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PARMESHVAR DAS VAISHNAV
INTRODUCTION10-20% of all tuberculosisDue to failure of TB control in adults.Commonest age group is 1-4 years.Most children are sputum –ve and not
infectious to others.
SOURCE OF INFECTION• Adult or family member with sputum smear
positive.• Frequency of infection in a given population
depends on: (A) no: of infectious cases (B) closeness of contact with an infectious case (C) age of child when exposed and the age
structure of the population
PREDISPOSING FACTORS• Extent of exposure to infectious droplet
nuclei.• Infant whose mother has sputum smear
positive PTB.• Chance of developing infection is greatest
shortly after infection• Children under 5 yrs- less developed immune
system.• Young age is a risk factor for sread of disease
to other part of body,i.e. dissemination..
ClINICAL SYMPTOMSNo specific features.Failure to thriveWeight loss( growth faltering)Respiratory symptoms( cough> 3 weeks in
child who received a course of broad spectrum anti- biotics.
DIAGNOSISParticularly difficult because they rarely
cough up sputum.ExposureTuberculin skin testChest X ray.
TREATMENTA symptomatic child with a positive Mantoux
test(>10mm) is to be treated as a case regardless of BCG vaccination in past
Dosages of anti-TB medication for children:-
DRUGS THERAPY PER DOSE(THRICE A WEEK)
Isoniazid 10-15 mg/kg
Rifampicin 10mg/kg
Pyrazinamide 35mg/kg
Streptomycin 15mg/kg
Ethambutol 30mg/kg
CHEMOPROPHYLAXIS• For infant whose mother or any other houshold
member is smear-positive,then Chemoprophylaxis should be given for 3
months. Then a mantoux test is done… .If test is negative-stop chemoprophylaxis and BCG is given .If test is positive,chemoprophylaxis is continued for a total duration of 6 months..
Guidelines IF AND THEN
child has symptoms of TB
An MO determines (preferably in consultation with a paediatrician) that the child has TB….
A full course of anti TB treatment(CAT3) should be given…
The child does not have symptoms of TB.
. A tuberculin test is not available . .A tuberculin test is available
Chemoprophylaxis for 6 months(Isoniazide daily-5mg/kg) The child should receive 3 months ofINH chemoprophylaxis IF
IF THEN
The induration is less than 6mm in diameter
Stop chemoprophylaxis and give BCG .
The induration is 6mm or more in diameter
Continued INH chemoprophylaxis for another 3 months
TUBERCULOSIS & HIV
INTRODUCTIONTo make global situation worse, tuberculosis has formed lethal partnership with HIV.• Co-infection of tb &hiv has increased the risk
of activation of infection from 10% over the lifespan to 10%per year. worldwide approximately 1/3 rd of all AIDS
related deaths are associated with TB.
HIV infection infection increases the risk of developing active TB by a factor of 100.
Levels of plasma HIV RNA increase in setting of active TB and decline in setting of successful l TB treatment.
EPIDEMIOLOGICAL IMPACTReactivation of latent infection: 25-30% more likely to develop the disease
than the people only with TB. Primary infectionRecurring infectionIn the community
CLINICAL FEATURESDepend on the count of the CD4 cells.
high lowPulmonary reactivation disseminated disease diffuse or
lower fever, cough, dyspnoea, lobe, reticulonodular infiltrates Weight loss, night sweats, miliary spread, pleural effusions, Chest X ray: cavitary apical hilar and/or mediastinal
adenopathy.disease of upper lobes
DIAGNOSISClinical symptoms are similar as in people
without HIV infection in the early stage.Diagnosis is more difficult in advanced HIV
because: (a) Higher frequency of –ve sputum smears. Sputum culture required for confirmation.(b) Tuberculin skin test fails- immune system
damaged- false negative results.
(c) Chest radiography may be less useful- less cavitation – decreased immune response
(d) Cases of extra pulmonary tuberculosis seem to be more common in people who are co-infection.
In short screen: Sputum smear microscopy
positive negative( suspected) start treatment
treatment if if sputum culture not
sputum culture done, treatment given
positive according to X ray
findings
TREATMENTStandard treatment regimens are equally
efficacious in HIV +ve and –ve patients. adverse effects are more pronounced.Thiacetazone- fatal skin reactions- not used
nowadays.Three important considerations: an incresed frequency of paradoxical
reactions.
interaction between ART and rifamycinsDevelopment of rifampin monoresistance with
widely spaced intermittent treatment.IRIS- Immune Reconstitution Inflammatory
Syndrome: It is the exacerbation in signs, symptoms, radiographic and laboratory manifestations of TB due to ART administration.
IRIS more common in advanced immunosuppressed and extrapulmonary TB.
IRIS is an immune response elicited by antigens released as bacilli are killed during effective chemotherapy
Temporarily associated with improved immune function.
Managed by symptomatic treatment with glucocorticoids.
Rifampicin a potent inducer of enzyme of the cytochrome P450 system – lower the serum level of many HIV protein inhibitors and some NNRTIs.
Rifabutin- has much less enzyme inducing activity. So recommended in place of
Rifampicin.
TB IN PREGNANCY
INTRODUCTIONEncountered in 1-2% of pregnant women.Course of TB is unmodified during
pregnancy.Lesions remaining the same, there is no
difference in mortality between pregnant and non-pregnant.
EFFECT OF TB ON PREGNANCYPulmonary TB does not affect fertility unless
there is associated genital TB.Usually there is no effect on the course of
pregnancy except for a slight increase in the incidence of the abortion and premature
labour.Rarely affect the foetus by transplacental
route.
Greater danger is the possibility of infection of the newborn by close contact when the mother has open TB.
Diagnosis is based on symptoms, sputum examination and chest radiographs.
MANAGEMENTProblem- Possible effect on the foetus of the
chemotherapeutic drugs.Time of institution of the treatment should be
irrespective of period of gestation. the anti TB drug considered safe are: Ethambutol- 5-25mg/kg daily Isoniazid – 5 mg/kg not to exceed 300mg
daily Pyridoxine- 50mg daily to reduce risk of INH
induced neuropathy.
Rifampicin 10 mg/kg daily not to exceed 600 mg daily.
duration – 9 monthsRoutine AN care should be continued and
foetal monitoring should be done to diagnose IUGR.
Streptomycin, pyrazinamide - teratogenic- contraindicated
Congenital TB: foetus affected either haematogenously or through the umbilical vein .
The fetus infected by aspiration of infected contents at delivery.
Breastfeeding: shouldnot be discouraged.
NEONATAL RISK AND THE MANAGEMENT.Tuberculin +ve mother without active
disease doesnot pose any risk .If mother is sputum –ve in the last 3 month of
gestation with active TB, the risk to infant is negligible.
If the mother is sputum +ve, then the neonate needs to be evaluated for active TB.
If there is no active TB in neonate, it should receive INH prophylaxis for 3 months until the mother’s sputum becomes –ve.