Extra-pulmonary tuberculosis in children

METHODS: The clinical and epidemiological features of 102 children with extra-pulmonary tuberculosis, diagnosed between 1982 and 1998 at P & A Kyriakou Children's Hospital were reviewed. RESULTS: During the past decade, a 50% increase of admissions for extra-pulmonary tuberculosis was observed. The source of infection was disclosed in 48 patients. Diagnoses included superficial lymphadenitis (n = 48), pleural effusion (n = 27), meningitis (n = 16), skeletal tuberculosis (n = 5), miliary tuberculosis (n = 3), abdominal tuberculosis (n = 2), and pericarditis (n = 1). Miliary tuberculosis developed in infants, lymphadenitis and meningitis in preschool children, and pleural effusion and skeletal tuberculosis in older children. None of the patients with extra-pulmonary tuberculosis died; however, six patients with meningitis developed permanent neurological deficits. In these patients, antituberculous treatment was introduced at a median of six days following admission as compared with one day in patients with no complications. Poverty, immigration, and limited access to medical services were common among patients with meningitis.     

Extra-pulmonary tuberculosis in BCG-vaccinated patients.

Six patients with extra-pulmonary tuberculosis who presented within a 2-year period to the Paediatric Department of the Faculty of Medicine, Galle, Sri Lanka, are presented. In spite of the BCG vaccination being given to all of them at birth, five patients subsequently developed miliary tuberculosis and one patient bone tuberculosis. The likely reasons for failure of BCG vaccination to prevent extra-pulmonary complications developing are discussed.     

Abdominal tuberculosis in children.

Abdominal tuberculosis (AT) is a rare cause of intraabdominal infection. Surgical intervention is rarely indicated, other than obtaining a specimen for histopathological diagnosis or for the treatment of complications. METHODS: The medical records of 14 patients who were operated on after the diagnosis of AT between 1983 and 2000 were reviewed retrospectively. RESULTS: Median age was 7 years (6 months to 10 years). The presenting clinical signs and symptoms were as follows: colicky abdominal pain (9), weight loss (8), abdominal mass (6), vomiting (5), and night fever (5). Two patients were operated at another centre and referred to our department with faecal fistula and severe malnutrition. Twelve patients were operated on, while diagnostic laparoscopy was performed in two. In uncomplicated cases, surgical intervention was limited to sampling of peritoneal tissue, lymph node and ascites. The reasons for surgical intervention were intestinal obstruction (9), abdominal mass and ascites (6), psoas abscess (1) and intussusception (1). Adhesive peritonitis and ileal loops were the cause of abdominal mass. Necrosis of the bowel (2) and perforation (1) were detected in three patients. The diagnosis was confirmed either by histopathological or microbiological examination. In eight patients, AT was defined at the intestinal mesentery, in three patients it was localised to the peritoneum and in two patients the disease was diffuse. All patients except one with faecal fistula survived and were treated successfully with antituberculous therapy (isoniasid, rifampicin, streptomycin and pyrazinamide combination). CONCLUSION: The diagnosis of AT is difficult before presentation with complications of intraabdominal infection. Since the response to chemotherapy is usually excellent in patients with suspected AT, aggressive surgery should be avoided and initial surgical intervention should be limited to tissue and/or fluid sampling.     

Osteoarticular tuberculosis in children.

One hundred and four cases of osteoarticular tuberculosis were studied. There were 74 boys (71.2%) and 30 girls (28.8%). The mean age at the onset of symptoms was 7.3 years, ranging from 9 months to 18 years. Seventy four cases (71%) reported 3 months after onset of symptoms. The spine was the commonest site involved (43%) followed by hip (14.9%) and knee joints (10.3%). Evidence of active or inactive pulmonary tuberculosis was found in 16.2%. All cases were treated by three drug regimen of rifampicin, isoniazid and ethambutol; rifampicin was discontinued after 6 months, ethambutol after 12-14 months. In 12 cases (11.5%) isoniazid was continued for 18 months. Along with chemotherapy suitable braces, splints, tractions, exercises and other form of physical therapy produced satisfactory results. Seventy eight patients (75%) showed clinical and radiological improvement with one year of treatment. The follow up period ranged between 4 months to 24 months with an average of 17 months. Children because of capacity to grow, showed progressive deformity in knee in 3 cases (2.8%), hip in 98 cases (8.6%), shortening of limbs in 14 cases (13.4%) and kyphosis in 13 cases (12.5%).     

Fatal tuberculosis in young children.

Three young children with advanced cavitary pulmonary tuberculosis died between 1974 and 1978. Two of the patients had tuberculous meningitis as well. All diagnoses were verified at autopsy; however, all tuberculin skin tests were negative. These instances emphasize the difficulty of establishing the diagnosis of tuberculosis in young children. Tuberculosis should be considered in the differential diagnosis of cavitary chest disease in young children, even those with negative tuberculin skin tests.     

Miliary tuberculosis in children. A clinical review

Eighty cases of miliary tuberculosis admitted to our hospital between January 1981 and December 1984 were reviewed. The age of the patients ranged from 3 months to 12 years, with an average of 2 years 2 months (26.5 months). Nine cases (11.25%) died during hospitalization due to the severe condition at the time of admission. Only 8 patients (10%) were in good nutritional condition. Seventy-two patients (90%) had been visiting the primary health care clinic for several times since 2-3 months but were never diagnosed as suffering from tuberculosis. Fever or recurrent fever were found in 78 cases (97.5%), anorexia in 65 cases (81.3%), chronic and/or recurrent cough in 72 cases (90%) and malaise in 43 (53.8%). Forty-one (51.3%) denied the presence of a close contact with source of infection. Hepatomegaly was found in 44 cases (55%), 19 (23.8%) of which were associated with splenomegaly. Choroidal tubercle was found in 4 cases; 1 case with coxitis, 1 with brain tuberculoma, 1 with ascites, 1 with endobronchitis and 1 with hepatitis. Forty-three (53.8%) were tuberculin negatives, 24 of which become positives after treatment. Fourteen cases had BCG scar. History of measles was found in 21 cases. Children with longterm and recurrent fever, anorexia, decrease of body weight and recurrent cough should be suspected of having TB thus enabling to get an early diagnosis.     

Skeletal tuberculosis in children

The objective of this review is to present the imaging findings of skeletal tuberculosis in children. The incidence of tuberculosis is increasing and skeletal tuberculosis accounts for 10–20% of all extra-pulmonary cases. The most common manifestations of skeletal tuberculosis in children are spondylitis, arthritis and osteomyelitis. Tuberculous spondylitis involves the intervertebral disc only late in the disease. Subligamentous spread of the infection may lead to multiple levels of vertebral body involvement that may either be continuous or skipped. Extension of the disease into the paravertebral or extra-dural space may occur. Tuberculous arthritis usually occurs as a result of metaphyseal spread to the joint. Tuberculous osteomyelitis may appear as cystic, well-defined lesions, infiltrative lesions or spina ventosa. The latter is a term used to describe a form of tuberculous osteomyelitis where underlying bone destruction, overlying periosteal reaction and fusiform expansion of the bone results in cyst-like cavities with diaphyseal expansion. Radiographs are still the mainstay of evaluation of patients with bony lesions. Ultrasonography can detect soft-tissue extension of the bony lesions and guide drainage or biopsy procedures. CT accurately demonstrates bony sclerosis and destruction, especially in areas difficult to assess on radiographs such as the posterior elements of the vertebral body. MRI is the modality of choice in evaluating early marrow involvement and soft-tissue extension of the lesion.     

Pleural tuberculosis in children

Pleural tuberculosis effusion (PTE) in children is a diagnosis which must be considered in isolated pleural effusions in non-toxemic children. It is more common in children over 5 years of age. A history of close contact with an adult with pulmonary tuberculosis reinforces the suspicion for its diagnosis. Pleural effusion without any parenchymal lesion is the characteristic finding on the chest x-ray. However, in 20% to 40% of patients, intrathoracic disease may also occur. Adenosine deaminase, interferon-gamma, analysis of pleural fluid and pleural biopsy are the main tools for diagnostic confirmation. Tuberculin skin test may provide supporting evidence of tuberculous infection. PTE has a good prognosis in children and no long term sequelae are expected.     

不典型起病的小儿结核病5例分析

目前,临床结核病的表现似乎日趋复杂化,给临床诊断带来一定的难度。现将我院1994年9月至1999年2月的几例不典型起病的结核病报告如下:1　临床资料　　例1,男,4岁,阵发脐周疼痛2月余,夜间较重。腹痛与饮食无关,时有腹胀、便秘,无腹泻、呕吐、无盗汗。接种过卡介苗。以腹痛待查入院。查体:Ｔ36.6℃,体重12ｋｇ,慢性病容,皮肤无黄疸。心肺正常,腹平软,脐周轻压痛,无反跳痛,肝脾未触及,肠鸣音正常。化验:三大常规正常。腹部Ｂ超:正常。腹平片正常。胃肠钡餐正常。肝、肾功能正常。治疗予雷尼替丁、颠茄合剂、氟哌酸等无效。在观察中发现患儿除了…     

Abdominal tuberculosis in children

Four boys with abdominal tuberculosis, one of whom had acquired immunodeficiency syndrome, are presented. Abdominal imaging findings on plain radiography, ultrasonography, computed tomography, and gastrointestinal contrast studies included tuberculous peritonitis and ascites in all patients, tuberculous adenopathy in two, gastrointestinal tuberculosis in two, and omental tuberculosis in two. The radiographic features particularly characteristic of abdominal tuberculosis were: (1) low attenuating adenopathy with rim enhancement, (2) omental or ileocecal inflammatory mass, (3) high density ascites, and (4) gastrointestinal enteritis involving the ileocecal region. All patients had acidfast bacilli identified in cultures of bodily fluids and/or pathologic specimens and three patients had cultures positive forMycobacterium tuberculosis. The patient with a negative culture had a positive PPD skin test and a surgical specimen showing caseating granulomata and acid-fast bacilli in the omentum. The radiologist must maintain a high degree of suspicion for abdominal tuberculosis particularly in normal or immunosuppressed children with acquired immunodeficiency syndrome. Fine needle aspiration and biopsy of abdominal adenopathy, inflammatory mass or ascites may be necessary for diagnosis.     

Isoniazid pharmacokinetics in children treated for respiratory tuberculosis.

AIMS: To define the pharmacokinetics of isoniazid (INH) in children with tuberculosis in relation to the N-acetyltransferase 2 (NAT2) genotype. METHODS: The first order elimination rate constant (k) and area under the concentration curve (AUC) were calculated in 64 children <13 years of age (median 3.8) with respiratory tuberculosis from INH concentrations determined 2-5 hours after a 10 mg/kg INH dose. The NAT2 genotype was determined; 25 children were classified as homozygous slow (SS), 24 as heterozygous fast (FS), and 15 as homozygous fast (FF) acetylators. RESULTS: The mean (SD) k values of the genotypes differed significantly from one another: SS 0.254 (0.046), FS 0.513 (0.074), FF 0.653 (0.117). Within each genotype a median regression of k on age showed a significant decrease in k with age. The mean (SD) INH concentrations (mg/l) two hours after INH administration were SS 8.599 (1.974), FS 5.131 (1.864), and FF 3.938 (1.754). A within genotype regression of 2-hour INH concentrations on age showed a significant increase with age. A within genotype regression of 3-hour, 4-hour, and 5-hour concentrations on age also showed a significant increase with age in each instance. In ethnically similar adults, mean (SD) 2-hour INH concentrations (mg/l) for each genotype were significantly higher than the children's: SS 10.942 (1.740), FS 8.702 (1.841), and FF 6.031 (1.431). CONCLUSIONS: Younger children eliminate INH faster than older children and, as a group, faster than adults, and require a higher mg/kg body weight INH dose to achieve serum concentrations comparable to adults.