Standing as Nation Against TB!
Despite these challenges, it is clear that
improvements in diagnostics are driving a feedback
loop in Indian health care. The promise of improved
tests drives their uptake, their uptake results in
better health outcomes, improved outcomes attract
more funding for health care systems and better-
funded systems are an incentive to the development
of even better technologies. We are particularly
optimistic about the potential role of our
government in the execution of the strategy and
implementation. We now have the capacity to
develop low-cost generic or novel assays adapted to
local framework and incorporate that scale-up in
both, National Tuberculosis-Control Programs and
private laboratories, supported by a successful
public-private partnership. It would not be wrong if
we say, that if we tackle our own TB
problems
successfully, the elimination of TB by 2025
might become a reality!
How often does our mind trail to the thoughts of an otherwise squealing baby now muffling
uncomfortably might be a sign of an imminent malady?
We usually have the tendency to neglect certain undoubted incidences and then bewail later
when adversity finally strikes. A very evident alteration in behavior and appearance is the first
sign to raise your guards. Reduced playfullness, apparent weight loss, persistent fever
, and
breathlessness are the prominent prodromes of thriving illness. Children are more prone to
getting infections because they yet have not developed their protective immunities. Also,
toddlers are exposed to the risk as they are always surrounded by people and in contact with
many other children, thus transmission of infection becomes easy. One such threat which is
arising predominantly among the young is Tuberculosis-termed as 'Pediatric TB'.
TB is an airbome infection caused by inhalation of droplet nuclei contaminated with an acid-fast
bacilli, Mycobacterium tuberculosis of the M. tuberculosis complex group, which are disease-causing
pathogen.
What causes TB in infants?
TB in infants is a matter of concern because it often goes unnoticed or is overlooked due to
csymptoms and difficulty in diagnosis. This is the cause of inefficiency in estimating the actua expanse
of pediatric TB leading to mortality in children, even though TB is a preventable and curable, disease
.
Because most of the cases so unrecognized and left untreated, pediatric TB has been termed as
"hidden epidemic". World Health Organization (WHO) has estimated a prevalence of about 10 lakh,
children being infected with TB each year.
Adults are The Primary Source of infection for Pediatric TB
Young children are prone to infection because their immune system is not as strong and developed as
the adults. When such infants and children are exposed to adults with active-TB, they contract the
TB bacilli. Pediatric TB is usually considered as primary intection because once they are exposed to
the bacilli they have higher risk of developing active TB than adults. They also have high possibilities
of developing extrapulmonary forms of TB i.e. miliary TB and TB meningitis. If a child is diagnosed
with active tuberculosis it is advised to investigate the family to analyze the source of the infection.
Book TB whole genome sequencing profile
What are the major risk factors of tuberculosis in Children?
Children are at a higher risk of acquiring TB infection and
developing into active TB. Other risk factors include
contact with infected adults with active-TB or with latent
stage TB infected adult, HIV patients with weakened
immunity and poor hygienic conditions.
The risk of infection progression also depends on age.
The children who are more prone to these risks are-
infants below 3 years of age, and adolescents before or
during puberty.
What is the first major symptom of tuberculosis?
The initial signs that set the alarm on, includes: fever
,
anorexia, malaise (irritability, restlessness), night sweats,
mild dyspnea (shortness of breath), swollen glands, and
persistent cough.
Usually the characteristics of TB in young children varies
depending upon the site of infection involved i.e.
pulmonary or extrapulmonary tuberculosis (EPTB).
What is Pulmonary TB?
It is a condition where the child's lungs are infected.
The manifestations are shown according to the specificity:
Endobronchial TB- It is an infection of the
tracheobronchial tree of the airways from larynx to
the lungs. Signs and symptoms include enlargement
of lymph nodes resulting in bronchial obstruction
(air-way blockage), esophageal compression
(narrowing of normal opening of swallowing tube),
vocal cord paralysis, hemidiaphragmatic paralysis
(paralysis of one side of diaphragm).
Progressive Primary Pulmonary TB- It is an
infection of the functional parts of the pulmonary
system and signs and symptoms include,
enlargement of caseous area resulting in
pneumonia, atelectasis and air-trapping. The child
suffers from persistent coughing that may last for
more than 2-3 weeks along with chest pain and may
also cough out blood due to infection causing
damage in pulmonary artery
Extra-Pulmonary TB
It is an infection outside the lungs. It is reported that one
third of all TB cases show EPTB. Children appear to have
a higher tendency of developing it.
The manifestations are shown according to the specificity:
Lymphadenopathy. It involves the anterior or
posterior cervical and supraclavicular nodes. Signs
and symptoms include having history of enlarged
nodes. Infected lymph nodes are firm and non-
tender with no signs of inflammation.
What is TB Meningitis?
It is one of the most severe
complication of TB. It develops majorly in children
younger than 2 years. Moderately acute signs and
symptoms occur after 3-6 months of initial infection
which includes anorexia, weight loss, fever,
vomiting, seizures and alteration in sensory
apparatus. Extreme conditions (final stage) may
cause major neurologic defects including coma and
abnormal movements (e.g. paralysis, paresis).
Why is Diagnosis in young children extremely difficult?
Diagnosis in young children is extremely difficult for two
reasons:
1. They cannot cough up enough sputum for
laboratory tests (e.g. Sputum smear microscopy).
2. Most children with active pulmonary TB will have
paucibacillary disease (with few bacillus) and they
show no or rare symptoms of infection.
It becomes challenging to perform definitive diagnosis
but it is very crucial to prevent the infection from
progressing to life threatening disease. It is estimated by
WHO that out of 13 lakh pediatric TB cases only 13%
turn out to be eligible for preventive measures. This
statistics showcases the seriousness of early diagnosis
because earlier the infection is detected, more cautious
and safe the patient will get to be.
Most common method used for obtaining the organism
from children is Gastric lavage. As children tend to
swallow their secretions, the organisms can be procured
from their stomach. The Nasogastric (NG) tube is passed
through the stomach and lavaged. The gastric contents
are removed containing the organism and sent for
Pathology Test.
What are the Tests for detection of TB?
1. Radiology. This method is not specifically diagnostic but radiological finding is important for TB meningitis.
Lymphadenopathy, hilar and paratracheal adenopathy are the most common abnormalities identified by chest
radiography.
2. Immunology. This section involves tests which can not differentiate between latent and
active TB.
a. Tuberculin Skin Test (also known as Mantoux test)-Detects the presence
of tuberculosis infection by studying the reaction of patient's body on
injecting small amount of tuberculin protein (purified protein derivative; PPD).
b. Interferon Gamma Release Assay (IGRA)- It is the in vitro detection
of immune response against M. tuberculosis antigens
3. TB Culture and Drug Susceptibility Test- Culturing of the
Mycobacterium proves to be more sensitive than smear microscopy, and it
can also allow subsequent characterization of the strain and Drug
Susceptibility Testing (DST), Mycobacterial Growth Indicator Tube (MGIT),
can be used for culturing, but growth can be evident within 3-6 weeks,
which delays in obtaining the results. Microscopic Observation Drug
Susceptibility (MODS) is another technique of DST.
4. TB-PCR- It is DNA based test which detects specific DNA of MTB, this
technique has greater sensitivity than conventional diagnostic techniques. Along
with sputum, it can be used for EPTB samples also, such as gastric aspirate, pleural fluid
and cerebrospinal fluid.
5.CBNAAT (GeneXpert MTB/RIF)- MTB/RIF is an automated, TB specific CBNAAT that uses real time PCR for the
rapid detection of TB, as well as for detection of rifampicin resistance, which counts as a surrogate marker for MDRTB.
The sample preparation, amplification and detection are done by automation and the results can therefore be
achieved in as few as 100 minutes. It aids in diagnosing pulmonary TB and EPTB in adults as well as in children.
6. MDR/XDR Line Probe Assay.Line probe assay technology detects the genetic mutations associated with
resistance to (first line; MDR) rifampicin, isoniazid and (second line; XDR) fluoroquinolone, aminoglycosides, cyclic
peptides.
The Course of Managing and Treating
The treatment for pediatric tuberculosis is basically same as that for adults. Children are first prompted to intensive phase of
treatment following a continuation phase. The first intensive phase is crucially induced to eradicate maximum tuberculosis
bacteria from child's system followed by the second
continuation phase that helps to slowly banish the
remaining passive bacteria
What drugs are used primarily to treat tuberculosis?
The first and second line drugs like rifampicin,
moxifloxacin, rifabutin, linezoid, etc., are given daily
for initial intensive phase. The next continuation phase
starts only after the chest radiography and sputum test
results are out and the medications are extended for a
duration of 5-7 months.
The relationship between the children and every other
family member is based on pillars of care and love and
our support is the best we can give in such critical times
of our lives. At our extent, awareness and knowledge is
the crucial factor for precautionary measures. TB is a
curable disease and its early diagnosis is the path to
well-being!
