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.