is mandatory in case of HIV infection. Post-exposure prophylaxis in children is a highly effective strategy to reduce the risk of TB disease. The optimal therapy for treatment of latent infection with a presumably multidrug-resistant Mycobacterium tuberculosis strain is currently not known.
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Affiliation(s)
- A Hamzaoui
- Pavillon B, hôpital Abderrahmen-Mami, 2080 Ariana, Tunisie.
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20
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Morris SK, Demers AM, Lam R, Pell LG, Giroux RJP, Kitai I. Epidemiology and clinical management of tuberculosis in children in Canada. Paediatr Child Health 2015; 20:83-8. [PMID: 25838781 PMCID: PMC4373581 DOI: 10.1093/pch/20.2.83] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2014] [Indexed: 11/14/2022] Open
Abstract
Although often regarded as a foreign disease, latent tuberculosis or tuberculosis disease will be encountered in many clinical situations by the Canadian child health practitioner. There are key differences between tuberculosis in children and adults. In the present article, the changing epidemiology of tuberculosis in children in Canada and around the world, the pathogenesis of infection, diagnostic tests, and clinical management of childhood latent tuberculosis and tuberculosis disease are reviewed.
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Affiliation(s)
- Shaun K Morris
- Division of Infectious Diseases, Toronto, Ontario
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Anne-Marie Demers
- Department of Microbiology and Immunology and Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec
| | - Ray Lam
- Division of Infectious Diseases, Toronto, Ontario
| | - Lisa G Pell
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario
| | - Ryan JP Giroux
- Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Ian Kitai
- Division of Infectious Diseases, Toronto, Ontario
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario
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21
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Abstract
Clinical deterioration while receiving antituberculosis (anti-TB) therapy can be due to a number of etiologies, including drug resistance, disease progression despite effective therapy, or alternative diagnoses. We present the case of a 22-month-old girl diagnosed with TB meningitis 4 months prior to presentation. At time of her initial diagnosis, computed tomography showed hydrocephalus and basilar meningitis with some evidence of ischemic damage. She required placement of a ventriculoperitoneal shunt and was discharged on multidrug anti-TB therapy and corticosteroids. At the time of her second emergency department presentation, she had developed new-onset seizures and hemiparesis. Her steroids had been tapered and discontinued. Differential diagnosis included shunt malfunction and/or shunt infection. Magnetic resonance imaging of the brain showed interval development of tuberculomas. Symptomatic and radiographic improvement was seen after initiation of corticosteroids for immune reconstitution inflammatory syndrome, which can be seen in immunocompetent children, with onset weeks to months after starting antituberculous therapy.
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22
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Abstract
Patients with inflammatory bowel disease are predisposed to opportunistic infections. We report 2 cases of disseminated tuberculosis in adolescents receiving a TNF antagonist, infliximab. Both had negative baseline tuberculin skin tests. Multimodal testing using tuberculin skin tests and interferon gamma release assays at the time of inflammatory bowel disease diagnosis and annually may increase the sensitivity of LTBI testing in these high risk children.
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23
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Outcomes in Adolescents Undergoing Treatment for Drug-resistant Tuberculosis in Cape Town, South Africa, 2008-2013. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2014. [DOI: 10.5812/pedinfect.17934] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kitai I, Morris SK. Encounters with an old foe: Childhood tuberculosis in Canada. Paediatr Child Health 2014; 19:89-90. [PMID: 24596483 DOI: 10.1093/pch/19.2.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2013] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ian Kitai
- Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Shaun K Morris
- Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario
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25
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Goussard P, Gie R. The role of bronchoscopy in the diagnosis and management of pediatric pulmonary tuberculosis. Expert Rev Respir Med 2013; 8:101-9. [DOI: 10.1586/17476348.2013.863712] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Affiliation(s)
- Daniel Blázquez
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitario 12 de Octubre, , Madrid, Spain
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27
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Bronchoscopic evaluation in childhood pulmonary tuberculosis: risk factors of airway involvement and contribution to the bacteriologic diagnosis. Pediatr Infect Dis J 2013; 32:921-3. [PMID: 23470678 DOI: 10.1097/inf.0b013e31829042a0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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28
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Isaakidis P, Paryani R, Khan S, Mansoor H, Manglani M, Valiyakath A, Saranchuk P, Furin J. Poor outcomes in a cohort of HIV-infected adolescents undergoing treatment for multidrug-resistant tuberculosis in Mumbai, India. PLoS One 2013; 8:e68869. [PMID: 23894358 PMCID: PMC3716893 DOI: 10.1371/journal.pone.0068869] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 06/01/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about the treatment of multidrug-resistant tuberculosis (MDR-TB) in HIV-co-infected adolescents. This study aimed to present the intermediate outcomes of HIV-infected adolescents aged 10-19 years receiving second-line anti-TB treatment in a Médecins Sans Frontières (MSF) project in Mumbai, India. METHODS A retrospective review of medical records of 11 adolescents enrolled between July 2007 and January 2013 was undertaken. Patients were initiated on either empirical or individualized second-line ambulatory anti-TB treatment under direct observation. RESULTS The median age was 16 (IQR 14-18) years and 54% were female. Five (46%) adolescents had pulmonary TB (PTB), two (18%) extrapulmonary disease (EPTB) and four (36%) had both. Median CD4 count at the time of MDR-TB diagnosis was 162.7 cells/µl (IQR: 84.8-250.5). By January 2013, eight patients had final and 3 had interim outcomes. Favourable results were seen in four (36.5%) patients: one was cured and three were still on treatment with negative culture results. Seven patients (64%) had poor outcomes: four (36.5%) died and three (27%) defaulted. Three of the patients who died never started on antiretroviral and/or TB treatment and one died 16 days after treatment initiation. Two of the defaulted died soon after default. All patients (100%) on-treatment experienced adverse events (AEs): two required permanent discontinuation of the culprit drug and two were hospitalized due to AEs. No patient required permanent discontinuation of the entire second-line TB or antiretroviral regimens. CONCLUSIONS Early mortality and mortality after default were the most common reasons for poor outcomes in this study. Early mortality suggests the need for rapid diagnosis and prompt treatment initiation, and adolescents might benefit from active contact-tracing and immediate referral. Default occurred at different times, suggesting the need for continuous, intensified and individualized psychosocial support for co-infected adolescents. Operational research among co-infected adolescents will be especially important in designing effective interventions for this vulnerable group.
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Paradoxical reaction during tuberculosis treatment in immunocompetent children: clinical spectrum and risk factors. Pediatr Infect Dis J 2013; 32:446-9. [PMID: 23271443 DOI: 10.1097/inf.0b013e3182846c4e] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Paradoxical reaction (PR) during antituberculosis (TB) therapy, defined as clinical or radiologic worsening of preexisting TB lesions or the development of new lesions, has not been widely studied in immunocompetent children. METHODS All children (<17 years) with the diagnosis of TB who sought care at our center between 1994 and 2007 were included in this retrospective study. Data on demographic characteristics, bacteriologic results, medical imaging, treatment regimens and outcomes were abstracted from medical records. Patients with and without PR were compared. RESULTS Of 115 TB cases, 12 (10.3%) developed PR. Children with PR were younger than those with TB without complication: median age at diagnosis was 26 months (range, 5-148) compared with 66 months (range, 6-205) for those without complications (P = 0.013). None of the children in the PR group had received Calmette-Guérin bacillus vaccination, compared with 34 of 103 (33%) children without PR (P = 0.017). Children with a diagnosis of PR were more frequently symptomatic at diagnosis of TB disease when compared with children without PR (P = 0.028). PR occurred at a median interval of 39 days (range, 15-75) after initiation of antituberculosis treatment. The most common PR was worsening of preexisting pulmonary lesions (75%). New lesions in anatomical sites other than those observed at initial presentation developed in 3 children. CONCLUSION Paradoxical deterioration during treatment of TB disease is common in immunocompetent children. Young age and absence of Calmette-Guérin bacillus vaccination appeared to be associated with PR.
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