Download MBBS Childhood Tuberculosis Lecture PPT

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What is Tuberculosis?
It is a chronic infectious disease
caused by bacteria,
Mycobacterium Tuberculosis.

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Where does Tb af ect?

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Tuberculosis primarily affects lungs
Pulmonary Tuberculosis
Other sites-
intestine
meninges

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bones and joints
skin and other tissues of body
Of this, pulmonary tuberculosis is the
most important one that affects man.

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Causative organism for tuberculosis was discovered
more than 100 years ago

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Highly effective drugs and vaccines are available
This means, tuberculosis is a preventable
and curable disease.
Then, Why are we so concerned
about this disease?

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Despite al these facts, tb stil remains one of
the deadliest diseases in the world, kil ing nearly
2 mil ion people every year.
WHY?
More than 90% of all tuberculosis cases occur

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in developing countries, where limited resources are
available for optimal treatment and standard of living is
lower.

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Therefore, control of tuberculosis
can be achieved with

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application of available technical knowledge and
health resources(vaccines and drugs),
coupled with
changes in non specific determinants of disease
improvement in standard of living

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quality of life of people

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The actual burden of pediatric tuberculosis is not known due
to diagnostic difficulties. It is assumed that 10% of tuberculosis
burden is in children.

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In developing countries, 2-5% of children are at risk of
tuberculosis infection.
? A child infected with
M.tuberculosis has 10%
In India, over

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chance of developing
tuberculosis disease
1lakh children
during lifetime.
die from Tb

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every year.

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Agent-
Reservoir of infection-
tuberculosis patient
who discharge tb

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bacilli in sputum
and
nasopharyngeal
secretions
Transmitted by-

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inhalation
of droplets
of infected
secretions.
Rarely, through skin, mucus membrane and transplacental y

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HOST FACTORS

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AGE-
Tb can develop in any age
ENVIRONMENT-
group.
The risk of acquiring

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An Infant is more likely to
infection is associated with
develop infection as
extend of contact with
compared to older child.

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index case.
SEX-
MALNUTRITION-
Adolescent girls are
Undernourished

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prone to develop active
children are more
tuberculosis during
susceptible to develop
IMMUNODEFICIENCY-

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puberty.
tuberculosis due to
Children with primary or
depressed immunity.
secondary immune

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deficiencies are more likely
to develop tuberculosis.

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Lung is the first organ to be
How Is It Caused?

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affected in by tb bacil i.
This initial infection is
primary pulmonary
tuberculosis.
It usually occur in

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children.
Tb p
B at
ac ie
il nit l dis

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o ch
dg arg
e ine
p tu
ul be

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m rc
onle
a bac
ry ailli in
lve oli,

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n
mas
o op
stl hyary
in n

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ge
up al
per
s
p eacre

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rt t ion
of or s
lo p
weut
r ulm

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o
be
during sneezing and
and lower part of
coughing

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upper lobe

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This is fol owed by Inflammation of the site of
lesion, with hyperemia and congestion.
This primary

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focus of
Initial y PMNL infiltrate site of lesion,
inflammation
but their phagocytic ability is poor
in lungs is

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and is eliminated.
GHON'S
FOCUS
Enlarged regional lymph
GHON'S

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nodes + interconnecting
COMPLEX
lymphatic vessels

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Further course of disease depends on
immune response of host.

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Good immune response
Weak immune response
Inflammatory exudate around
Bacil i continue to multiply,
primary focus is absorbed and

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inflammatory process extends
caseous area inspissated.
to contiguous areas
fibrosis and calcification.
Healing

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Primary complex enlarge steadily
and develop large caseous center

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Progressive
primary
disease
The caseous center liquefies, then empty into adjacent bronchus
Bacil i continue to multiply and

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CAVITY
spread to other parts of lobe or
FORMATION
entire lung
This leads to

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Consolidation
bronchopneumonia
of area

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enlarged lymph nodes
compressing airway leads to
-Airway obstruction
Stridor and
Dysphagia

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Bronchial
respiratory distress
(subcarinal nodes
obstruction
(due to enlarged Para

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impinge on esophagus)
tracheal lymph nodes)
Outcomes of Bronchial obstruction are:
? Atelectasis, if obstruction of bronchus is complete.
? Complete expansion and resolution of chest X-ray findings

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? Bronchiectasis
? Disappearance of the segmental lesions
? A caseated lymph node may erode through
the wall of the bronchus resulting in
endobronchial tuberculosis.

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Bacilli reach blood stream through lymphnodes
Focii of infection in
different organs
Hematogenous
dissemination

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Good host immune system
Lowered host immunity
? In young infants
Activation of
? Malnourished

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Disease doesnot occur
metastatic foci in
children
different organs
? Children with

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immunodeficiency
Development of disease

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Massive entry of bacil i into blood stream leads to
Miliary Tuberculosis

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Numerous tubercles develop in affected tissues
Lungs
Liver
Spleen
These coalase to form multiple lesions

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Kidney
of size of millet seeds
Meninges
Brain
Bones

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Joint
Intestine
Skin
? Tuberculous meningitis occurs as a Choroid of eye
component of miliary tuberculosis when organism reaches

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? Pulmonary tuberculosis resulting from endogenous
CNS through blood stream
reactivation of foci of infection is uncommon in
children;

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Cli
Honi
w ca
d lo eFsea

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t tur
he es
disease present?
Patient presents with symptoms 4-8 weeks after
exposure to TB bacil i.

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Clinical features are different for
Intrathoracic Extrathoracic
Primary infection
tuberculosis
tuberculosis

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Tuberculosis
of abdomen
Progressive
primary disease
Pleural effusion

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Miliary tuberculosis
TB of the
Tuberculous meningitis
Endobronchial
superficial

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tuberculosis
lymph nodes

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Clinical Features of Primary Infection
o Cough is an inconsistent symptom
and may be absent even in

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Primary infection usual y passes off unrecognized.
advanced disease. Irritating dry cough can
Asymptomatic
be a symptom of bronchial and tracheal compression
due to enlarged lymph nodes.

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Most symptoms in children with
infection
pulmonary primary complex
infection associated
(PPC) are

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tuberculin hypersensitivity
o In some children, the lymph nodes continue to enlarge
?
even after resolution of parenchymal infiltrate. This may
mild fever

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and a positive tuberculin
lead to compression of neighboring regional bronchus.
? anorexia,
test but with no striking
? weight loss

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clinical or x ray
? decreased activity.
manifestations.
Cough is an inconsistent symptom and
may be absent even in advanced disease.

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? is the result of the progression of primary disease.

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? Children with PPD present with
? high-grade fever
usual y associated with
? cough
advanced disease and

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? Expectoration of sputum and
development of cavity or
ulceration of the bronchus.
? hemoptysis
? Abnormal chest signs --dullness,

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decreased air entry
crepitations.
? Cavitating pulmonary tuberculosis is uncommon in children.

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Endobronchial
tuberculosis
Children present with
? fever and
? troublesome cough (with or without expectoration).

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? Dyspnea, wheezing and cyanosis may be present.
Occasional y, the child may be misdiagnosed as asthma.
In a wheezing child, not responding to
bronchodilators less than 2-yr-old, the
possibility of endobronchial tuberculosis

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should always be considered.

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Miliary Tuberculosis
Organs

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Miliary tuberculosis is characterized by hematogenous
padam
spread and progressive development of innumerable
smal foci throughout the body.
The disease is most common in infants and

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young children.
The onset of il ness is often sudden.
The clinical manifestations depend on the numbers
of disseminated organisms and the involved organs.

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? dyspnea and cyanosis.
? High-grade fever,
which is quite

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unlike other forms
of tuberculosis.
There are hardly any pulmonary findings but fine crepitations and
rhonchi may be present.
In severe il ness, child has high fever, rigors and alteration of

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sensorium.
In addition, these children may have lymphadenopathy and
hepatosplenomegaly.
The other presentation of miliary tuberculosis may be insidious with
the child appearing unwel , febrile and losing weight.

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Choroid tubercles may be seen in about 50% patients. Meningitis
may occur in 20-30% cases.

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PLEURAL EFFUSION IN
TUBERCULOSIS
How is it caused?
? Due to rupture of a subpleural focus into the pleural
cavity.

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OR
? The pleura infected by hematogenous spread from the
primary focus.
? It usually occurs because of hypersensitivity to tubercular
proteins. If the sensitivity is high, there is significant pleural

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effusion along with fever and chest pain on affected side.
Tuberculous effusion is uncommon in children
younger than 5yr of age

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Clinical presentation of Pleural
Effusion
Onset insidious or acute
Pain in chest may disappear once the fluid
Presents with

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rise in temperature
cough
separates the inflamed pleural surfaces; this
dyspnea
may be replaced by some discomfort.

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pleuritic pain on the affected side.
There is usually no expectoration.
Increase in effusion may
clinical findings
make breathing shallow and difficult.

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depend on the amount of fluid in the pleural cavity.
Early signs
As the fluid col ection
? Pleural rub
increases, the signs of

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? decreased chest wal movement,
pleural effusion become
? impairment of percussion note
more definite.
? diminished air entry on the affected side.

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The most common forms of extrathoracic disease in
children include tuberculosis of the superficial
lymph nodes and the central nervous system.
Other rare forms of extrathoracic disease in

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children ------- Osteoarticular
Abdominal
gastrointestinal,
genitourinary,
cutaneous and congenital disease.

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TB of the superficial lymph nodes can be
associated with
drinking unpasteurized cow's milk or can be
caused by

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extension of primary lesions of the upper lung
fields or
abdomen leading to involvement of the
supraclavicular,
anterior cervical, tonsil ar and submandibular

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nodes.
Although lymph nodes may become fixed to
surrounding
tissues, low grade fever may be the only
systemic

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symptom. A primary focus is visible
radiological y only
30 to 70% of the time. Tuberculin skin test
results are
usual y reactive. Although

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Central nervous system disease is the most
serious complication
of tuberculosis in children and arises from the
formation of a caseous lesion in the cerebral
cortex or

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meninges that results from occult
lymphohematogenous
spread. Infants and young children are likely to
experience
a rapid progression to hydrocephalus, seizures

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and raised
intracranial pressure. In older children, signs
and symptoms
progress over the course of several weeks,
beginning with

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TB of the superficial lymph
fever, headache, irritability and drowsiness.
The disease
advances with symptoms of lethargy, vomiting,
nodes

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nuchal
rigidity, seizures, hypertonia and focal signs.
How is it caused?
The final stage
of disease is marked by coma, hypertension,

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associated with drinking unpasteurized cow's milk
decerebrate
and decorticate posturing and death. Rapid
or
confirmation

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can be caused by extension of primary lesions of the
of tuberculous meningitis can be difficult
because of the
upper lung fields or abdomen.
wide variability in cerebrospinal characteristics,

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nonreactive
tuberculin skin tests in 40% and normal chest
Lymph nodes commonly involved-
radiographs
supraclavicular

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in 50%. Because improved outcomes are
anterior cervical
associated with
early institution of antituberculous therapy, the
tonsillar

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diagnosis
submandibular nodes.
should be considered for any patient with
basilar
meningitis, hydrocephalus or cranial nerve

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involvement
that has no other apparent cause.
Tuberculosis of abdomen is often due to
hematogenous
spread from the primary focus in the lungs. It

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may, however,
be secondary to swal owing of the infected
sputum
by a patient with pulmonary lesions. Primary
tuberculosis

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of the intestines due to ingestion of the food
contaminated
by tubercle bacil i is relatively less common in
India as
the milk is general y boiled before use. Patients

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with abdominal
tuberculosis may remain asymptomatic initial y.
Symptomatic patients show evidence of
tuberculous
toxemia and may present with colicky

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abdominal pain,
vomiting and constipation. The abdomen feels
characteristical y
doughy. The abdominal wal is not rigid but
appears tense, so that the abdominal viscera

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cannot be
palpated satisfactorily. The rol ed up omentum
and
enlarged lymph nodes may appear as irregular
nodular

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masses with ascites. The liver and spleen are
often
enlarged. Histological examination of the liver
may show
granulomatous hepatitis and fatty change.

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Clinical features of tb
lymphadenitis
o low grade fever may be the only systemic symptom.
o A primary focus is visible in x-ray 30 to 70% of the time.
o Tuberculin skin test results are usually reactive.

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Spontaneous resolution may occur, but untreated
lymphadenitis frequently progresses to
spread to adjacent
caseating necrosis
nodes and overlying

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skin
capsular rupture
draining sinus tract

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It is the most serious complication of tuberculosis in children.
How is it caused?
lymphohematogenous spread of tb bacilli

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formation of a caseous lesion in the cerebral cortex
In older children, signs and
Infants and young children are
symptoms progress over the
likely to experience a rapid

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course of several weeks,
progression to hydrocephalus,
beginning with fever,
seizures and raised
headache, irritability and

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intracranial pressure.
drowsiness.

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Clinical features of Tuberculous Meningitis
? The disease advances with symptoms of
lethargy, vomiting, nuchal rigidity, seizures,

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hypertonia and focal signs.
? The final stage of disease is marked by coma,
hypertension, decerebrate and decorticate
posturing and death.
? Rapid confirmation of tuberculous meningitis can be difficult

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because of the wide variability in cerebrospinal characteristics,
nonreactive tuberculin skin tests in 40% and normal chest
radiographs in 50%.

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Tuberculosis of Abdomen
How is it caused?
due to hematogenous spread from the primary focus in the

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lungs.
OR
secondary to swallowing of the infected sputum by a patient
with pulmonary lesions.
OR

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due to ingestion of the food contaminated by tubercle bacil i
(ths is relatively less common in India as the milk is generally
boiled before use.)

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Clinical features of Abdominal Tuberculosis
Patients with abdominal tuberculosis may remain
asymptomatic initially.
Symptomatic patients show evidence of tuberculous
toxemia and may present with:

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? colicky abdominal pain
? vomiting and constipation.
? The abdomen feels characteristically doughy.
? The abdominal wall is not rigid but appears tense, so
that the abdominal viscera cannot be palpated

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satisfactorily.
? The rolled up omentum and enlarged lymph nodes
may appear as irregular nodular masses with ascites.
? The liver and spleen are often enlarged.

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Thank You...

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