Radiological findings in young children investigated for tuberculosis in Mozambique

Chest X-Ray-Based Telemedicine Platform for Pediatric Tuberculosis Diagnosis in Low-Resource Settings: Development and Validation Study

BACKGROUND

Tuberculosis (TB) remains a major cause of morbidity and death worldwide, with a significant impact on children, especially those under the age of 5 years. The complex diagnosis of pediatric TB, compounded by limited access to more accurate diagnostic tests, underscores the need for improved tools to enhance diagnosis and care in resource-limited settings.

OBJECTIVE

This study aims to present a telemedicine web platform, BITScreen PTB (Biomedical Image Technologies Screen for Pediatric Tuberculosis), aimed at improving the evaluation of pulmonary TB in children based on digital chest x-ray (CXR) imaging and clinical information in resource-limited settings.

METHODS

The platform was evaluated by 3 independent expert readers through a retrospective assessment of a data set with 218 imaging examinations of children under 3 years of age, selected from a previous study performed in Mozambique. The key aspects assessed were the usability through a standardized questionnaire, the time needed to complete the assessment through the platform, the performance of the readers to identify TB cases based on the CXR, the association between the TB features identified in the CXRs and the initial diagnostic classification, and the interreader agreement of the global assessment and the radiological findings.

RESULTS

The platform's usability and user satisfaction were evaluated using a questionnaire, which received an average rating of 4.4 (SD 0.59) out of 5. The average examination completion time ranged from 35 to 110 seconds. In addition, the study on CXR showed low sensitivity (16.3%-28.2%) but high specificity (91.1%-98.2%) in the assessment of the consensus case definition of pediatric TB using the platform. The CXR finding having a stronger association with the initial diagnostic classification was air space opacification (χ21>20.38, P<.001). The study found varying levels of interreader agreement, with moderate/substantial agreement for air space opacification (κ=0.54-0.67) and pleural effusion (κ=0.43-0.72).

CONCLUSIONS

Our findings support the promising role of telemedicine platforms such as BITScreen PTB in enhancing pediatric TB diagnosis access, particularly in resource-limited settings. Additionally, these platforms could facilitate the multireader and systematic assessment of CXR in pediatric TB clinical studies.

Multidrug-Resistant TB (MDR-TB) and Extensively Drug-Resistant TB (XDR-TB) Among Children: Where We Stand Now

Drug-resistant tuberculosis (DR-TB) has continued to be a global health cataclysm. It is an arduous condition to tackle but is curable with the proper choice of drug and adherence to the drug therapy. WHO has introduced newer drugs with all-oral shorter regimens, but the COVID-19 pandemic has disrupted the achievements and raised the severity. The COVID-19 controlling mechanism is based on social distancing, using face masks, personal protective equipment, medical glove, head shoe cover, face shield, goggles, hand hygiene, and many more. Around the globe, national and international health authorities impose lockdown and movement control orders to ensure social distancing and prevent transmission of COVID-19 infection. Therefore, WHO proposed a TB control program impaired during a pandemic. Children, the most vulnerable group, suffer more from the drug-resistant form and act as the storehouse of future fatal cases. It has dire effects on physical health and hampers their mental health and academic career. Treatment of drug-resistant cases has more success stories in children than adults, but enrollment for treatment has been persistently low in this age group. Despite that, drug-resistant childhood tuberculosis has been neglected, and proper surveillance has not yet been achieved. Insufficient reporting, lack of appropriate screening tools for children, less accessibility to the treatment facility, inadequate awareness, and reduced funding for TB have worsened the situation. All these have resulted in jeopardizing our dream to terminate this deadly condition. So, it is high time to focus on this issue to achieve our Sustainable Development Goals (SDGs), the goal of ending TB by 2030, as planned by WHO. This review explores childhood TB's current position and areas to improve. This review utilized electronic-based data searched through PubMed, Google Scholar, Google Search Engine, Science Direct, and Embase.

Xpert MTB/RIF Ultra and mycobacterial culture in routine clinical care at a paediatric hospital

Background

Microbiological confirmation of pulmonary tuberculosis (PTB) in children is a well-documented challenge. This study evaluated Xpert Mycobacterium Tuberculosis (MTB)/Rifampicin (RIF) Ultra (Ultra) and mycobacterial cultures in routine clinical care at a tertiary paediatric hospital.

Methods

Children treated for PTB and who had at least one respiratory specimen investigated by Ultra and mycobacterial culture before tuberculosis (TB) treatment was commenced were included. The findings of this retrospective study were summarised using descriptive and inferential statistics.

Results

A total of 174 children were included. The median age was 2.5 years. Microcytic anaemia, airway compression, cavitary disease and miliary TB were significantly observed in children with microbiologically confirmed TB (cTB). Tuberculosis was microbiologically confirmed in 93 (53.4%) children. The positive yield from testing the first respiratory specimens was 68/174 (39.1%) on Ultra and 82/174 (47.1%) on combined Ultra and mycobacterial culture. In the subset of children (n = 70) tested with Ultra on two sequential respiratory specimens, the incremental yield from the second specimen was 30.3%. In the subset of children (n = 16) tested with Ultra on three sequential respiratory specimens, the incremental yield from the second and third specimens was 16.7% and 0.0%, respectively. When Ultra and mycobacterial culture results were combined, the incremental yield in children who had two sequential respiratory specimens tested was 24.4% and 3.1% on Ultra and mycobacterial culture, respectively.

Conclusion

Ultra and mycobacterial culture on a single respiratory specimen resulted in a high microbiological yield. Ultra-testing on a second respiratory specimen increased the yield of microbiologically cTB. Additional diagnostic testing may require further study.

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines

BACKGROUND

Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis.

OBJECTIVES

To produce revised guidelines for pneumonia in South African children under 5 years of age.

METHODS

The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision.

RECOMMENDATIONS

Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided.

VALIDATION

The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.

Reliability of chest radiograph interpretation for pulmonary tuberculosis in the screening of childhood TB contacts and migrant children in the UK

AIM

To determine interobserver agreement between paediatric radiologists interpreting tuberculosis (TB) screening chest radiographs (CXR) in children in the UK, and the TB detection rate.

MATERIALS AND METHODS

A retrospective review was undertaken of electronic request, notes, and CXRs (>7 years) in children exposed to an infectious case of TB and new entrants to the UK, at a tertiary children's hospital. Included were those with positive Mantoux/interferon gamma release assay (IGRA), positive culture, or high clinical suspicion of TB. CXR reports were categorised as normal, abnormal without features of TB, or abnormal with features of pulmonary TB. Three paediatric radiologists from a dedicated paediatric radiology department evaluated available CXRs, aware of the TB screening indication, using a published CXR reporting tool and blinded to the initial CXR report and to each other. A majority decision was collated, and considered lymphadenopathy and miliary nodules as diagnostic of primary TB. Interobserver agreement was calculated using Cohen's kappa.

RESULTS

One hundred and forty-eight children underwent TB screening with a CXR. One hundred and twenty-five had available CXR reports and case notes, which indicated 20/125 (16%) had CXR features of TB. One hundred and twenty-one of the 125 had CXRs available to for panel review. Twenty of these 121 (17%) yielded a majority decision of pulmonary TB. Inter-reader agreement was moderate in all aspects (kappa 0.4-0.6).

CONCLUSION

The high percentage of pulmonary TB on CXR (16% original reports; 17% by panel review) suggests that it is worthwhile investigating childhood TB contacts; however, the routine use and recommendation for CXR is questionable because of only moderate interpretation reliability (kappa 0.5), even by experts.

The Incidence of Tuberculosis in Infants, Siaya District, Western Kenya

BACKGROUND

Infants are a target population for new tuberculosis (TB) vaccines. TB incidence estimates are needed to guide the design of trials. To determine the TB incidence and cohort retention among young children using comprehensive diagnostic methods in a high burden area.

METHODS

Infants 0-42 days were enrolled. Through 4 monthly follow-up and unscheduled (sick) visits up to the age of 2 years, infants with presumptive TB based on a history of contact, TB symptoms or pre-determined hospitalization criteria were admitted to a case verification ward. Two induced sputa and gastric aspirates were collected for culture and GeneXpert. Mantoux and HIV tests were done. Clinical management was based on the Keith Edwards score. Cases were classified into microbiologically confirmed or radiologic, diagnosed by blinded expert assessment. Cox regression was used to identify risk factors for incident TB and study retention.

RESULTS

Of 2900 infants enrolled, 927 (32%) developed presumptive TB, 737/927 (80%) were investigated. Sixty-nine TB cases were diagnosed (bacteriologic and radiologic). All TB incidence was 2/100 person-years of observation (pyo) (95% CI: 1.65-2.65). Nine were bacteriologic cases, incidence 0.3/100 pyo. The radiologic TB incidence was 1.82/100 pyo. Bacteriologic TB was associated with infant HIV infection, higher Keith Edwards scores. Completeness of 4-month vaccinations and HIV infection were positively associated with retention.

CONCLUSIONS

TB incidence was high. An all TB endpoint would require a sample size of a few thousand children, but tens of thousands, when limited to bacteriologic TB.

From Diagnosis to Treatment of Pediatric Tuberculosis: Ten Years Experience in a Single Institution

Aim and Objectives. To describe the patient characteristics, clinical-epidemiologic-microbiologic profile, and treatment outcomes, and to draw attention to tuberculosis (TB) in Turkey. Methods. A retrospective, descriptive study was undertaken of 93 children aged 0 to 18 years who were admitted to Hacettepe University Pediatric Pulmonology Department for treatment from January 2005 to December 2015. Review of hospital records was performed for all children diagnosed as having TB. Results. Pulmonary TB was detected in 51.6% of the patients, extrapulmonary involvement in 33.3%, and pulmonary TB with extrapulmonary involvement in 15.1%. The history of contact with an adult with TB was found in 29% of cases. The most common extrapulmonary TB was TB lymphadenitis. The most common symptom was cough followed by fever and night sweats. One fifth of the patients had normal physical examinations at the time of diagnosis. One fifth (20.4%) of the patients had culture, 17.2% had polymerase chain reaction, and 15% had acid-resistant bacillus positivity. In 21.4% of patients with culture growth, at least one anti-TB drug resistance was found. The mean duration of treatment of patients treated according to the national guideline was 8.6 months (range = 6-36 months). Recovery was seen in 91.4% of patients. Conclusion. The most important way to prevent childhood TB is to fight adult TB through early diagnosis and effective treatment. The presence of contact history must direct us to search for TB. While evaluating children with persisted nonspecific symptoms, TB must be kept in mind even if physical examinations are normal.

Chest ultrasound compared to chest X-ray for pediatric pulmonary tuberculosis

INTRODUCTION

Chest ultrasound is increasingly used to radiologically diagnose childhood pneumonia, but there are limited data on its use for pulmonary tuberculosis (PTB).

AIM

Compare chest ultrasound with a chest X-ray (CXR) findings.

METHODS

Children (up to 13 years) with suspected PTB were enrolled. Bedside chest ultrasound findings were compared to CXR. The analysis was stratified by PTB category: confirmed PTB (microbiologically confirmed), unconfirmed PTB (clinical diagnosis with negative microbiological tests), or unlikely PTB (other respiratory diseases with improvement without tuberculosis treatment).

RESULTS

One hundred fifty-nine children were enrolled (57% boys, median age 26.6 months [interquartile range 15.1-59.3]). Ultrasound detected abnormalities in 72% (n = 114), CXR in 56% (n = 89), P < .001. Pleural effusion was detected on ultrasound in 15% (n = 24) compared 9% (n = 14) on CXR, P = .004, more in confirmed PTB (33%, n = 12 vs 8%, n = 4 unlikely PTB, P = .013). Ultrasound detected enlarged mediastinal lymph nodes more commonly (22%, n = 25) than CXR (6%, n = 10, P = .001); the size of lymph nodes in the unlikely category (1.0 cm) was smaller than the other two PTB categories (1.4 and 1.5 cm, P = .001). Inter-reader agreement (kappa Cohen) was higher for ultrasound than CXR for several findings (consolidation 0.67 vs 0.47, pleural effusion 0.86 vs 0.56, enlarged lymph nodes 0.56 vs 0.27).

CONCLUSION

Ultrasound detected abnormalities more frequently than CXR with the higher inter-reader agreement; ultrasound abnormalities were most common in children with confirmed PTB. Ultrasound is a promising modality for detecting abnormalities in PTB. Further studies should evaluate the diagnostic accuracy of ultrasound against a gold standard.

Chest ultrasound findings in children with suspected pulmonary tuberculosis

INTRODUCTION

Chest ultrasound is increasingly used for the diagnosis of pediatric lung disease but there are limited data for its use in pediatric pulmonary tuberculosis (PTB).

AIM

To describe chest ultrasound findings in children with suspected PTB.

METHODS

Consecutive children, presenting with suspected PTB to a tertiary children's hospital in Cape Town between July 2014 and March 2016, were enrolled in this cohort study. Children were categorized into three groups based on microbiological and clinical features; confirmed PTB (microbiologically confirmed), unconfirmed PTB (clinical diagnosis only), and unlikely PTB (respiratory disease not due to PTB). A clinician, blinded to categorization, performed chest and mediastinal ultrasound for consolidation, pleural gaps, pleural effusions, B-lines or enlarged mediastinal lymph nodes at enrolment and 1, 3, and 6 months thereafter. Two readers interpreted the ultrasounds independently.

RESULTS

One hundred seventy children (median age 26.6 months) were enrolled; 40 (24%) confirmed PTB, 85 (50%) unconfirmed PTB, and 45 (26%) unlikely PTB. In children with confirmed PTB, pleural effusion was more common (30% vs 9% in unlikely PTB, P = 0.024), mediastinal lymph nodes were larger (median size 1.5 cm vs 1.0 cm in unlikely PTB, P = 0.027), resolution of consolidation occurred less commonly at 1-month follow-up (24% vs 67% unlikely TB, P = 0.014) and the proportional size reduction of a consolidation was lower (44% vs 80% in unlikely PTB, P = 0.009). Inter-reader agreement was perfect to moderate.

CONCLUSION

Chest ultrasound identified abnormalities suggestive of PTB with a high inter-reader agreement. Consolidation showed slower resolution in children with confirmed PTB.

Adherence to Childhood Tuberculosis Treatment in Mozambique

BACKGROUND

There is limited literature regarding adherence rates for the treatment of tuberculosis (TB) in children. We aimed to describe TB treatment outcomes and adherence as well as to evaluate associated factors to poor adherence in Mozambican children.

METHODS

This is a sub-study of a community TB incidence study among children <3 years of age. Incomplete adherence included the sum of lost-to-follow-up cases plus those with a delay of > 3 weeks to treatment completion.

RESULTS

Fifty TB treatments were assessed. Forty-four (88.0%) patients completed treatment, two (4.0%) died during treatment and four (8.0%) were lost to follow-up. Incomplete adherence was observed in 31.3% (15 of 48) of cases and was associated with malnutrition or history of a migrant mother.

CONCLUSION

Although treatment outcome is overall good, there is still a significant proportion of incomplete adherence. Further larger paediatric TB cohorts and qualitative approaches are needed to assess and confirm potential factors for non-adherence.

García-Basteiro A, Augusto OJ, Fraile O, Bulo H, Ira T, Gondo K, van Ingen J, Naniche D, Sacarlal J, Alonso PL. High Rates of Non-Tuberculous Mycobacteria Isolation in Mozambican Children with Presumptive Tuberculosis

INTRODUCTION

Non-tuberculous mycobacteria (NTM) can cause disease which can be clinically and radiologically undistinguishable from tuberculosis (TB), posing a diagnostic and therapeutic challenge in high TB settings. We aim to describe the prevalence of NTM isolation and its clinical characteristics in children from rural Mozambique.

METHODS

This study was part of a community TB incidence study in children <3 years of age. Gastric aspirate and induced sputum sampling were performed in all presumptive TB cases and processed for smear testing using fluorochrome staining and LED Microscopy, liquid and solid culture, and molecular identification by GenoType® Mycobacterium CM/AS assays.

RESULTS

NTM were isolated in 26.3% (204/775) of children. The most prevalent NTM species was M. intracellulare (N = 128), followed by M. scrofulaceum (N = 35) and M. fortuitum (N = 9). Children with NTM were significantly less symptomatic and less likely to present with an abnormal chest radiograph than those with M. tuberculosis. NTM were present in 21.6% of follow-up samples and 25 children had the same species isolated from ≥2 separate samples. All were considered clinically insignificant and none received specific treatment. Children with NTM isolates had equal all cause mortality and likelihood of TB treatment as those with negative culture although they were less likely to have TB ruled out.

CONCLUSIONS

NTM isolation is frequent in presumptive TB cases but was not clinically significant in this patient cohort. However, it can contribute to TB misdiagnosis. Further studies are needed to understand the epidemiology and the clinical significance of NTM in children.

Knowledge, attitudes and practices regarding tuberculosis care among health workers in Southern Mozambique

Background

Tuberculosis (TB) control is more likely to be achieved if the level of knowledge regarding TB is increased among health workers managing high-risk groups. No formal assessments regarding knowledge, attitudes and practises of health workers about TB have been published for Mozambique, a country facing challenges in the fight against TB, with a fragile health system and considerable work overload of health personnel. The main objective of the study was to determine the level of knowledge, identify attitudes and assess practices regarding TB care and control among health care workers of the district of Manhiça.

Methods

A descriptive cross-sectional study was performed through the use of a specifically designed Knowledge, Attitudes and Practices (KAP) questionnaire in the district of Manhiça, a high tuberculosis and HIV burden rural area in Southern Mozambique. In this district, 14 health care facilities service a population of approximately 160,000 people. The questionnaire took 30–45 min to administer with external assistance not permitted. The survey contained 79 questions pertaining to four different areas: demographics, TB knowledge, attitudes and practices.

Results

The study sample included 170 health care workers. The average knowledge score was 14.89 points (SD = 3.61) out of a total possible 26 points. Less than 30% of respondents had heard of Xpert MTB/RIF®. Seventy per cent agreed there was stigma associated with TB and 48.2% believed this stigma was greater than that associated with HIV. The average practice score was 3.2 out of 9 points (35.6%, SD = 2.4).

Conclusion

Health care worker’s knowledge gaps identified in this study may result in substandard patient care. Specific deficiencies in understanding existed in terms of paediatric TB and Xpert MTB/RIF® testing. The present study provides impetus for tailored TB education among health care workers from a high TB burden rural area in Southern Mozambique.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0344-8) contains supplementary material, which is available to authorized users.