Multifocal tuberculosis with cerebellar tuberculoma]

A 10-year old child was admitted for vomiting and a high grade fever. He had been previously immunized twice against tuberculosis. A cerebellar syndrome appeared, and the brain CT scan showed an intracerebellar mass. Disseminated lesions were detected on abdominal (splenic abscess) and thoracic (mediastinal lymph nodes) CT scans. The bone scintigraphy also showed multiple localisations. A craniotomy was performed that revealed a cerebellar tuberculoma which was completely removed. The child received an antituberculous treatment over 18 months and is currently well with a 5 year follow-up.     

Infantile pulmonary tuberculosis: the great mimic

Purpose

Infantile tuberculosis is common in developing countries and rarely presents as space occupying thoracic lesions mimicking congenital malformations. This case series reviews four such infants with varied presentations and their outcome.

Methods

Four cases of infantile pulmonary/mediastinal tuberculosis that presented like congenital thoracic lesions are described. Details of demography, symptomatology, contact history, immunization status, provisional diagnosis, tuberculin testing, imaging, histopathology, final diagnosis, management and outcome were retrospectively collated and analyzed.

Results

They were 4–6-month males, term-born and immunized. They presented with pneumonia/hyperactive airway disease since 2–12?weeks. One had a suspect and another a close tuberculous contact. The provisional diagnosis after imaging were infected congenital lung cyst, posterior mediastinal cyst and bronchopulmonary malformation. Two were tuberculin positive; none had gastric acid-fast bacilli. One underwent a pulmonary lobectomy for necrotic lung cyst; the second had a biopsy and drainage of a posterior mediastinal cyst that contained caseating material and was densely adherent to the esophagus. Surgical biopsy showed necrotizing granulomatous inflammation in both; one with acid-fast bacilli. Both succumbed to postoperative complications. The other two with tuberculous contacts who were managed with early antituberculous therapy, responded well and recovered uneventfully.

Conclusions

Infantile pulmonary/mediastinal tuberculosis may mimic congenital thoracic malformations. A review of contact history, investigations and imaging help to establish the tuberculous etiology, avoids surgical misadventures and prompts early antituberculous therapy to achieve a favorable outcome.     

Oesophageal perforation as a complication of primary pulmonary tuberculous lymphadenopathy in children

Background Involvement of the oesophagus by tuberculosis is rare, and erosion and perforation of the oesophagus by tuberculous lymphadenopathy is an unusual complication of primary pulmonary tuberculosis. There are very few reports describing both CT and contrast swallow appearances of these lesions. Objective To describe the CT and contrast swallow appearances of oesophageal erosion and perforation by lymphadenopathy as a complication of primary pulmonary tuberculosis in children. Materials and methods Imaging of three children with confirmed pulmonary tuberculosis and oesophageal perforation was retrospectively reviewed. Results Tuberculosis was confirmed by culture in all three patients. Contrast swallow demonstrated a contained leak in two patients and a tracheo-oesophageal fistula in one. Two patients had mediastinal air and one patient had a mediastinal collection on CT. All patients had features diagnostic of pulmonary tuberculosis on CT. Conclusion The imaging features comprise leakage of contrast medium with or without fistula formation on contrast swallow, large low-density lymph nodes on CT, and mediastinal air. The use of retrievable stents is a promising idea in this condition.     

Evaluation of young children in household contact with adult multidrug-resistant pulmonary tuberculosis cases.

BACKGROUND: The prevention and management of multidrug-resistant (MDR) tuberculosis has received much attention, but little attention has been given to children with MDR tuberculosis or children in contact with adults with MDR tuberculosis. The aim of this study was to determine the prevalence of tuberculous infection and disease in childhood contacts of adults with MDR pulmonary tuberculosis. METHOD: All children <5 years of age in household contact with 75 recently diagnosed adults with MDR pulmonary tuberculosis were evaluated. Evaluation included clinical examination, tuberculin skin test, chest radiography and culture for Mycobacterium tuberculosis from gastric aspirates. RESULTS: One hundred twenty-eight children, median age 27 months, were evaluated. Fifty children had recent contact with other adult tuberculosis cases. Sixty-six children previously had chemoprophylaxis or treatment of whom 36 defaulted treatment or received insufficient chemoprophylaxis. One child had HIV infection. Forty-seven children were classified as noninfected, 66 were considered infected only (Mantoux test, > or = 15 mm) and 15 had disease. Three children, who had not previously received antituberculosis drugs, had positive cultures for M. tuberculosis; all were multidrug-resistant. CONCLUSION: This study documents the transmission of multidrug-resistant M. tuberculosis to childhood contacts, the development of disease in these contacts and the importance of knowing the index case's M. tuberculosis susceptibility pattern in choosing a proper treatment regimen for the childhood contact.     

Intracranial tuberculosis in the Netherlands: Four paediatric cases

Abstract Since 1987 a resurgence of tuberculosis is occurring in the Netherlands in analogy to the situation in other industrialised countries. So far this has not been associated with an increased incidence of tuberculous meningitis, which is still a rare complication of the disease. Four cases of intracranial tuberculosis were recently diagnosed in our hospital. All children were from middle-class Dutch families with no identified risk for tuberculosis. An extensive contact identification search could identify a contact in two patients. Two children were in an advanced stage of disease before diagnosis. Skin tests were repeatedly negative in all cases which delayed treatment in two cases for almost 2 weeks. One patient developing a cerebral tuberculous focus during therapy responded well to a second course of corticosteroids. Three children developed severe neurological sequelae.Conclusion This report illustrates that suspicion of intracranial tuberculosis is warranted in the case of an ill-defined inflammatory neurological syndrome.     

Outcome of residual mediastinal masses of thoracic lymphomas in children: impact on management and radiological follow-up strategy

Background. Following treatment with chemotherapy and radiotherapy, patients with thoracic lymphomas may demonstrate benign residual mediastinal masses, composed of inflammatory, fibrous or necrotic tissue. Because of the potential risk of viable tumour cells within the mass, histological verification of the nature of these masses may be requested. Objective. To study the outcome of thoracic lymphomas in children in order to optimise the radiological follow-up strategy of residual mediastinal masses (RMM). Materials and methods. A retrospective study of 39 children [24 with Hodgkin's disease (HD), 10 with non-Hodgkin's lymphoma (NHL), and 5 with anaplastic lymphoma (AL)]. The results of chest X-rays (CXR) and thoracic CT performed at the time of re-assessment were compared with the histology of the residual masses (n = 11) or the clinical course (n = 28). Results. At the time of re-evaluation, 16/39 patients had residual mediastinal enlargement (RME) on CXR, and 18/39 patients had RMM on CT. Good concordance was observed between the two imaging modalities (K = 0.69). Two children with a RMM died from extra-mediastinal progression. Two children with NHL had active residual mediastinal lesions but neither had RMM. Sixteen cases of RMM were observed in the remaining 35 children and 9 of these masses were histologically verified as benign. A favourable course was observed in these 35 cases. Conclusions. RMM are frequent and generally benign. They are well shown on CXR and have a non-specific appearance on CT. Except when required by a treatment protocol, they could be submitted to further radiological follow-up before contemplating surgical verification. Received: 4 June 1997 Accepted: 9 January 1998     

Chylothorax as a complication of pulmonary tuberculosis in children

Chylothorax is a rare clinical entity characterized by a milky white aspirate with increased triglyceride levels. The commonest aetiology is malignancy and trauma. Pulmonary tuberculosis is an extremely rare cause of chylothorax. Two children with chylothorax and pulmonary tuberculosis are described. One child had bilateral and the other unilateral chylous effusions. Extensive mediastinal and hilar lymphadenopathy was demonstrated. Diseased lymph nodes may infiltrate other intrathoracic structures such as the thoracic duct, and they can also obstruct the cisterna chyli and thoracic duct. A possible explanation for the development of a chylothorax in our patients is obstruction of the thoracic duct by tuberculous lymphadenopathy with subsequent increase in pressure in the surrounding lymphatic system and leaking of chyle into the pleural space.     

Tuberculous meningitis in children: problem to be addressed effectively with thorough contact tracing

Worldwide, tuberculosis is the most common cause of death from a single infectious agent in children. There has been an increase in its incidence in Europe in recent years. Early diagnosis of tuberculous meningitis in children is extremely difficult because of its nonspecific early presentation and it is universally fatal if not recognised and treated. Young children are at increased risk of acquiring tuberculosis and it is more likely to be disseminated in neonates. In summarising the cases of three children with tuberculous meningitis admitted to our centre, we highlight the importance of diagnosis and contact tracing of the source case. Conclusion Diagnosis of tuberculous meningitis requires a high index of suspicion, thorough contact tracing, and appropriate investigations with early treatment as the key to reducing morbidity and mortality. Received: 17 July 1999 and in revised form: 10 December 1999 and 24 January 2000/Accepted: 31 January 2000     

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.     

Thoracic sequelae after surgical closure of the patent ductus arteriosus in premature infants

Thirty-six children (median chronological age 6 years 1 month) who had undergone surgical closure of a patent ductus arteriosus through a left posterolateral thoracotomy in the neonatal period (median gestational age 32 weeks) were investigated prospectively with respect to anatomical and functional changes of the chest. At follow-up examination, residual or recurrent patent ductus arteriosus was not observed. Three patients had chronic bronchial obstruction. Two patients showed pathological musculoskeletal thoracic sequelae that did not require any treatment at the time of follow-up: persistence of immediate postoperative left phrenic palsy ( n = 1) and thoracic scoliosis ( n = 1). Twenty of the 27 patients in whom chest X-ray was performed had minor radiological skeletal anomalies in the form of rib deformation or fusion related to die thoracotomy, lesions which have a potential to induce thoracic scoliosis. Left shoulder elevation at chest X-ray and isolated left arm dysfunction at clinical examination were not observed. Despite the low incidence of scoliosis and the absence of left arm dysfunction observed at mid-term follow-up in our series, the incidence of minor rib deformations with a potential to induce severe anomalies such as scoliosis should motivate late follow-up examination at adolescence to definitively assess the prevalence of thoracic sequelae after surgical closure of the patent ductus arteriosus in premature infants.     

Chest radiography in ambulatory children with acute lower respiratory infections: effective tuberculosis case-finding?

A study was performed to determine the proportion of ambulatory children with acute lower respiratory infections in whom clinical management was changed by findings on routine chest radiography that suggested tuberculosis. The children studied were aged between 2 and 59 months and met the World Health Organization's case definition for pneumonia. They lived in an area with a very high prevalence of tuberculosis. Exclusion criteria included a cough of more than 14 days' duration and a history of a current household contact with active tuberculosis. Twelve (4.4%) of 273 children had radiological findings suggesting tuberculosis, nine of which were suspected mediastinal lymphadenopathy. Eight children were further investigated for tuberculosis: seven of them did not require treatment for tuberculosis and one was lost to follow-up. It is concluded that chest radiography in ambulatory children with acute lower respiratory infections of less than 14 days' duration and not in contact with active tuberculosis does not result in a meaningful increase in the diagnosis of tuberculosis.     

Contact investigation and genotyping to identify tuberculosis transmission to children

BACKGROUND: Tuberculosis (TB) in young children is an indicator of ongoing community transmission. We examined contact investigations related to pediatric TB, yield for source case identifications and genotypes for relevant Mycobacterium tuberculosis isolates in a low-incidence setting. METHODS: We reviewed public health data for all patients with TB aged <18 years reported to Montreal authorities during 1996 to 2000. M. tuberculosis isolates from patients of all ages were subjected to IS6110-based genotyping, supplemented by spoligotyping, to compare isolates from children and adults during the same years. RESULTS: Sixty-six patients aged <18 years were diagnosed with active TB from 1996 to 2000. Mean age was 11.1 years (standard deviation 6.7 years). Twenty-five children (38%) were Canadian-born, all with at least one foreign-born parent. Nineteen children were diagnosed after contact investigations of known adult cases; 8 underwent no contact investigation. For the remaining 39 children, a total of 616 contacts were identified. The median number of contacts per child was 9 (interquartile range, 6-10). Four hundred eighty-one contacts (78%) underwent tuberculin testing; 188 (39%) were reactors and 186 (39%) began treatment of latent TB. Investigations uncovered 4 probable source cases, all involving parents or other relatives. M. tuberculosis genotyping for 38 children identified up to 14 additional possible source cases; in only one was a possible epidemiologic link evident from public health records. CONCLUSIONS: Among largely foreign-born children with active TB, contact investigations were extensive and often identified latent tuberculosis infection--but rarely source cases. However, genotyping suggested substantial, previously unrecognized transmission to children despite low overall incidence.     

Inhaled corticosteroid therapy is safe in tuberculin-positive asthmatic children

BACKGROUND: Although treatment with oral corticosteroids can cause reactivation of latent Mycobacterium tuberculosis (TB) infection in purified protein derivative (PPD)-positive individuals with no evidence of clinical disease, little is known about the effects of inhaled corticosteroids in this respect. OBJECTIVE: This study was undertaken to assess whether inhaled corticosteroid (CS) therapy reactivates latent TB infection in PPD-positive asthmatic children. METHOD: We studied 32 PPD skin test-positive (> or =10 mm) children [age (mean +/- SD), 7.9 +/- 4.1 years] with no family history and no evidence of TB infection on chest radiograms who were receiving inhaled budesonide for the treatment of asthma. They were further evaluated with thorax computed tomography (CT) and erythrocyte sedimentation rate and closely observed for an additional 9 months. RESULTS: At enrollment the mean diameter of PPD reaction was 12.8 +/- 2.7 mm. The mean duration of inhaled CS treatment and the mean cumulative CS dose were 9.8 +/- 7.6 months and 275 +/-199 mg, respectively. Thorax CT studies revealed mediastinal lymph nodes in 7 of the 32 patients. There was no significant difference between children with and without mediastinal lymph nodes according to age, gender, size of PPD skin testing, erythrocyte sedimentation rate and duration and cumulative CS dose of inhaled budesonide therapy before study. A second thorax CT was obtained 9 months later in those 7 patients with lymphadenopathy (additional mean cumulative CS dose, 222.57 mg). There was no change in the size of their lymph nodes. CONCLUSION: Long term inhaled budesonide therapy appears to be safe in PPD-positive asthmatic children.     

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??Objective To investigate and analyze the characteristics of MSCT manifestation of infants and young children with intra-thoracic tuberculosis. Methods A retrospective analysis of MSCT chest performances of 76 cases of infants and young children ??ages 0-3 years??with intrathoracic tuberculosis from January 2010 to June 2012 in our hospital was done to find the characteristics and classify pulmonary lesions of it. Results In this study?? the male to female ratio was 48:28?? 7 cases were miliary tuberculosis?? 6 cases were with cavitates?? 15 cases with tuberculous meningitis. 6 cases had no pulmonary lesions?? 18 cases only had single lobe involved??and 31 cases had four or more than four lobes involved??among all the cases?? the right upper lobe was involved in 48 cases?? right middle lobe 43 cases?? right lower lobe 53 cases?? left upper lobe 36 cases?? left lower lobe 40 cases. We classified cases of pulmonary lesions into five types based on the CT features: ??1?? nodular type: pulmonary lesions were mainly nodular?? a total of 16 cases?? ??2?? inflammatory type: pulmonary lesions were ground-glass opacities?? patches?? cords and ??or?? consolidation?? 24 cases?? ??3?? mass type: pulmonary lesions were mainly clumps?? 19 cases?? ??4?? military type: 7 cases?? ??5?? endobronchial tuberculosis type: 4 cases.Totally 71 cases of hilar and mediastinal adenopathy were found?? and mainly in 2R ??75.00%???? 4R ??76.32%???? district 5 ??57.89%???? district 7 ??76.32%???? 8 ??68.42%?? and 10R ??75.00%???? 11R ??64.47%??. Most of the swollen lymph nodes in plain CT scan were medium-density?? and calcification was found in 40 cases. Totally 39 cases had enlarged axillary lymph nodes. There were 8 cases with left pleurisy?? 9 cases with right pleurisy. Conclusion The main MSCT manifestation of infants and young children with intra-thoracic tuberculosis is pulmonary lesions with hilar and mediastinal adenopathy?? but the majority of pulmonary lesions of them on CT are different with primary complex?? hilar and mediastinal adenopathy??enlarged axillary lymph nodes and lymph nodes with calcification are common??while endobronchial tuberculosis??pleurisy and cavitas are rare.     

MRI in Thoracic Tuberculosis of Children

Objective

To explore the utility of lung magnetic resonance imaging (MRI) in children with thoracic tuberculosis (TB).

Methods

This prospective study of forty children (age range of 5 to 15 y) with thoracic TB was approved by the institutional ethics committee. Chest radiograph, lung MRI and computed tomography (CT) scan were performed in all children. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of MRI were calculated and kappa test of agreement was used to determine the strength of agreement between the MRI and CT findings.

Results

MRI performed equivalent to CT scan in detection of mediastinal and hilar lymphadenopathy, pleural effusion and lung cavitation (considered typical for TB) with sensitivity and specificity of 100%. MRI also yielded a sensitivity of 88.2% and specificity of 95.7% for nodules, with sensitivity of 100% and specificity of 92.9% for consolidation. Kappa agreement between CT and MRI in detection of each finding was almost perfect (k: 0.8–1).

Conclusions

Although CT scan is still superior to MRI in detection of smaller nodules, MRI demonstrates a very high degree of correlation and agreement with CT scan for detecting lung and mediastinal pathology related to TB, in children with thoracic TB and can be particularly useful in select population and follow-up of these children to avoid repeated radiation exposures.

     

Transmission of tuberculosis to contacts of sputum positive adults in Malawi

Over a period of one year from June 1993 to May 1994, 282 children under 6 years old who were household contacts of sputum positive adults with tuberculosis were evaluated in a screening clinic. Of these, 180 (63.8%) had evidence of tuberculosis, a much higher transmission rate than reported elsewhere. HIV seropositivity was 77.4% in the adult index cases and 18% in the contact children. No increased infectivity to household contacts was detected in HIV seropositive index adults compared with those who were seronegative. Child tuberculosis contact tracing is essential in these families, where transmission of disease is higher than reported elsewhere, and attention to the health needs of the children may be diminished by the high morbidity and mortality among adult family members.     

Transmission of tuberculosis to contacts of sputum positive adults in Malawi.

Over a period of one year from June 1993 to May 1994, 282 children under 6 years old who were household contacts of sputum positive adults with tuberculosis were evaluated in a screening clinic. Of these, 180 (63.8%) had evidence of tuberculosis, a much higher transmission rate than reported elsewhere. HIV seropositivity was 77.4% in the adult index cases and 18% in the contact children. No increased infectivity to household contacts was detected in HIV seropositive index adults compared with those who were seronegative. Child tuberculosis contact tracing is essential in these families, where transmission of disease is higher than reported elsewhere, and attention to the health needs of the children may be diminished by the high morbidity and mortality among adult family members.     

X-ray findings in pulmonary tuberculosis in children and its complications]

Pulmonary tuberculosis is still a common disease in children, especially those of immigrant families. Prevention and diagnosis rest on the plain chest film which should remain the first step of the work-up. Apart from cerebromeningeal complication, CT scan is also useful for evaluating chest lesions including mediastinal lymphadenopathies and lung parenchyma involvement. CT scan combined with endoscopy ensures detection of complications including bronchogenic dissemination. With a few cases as illustrations, the role of roentgenographic investigations in the management of pediatric tuberculosis is outlined.     

Diagnosis of pediatric tuberculosis in the modern era

BACKGROUND: Correctly diagnosing tuberculosis (TB) in children is critical to provide appropriate treatment and to detect undiagnosed source cases. However, diagnosing TB in children may be difficult. OBJECTIVE: We sought to determine whether Amplicor, a Food and Drug Administration-approved polymerase chain reaction (PCR) assay used to detect Mycobacterium tuberculosis in sputum and computerized tomography (CT) would facilitate the diagnosis of TB in children. We also examined the applicability of the Centers for Disease Control and Prevention clinical case definition for TB. SETTING: A university-affiliated pediatric hospital in New York City. SUBJECTS: From March, 1995, to November, 1997, 27 children < 15 years of age (mean age, 3.9 years) were evaluated for suspected TB. RESULTS: M. tuberculosis was cultured from 5 of 76 (6.6%) gastric aspirate specimens, and PCR detected M. tuberculosis DNA in 3 (4.1%) of these specimens. There was poor correlation between culture and PCR because 6 specimens were discordant. CT scans were diagnostic of mediastinal or hilar adenopathy in 6 children with equivocal or negative chest radiographs and confirmed adenopathy in 8 others. Six children received alternative diagnoses. CONCLUSIONS: We conclude that the commercially available PCR technology had very limited utility in detecting M. tuberculosis from gastric aspirates, but CT scans were useful in assessing pediatric patients with suspected TB.     

Interpretation of the tuberculin skin test in bacille Calmette-Guérin vaccinated and nonvaccinated school children

BACKGROUND: Our objective was to conduct a prevalence survey of purified protein derivative (PPD) reactions among Lebanese healthy school children to identify those with tuberculosis or latent tuberculosis and to investigate the effect of bacille Calmette-Guérin (BCG) vaccine on the interpretation of PPD reactivity. METHODS: A self-administered questionnaire, including demographic characteristics, time of prior BCG vaccine and number of doses, known household contact with tuberculosis as well as parents' characteristics and living conditions was administered. PPD testing was performed on all children in diverse Lebanese regions aged 3 to 19 years. Reactivity that measured <5 mm were considered negative induration, doubtful if between 5 and 9 mm and positive if 10 mm or above. Chest radiographs were obtained as part of the evaluation for children with positive induration. RESULTS: Of 4895 children, 4271 entered into the final data analysis. A total of 3259 children (76.3%) did not develop a reaction to PPD (0 mm), 170 (4%) had 1 to <5 mm reading, 509 (11.9%) had 5 to 9 mm and 333 (7.8%) had > or =10 mm. Approximately 62% of the vaccinated children had received BCG vaccine in first year of life. Two hundred ninety (61.8%) of 469 children < or =5 were vaccinated and 179 (38.2%) were not. Only 22 of the youngest vaccinated had positive PPD. Twelve children were diagnosed with tuberculosis, a prevalence of 280 per 100,000. However, the prevalence of latent tuberculosis was 7.51%. CONCLUSION: Our prevalence of tuberculosis and latent tuberculosis is a sentinel indicator of continued transmission in the community. The data support the current recommendations that children who receive BCG can and should be tested with PPD for latent tuberculosis and tuberculosis.