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Unit 9 Diagnosis and Treatment of Paediatric TB: B Family Case

Unit 9 Diagnosis and Treatment of Paediatric TB: B Family Case. Botswana National Tuberculosis Programme Manual Training for Medical Officers. B Family Background. Remember the B Family? Mr. B is on TB retreatment and ART

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Unit 9 Diagnosis and Treatment of Paediatric TB: B Family Case

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  1. Unit 9 Diagnosis and Treatment of Paediatric TB: B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

  2. B Family Background Remember the B Family? • Mr. B is on TB retreatment and ART • Because he is receiving streptomycin injections, he is not eligible for DOTS • The B’s have 3 children: • BB (3 mos) • KB (3 yrs) • JB (7 yrs) Unit 9: Case Studies

  3. BB Mrs. B’s 3 month-old daughter Mrs. B states BB is eating well, hasn’t had a fever or cough and is active BB is afebrile, has age appropriate behaviour and weighs 5 kg KB Mrs. B’s 3 year-old son Mrs. B states KB is playing with children, doesn’t have a fever or cough and has a healthy appetite KB is afebrile, has age-appropriate behaviour and weighs 15 kg B Family Case (1) Unit 9: Case Studies

  4. B Family Case (2) • Mrs. B is HIV positive • Mr. B has smear-positive TB • A breast-feeding child of a smear-positive mother has a higher risk of infection (compared to a child living in the same household as a smear-positive patient). • Both are eligible for INH (if not symptomatic for TB) Unit 9: Case Studies

  5. B Family Case: Question 1 • What is your management plan for BB? • What is your management plan for KB? • Would you give pyridoxine in either of these cases? Unit 9: Case Studies

  6. BB (3 month-old girl) INH at 5mg/kg = 25 mg/day x 6 months Repeat BCG if no scar on forearm Note that CXR and TST are NOT necessary HIV test KB (3 year-old boy) INH at 5mg/kg = 75 mg/day, but you give 100 mg/day due to drug formulation available Note that CXR and TST are NOT necessary HIV test B Family Case: Answer 1 Neither of these cases should get pyridoxine Unit 9: Case Studies

  7. B Family Case: Question 2 • JB is Mrs. B’s 7 year-old daughter • Mrs. B. states that JB has had an intermittent cough for 4 weeks • She has not been to school for 3 days because she has been complaining of feeling tired • She has not been eating well lately • JB is short for her age, appears thin, is febrile (38.1 C) and weighs 18 kg Unit 9: Case Studies

  8. B Family Case: Question 2 What do you do for Mrs. B’s daughter, JB? Unit 9: Case Studies

  9. B Family Case: Answer 2 TB investigations • TST • Sputum collection • CXR • HIV test Unit 9: Case Studies

  10. B Family Case: Question 3 • JB is found to be HIV negative • Mantoux is 12mm • Only 1 sputum was sent and it was negative • Chest x-ray shows a pleural effusion Source: B. Marais, Stellenbosch University What do you do next for JB? Unit 9: Case Studies

  11. B Family Case: Answer 3 • Start JB on Category III treatment: • Intensive phase: 2HRZ • 2 tabs R60H30Z150 daily x 2 months • Continuation phase: 4HR • 2 tabs R60H30 x 4 months • She will likely show marked improvement after 2 weeks • NOTE: the dose will change as JB gains weight Unit 9: Case Studies

  12. Unit 9 Diagnosis and Treatment of Paediatric TB Additional Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

  13. Additional Case (1) • Agnes is 2 years old • Her mother was just diagnosed with smear-positive pulmonary TB • Agnes is brought to the hospital by her parents • Agnes’ father says she has been ill for 3 weeks • She eats poorly, is losing weight, doesn’t play, and feels hot most days Unit 9: Case Studies

  14. Additional Case (2) • Physical exam • T 39°C • Weight 70% of the expected weight for her age • Enlarged lymph nodes in the neck, axilla, and inguinal areas • Swollen parotid glands, enlarged liver and spleen • Malaria smear negative • Management • Prescribe ampicillin • Educate the parents, and ask them to return in 3 days Unit 9: Case Studies

  15. Additional Case: Question 1 • What are common signs and symptoms of TB in small children? • What tests provide a confirmed diagnosis of tuberculosis disease in small children? • What tests provide supporting evidence of TB in small children? Unit 9: Case Studies

  16. Additional Case: Answer 1 (1) • Signs and symptoms in small children: • Chronic cough not improving and present for two to three weeks • Night sweats • Fever of >38 degrees for two weeks • Weight loss or failure to thrive • Fatigue • Blood-streaked sputum Unit 9: Case Studies

  17. Additional Case: Answer 1 (2) • Confirmed TB in small children • Positive gastric aspirate smear or culture • Other positive culture • Positive acid-fast stain on lymph node aspirate • Caseous material on biopsy • Cheesy material on visual inspection of biopsied lymph node Unit 9: Case Studies

  18. Additional Case: Answer 1 (3) • Supportive evidence of TB in small children • Positive TST • BUT do not treat active TB in children based only on positive TST • Suggestive x-ray images • Widened mediastinum from hilar or mediastinal lymphadenopathy • Miliary pattern • Pleural effusion Unit 9: Case Studies

  19. Additional Case: Question 2 What signs and symptoms are helpful in making a presumptive diagnosis of TB if microbiologic or radiologic testing is not possible? Unit 9: Case Studies

  20. Prolonged cough Fatigue No response to broad spectrum antibiotic Fever Weight loss Positive PPD A minority of patients with active TB will have a negative skin test, particularly if malnourished or otherwise debilitated Additional Case: Answer 2 Unit 9: Case Studies

  21. Additional Case: Question 3 • Knowing what you know now about Agnes, should she be started on treatment for tuberculosis disease? • If Agnes improves on ampicillin, the treatment for bacterial pneumonia, would you do anything additional for her? Unit 9: Case Studies

  22. Additional Case: Answers 3 (1) • Yes, she should receive TB treatment because: • She is the child of a smear-positive patient • She has all the symptoms of TB and did not respond to antibiotics • There were non-specific chest X-ray changes Unit 9: Case Studies

  23. Additional Case: Answers 3 (2) • Remember that in immunosuppressed patients, more than one disease frequently exists at the same time • Due to the presence of enlarged lymph nodes, liver, and spleen, Agnes may have HIV or pneumonia that is superimposed on TB– test her for HIV • She needs further evaluation before starting on IPT (lymph node aspirate, etc.) Unit 9: Case Studies

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