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Screening and Treating Pediatric TB. David Hilmers, MD January 9, 2006. Epidemiology. Worldwide 8 million new cases (all ages) each year 3 million deaths per year US 1000 kids develop active TB each year Highest rates in minorities Texas is among highest states for new cases.

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screening and treating pediatric tb

Screening and Treating Pediatric TB

David Hilmers, MD

January 9, 2006

epidemiology
Epidemiology
  • Worldwide
    • 8 million new cases (all ages) each year
    • 3 million deaths per year
  • US
    • 1000 kids develop active TB each year
    • Highest rates in minorities
    • Texas is among highest states for new cases
stages of tb
Stages of TB
  • 1. Exposure
    • Contact with someone with pulmonary TB
    • Asx and has negative PPD
  • 2. Latent infection
    • TB present only in lungs
    • Asx
    • CXR with only calcifications/granulomas
    • Positive PPD
  • 3. TB disease
    • Clinical manifestations
    • Radiographic evidence of disease
transmission
Transmission
  • Spread via respiratory route when someone with TB sneezes, laughs, talks
  • Kids get TB from adults and are less contagious because of lower TB burden
  • After growing in alveolar macrophages, 103 –104 organisms needed for + PPD
  • Spread via lymphatics to lymph nodes and to distant sites through bloodstream
  • If intact cellular immunity, spread is limited by production of granulomas = latent TB infection
latent infection
Latent Infection
  • 40% of infants develop TB disease within 2-12 months after initial infection
  • Targeted PPD testing recommended now
  • Risk factors include:
    • Foreign traveler, immigrant
    • Exposure to high-risk individual or one with TB
    • Consuming raw milk or unpasteurized cheese
    • Living in jail or shelter
    • Having been exposed to HIV-positive person or drug user
latent infection diagnosis
Latent Infection Diagnosis
  • Medical history for sxs and exposures; attempt to find source case
  • PEX for signs of disease and CXR
  • Gastric aspirates in early am x 3
  • TB skin test still best method (sensitivity 80-96%)
  • Shows delayed hypersensitivity reaction induced by antigenic components of M. TB
  • Interpretation of results (next slide)
treatment of latent tb
Treatment of Latent TB
  • INH drug of choice if susceptible or susceptibility unknown
  • Evaluate for risk factors for INH-induced hepatitis, LFT’s NOT necessary
  • Daily rifampin is acceptable if sensitive and if INH not tolerated or INH resistance
  • B6 not needed unless there is risk factor for B6 deficiency (diabetes, uremia, HIV, alcoholism, low B6 in diet) or if breastfeeding
  • What is the duration of treatment?
  • 9 months
tb disease
TB disease
  • Test high-risk kids with PPD, 10% of immunocompetent kids with dz have false neg
  • TB of superficial lymph nodes is most common extrapulmonary manifestation
  • Fever is common but other systemic signs are often absent
  • CXR may show LAD, atelectasis, consolidation, densities, effusions or mass
  • Cavities are rare
  • Try to isolate by gastric aspirates but yield is only 50%
clinical forms
Clinical Forms
  • Pulmonary
  • Disseminated most commonly miliary TB with massive release of bacilli into blood affecting at least 2 organs
  • CNS TB from formation of caseous granulomas in cerebral cortex during lymphohematogenous dissemination
  • Skeletal TB (Pott’s if in spine) also from lymphohematogenous dissemination
treatment
Treatment
  • Drug susceptible
    • 2 months of INH, RIF, and PZA
    • 4 months of INH and RIF qD or twice weekly
  • If areas of low-resistance
    • 1 month of INH and RIF daily
    • 8 months of INH and RIF qD or twice weekly
  • Extrapulmonary TB treated the same except tuberculous meningitis
  • TB meningitis
    • 2 months INH, RIF, PZA, and either ethambutol or streptomycin
    • 7-10 months INH and RIF qD or twice weekly
treatment complications
Treatment Complications
  • Few side effects, most common is hepatotoxicity from INH
  • NO LFT’s needed at baseline unless sxs develop (abdominal pain, icterus, e.g.) or if coexisting conditions (HIV, drug abuse) or hepatotoxic meds (anticonvulsants)
  • INH can cause peripheral neuropathy, neuritis, ataxia, seizures
  • RIF can cause hepatitis and may inhibit effectiveness of OCP’s, should use alternate form of birth control
  • Streptomycin affects the vestibular and auditory portions of 8th cranial nerve
  • Ethambutol can cause optic neuritis
but i ve had the bcg vaccine
But I’ve had the BCG vaccine!
  • 16 yo female from Guatemala presents with fever, cough, and malaise for several weeks. You are concerned about pulmonary TB. Her shot record indicates she received the BCG vaccine. Do you place a PPD on this patient?
  • Yes
bcg vaccination
BCG Vaccination
  • Attenuated strain of M. bovis
  • Used world-wide except in US
  • Efficacy is 52%, seemingly more effective in extrapulmonary TB
  • Given in US only if negative PPD and cannot be treated for LTBI but are at high risk of continuous exposure to TB
  • In patients who have had BCG vaccine, PPD should be interpreted similarly to those who have not been vaccinated
case 1
Case 1
  • A 9 month old male, born in the US to a family from Mexico, has been visiting his grandmother who has been recently dx’d with pulmonary TB.
  • He is asymptomatic, has a normal exam. His PPD and CXR are negative.
  • Does he require any further testing?
  • Yes, repeat PPD in 12 weeks. After exposure, it can take 2-12 weeks for bacteria to grow to significant levels to cause an immune response/PPD conversion
case 2 serial testing
Case 2 - Serial Testing
  • 2a - 26 yo intern had a PPD placed but missed his/her f/u for reading due to falling asleep post-call. The intern did take note that the test was negative. They return to Occupational Health the next week to have the PPD placed again. Can serial TB testing induce a positive PPD?
  • Depends…did the intern have a past positive ppd.
booster effect
Booster Effect
  • PPD skin sensitivity persists throughout life
  • Over time, the size of the skin test can decrease and may disappear.
  • If a PPD comes back small or absent in a previously infected person, then there can be an accentuation of a response on repeat testing.
  • This can be misinterpreted as a skin test conversion if the history is not correctly taken.
  • Repeated testing on persons with no cellular immunity to the antigens in PPD will not induce a conversion.
how well do you know tb
How well do you know TB?
  • What does PPD stand for?
  • purified protein derivative
  • What does BCG stand for?
  • bacillus Calmette-Guerin - named after the two French investigators who developed the vaccine