Transcript Paediatric aspects of Tuberculosis

Paediatric aspects of
Tuberculosis
Patricia Fenton
Sheffield Children’s Hospital
BSMT 12th May 2006
Challenges
Rare disease
Children susceptible
Variable presentation
Dissemination common
Rarely “smear positive”
Drug treatment difficult
Must locate source adult
Paediatric TB is rare
We know this because….
In Sheffield Children’s Hospital we don’t
see very much
Children are susceptible
Smear positive adult
plus
Child in same house
equals
50% chance
Geuns et al 1975
Swimming is good for you
 Smear positive life
guard
 3,764 children traced
 108 infected nonswimmers>swimmers
CHILDREN ARE
SUSCEPTIBLE
Rao et al 1980
Dangerous times
Up to 5 years
 Dissemination
 Meningitis
5 to puberty
 LN and skeleton
Adolescence
 Pneumonitis
 Hilar adenitis
VARIABLE PRESENTATION
Variable presentation
Stage 1 – primary complex
Stage 2 – haematogenous dissemination
Stage 3 – pleurisy
Stage 4 – bones and joints
May just have a fever
BCG – bile and glycerol flavour
 Bovine mastitis strain
 Passaged 230 times
 1921 oral
 Lubeck disaster 1930
(73 died)
 WWII freeze dried
Prevents dissemination?
 1950 UK schools
 1960 selected
neonates
 Efficacy 0 to 80%
 Prevents meningitis
 JCVI weighed
evidence
 CMO letter July 05
Bacille Calmette-Guérin
Improved programme
Targeted
Neonatal
Others at risk
NO MORE SCHOOL
PROGRAMME
New arrangements
Local arrangements (logistics and training)
No more Heaf – mantoux
All infants living where TB > 40/100,000
Parents or grandparents born where…
Unvaccinated new immigrants from areas..
School children screened for risk factors
Challenge
PCTs HAVE A HUGE
RESPONSIBILITY
To ensue new
arrangements are
robust
Rarely “smear positive”
ADULT
CHILD
 Pulmonary
 Productive
 Sputum
 Different sites
 Not productive
 Gastric washings?
 Induced sputum?
 BAL?
 LN biopsy?
 Bone marrow?
Gastric washings
 Single room
 3 nights
 Pass NG tube
 Starve overnight
Induced sputum
 Negative pressure
 Masks FFP3
 Gloves
 Apron
 Nebulised saline
FRIGHTENING
Tissue
General anaesthetic
Treatment
Start on suspicion
Cannot swallow tablets
Four drugs
Taste
Volume
Long course of treatment
Contact tracing
Household
Close relatives
School
Social groupings
Abroad
The unexpected
Tuberculous meningitis
 Symptoms >6 days
 Optic atrophy
 Focal neurology
 Abnormal movements
 Neutrophils < half
MPS Casebook February 2006
 Term baby
 Mum European
 Dad N African
 Triple/polio
 BCG section blank
 Noted to visit N Africa
for 2 months – no
BCG given
Seven months old
Visit to GP
Noted smokers in home
Scattered coarse transmitted chest sounds
Salbutamol ? Asthma
Mum felt salbutamol helped
Letter to local housing authority
Nine months old
Vomiting
High temperature
Listlessness
Coarse transmitted sound at lung bases
3 GP visits in as many days
CXR and abdo XR abroad – not repeated
Five days later
Still vomiting
Staring blankly
Not moving right arm
Blurred disc margin on fundoscopy
Urgent neuro opinion
Neurosurgical assessment
 Cavitating lesion
 Left cerebrum
 Hydrocephalus
 Tuberculous
meningitis
 Limited motor ability
and unintelligible
speech
This case illustrates
Non-specific symptoms
Irreversible damage
Missed opportunity to follow BCG
guidance
Challenges
Rare disease
Children susceptible
Variable presentation
Dissemination common
Rarely “smear positive”
Drug treatment difficult
Must locate source adult
Conclusion