Tuberculosis in children

Overview & Definition

A four-year-old boy is brought in thin, tired and coughing for six weeks, and his uncle was recently diagnosed with pulmonary tuberculosis. This is the everyday face of childhood TB: a contact history, an indolent symptom, and a chest radiograph showing lymph-node enlargement. The fellowship skill the case tests is moving correctly along the spectrum \u2014 exposure, infection, disease \u2014 and treating the right thing. [1]

Tuberculosis is the disease caused by Mycobacterium tuberculosis complex. In children the decisive idea is that most who are infected never develop disease: they have TB infection (formerly called latent TB), in which viable bacilli are contained by cell-mediated immunity and the child is well, but remain at lifelong \u2014 usually low \u2014 risk of progression. TB disease is the symptomatic and/or radiological illness that follows when that containment fails. [1] [2]

Why children are a distinct clinical problem is the combination of paucibacillary disease and rapid progression. Children swallow sputum rather than expectorate it, produce few bacilli, and are therefore smear-negative and hard to confirm microbiologically; at the same time, their immature cell-mediated immunity lets the few bacilli they have progress quickly to disseminated, miliary and meningeal disease, especially in the first few years of life. [1]

The clinician's role is therefore threefold: find the child with disease (and treat it correctly), find the child with infection (and offer preventive treatment), and find the source case (and break the transmission chain). All three rest on the same foundation \u2014 a contact history, a chest radiograph and a microbiological sample \u2014 and all three carry a public-health responsibility. [1]

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1. [1]Perez-Velez CM, Marais BJ Tuberculosis in children. N Engl J Med, 2012.PMID 22830465
2. [2]Marais BJ, Gie RP, Schaaf HS, et al The natural history of childhood intra-thoracic tuberculosis: a critical review of literature from the pre-chemotherapy era. Int J Tuberc Lung Dis, 2004.PMID 15141729
3. [3]Marais BJ, Gie RP, Beyers N, et al A proposed radiological classification of childhood intra-thoracic tuberculosis. Pediatr Radiol, 2004.PMID 15300340
4. [4]Dodd PJ, Yuen CM, Sismanidis C, Seddon JA, Jenkins HE The global burden of tuberculosis mortality in children: a mathematical modelling study. Lancet Glob Health, 2017.PMID 28807188
5. [5]Kay AW, González Fernández L, Takwoingi Y, et al. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children. Cochrane Database Syst Rev, 2020.PMID 32853411
6. [6]Seddon JA, Tugume L, Solomons R, et al The current global situation for tuberculous meningitis: epidemiology, diagnostics, treatment and outcomes. Wellcome Open Res, 2019.PMID 32118118
7. [7]Turkova A, Wills GH, Wobudeya E, et al. Shorter Treatment for Nonsevere Tuberculosis in African and Indian Children. N Engl J Med, 2022.PMID 35263517
8. [8]Machingaidze S, Wiysonge CS, Gonzalez-Angulo Y, et al The utility of an interferon gamma release assay for diagnosis of latent tuberculosis infection and disease in children: a systematic review and meta-analysis. Pediatr Infect Dis J, 2011.PMID 21427627