In 2015, one million children under 14 developed tuberculosis. Among them, 170,000 children could not stand the disease.
Tuberculosis is a serious disease that can be fatal in its active state. However, if detected early, you can prevent her from causing any real damage to the child's health. Learn more about TB in children, its symptoms, causes and treatment in this article.
Tuberculosis and its types
Tuberculosis is a contagious infection caused by bacteria - Mycobacterium tuberculosis. The bacteria can affect any part of the body, but the infection primarily affects the lungs. Then the disease is called pulmonary tuberculosis or basic tuberculosis. When TB bacteria spread the infection outside the lungs, it is known as non-pulmonary or extrapulmonary TB.
There are many types of tuberculosis, but the main 2 types are active and latent (latent) tuberculosis infection.
Active tuberculosis Is an intensely symptomatic disease that can be transmitted to others. Latent illness is when a child is infected with germs, but the bacteria do not cause symptoms and are absent in the sputum. This is due to the work of the immune system, which inhibits the growth and spread of pathogens.
Children with latent tuberculosis usually cannot transmit bacteria to others if the immune system is strong. The weakening of the latter causes reactivation, the immune system no longer suppresses the growth of bacteria, which leads to a transition to an active form, so the child becomes infectious. Latent TB is similar to chickenpox infection, which is inactive and can reactivate years later.
Many other types of tuberculosis can also be either active or latent. These species are named for the traits and body systems that Mycobacterium tuberculosis infects, and the symptoms of infection are different for each person.
Thus, pulmonary tuberculosis mainly affects the pulmonary system, skin tuberculosis has cutaneous manifestations, and miliary tuberculosis implies large-scale small infected areas (lesions or granulomas about 1 to 5 mm in size) found in all organs. It is not uncommon for some people to develop more than one type of active tuberculosis.
The atypical mycobacteria that can cause disease are M. avium complex, M. fortuitum complex and M. kansasii complex.
How does infection and infection develop?
Tuberculosis is contagious and spreads through coughing, sneezing, and contact with phlegm. Therefore, the infection of the child's body occurs through close interaction with the infected. Outbreaks occur in places of constant close contact with large numbers of people.
When infectious particles reach the alveoli in the lungs, another cell, called a macrophage, engulfs the tuberculosis bacteria.
The bacteria are then transferred to the lymphatic system and bloodstream, passing to other organs.
The microbes then multiply in organs with a high oxygen content, such as the upper lobes of the lungs, kidneys, bone marrow, and the soft membranes of the brain and spinal cord.
The incubation period is within 2 - 12 weeks. A child can remain infectious for a long time (as long as viable bacteria are in the sputum) and may remain infectious for several weeks until appropriate treatment is given.
However, individuals have a good chance of being infected, but they contain the infection and show symptoms years later. Some never develop symptoms or become contagious.
Symptoms of Tuberculosis in Children
Pulmonary tuberculosis in children is considered the most common, but the disease can affect other organs in the body. The signs of extrapulmonary tuberculosis in children depend on the localization of foci of tuberculosis infection. Infants, young children, and immunocompromised children (such as children with HIV) are more at risk of developing the most serious forms of tuberculosis - tuberculous meningitis or disseminated tuberculosis.
Children may not have early signs of tuberculosis.
In some cases, the following first signs of tuberculosis in children appear.
- Heavy perspiration at night. This manifestation of tuberculosis often occurs earlier than others and persists until anti-tuberculosis therapy is started.
- Increased fatigue, weakness, drowsiness. At first, these early childhood TB symptoms are mild, and many parents believe they are due to fatigue. Parents try to get the child to rest and sleep more, but if the child is sick with tuberculosis, such measures will be ineffective.
- Dry cough. For the later stages of the development of pulmonary tuberculosis (as well as in some cases of extrapulmonary tuberculosis), a productive cough is typical, when expectoration is observed, sometimes with blood. In the early stages, patients begin to have a dry cough, which can be easily confused with a symptom of a common cold.
- Subfebrile temperature. This is a condition when the body temperature rises slightly, usually no more than 37.5 ºС. In many children, this temperature persists in the later stages, but in general, the body temperature rises to 38 ° C or more with a far-reaching process.
The first symptoms of tuberculosis in children are almost identical to those in adults, although in young patients there is a decrease in appetite and, as a result, weight loss is observed.
Primary pulmonary tuberculosis
Symptoms and physical signs of primary pulmonary tuberculosis in children are surprisingly few. With active detection, up to 50% of infants and children with severe pulmonary tuberculosis have no physical manifestations. Babies are more likely to show subtle signs and symptoms.
An unproductive cough and mild shortness of breath are the most common symptoms of tuberculosis in children.
Systemic complaints such as fever, night sweats, and weight and activity loss are less common.
Some babies find it difficult to gain weight or develop as normal. And this trend will continue until several months of effective treatment have been passed.
Pulmonary symptoms are even less common. Some infants and young children with bronchial obstruction have localized wheezing or noisy breathing, which may be accompanied by increased breathing or (less commonly) respiratory distress. These pulmonary symptoms of primary tuberculous intoxication are sometimes relieved by antibiotics, suggesting bacterial superinfection.
Reactive tuberculosis
This form of tuberculosis is rare during childhood, but can occur during adolescence. Children with a cured TB infection acquired before the age of 2 years rarely develop chronic recurrent lung disease. It is more common in those who acquire the initial infection after the age of 7 years. This form of the disease usually remains localized to the lungs because an established immune response prevents further extrapulmonary spread.
Adolescents with tuberculosis reactivation are more likely to develop fever, malaise, weight loss, night sweats, productive cough, hemoptysis, and chest pain than children with primary pulmonary tuberculosis.
The signs and symptoms of reactive pulmonary tuberculosis in children improve within a few weeks of starting effective treatment, although the cough can last for several months. This form of tuberculosis can be highly contagious if there is significant sputum production and coughing.
The prognosis is complete recovery if the patients are prescribed appropriate therapy.
Pericarditis
The most common form of heart tuberculosis is pericarditis, an inflammation of the pericardium (heart shirt). This is rare among episodes of TB in children. Symptoms are nonspecific and include low-grade fever, malaise, and weight loss. Chest pain is not common in children.
Lymphohematogenous tuberculosis
TB bacteria spread from the lungs to other organs and systems through the blood or lymphatic system. The clinical picture caused by lymphohematogenous spread depends on the number of microorganisms released from the primary focus and the adequacy of the patient's immune response.
Lymphohematogenous spread is usually asymptomatic. Although the clinical picture is acute, more often it is sluggish and prolonged, with fever accompanying the release of microorganisms into the bloodstream.
Multiple organ involvement is common, resulting in hepatomegaly (enlarged liver), splenomegaly (enlarged spleen), lymphadenitis (inflammation) of superficial or deep lymph nodes, and papulonecrotic tuberculomas appearing on the skin. Bones, joints, or kidneys can also be affected. Meningitis occurs only late in the disease. Lung involvement is surprisingly mild but diffuse, and involvement becomes apparent with prolonged infection.
Miliary tuberculosis
The most clinically significant form of disseminated tuberculosis is miliary disease, which occurs when large numbers of tuberculosis bacteria enter the bloodstream, causing disease in 2 or more organs. Miliary tuberculosis usually complicates the primary infection that occurs within 2 to 6 months of the onset of the initial infection. Although this form of the disease is most common in infants and young children, it also occurs in adolescents as a consequence of a previously caused primary lung injury.
The onset of miliary TB is usually severe and, after a few days, the patient may become seriously ill. Most often, the manifestation is insidious, with early systemic signs, including weight loss and low-grade fever. At this time, pathological physical signs are usually absent. Lymphadenopathy and hepatosplenomegaly develop within a few weeks in about 50% of cases.
Fever becomes higher and more persistent as the disease progresses, although chest x-ray is usually normal and respiratory symptoms are minor or absent. For several more weeks, the lungs are populated with billions of infectious droppings, coughing, shortness of breath, wheezing or wheezing occur.
When these lesions are first seen on a chest x-ray, they are less than 2 to 3 mm in diameter. Small lesions coalesce to form larger ones. Signs or symptoms of meningitis or peritonitis occur in 20 to 40% of patients with advanced disease. Chronic or recurrent headache in a patient with miliary tuberculosis often indicates the presence of meningitis, while abdominal pain or tenderness on palpation is a sign of tuberculous peritonitis. Cutaneous lesions include papulonecrotic tuberculomas.
The cure for miliary tuberculosis is slow, even with proper therapy. Fever usually subsides within 2 to 3 weeks of starting chemotherapy, but radiographic signs of illness may persist for many months. The prognosis is excellent if the diagnosis is made early and adequate chemotherapy is given.
Tuberculosis of the upper respiratory tract and the organ of hearing
Upper respiratory tract tuberculosis is rare in developed countries, but still occurs in developing countries. Children with tuberculosis of the larynx have a croupy cough, sore throat, hoarseness, and dysphagia (difficulty swallowing).
The most common signs of middle ear tuberculosis are painless unilateral otorrhoea (fluid from the ear), tinnitus, hearing loss, facial paralysis, and perforation (loss of integrity) of the tympanic membrane.
Lymph node tuberculosis
Superficial lymph node tuberculosis is the most common form of extrapulmonary tuberculosis in children.
The main symptom of this type of tuberculosis is a gradual enlargement of the lymph nodes, which can last for weeks or months. When pressing on the enlarged lymph nodes, the patient may experience mild to moderate pain. In some cases, in the later stages of the disease, there are signs of general intoxication: fever, weight loss, fatigue, intense sweating at night. A severe cough is often a symptom of mediastinal lymph node tuberculosis.
At the initial stages of the disease, the lymph nodes are elastic and mobile, the skin above them looks completely normal. Later, adhesions (adhesions) form between the lymph nodes, and inflammatory processes occur in the skin above them. At later stages, necrosis (necrosis) begins in the lymph nodes, they become soft to the touch, and abscesses appear. Severely enlarged lymph nodes sometimes press on adjacent structures, and this can complicate the course of the disease.
Central nervous system tuberculosis
CNS tuberculosis is the most serious complication in children and is fatal without timely and appropriate treatment.
Tuberculous meningitis usually occurs due to the formation of metastatic lesions in the cerebral cortex or meninges, which develops when the primary infection spreads in lymphohematogenous form.
Tuberculous meningitis complicates about 0.3% of untreated TB infections in children. This often happens in children from 6 months to 4 years old. Sometimes tuberculous meningitis occurs many years after infection. The clinical progression of tuberculous meningitis is rapid or gradual. Rapid progression is more common in infants and young children, who may experience symptoms just days before the onset of acute hydrocephalus, seizures, and cerebral edema.
Typically, signs and symptoms progress slowly over several weeks and can be divided into 3 stages:
- 1st stage usually lasts 1 to 2 weeks and is characterized by nonspecific manifestations such as fever, headache, irritability, drowsiness, and malaise. There are no specific neurological signs, but babies may have developmental arrest or loss of basic skills;
- second phase usually starts more abruptly. The most common signs are lethargy, neck stiffness, seizures, hypertension, vomiting, cranial nerve palsy, and other focal neurologic signs. Progressive disease occurs with the development of hydrocephalus, high intracranial pressure and vasculitis (vascular inflammation). Some children show no signs of irritation of the meninges, but signs of encephalitis, such as disorientation, impaired movement, or speech impairment;
- third stage characterized by coma, hemiplegia (one-sided paralysis of the limbs) or paraplegia (bilateral paralysis), hypertension, extinction of vital reflexes and, ultimately, death.
The prognosis of tuberculous meningitis most closely correlates with the clinical stage of the disease at the time of initiation of treatment. Most stage 1 patients have excellent outcomes, while most stage 3 patients who survive have persistent impairments, including blindness, deafness, paraplegia, diabetes insipidus, or mental retardation.
The prognosis for babies is generally worse than for older children.
Tuberculosis of bones and joints
Infection of bones and joints, complicating tuberculosis, in most cases occurs with damage to the vertebrae.
More common in children than adults. Bone tuberculous lesions may resemble purulent and fungal infections or bone tumors.
Skeletal tuberculosis is a late complication of tuberculosis and is very rare since the development and introduction of anti-tuberculosis therapy
Tuberculosis of the peritoneum and gastrointestinal tract
Tuberculosis of the mouth or pharynx is quite uncommon. The most common lesion is a painless mucosal ulcer, palate, or tonsil with enlarged regional lymph nodes.
Esophageal tuberculosis in children is uncommon. These forms of tuberculosis are usually associated with extensive lung disease and the ingestion of infected sputum. However, they can develop in the absence of pulmonary disease.
Tuberculous peritonitis is more common in young men and rarely in adolescents and children. Typical manifestations are abdominal pain or tenderness on palpation, ascites (accumulation of fluid in the abdominal cavity), weight loss, and low-grade fever.
Tuberculous enteritis is caused by hematogenous spread or ingestion of tuberculous bacteria that are released from the patient's lungs. Typical manifestations are small ulcers accompanied by pain, diarrhea or constipation, weight loss, and low-grade fever. The clinical picture of tuberculous enteritis is non-specific, mimics other infections and conditions that cause diarrhea.
Tuberculosis of the genitourinary system
Renal tuberculosis is rare in children because the incubation period is several years or more. Tuberculous bacteria usually reach the kidney during lymphohematogenous spread. Renal tuberculosis is often clinically asymptomatic in its early stages.
With the progression of the disease, dysuria (urination disorder), pain in the side or abdomen, hematuria (blood in the urine) develop. Superinfection with other bacteria is common and can delay the diagnosis of tuberculosis underlying kidney damage.
Genital tuberculosis is rare in boys and girls before puberty. This condition develops as a result of lymphohematogenous introduction of mycobacteria, although there have been cases of direct spread from the intestinal tract or bone. Teenage girls can become infected with genital tuberculosis during their primary infection. The fallopian tubes are most commonly involved (90-100% of cases), followed by the endometrium (50%), the ovaries (25%) and the cervix (5%).
The most common symptoms are lower abdominal pain, dysmenorrhea (pain during menstruation), or amenorrhea (no menstruation for more than 3 months). Genital tuberculosis in adolescent boys causes epididymitis (inflammation of the epididymis) or orchitis (inflammation of the testicle). The condition usually presents as unilateral, nodular, painless swelling of the scrotum.
Congenital tuberculosis
Symptoms of congenital tuberculosis may be present at birth, but more often begin in the 2nd or 3rd week of life. The most common signs and symptoms are respiratory distress syndrome (a dangerous dysfunction of the lungs), fever, enlarged liver or spleen, poor appetite, lethargy or irritability, lymphadenopathy, bloating, stunting, skin lesions. Clinical manifestations differ depending on the location and size of the lesions.
Diagnosis of tuberculosis in children
After the medical history and physical examination data are obtained, the next routine test is the Mantoux test. It is an intradermal injection of tuberculin (a substance from killed mycobacteria). After 48 - 72 hours, a visual assessment of the injection site takes place.
A positive test indicates that the child has been exposed to live mycobacteria or is actively infected (or has been vaccinated); a lack of response does not imply that a child has a negative TB test. This test can have false positive results, especially in people who have been vaccinated against tuberculosis. False negative results are possible in immunocompromised patients.
Other studies:
- a chest x-ray may indicate an infection in the lungs;
- sputum culture, cultivation to check the activity of bacteria. It will also help doctors know how the child will respond to antibiotics.
Treatment of tuberculosis in children
The main principles of TB treatment in children and adolescents are the same as in adults. Several drugs are used to act relatively quickly and to prevent secondary drug resistance from occurring during therapy. The choice of regimen depends on the incidence of tuberculosis, the individual characteristics of the patient, and the likelihood of drug resistance.
The standard therapy for pulmonary tuberculosis and lesions of the intrathoracic lymph nodes in children is a 6-month course of Isoniazid and Rifampicin, supplemented in the 1st and 2nd months of treatment with Pyrazinamide and Ethambutol.
Several clinical trials have shown that this regimen offers a high chance of success, approaching 100%, with a clinically significant adverse reaction rate of <2%.
A nine-month regimen of Isoniazid and Rifampin alone is also highly effective for drug-susceptible tuberculosis, but the duration of treatment and the relative lack of protection against possible initial drug resistance have led to the use of shorter regimens with complementary drugs.
Most experts recommend direct observation of the entire course of treatment. This means that a healthcare professional is physically present when drugs are administered to patients.
Extrapulmonary tuberculosis is usually caused by low numbers of mycobacteria. In general, treatment for most forms of extrapulmonary tuberculosis in children is the same as for pulmonary tuberculosis. Exceptions are bone and articular, disseminated and CNS tuberculosis. These infections take 9 to 12 months to heal. Surgery is often necessary for bone and joint damage and ventriculoperitoneal shunting (neurosurgical procedure) for CNS disease. Corticosteroids are also prescribed.
Corticosteroids are helpful in treating some children with TB disease. They are used when the patient's inflammatory response contributes significantly to tissue damage or organ dysfunction.
There is strong evidence that corticosteroids reduce mortality and long-term neurological complications in selected patients with tuberculous meningitis, reducing vasculitis, inflammation, and ultimately intracranial pressure.
Reducing intracranial pressure limits tissue damage and promotes the spread of anti-TB drugs across the blood-brain barrier and meninges. Short courses of corticosteroids are also effective for children with endobronchial tuberculosis, which causes respiratory distress syndrome, localized emphysema, or segmental lung lesions.
Drug-resistant tuberculosis
The incidence of drug-resistant tuberculosis is on the rise in many parts of the world. There are two main types of drug resistance. Primary resistance occurs when a child is infected with M. tuberculosis, which is already resistant to a particular drug.
Secondary resistance occurs when drug-resistant microorganisms emerge as the dominant population during treatment. The main causes of secondary drug resistance are poor patient adherence or inadequate treatment regimens prescribed by a physician.
Violation of one drug regimen is more likely to result in secondary resistance than refusal to take all drugs. Secondary resistance is rare in children due to the small size of their mycobacterial population. Thus, drug resistance in children is in most cases primary.
Treatment of drug-resistant tuberculosis is successful when 2 bactericides are given, to which the infectious M. tuberculosis strain is susceptible. When a child has drug-resistant TB, usually 4 or 5 drugs should be given initially until a susceptibility pattern is determined and a more specific regimen can be developed.
The specific treatment plan should be individualized for each patient according to the susceptibility test results. Duration of treatment of 9 months with Rifampicin, Pyrazinamide and Ethambutol is usually sufficient for Isoniazid-resistant tuberculosis in children. When resistance to Isoniazid and Rifampicin is present, the total duration of therapy should often be increased to 12 to 18 months.
The prognosis of TB with single or multidrug resistance in children is usually good if drug resistance is detected early in treatment, the right drugs are administered under the direct supervision of a healthcare professional, there are no adverse drug reactions, and the child and family live in a supportive environment.
Treatment of drug-resistant tuberculosis in children should always be carried out by a specialist with specialized knowledge of the treatment of tuberculosis.
Home care for children with tuberculosis
In addition to treatment, children with a disease such as tuberculosis need extra help at home for a speedy recovery. Isolation is usually necessary if the person has MDR-TB. In such cases, the child may be hospitalized.
In other types of tuberculosis, the drugs work quickly and help the patient get rid of the infection within a short time. You can take your child home and continue treatment.
Here are some home care tips to follow when looking after a child with an active TB infection:
- make sure you are giving the medicine in the correct doses as prescribed by your doctor. If there are any adverse reactions, tell your doctor immediately;
- a healthy diet and lifestyle are also needed to help the child regain the weight they have lost;
- ask your child to rest as much as possible, as illness can sometimes tire him or her.
Prevention
The highest priority of any TB campaign should be to find measures that interrupt the transmission of infection between people through close contact. All children and adults with symptoms suggestive of tuberculosis and those in close contact with an adult suspected of pulmonary tuberculosis should be evaluated as soon as possible.
BCG vaccine
The only vaccine available for tuberculosis is BCG, named after two French researchers, Calmette and Gérin.
The route and schedule of BCG vaccine administration are important components of the effectiveness of vaccine prevention. The preferred route of administration is intradermal injection using a syringe and needle, as this is the only way to accurately measure an individual dose.
Recommended vaccination schedules vary widely between countries. The official recommendation by the World Health Organization is a single dose administered during infancy. But children with HIV infection should not get the BCG vaccine. In some countries, revaccination is universal, although no clinical trials support this practice. The optimal age for insertion is not known because adequate comparative trials have not been performed.
Although dozens of BCG trials have been reported in different populations, the most useful data comes from several controlled studies. The results of these studies were scattered. Some have shown protection against BCG vaccination, while others have not shown any effectiveness. A recent meta-analysis (pooling of results) of published studies of BCG vaccination showed that BCG vaccine is 50% effective in preventing pulmonary tuberculosis in adults and children. The protective effect in disseminated and meningeal tuberculosis appears to be somewhat higher, with BCG preventing 50 - 80% of cases. BCG vaccination given in infancy has little effect on the incidence of tuberculosis in adults, suggesting that the vaccine's effect is limited in time.
BCG vaccination has worked well in some situations and poorly in others. It is clear that BCG vaccination has had little impact on the ultimate control of tuberculosis worldwide, as more than 5 billion doses have been administered, but tuberculosis remains at epidemic levels in most regions. BCG vaccination does not significantly affect the transmission chain, since cases of open pulmonary tuberculosis in adults, which can be prevented by BCG vaccination, constitute a small part of the sources of infection in the population.
The best use of BCG vaccination appears to be to prevent life-threatening types of tuberculosis in infants and young children.
Tuberculosis in children is not a disease that you should take lightly. Whether it is latent or active, you need to take the utmost care of your child to make sure they receive the necessary treatment and nutrition to fight off disease causing bacteria.
You also need to support the child morally, as the disease is difficult and long-term. Your support will help your child fight the illness.
