|Year : 2020 | Volume
| Issue : 1 | Page : 43-47
Clinical profile of tuberculosis in children
Ira Shah, Naman S Shetty, Anmol Goyal, Nikhil Patankar, Sujeet M Chilkar
Department of Pediatrics, Pediatric Tuberculosis Clinic, B.J. Wadia Hospital for Children, Mumbai, Maharashtra, India
|Date of Submission||22-Mar-2019|
|Date of Decision||21-Jul-2019|
|Date of Acceptance||15-Oct-2019|
|Date of Web Publication||16-Dec-2019|
1/B Saguna, 271/B St. Francis Road, Vile Parle (W), Mumbai - 400 056, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: The study aimed to describe the clinical profile tuberculosis (TB) in children at various ages. Materials and Methods: Clinical profile of various types of TB and factors associated with them was compared. Results: A total of 135 children were diagnosed with TB in the study period. The mean age of the presentation was 5.3 ± 3.5 years. Common clinical features at presentation included fever in 112 (83%), cough in 63 (46.7%), and loss of appetite in 51 (37.8%). On biochemical evaluation, 72 (74.22%) of 97 records showed raised erythrocyte sedimentation rate (ESR) levels. One hundred and twenty-one (89.6%) children had received Bacille Calmette–Guérin (BCG) vaccination, 44 (32.6%) were found to be tuberculin skin test (TST) positive, and 58 (43%) were malnourished. On diagnosis, pulmonary TB was seen in 49 patients (36.3%), neuro TB in 20 (14.8%), TB lymphadenopathy in 12 (8.9%), abdominal TB, TB serositis and latent TB in 11 cases (8.2%) each, musculoskeletal involvement in 8 (5.9%) cases, and 6 (4.4%) showed disseminated form. The rest two of them were diagnosed with BCGosis and atypical mycobacterium infection. On statistical analysis, it was found that fever (P = 0.002) and raised ESR (P = 0.045) were least common in abdominal TB and disseminated TB, whereas loss of appetite was more common in disseminated TB and least in abdominal TB (P = 0.02). Conclusion: Pulmonary TB is the most common type of TB in children with boys more affected as compared to girls. TST is positive in less than half of the children with TB. Fever is the most common symptom of TB in children. In abdominal TB and disseminated TB, ESR was normal, and fever was absent. Loss of appetite is commonly seen in disseminated TB.
Keywords: Children, risk factors, tuberculosis
|How to cite this article:|
Shah I, Shetty NS, Goyal A, Patankar N, Chilkar SM. Clinical profile of tuberculosis in children. Med J DY Patil Vidyapeeth 2020;13:43-7
|How to cite this URL:|
Shah I, Shetty NS, Goyal A, Patankar N, Chilkar SM. Clinical profile of tuberculosis in children. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Aug 9];13:43-7. Available from: http://www.mjdrdypv.org/text.asp?2020/13/1/43/272893
| Introduction|| |
As per statistics in 2012, 8.7 million people are living with tuberculosis (TB). More than 40% of the population is infected in India, with a prevalence of 1–6 per thousand pediatric years among the pediatric age group. Childhood TB is a good indicator of transmission of TB infection in the community, and its resurgence is mainly due to HIV infection, overcrowding, and immigration. In children, TB often goes undiagnosed due to the inability to recognize the signs and symptoms in this age group along with the presence of extrapulmonary TB and lack of smear positivity, as these investigations may not always be positive. We thus undertook this study to determine whether certain clinical parameters are associated with different types of TB infection, thereby aiding in the diagnosis.
| Materials and Methods|| |
This cross-sectional observational study was conducted from October 2007 to October 2008 over a period of 1 year at our pediatric TB clinic (200-bedded tertiary care children's hospital) after approval from the Institutional Ethics Committee and informed consent from the parents of the children. All children <15 years of age who were diagnosed to have TB were studied. Children were defined to have TB if their culture from diseased site grew the bacteria or histopathology was suggestive of caseous granulomas or they were in contact with an adult having TB and had features of TB such as nonresolving pneumonia, positive tuberculin skin test (TST), or body fluid and imaging were suggestive of TB. Patients were classified as pulmonary TB if lung parenchymal involvement was present, abdominal TB if there was the presence of ascites, neurological TB if along they had hydrocephalus, basal exudates, tuberculomas, and/or meningitis; abdominal lymph node with histopathology or culture suggestive of TB and/or intestinal involvement. Patients with the involvement of lymph nodes were diagnosed with TB lymphadenopathy, whereas the involvement of the serous linings of the body such as the lungs, heart, and abdomen was labeled as TB serositis. Patients with bone involvement were labeled as bone TB, whereas those with asymptomatic positive TST who were in close contact with an adult having open TB in the past 2 years were labeled as latent TB. Patients with involvement of two organs were labeled as disseminated TB.
A physical examination along with a detailed clinical history was done in all patients. History of past TB or contact with TB, Bacille Calmette–Guérin (BCG) vaccination was elicited, and growth parameters such as weight and height were noted. Malnutrition was determined if weight or height was <5th centile for age as per Agarwal's charts. Investigations such as hemogram, TST by Mantoux test (5 TU), erythrocyte sedimentation rate (ESR), chest X-ray, and liver enzyme estimation were done at the start of therapy. Specific investigations such as body fluid analysis, culture, biopsy, and other imaging studies were done as and when required. All patients were receiving anti-TB treatment as per the revised national TB control program guidelines. Drug sensitivity testing on positive TB culture tests was used to detect drug-resistant (DR) TB.
Anemia was defined when hemoglobin was <10 g/dl; lymphocyte count more than 6500 cells/mm 3 was defined as lymphocytosis; thrombocytosis was defined when platelet count was more than 450,000 cells/mm 3; and Bacille Calmette–Guérin 1500 cells/mm 3 was defined as lymphopenia. More than 20 mm at the end of 1 h by Westergren method was defined as elevated ESR.
Clinical and biochemical features associated with different types of TB were analyzed. Statistical analysis was calculated by Chi-square test or Fisher's exact test. Descriptive data were analyzed by percentage. P < 0.05 was considered statistically significant.
| Results|| |
A total of 135 children were diagnosed with TB in the study period. The mean age of the presentation was 5.3 ± 3.5 years. The male: female ratio was 89:46. The common clinical features at presentation included fever in 112 (83%), cough in 63 (46.7%), and loss of appetite in 51 (37.8%). Among other clinical features, there was chest pain in 11 (8.2%), respiratory distress in 3 (2.2%), hemoptysis in 1 (0.7%), mass in abdomen in 2 (1.5%), vomiting in 8 (5.9%), abdominal pain in 9 (6.7%), abdominal distension in 4 (2.9%), altered sensorium in 5 (3.7%), convulsions in 12 (8.9%), headache in 3 (2.2%), squint in 1 (0.7%), neuroregression in 1 (0.7%), limb weakness in 2 (1.5%), and cervical swelling in 9 (6.7%) patients.
On biochemical evaluation, 72 of 97 (74.22%) records showed raised ESR levels. Anemia was recorded in 43 of 118 (36.4%) patients, 29 of 80 (36.3%) showed thrombocytosis, 35 of 113 (31%) recorded lymphocytosis, whereas 2 of 113 (1.8%) showed lymphopenia. On analyzing liver functions, 1 of 14 (7.1%) had hypoalbuminemia while 21 of 24 (87.5%) showed raised SGOT levels and 51 of 97 (52.6%) showed raised SGPT levels. The mean duration of various symptoms and mean values of biochemical parameters are depicted in [Table 1].
|Table 1: Mean and median duration of various symptoms and values of biochemical parameters|
Click here to view
One hundred and twenty-one (89.6%) children had received BCG vaccination, and 44 (32.6%) were tested to be TST positive. Hepatomegaly was seen in 22 children (16.3%), whereas 7 (5.2%) had splenomegaly. Fifty-nine children (43.7%) had lymphadenopathy, and 58 (43%) were malnourished.
On diagnostic evaluation, 109 children underwent chest X-ray examination, of which 34 (31.2%) showed primary complex, 21 (19.3%) had consolidation, 16 (14.7%) developed pleural effusion, 6 (5.5%) had mediastinal widening, and 4 (3.7%) had hilar lymphadenopathy. Among the rest, 4 (3.7%) showed cavitary lesions, whereas 24 (22%) had a normal chest X-ray.
Twenty-six children underwent ultrasound (USG) abdomen, of which 13 (50%) showed abdominal lymph nodes, 3 (11.5%) had ascites, 3 (11.5%) had hepatomegaly, 1 (3.9%) had splenomegaly, while 6 (23.1%) showed normal USG.
In children with bone involvement, spine and femur was involved in two patients each (40%) and 1 involved ulna (20%). Twenty-two children underwent a CT scan of the brain, of which 13 (59.1%) had hydrocephalus, 12 (54.5%) showed basal exudates, 6 (27.3%) had tuberculomas, 3 (13.6%) had gliotic scars, and one of them had an epidural abscess. Chest computed tomography (CT) was done in 19 patients, of which 12 (63.2%) had mediastinal lymphadenopathy, 5 (26.3%) had consolidation, 5 (26.3%) showed effusion, while 4 (21.1%) had cavitary lesion.
DR TB was seen in 8 (5.9%) children, of which 3 (37.5%) had pulmonary, 2 (25%) were latent, while abdominal, neuro, and osteoarticular TB each comprised 1 (12.5%) case.
Thirty-nine children (28.9%) had contact with an adult suffering from TB, whereas 4 (3%) of them had a previous history of TB. There were 4 (3%) children with relapse, whereas 3 (2.2%) children were defaulter.
Complications were observed in 9 patients with hepatitis being the most common as seen in 5 (55.5%) of these cases, followed by intestinal perforation, middle lobe syndrome, hemiparesis, and central diabetes insipidus with hypothyroidism seen in 1 case (11.1%) each.
On diagnosis, pulmonary TB was found more commonly in 49 (36.3%) followed by neuro TB in 20 (14.8%) and then by TB lymphadenopathy (8.9%). Abdominal TB, TB serositis, and latent TB comprised 11 cases (8.2%) each. Musculoskeletal involvement was seen in 8 (5.9%) cases, whereas 6 (4.4%) showed disseminated form. The rest 2 cases were BCGosis and atypical mycobacterium infection [Figure 1]. Factors associated with different types of TB are depicted in [Table 2]. On statistical analysis, it was found that fever (P = 0.002) and raised ESR (P = 0.045) were the least common in abdominal TB and disseminated TB, whereas loss of appetite was more common in disseminated TB and least in abdominal TB (P = 0.02). The results of our study have been compared to those of other studies in [Table 3].
| Discussion|| |
India contributes 1/5th of the total global burden of TB. Usually, malnourished children <5 years of age are found to be more frequently affected. However, our study shows that TB affects all age groups, with a mean age of 5.3 years. The inability to get tissue cultures in younger children may be the reason behind this slightly older age group. Furthermore, malnutrition was found in only 43% of the patients.
The diagnosis of TB in children usually follows the discovery of a case in an adult and needs to be confirmed by clinical signs and symptoms, chest radiograph, and tuberculin skin testing. The most common symptoms in our patients included fever, cough, and loss of appetite which were similar to that reported by Chaulk et al. We found that fever was the most common presenting symptom in our patients. However, fever was only seen in 50% of patients with abdominal TB and disseminated TB. This is lower as compared to the study conducted in Philippines by Pama et al. This may be due to different ethnic status and requires further evaluation.
We also found that loss of appetite was one of the significant common complaints. It was most commonly seen in case of disseminated type of TB, which is similar to a study done by Shrestha et al. However, it was the least common symptom among the cases of abdominal TB. This is in contrast to a study done by Basu et al. in Darjeeling who found 60% of abdominal TB patients presenting with loss of appetite. Since our study was conducted in Western India, the patients being referred to us belong to a different ethnic background and maybe the reason for the difference in fever in abdominal TB.
A male predominance was detected in our study similar to a study by Shrestha et al. showing more males being more affected. The ambulatory nature of males which increases exposure to the TB-infected cases may be the cause of male predominance in the study.
Lungs were more commonly involved in our patients, which are similar to the study conducted in the Philippines, where the most common diagnosis was pulmonary TB. However, this may be due to respiratory system being the mode of transmission of TB bacilli and also due to difficulty in the diagnosis of TB in the extrapulmonary sites.
Even though the protective efficacy of BCG vaccination is known, our study showed that there is still a significant chance of developing complicated TB even in the presence of BCG vaccination, as all types of TB were seen in children who had received BCG immunization. Thus, we cannot comment on the efficacy of BCG vaccination in our study.
The diagnosis of TB can be supported a positive Mantoux test and has also been used for circumstantial evidence for the diagnosis of TB. A negative Mantoux test does not rule out the diagnosis of TB as our study showed that Mantoux test was found to be positive in less than half of the patients in our study.
TB contact is one of the main reasons of children developing TB but, in our study, only 29% patients gave a history of TB contact. History of TB may be hidden by family members due to stigma attached to disease. These reasons lead to under reporting of TB contacts.
Hematological parameters usually aid in the diagnosis. Most types of TB in our patients showed raised ESR which is similar to a study done by Yilmaz et al., who found a high ESR in 60% of their cases. Furthermore, ESR was normal in half of the patients with abdominal and disseminated TB. This is similar to a study done by Basu et al., in which 44% of their patients had normal ESR levels.
Chest X-ray findings is routinely done to aid the diagnosis of TB in children. Primary complex, consolidation, and pleural effusion were the most common chest X-ray in our patients which were similar to the findings in a study done by Shrestha et al., where pleural effusion and consolidation were commonly seen. Mediastinal adenopathy in our patients could not be identified on chest X-ray but HRCT scan helped in the diagnosis which suggests a role of HRCT chest in these patients.
Limitations of our study include the small number of patients and being hospital-based study, a different pattern in the clinical features and preponderance of the disease may have been noted.
| Conclusion|| |
Pulmonary TB is the most common type of TB in children with boys more affected as compared to girls. TST is positive in less than half of the children with TB. Fever is the most common symptom of TB in children; however, it is seen in only 50% of patients with abdominal TB and disseminated TB. Similarly, raised ESR is the common feature of most types of TB in children but is usually normal in disseminated and abdominal TB, whereas loss of appetite is commonly seen in disseminated TB. TB can occur in children at any age group and is more commonly seen in boys.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tuberculosis control and research strategies for the 1990s: Memorandum from a WHO meeting. Bull World Health Organ 1992;70:17-21.
Shingadia D, Novelli V. Diagnosis and treatment of tuberculosis in children. Lancet Infect Dis 2003;3:624-32.
Munoz FM, Starke JR. Tuberculosis. In: Behrman RE, Klegiman RM, Jenson HB, editors. Nelson Text Book of Pediatrics. 17th
ed. Philadelphia: W.B Saunders Company; 2004. p. 958-72.
Agarwal DK, Agarwal KN. Physical growth in Indian affluent children (birth-6 years). Indian Pediatr 1994;31:377-413.
World Health Organization. Treatment of Tuberculosis Guidelines for National Programmes. 2nd
ed. Geneva: World Health Organization; 1997.
Leung AN. Pulmonary tuberculosis: The essentials. Radiology 1999;210:307-22.
Marais BJ, Gie RP, Schaaf HS, Hesseling AC, Enarson DA, Beyers N. The spectrum of disease in children treated for tuberculosis in a highly endemic area. Int J Tuberc Lung Dis 2006;10:732-8.
Gray JW. Childhood tuberculosis and its early diagnosis. Clin Biochem 2004;37:450-5.
Chaulk CP, Khoo L, Matuszak DL, Israel E. Case characteristics and trends in pediatric tuberculosis, Maryland, 1986-1993. Public Health Rep 1997;112:146-52.
Pama CL, Gatchalian SR. Clinical profile of culture-proven tuberculosis cases among Filipino children aged 3 months to 18 years. Phil J Microbiol Infect Dis 2001;30:133-43.
Shrestha S, Marahatta SB, Poudyal P, Shrestha SM. Clinical profile and outcome of childhood tuberculosis at Dhulikhel hospital. J Nepal Paediatr Soc 2011;31:11-7.
Basu S, Ganguly S, Chandra PK, Basu S. Clinical profile and outcome of abdominal tuberculosis in Indian children. Singapore Med J 2007;48:900-5.
The role of BCG vaccine in the prevention and control of tuberculosis in the United States. A joint statement by the Advisory Council for the Elimination of Tuberculosis and the Advisory Committee on Immunization Practices. MMWR Recomm Rep 1996;45:1-8.
Khemiri M, Labessi A, Zouari S, Borgi A, Ben Mansour F, Oubich F, et al.
Tuberculosis in childhood: Clinical features and problems in diagnosis. Report of 30 cases. Tunis Med 2009;87:61-7.
Yilmaz T, Sever A, Gür S, Killi RM, Elmas N. CT findings of abdominal tuberculosis in 12 patients. Comput Med Imaging Graph 2002;26:321-5.
[Table 1], [Table 2], [Table 3]