The socioeconomic impact of tuberculosis on children and adolescents: a scoping review and conceptual framework

BACKGROUND

Tuberculosis (TB) has been repeatedly shown to have socioeconomic impacts in both individual-level and ecological studies; however, much less is known about this effect among children and adolescents and the extent to which being affected by TB during childhood and adolescence can have life-course implications. This paper describes the results of the development of a conceptual framework and scoping review to review the evidence on the short- and long-term socioeconomic impact of tuberculosis on children and adolescents.

OBJECTIVES

To increase knowledge of the socioeconomic impact of TB on children and adolescents.

METHODS

We developed a conceptual framework of the socioeconomic impact of TB on children and adolescents, and used scoping review methods to search for evidence supporting or disproving it. We searched four academic databases from 1 January 1990 to 6 April 2021 and conducted targeted searches of grey literature. We extracted data using a standard form and analysed data thematically.

RESULTS

Thirty-six studies (29 qualitative, five quantitative and two mixed methods studies) were included in the review. Overall, the evidence supported the conceptual framework, suggesting a severe socioeconomic impact of TB on children and adolescents through all the postulated pathways. Effects ranged from impoverishment, stigma, and family separation, to effects on nutrition and missed education opportunities. TB did not seem to exert a different socioeconomic impact when directly or indirectly affecting children/adolescents, suggesting that TB can affect this group even when they are not affected by the disease. No study provided sufficient follow-up to observe the long-term socioeconomic effect of TB in this age group.

CONCLUSION

The evidence gathered in this review reinforces our understanding of the impact of TB on children and adolescents and highlights the importance of considering effects during the entire life course. Both ad-hoc and sustainable social protection measures and strategies are essential to mitigate the socioeconomic consequences of TB among children and adolescents.

Detecting tuberculosis: rapid tools but slow progress

The World Health Organization (WHO) currently recommends Xpert^® MTB/RIF as the initial test for all people with presumptive tuberculosis (TB). A number of challenges have been reported, however, in using this technology, particularly in low-resource settings. Here we examine these challenges, and provide our perspective of the barriers to Xpert scale-up as assessed through a survey in 16 TB burden countries in which the Médecins Sans Frontières is present. We observed that the key barriers to scale-up include a lack of policy adoption and implementation of WHO recommendations for the use of Xpert, resulting from high costs, poor sensitisation of clinical staff and a high turnover of trained laboratory staff; insufficient service and maintenance provision provided by the manufacturer; and inadequate resources for sustainability and expansion. Funding is a critical issue as countries begin to transition out of support from the Global Fund. While it is clear that there is still an urgent need for research into and development of a rapid, affordable point-of-care test for TB that is truly adapted for use in low-resource settings, countries in the meantime need to develop functional and sustainable Xpert networks in order to close the existing diagnostic gap.

Validation of a homology model of Mycobacterium tuberculosis DXS: rationalization of observed activities of thiamine derivatives as potent inhibitors of two orthologues of DXS

We present the a homology model ofM. tuberculosisDXS that we validated by identifying thiamine and thiamine diphosphate analogues as potent inhibitors of DXS.

De novo fragment-based design of inhibitors of DXS guided by spin-diffusion-based NMR spectroscopy

A ligand-based NMR methodology (STI) enabled de novo fragment-based design of inhibitors of the enzyme DXS present in the non-mevalonate pathway in the absence of X-ray co-crystal structures.

Primary malignant rhabdoid tumours of the central nervous system: an immunohistochemical and ultrastructural study

Three cases of primary rhabdoid tumour of the CNS (RT-CNS) are presented. In case 1 a hemispheric tumour developed in a 10.5 months old girl, who survived for 6 months after incomplete resection, radio- and polychemotherapy. Case 2 was a 4 years and 8 months old boy with a large IIIrd ventricle tumour, who died of leptomeningeal tumour dissemination 7 months after diagnosis despite radiotherapy. In case 3 a pineal mass occurring in a 14 month old female was radioresistant and totally exstirpated. The child died due to tumour recurrence two months later. Autopsy examination revealed widespread leptomeningeal dissemination. All three cases fulfilled light and electron microscopic criteria of RT-CNS including abundant eosinophilic cytoplasm, vesicular nuclei with large nucleoli and conspicuous anti-vimentin positive filaments. Extensive immunohistochemical studies showed expression of epithelial (EMA, KL1), macrophage (alpha-1 antichymotrypsin), neuro-ectodermal (GFAP, NSE, beta-tubulin III) and myogenic markers (desmin, actin). Different stress proteins (alpha-B crystallin, HSP70) were also expressed. Tumour cells showed a proliferation (MIB1) index of 28.4% (case 1) and 33.4% (case 2). From our study it can be concluded that RT-CNS reveals significant immuno-morphological heterogeneity thus supporting the view that it is not a specific pathological entity but merely a phenotypic appearance of different neoplasms, some of which are linked to primitive neuro-ectodermal tumours.

[Ectopic neuroglial tissue associated with intrapulmonary congenital cystic adenomatoid malformation]

BACKGROUND

Few cases of ectopic neurological tissue have been reported in the lung. The aim of the present study was to give a brief overview of these cases and to examine an additional case of intrapulmonary neuroglial heterotopia. We have identified only sixteen similar cases in the literature.

CASE DESCRIPTION

The object of our study was a male fetus of Asian parents at the 23rd week of gestation, in which ultrasound tests revealed the presence of anterior encephalocele. Routine postmortem examination of lung samples showed neuroglial tissue and a congenital adenomatoid cystic malformation of type II. The lesion was made up of multiple small cysts lined with columnar or ciliated cuboidal epithelium. A possible link between adenomatoid malformation and intrapulmonary neurological tissue has not so far been reported in the literature. Immunohistochemical analysis showed the presence in the pulmonary parenchyma of neuronal cells (neuron-specific enolase positive), astrocytes (glial fibrillary acidic protein positive) and intra-alveolar squamous cells (citokeratines positive), indicative of fetal aspiration of amniotic fluid.

CONCLUSIONS

There are several possible explanations for the presence of intrapulmonary neuroglial heterotopia: fetal aspiration, neural crest migration defects or vascular embolization with implantation. However, in the view of the microscopic findings and at the same time recognizing the intrapulmonary aspiration of amniotic fluid, the authors maintain that the most likely explanation for the heterotopia is that of consequential multiple malformations. Moreover neuroglial ectopy and cystic adenomatoid congenital malformation of the lung could have appeared simultaneously, due to embryologic insult between the 4th and the 20th week of gestation.

Clinical and pathological features in hydrocarbon-induced parkinsonism

A neuropathological examination was performed on a patient with parkinsonism induced by prolonged exposure to a mixture of aliphatic hydrocarbons, mainly n-hexane and halogenated compounds. The patient developed a rapid-course disease that progressed even after withdrawal from the toxic exposure. Pathological examination and immunohistochemical analysis of the brain revealed severe and widespread dopaminergic neuronal loss, associated with severe gliosis, in the substantia nigra, and almost complete loss of tyrosine hydroxylase immunostaining in the striatum. No Lewy bodies were detected. Neuronal loss was also observed in the periaqueductal gray matter, locus ceruleus, and pedunculopontine nucleus. These changes, combined with the moderate anemia due to marrow suppression, and the mild axonal neuropathy observed in vivo, are suggestive of a hydrocarbon toxic insult.

Primary multiple epithelioid leiomyosarcoma of the liver

Sarcomas represent only 1-2% of primary malignant tumors of the liver. We report the twenty first case of primary hepatic leiomyosarcoma in the literature. Metastases from gastrointestinal tract, female genital system and lung have to be excluded before confirming diagnosis of a primary neoplasm. Extensive involvement of the liver parenchyma contraindicated surgery, the treatment of choice when the tumor is solitary or multiple but located in one lobe. Chemotherapy, as employed in our patient, is the alternative therapeutic option in inoperable cases, but its role has to be clarified.

Autoptic findings in HIV-1 positive children

The growing incidence of AIDS in children and newborns has been related to increasing incidence of AIDS in women. Case records were composed by 14 children with death occurring at different ages--from 1 hour to 12 years--and 1 female fetus, all with serological confirmation of AIDS. Brain and internal organs samples were collected at autopsy for morphological, immunohistochemical and "in situ" hybridization's technical examination. The prevailing extracerebral pathology observed at autopsy consisted of opportunistic infections. The cerebral findings were HIV-encephalopathy; cytomegalovirus encephalitis; vascular alterations such as necrosis and hemorrhage; calcifications and edema. Neurologic symptoms were reported in 3 children of intravenous drug-abuser mothers as drug withdrawal syndrome. HIV positivity in one or both the intravenous drug-abuser parents is the main risk factor of congenital AIDS. This factor means lack of care during the gestational stage and may determine relevant differences in the course of disease. The cerebral changes due to opportunistic infection must be differentiated from HIV-specific lesions; it has to be stressed that "diffuse" leukoencephalopathy is not AIDS-specific but can be found in every chronic encephalitis/encephalopathy especially in newborns and children. Chronologically, HIV encephalopathy appears as late manifestation of the disease, due to an infiltration of CNS of HIV-infected macrophages and not to an impairment of neuronal or glial cells infected by HIV in the early stages of the disease.

Progressive multifocal leukoencephalopathy (PML) in the acquired immunodeficiency syndrome (AIDS). A neuropathological autopsy study of 21 cases

In a neuropathological autopsy study of 21 cases of AIDS-associated PML no fundamental morphological differences to non-AIDS PML were found. PML in AIDS often showed very large foci as well as necrotizing lesions. Partial involvement of cerebral cortex and deep gray matter were common findings; infratentorial lesions could be observed in more than three quarters of cases. Perivascular mononuclear infiltrates within PML foci were frequent and obviously not associated with a more benign clinical course. Possible reasons for these peculiarities of PML in AIDS are discussed. In 7 cases evidence of concomitant HIV encephalopathy was found; this may be one relevant factor contributing to severity of PML in AIDS. PML has to be regarded as a common complication of HIV infection, which may show atypical morphological and neuroradiological features.

AIDS-myelopathy. A neuropathological study

Vacuolar myelopathy belongs to the AIDS-associated diseases. It is characterized by vacuolation and infiltration of the long tracts of the spinal cord by macrophages. The clinical and morphological findings of 8 AIDS-patients with vacuolar myelopathy are reported here. The syndrome developed during the final stages of AIDS and was associated with HIV-encephalopathy in 5 cases. The vacuoles were mainly due to intramyelinic swelling and vacuolation. Vacuolated macrophages and axons contributed only to a minor degree. In one case only, HIV-antigens were detected immunohistochemically. The results are discussed in the light of modern pathogenetical concepts of HIV-related diseases.

Evidence of clonal progression in a case of Richter syndrome

BACKGROUND

The debate continues as to whether Richter syndrome should be defined as non-Hodgkin lymphoma (NHL) because of a more malignant clone of neoplastic cells superimposed on preexisting chronic lymphocytic leukemia (CLL) or as the chance occurrence of two unrelated tumors. The cellular characteristics of the neoplastic clone involved in the CLL phase and the subsequent NHL were investigated in a patient in whom Richter syndrome developed.

METHODS

Cell analysis was performed with immunofluorescence, histologic analysis, DNA extraction, and Southern blot analysis.

RESULTS

The separated CLL and NHL B-cells from blood and bone marrow, as well as the neoplastic cells in autopsy specimens of the organs affected by NHL, particularly the brain, were found to express the same light chain of surface immunoglobulin (SIg). The change MD-->M in the SIg heavy-chain expression and the appearance of cytoplasmic IgMk suggested isotype switching simulating that observed on the final phases of primary B-cell differentiation. This hypothesis was confirmed by Southern blot analysis of DNA from blood cells in the CLL phase and in Richter transformation, which showed that the two cell populations had identical Ig gene rearrangement.

CONCLUSIONS

The NHL in the patient in this study represented a malignant progression of CLL, not a second lymphoid malignancy.

Progressive multifocal leukoencephalopathy and gliomas in a HIV-negative patient

A case of progressive multifocal leukoencephalopathy (PML) is reported, detected at autopsy of a 30-year-old patient. The clinical picture was characterized by a progressive course of mental deterioration and ingravescent neurological symptoms. The patient was HIV-negative. He died of bronchopneumonia, after a clinical course of 13 months. Autopsy disclosed pulmonary tuberculosis with involvement of regional lymph nodes. In the brain, besides numerous PML-foci of varying age and structure, a pleomorphic astrocytoma was found in the white matter of the right parietal lobe. In the brain stem glial proliferation resembling diffuse gliomatosis was also present. In situ hybridization revealed Papova-virus (JCV) in oligoglial nuclei, but not in neoplastic astrocytes. This is the third report on the concomitant occurrence of PML and glioma in man.

[Pathology of the internal organs and central nervous system in acquired immunodeficiency syndrome (with special reference to opportunistic infections)]

Extracerebral and cerebral pathology in AIDS (with particular emphasis on the opportunistic infections). The Authors present the extracerebral pathology of 27 cases of AIDS observed at the Department of Pathology of Milan and the cerebral pathology of 80 cases of AIDS collected by three Institutes (Department of Pathology of Milan, Department of Pathology of Rimini and Department of Neuropathology of Münster) with particular emphasis on the pathology of the opportunistic infections. In the adults' group, the most frequent infections are the protozoan ones (T. gondii) followed with equal incidence by the viral and fungal diseases. In the pediatric group the viral diseases are the most frequently seen. Almost all of the adults show multiple infections in the same organ or in different organs. Diffuse lesions with heavy pathologic fields were observed also without tissue reaction. As to cerebral pathology AIDS' patients with opportunistic infections show focal symptoms, whereas the so called "subacute microglial encephalitis" generally appears as a demential syndrome. In cases with progressive multifocal leukoencephalopathy JC virus was always found and in one case also SV 40 - and BK virus. The diffuse demyelinization in some cases of HIV-Encephalopathy is aspecific. In HIV-positive newborns with cerebral signs, the lesions are characterized by oedema, spongiosis and microcalcifications of the basal ganglia; these are aspecific lesions which can be found in toxic and infectious encephalopathies.

Cerebral listeriosis in adults. Three cases report

The Authors describe three autoptic cases of meningoencephalitis in adults due to an emerging pathogen, the Gram-positive bacillus Listeria monocytogenes. Only one of these was an immunosuppressed patient (recurrent carcinoma of the larynx and bladder papillomas), while no severe cause of debilitation was detected in the other two cases, excluding colonic diverticulosis in both. The post-mortem examination revealed leptomeningitis and encephalitis. Lympho-monocytic tissue reaction with perivascular cuffing was present in all the cases. The etiologic agent, L. monocytogenes, was identified by cultures from clinical or autoptic specimens.

[Primary teratocarcinoma of the pineal region]

Primary Teratocarcinoma of Pineal Region. A case of a 12 year old boy admitted for intracranial hypertension of sudden onset has been reported. CT scanning and MR showed a triventricular hydrocephalus due to a space-occupying lesion of the pineal region. Tonic-clonic fits of the upper limbs and Parinaud syndrome were followed by loss of consciousness. Intervention I: ventriculo-peritoneal shunt with sampling of CSF and assay for beta-HCG, alpha FP and CEA, which proved negative. Cytology for neoplastic cells in cerebrospinal fluid was negative. Intervention II: grossly total removal of the tumor. This was followed by partial remission of Parinaud syndrome, total remission of the hypertensive symptoms and discharge on day 12. The 3 cm. whitish-pink tumor of rubbery consistency proved on histological examination to be a teratocarcinoma. The patient was further submitted to chemioterapy and irradiation but died 7 months after the second intervention. This is a rare tumor, much more than teratoma of the pineal gland, which is relatively frequent. It is interesting histologically because of the presence not only of chondroid and mesenchymal portions but also of adamantinomatous rudiments and of epithelial zones resembling embryonal carcinoma of the testis.

Cerebral phaeohyphomycosis

The authors describe a case of cerebral phaeohyphomycosis with lethal outcome within five weeks from surgical resection. The lesion consisted of a multilocular abscess in the left parietal lobe. The histopathologic findings showed a granulomatous reaction surrounding the abscess cavities. The causative fungus was clearly visible because of its brown-pigmented, septate, branched hyphae and spherical thick-walled cells, sometimes inside the multinucleated giant cells. Although no cultures were obtained from the exsudate, the possible diagnosis of cerebral cladosporiosis is discussed.