Tuberculosis in HIV-infected children

Tuberculosis (TB) is the most common opportunistic infection in human immunodeficiency virus (HIV)-infected people worldwide. HIV-positive children are at risk of diagnostic error as well as delayed diagnosis of TB because of overlapping clinical and radiographic features with other lung diseases. Acute pneumonias and chronic lung diseases such as bronchiectasis and lymphocytic interstitial pneumonitis are difficult to distinguish from TB. TB manifestations are more severe in HIV-positive children and progression to death is more rapid than in HIV-negative children. The response to standard short-course therapy in HIV-positive children is not as good as in HIV-negative children due to lower cure rates and higher mortality. TB hastens the progression of HIV disease by increasing viral replication and reducing CD4 counts further. Although Bacille Calmette-Guerin vaccination could lead to disseminated Mycobacterium bovis disease in the presence of immunosuppression, this has been rarely reported. More studies are required to assess the role of newer diagnostic tests, TB preventive therapy and co-administration of anti-retroviral therapy in the control of TB among HIV-infected children.     

Detection of Mycobacterium tuberculosis in gastric aspirate and sputum collected from Ethiopian HIV-positive and HIV-negative children in a mixed in- and outpatient setting

AIM: To investigate, through a prospective study, the detection rate of Mycobacterium tuberculosis in sputa and gastric aspirate from tuberculous children in a low-income country with high prevalence of tuberculosis and an increasing HIV epidemic. METHODS: Gastric aspirates and/or sputum samples were collected from 355 children with pulmonary tuberculosis as follows: from 136 children under 5 y only gastric aspirate was taken, for 159 children aged 5 to 9 y both methods were used, and for 60 children over 10 y only sputum was analysed. The diagnosis of tuberculosis was based on clinical data, tuberculin test and chest radiography. All children were tested for HIV infection. RESULTS: Direct microscopy for acid-fast bacilli was positive for 55 (15%) and mycobacterial culture for 183 (52%) children. The proportion of positive cultures was similar in all age groups. Among the 5 to 9 year-old children who could produce a sputum sample, sputum gave just as good culture yield of M. tuberculosis as gastric aspirate. Of the clinical or radiological findings only weight loss was associated with a higher yield. Repeat gastric aspirate increased the culture yield by 6%. Mycobacterial culture from HIV-positive children gave lower yield compared with HIV-negative children. CONCLUSION: Our data suggest that one gastric aspirate for children less than 6 y and three sputum samples for the older children collected at an outpatient TB clinic, is enough to provide a close to 50% yield of M. tuberculosis available for culture and further analyses. However, with an increasing prevalence of HIV, this detection rate may be reduced.     

The diagnosis of tuberculosis

Childhood tuberculosis accounts for a significant proportion of the global tuberculosis disease burden. However, tuberculosis in children is difficult to diagnose, because disease tends to be paucibacillary and sputum samples are often not easy to obtain. The diagnosis of tuberculosis in children is traditionally based on chest radiography, tuberculin skin testing, and mycobacterial staining/culture from appropriate samples. Newer diagnostic strategies have included improved bacteriologic and molecular methods, as well as new methods for sample collection from children. Recently, immune-based diagnostics, such as the interferon-gamma release assays, have been introduced for clinical use. These tests do not offer substantial improvements in sensitivity over tuberculin skin testing for the diagnosis of active disease but may be useful in excluding false-positive tuberculin skin tests. Further research is needed to develop better diagnostic tests for tuberculosis in children.     

The diagnosis of pulmonary tuberculosis in malnourished Kenyan children

Guidelines available for the diagnosis of pulmonary tuberculosis (TB) in children vary widely. In an area of high prevalence, pulmonary TB was often suspected but difficult to confirm. In a prospective study, diagnostic methods were recorded in 144 consecutive children admitted and diagnosed as having pulmonary TB. Six of the 144 children had bacteriologically confirmed tuberculosis. Seventy-five children had probable tuberculosis, the diagnosis being based on the tuberculin response in 19, a history of family contact in 34 and a diagnostic chest radiograph in 22. The remaining 63 children had suspected tuberculosis: 23 of these had an inconclusive chest X-ray. The suspected group were significantly younger than the probable group (mean ages 2.8 and 4.4 years respectively), experienced a longer delay between admission and the start of antituberculous chemotherapy and suffered a significantly higher mortality (30% and 8% respectively). A diagnostic process is proposed which takes account of the high proportion of nonresponders to tuberculin in a young, malnourished population. A trial of anti-tuberculous therapy is accepted as a valid diagnostic manoeuvre in suspected cases who are malnourished or have recently had measles.     

Comparison of ultrasound with plain radiography and CT for the detection of mediastinal lymphadenopathy in children with tuberculosis

Background: Lymphadenopathy, with or without parenchymal abnormality, is the radiological hallmark of primary tuberculosis (TB) in children. However, lymph node enlargement may pass undetected on plain chest radiographs. Ultrasonography provides complementary information to that obtained by radiographs. Objective: To assess the clinical value of US for the detection of mediastinal lymphadenopathy in children with a positive intradermal tuberculin test. Materials and methods: Thirty-two children with a mean age of 6 years and a positive Mantoux test underwent chest radiography (frontal and lateral) and US (suprasternal and left parasternal access routes). Chest CT was performed at the discretion of the attending physician in six cases. Results: Eleven children had clinical symptoms and 90% a recent contact with a person with active TB. In 90.5% of children with chest radiographic images compatible with TB, coincident findings in the mediastinal US study were found. By comparison, 66.7% of those with normal chest radiography had evidence of mediastinal lymphadenopathy on the US scan. In all cases but one, US and CT findings agreed. Conclusions: Mediastinal US is useful for the detection of enlarged lymph nodes in children with a positive tuberculin reaction and normal chest radiography.     

A profile of bacteriologically confirmed pulmonary tuberculosis in children

OBJECTIVE: To describe the clinical profile of children with bacteriologically confirmed tuberculosis. STUDY DESIGN: A multicentric study was conducted in three hospitals in Chennai city between July 1995 and December 1997. Children aged 6 months to 12 years with signs and symptoms suggestive of tuberculosis were investigated further. Clinical examination, chest radiograph, tuberculin skin test with 1 TU PPD and, sputum or gastric lavage for mycobacterial smear and culture were done for all and, lymph node biopsy when necessary. RESULTS: A total of 2652 children were registered and tuberculosis was bacteriologically confirmed in 201. Predominant symptoms were history of an insidious illness (49%), fever and cough (47%), loss of weight (41%) and a visible glandular swelling (49%). Respiratory signs were few and 62% were undernourished. Over half the patients with confirmed TB had normal chest X-ray. Abnormal X-ray findings included parenchymal opacities in 47% and hilar or mediastinal lymphadenopathy in 26%. The prevalence of isoniazid resistance was 12.6% and MDR TB 4%. CONCLUSIONS: Children with tuberculosis present with fever and cough of insidious onset. Lymphadenopathy is a common feature even in children with pulmonary TB. A significant proportion of children have normal chest X-rays despite positive gastric aspirate cultures. Drug resistance rates in children mirror the pattern seen in adults in this geographic area.     

Comparison of diagnostic criteria of tuberculous meningitis in human immunodeficiency virus-infected and uninfected children

INTRODUCTION: Tuberculous (TB) meningitis is sometimes difficult to diagnose in young children. The decision to start anti-TB treatment of TB meningitis is usually made on clinical grounds and results of special investigations, such as cerebrospinal fluid examination and cranial computerized tomography (CT), because bacteriologic yield is low and the results delayed. AIM: To determine whether the clinical, laboratory, and radiologic criteria used in the diagnosis of TB meningitis in human immunodeficiency virus (HIV)-uninfected children apply to HIV-infected children. METHODS: Retrospective, case-control study. Clinical, laboratory, and radiologic features of TB meningitis were compared in 34 HIV-infected and 56 HIV-uninfected patients matched for age and stage of TB meningitis. RESULTS: All clinical differences found between the 2 groups at admission were related to the underlying HIV disease. Neurologic presentation and cerebrospinal fluid findings at admission did not differ significantly between the 2 groups. Significantly more HIV-infected than HIV-uninfected children had evidence of TB on chest radiography. The classic CT signs of TB meningitis (obstructive hydrocephalus and basal enhancement) were significantly less prominent in the HIV-infected group (P < 005). CONCLUSION: The diagnostic criteria for clinical diagnosis of TB meningitis apply to HIV-infected children. However, cranial CT findings in this group may be misleading and delay the diagnosis of TB meningitis.     

Risk factors for human immunodeficiency virus infection in Ethiopian children with tuberculosis.

BACKGROUND: Separate risk factors for HIV infection and for tuberculosis (TB) are well-studied, but it is unclear whether these risk factors still apply in the new epidemiologic situation of dual infection. This study examines risk factors associated with seropositivity for HIV in Ethiopian children with clinical TB. METHODS: A prospective, controlled study of children with TB diagnosed in Addis Ababa from December 11, 1995, to January 28, 1997, in which HIV-positive children were compared with HIV-negative children with regard to sociodemographic background, previous medical history and vaccination. RESULTS: HIV prevalence among children with clinical TB was 11.2%. High educational status of mothers, low age, loss of one or two parents and earlier Calmette-Guérin bacillus (BCG) vaccination of the child were factors independently related to HIV infection. CONCLUSION: Factors associated with HIV infection among children with clinical TB include higher education of parents, higher income and better living conditions. The HIV epidemic might thus modify traditional risk factors for tuberculosis. It might also decrease the overall effect of BCG vaccination given that BCG did not provide protection in children infected with HIV. An expected increase of dually infected children who are younger, more in need of hospitalization and often lacking one or both parents will put an additional burden on the Ethiopian health care system.     

Evaluation of the WHO clinical case definition for pediatric HIV infection in Bloemfontein,South Africa

The WHO clinical case definition for pediatric HIV infection has been designed to be used in countries where diagnostic laboratory resources are limited. We evaluated the WHO case definition to determine whether it is a useful instrument to discriminate between HIV-positive and HIV-negative children. In addition, clinical features not included in this case definition were recorded. We recorded clinical data from 300 consecutively admitted children in a state hospital in Bloemfontein, South Africa, and tested these children for HIV infection. A total of 222 children were included in the study; 69 children (31.1 per cent) were HIV positive. The sensitivity of the WHO case definition in this study was 14.5 per cent, the specificity was 98.6 per cent. Apart from weight loss and generalized dermatitis, the signs of the WHO case definition were significantly more often seen in HIV-positive than in HIV-negative children. Of the clinical signs not included in the WHO case definition, marasmus and hepatosplenomegaly especially occurred more frequently in HIV-positive children. Based on these findings we composed a new case definition consisting of four signs: marasmus, hepatosplenomegaly, oropharyngeal candidiasis, and generalized lymphadenopathy. HIV infection is suspected in a child presenting with at least two of these four signs. The sensitivity of this case definition was 63.2 per cent, the specificity was 96.0 per cent. We conclude that in this study the WHO case definition was not a useful instrument to discriminate between HIV-positive and HIV-negative children, mainly because its sensitivity was strikingly low. The simplified case definition we propose, proved to be more sensitive than the WHO case definition (63.2 vs. 14.5 per cent), whilst its specificity remained high.     

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.     

Evaluation of New Strategies for the Diagnosis of Tuberculosis Among Pediatric Contacts of Tuberculosis Patients

BACKGROUND:: In young children, underdiagnosis and diagnostic delay have an adverse effect on morbidity and mortality of tuberculosis (TB). This study evaluated new strategies for early TB diagnosis using an outpatient protocol in children between 0 and 5 years of age, with a recent household TB contact. METHODS:: Case recruitment was performed in Manaus, Amazonas, Brazil, from 2008 to 2009. Epidemiologic and clinical data, tuberculin test, chest radiograph and 2 induced sputum respiratory samples from each participant were obtained. Laboratory diagnosis was based on Lowenstein-Jensen (LJ) culture, mycobacteria growth indicator tube (MGIT) and polymerase chain reaction. We conducted a study of comparison of diagnostic tests and a study of cases and controls to identify the clinical characteristics of the population with positive culture and polymerase chain reaction results. RESULTS:: A total of 102 children were evaluated. Thirty-two fulfilled criteria of suspicion of TB. MGIT was more sensitive (P = 0.035) and faster (P < 0.001) than LJ. Clinical score, MGIT, LJ and polymerase chain reaction presented no concordance or slight concordance. A positive MGIT culture was only associated with a strong tuberculin test reaction (P = 0.026). The combination of MGIT with the clinical score allowed the diagnosis of 33% more cases with little or no symptomatology compared with the exclusive use of the clinical classification. CONCLUSIONS:: The sensitivity and speed of MGIT demonstrate the utility of liquid cultures for the diagnosis in children. Furthermore, these results suggest that the use of MGIT in children presenting recent household TB contact and a strong tuberculin test reaction may be a strategy to improve early TB diagnosis.     

Multidrug-resistant tuberculous meningitis in children in Durban, South Africa

BACKGROUND: Tuberculous meningitis (TBM) is the most frequent manifestation of central nervous system tuberculosis (TB) and is more common in children than in adults. The diagnosis of TBM in children is difficult because signs and symptoms are vague. Information about drug resistant TB in children is scarce, and there is no published information on drug resistant TBM in children. METHODS: This is a retrospective review of medical records of children with culture-confirmed multidrug-resistant tuberculous meningitis (MDR-TBM) at King George V Hospital in Durban, South Africa. RESULTS: Between 1992 and 2003, there were 8 children with MDR-TBM; 6 were HIV infected and 2 were HIV negative. Only one child survived. The diagnosis was made posthumously in almost all the children. DISCUSSION: The changes in the cerebrospinal fluid (CSF) in early TBM can be nonspecific and can change rapidly; therefore, CSF studies should always include culture and susceptibility testing. Factors that contributed to the high mortality were disseminated TB, HIV infection, delay in diagnosis and treatment, the absence of a standardized approach to the management of MDR-TBM and the poor CSF penetration of most MDR-TB drugs. MDR-TB therapy should be considered if there is a history of TB: a MDR-TB contact or a poor clinical response to TB therapy despite adequate adherence to treatment. Early diagnosis is important because TBM in children is often associated with a grave outcome.     

儿童结核病的诊治进展

结核病是一种严重危害人类健康的慢性传染性疾病,临床表现不典型,尚缺乏灵敏度较高的有效检查手段,临床诊断难度较大。由于多重耐药性结核菌株（MDR-TB）的产生及儿童用药的局限性,以致儿童结核病的治疗愈加困难。该文就儿童结核杆菌感染的流行病学史、临床表现、结核菌素皮肤试验、影像学检查、实验室检查等与结核病诊断有关的研究进展以及治疗措施在近些年的发展做一综述。     

Evaluation of Mycobacterium tuberculosis transmission from a pediatrician and initial compliance to prophylaxis of contacts in an outpatient pediatric clinic

OBJECTIVE: The risk that latent infection will progress to active tuberculosis is greater in infants and children than for most other age groups. We set out to determine the rate of transmission of Mycobacterium tuberculosis to pediatric patients exposed to a pediatrician with smear-negative and culture-positive pulmonary tuberculosis. We also explored factors associated with compliance to prophylaxis. METHODS: Clinic and hospital billing records were used to identify patients age 5 or less who were seen during the pediatrician's potential contagious period. Patient were notified by registered mail of their putative exposure and were offered a tuberculin skin test screening with 5 tuberculin units of purified protein derivative (Tubersol, Connaught) and chest radiography of children with a tuberculin skin test > or =5 mm. RESULTS: A total of 456 patients were identified as exposed; 140 contacts never responded for evaluation and 93 letters were not delivered because of incorrect mailing addresses. Of the 223 who completed screening 1 (0,4%) had a initial skin test result of 8 mm. The remaining 222 contacts had repeated negative test results. The only positive child (15 months old) was born in Honduras and had received Calmette-Guerin bacillus at birth. No active tuberculosis cases were identified in the 456 contacts up to 2 years after exposure. Compliance with prophylaxis was associated with having two or less children in the household (odds ratio, 2.5; 95% confidence interval, 1.1 to 5.9). CONCLUSION: We found no evidence of transmission of M. tuberculosis in an outpatient pediatric setting. Only 43% of exposed children completed screening, and 38% of those offered prophylaxis completed their initial 3 months of therapy.     

Outcome of HIV infected children with culture confirmed tuberculosis

Background: Tuberculosis (TB) is an important disease in human immunodeficiency virus (HIV) infected children living in regions where TB is endemic. There are limited data on the outcome of culture confirmed TB in HIV infected children. Aims and Methods: To describe the outcome on TB therapy and overall mortality in HIV infected children with culture confirmed TB through a retrospective cohort study. Results: Eighty seven children, median age 24 months, contributed to 93 TB episodes; six children had two confirmed episodes. Pulmonary disease (PTB) was present in 71 episodes (76.3%), extrapulmonary disease (EPTB) in 43 (46.2%), and of these, both PTB and EPTB were present in 21 (22.6%). There was cure based on bacteriological and/or radiological criteria in 54 episodes (58.1%). Eighteen children died during TB therapy and there were a total of 34 deaths (39.1%). In univariate analysis (n = 87 patients), severe malnutrition, age ⩽1 year, and a negative tuberculin skin test were significant risk factors for death during TB therapy. In multivariate survival analysis (n = 87 patients), HIV disease category, severe malnutrition at diagnosis, and lack of cure at the end of TB therapy were significantly associated with overall mortality. Conclusion: In the absence of antiretroviral therapy, HIV infected children with confirmed TB have poor outcomes on antituberculosis therapy and are at high risk of death during and after completion of antituberculosis therapy, especially due to non-TB related causes. There is an urgent need to optimise and monitor antituberculosis therapy in HIV infected children and to improve access to TB and other preventative therapy.     

Outcome of HIV infected children with culture confirmed tuberculosis.

BACKGROUND: Tuberculosis (TB) is an important disease in human immunodeficiency virus (HIV) infected children living in regions where TB is endemic. There are limited data on the outcome of culture confirmed TB in HIV infected children. AIMS AND METHODS: To describe the outcome on TB therapy and overall mortality in HIV infected children with culture confirmed TB through a retrospective cohort study. RESULTS: Eighty seven children, median age 24 months, contributed to 93 TB episodes; six children had two confirmed episodes. Pulmonary disease (PTB) was present in 71 episodes (76.3%), extrapulmonary disease (EPTB) in 43 (46.2%), and of these, both PTB and EPTB were present in 21 (22.6%). There was cure based on bacteriological and/or radiological criteria in 54 episodes (58.1%). Eighteen children died during TB therapy and there were a total of 34 deaths (39.1%). In univariate analysis (n = 87 patients), severe malnutrition, age < or =1 year, and a negative tuberculin skin test were significant risk factors for death during TB therapy. In multivariate survival analysis (n = 87 patients), HIV disease category, severe malnutrition at diagnosis, and lack of cure at the end of TB therapy were significantly associated with overall mortality. CONCLUSION: In the absence of antiretroviral therapy, HIV infected children with confirmed TB have poor outcomes on antituberculosis therapy and are at high risk of death during and after completion of antituberculosis therapy, especially due to non-TB related causes. There is an urgent need to optimise and monitor antituberculosis therapy in HIV infected children and to improve access to TB and other preventative therapy.     

Evaluation of household contacts of children with positive tuberculin skin tests

BACKGROUND: Associate investigation, defined as screening the contacts of children with positive tuberculin skin tests (TST) and normal chest radiographs, has been recommended to improve case finding for active tuberculosis (TB). The success of this strategy has not been adequately studied in either adults or children. METHODS: A 2-year prospective study was conducted wherein 187 children and adolescents with infection caused by Mycobacterium tuberculosis (positive TST and normal chest radiograph) were referred to a TB Screening Clinic. An associate investigation was performed among their 659 household contacts who were interviewed to assess risk factors for TB and screened with TSTs and with chest radiographs when appropriate. RESULTS: No cases of active TB were detected, but 32% of household contacts had TSTs > or = 10 mm and were candidates for preventive therapy. Logistic regression analysis revealed that household contacts with Calmette-Guérin bacillus immunization and foreign birth were 2.26 and 3.92 times more likely (P < 0.001 and 0.002, respectively) to be tuberculin-positive. Univariate analysis of the 187 households revealed that the following risk factors present in a household member were associated with detecting a household contact with a positive TST: Calmette-Guérin bacillus immunization (P = 0.001), foreign birth (P = 0.017) and a history of having hosted foreign visitors (P = 0.032). CONCLUSION: In this Hispanic immigrant population, primarily from the Dominican Republic, screening household contacts of children with positive TSTs did not identify new cases of active TB. However, this strategy did identify household contacts who were eligible for preventive therapy.     

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.     

Aetiology and outcome of pneumonia in human immunodeficiency virus-infected children hospitalized in South Africa

To determine the aetiology and outcome of pneumonia in human immunodeficiency virus (HIV)infected children, we prospectively investigated 250 children hospitalized with pneumonia who were known or clinically suspected to be HIV-positive, or who required intensive care support in Cape Town, South Africa. Blood culture, induced sputum or bronchoalveolar lavage, nasopharyngeal aspirate and gastric lavage were performed. Of the total, 151 children (60.4%) were HIV-infected. Pneumocystis carinii pneumonia (PCP), occurring in 19 (7.6%) children (15 HIVpositive), was the AIDS-defining infection in 20.3%. The incidence and type of bacteraemia (14.3%) were similar in HIV-positive and HIV-negative patients; S. pneumoniae (5%) and S. aureus (2%) were the predominant isolates. Sputum or BAL cultures yielded bacteria in 145 of 243 (60%) specimens; viruses were cultured in 37 (15.2%). Bacterial prevalence (including M. tuberculosis in 8%) and anti-microbial resistance did not differ by HIV status except for S. aureus which was more common in HIV-infected children. Thirty-one (20%) HIV-positive and 8 (8%) HIV-negative children died [RR 1.16 (95% CI 1.05-1.28), p = 0.008]; using multiple logistic regression, PCP was the only risk factor for mortality (p = 0.03). Conclusion: In South Africa, PCP is an important AIDS-defining infection in children; bacterial pathogens occur commonly and with a similar prevalence in HIV-positive and HIV-negative children hospitalized for pneumonia. HIV-infected children with pneumonia have a worse outcome than HIV-negative patients.     

Prevalence and risk factors for transmission of infection among children in household contact with adults having pulmonary tuberculosis.

AIMS: To study the prevalence of tuberculosis infection among children in household contact with adults having pulmonary tuberculosis, and identify the possible risk factors. METHODS: Children under the age of 5 years who were in household contact with 200 consecutive adults with pulmonary tuberculosis underwent tuberculin skin testing. Transverse induration of greater than 10 mm was defined as positive tuberculin test suggestive of tubercular infection. Infected children underwent chest radiography and analysis of gastric lavage fluid or induced sputum for detection of acid fast bacilli. RESULTS: Tuberculin test was positive in 95 of 281 contacts (33.8%), of which 65 were contacts of sputum positive patients, while 30 were contacts of sputum negative patients. Nine of these children were diagnosed as having tuberculosis based on clinical features and/or recovery of acid fast bacilli; seven were in contact with sputum positive adults. The important risk factors for transmission of infection were younger age, severe malnutrition, absence of BCG vaccination, contact with an adult who was sputum positive, and exposure to environmental tobacco smoke. CONCLUSION: The prevalence of tuberculosis infection and clinical disease among children in household contact with adult patients is higher than in the general population, and risk is significantly increased by contact with sputum positive adults.