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LECTURE
doc. Kravchenko N.S.
TERMINOLOGY
The terminology used to describe various stages and presentations
of pediatric tuberculosis often has been a source of confusion for
physicians. It follows the pathophysiology, but the stages are often less
distinct in children.
Exposure means that the child has had significant contact with an
adult or adolescent with infectious pulmonary tuberculosis. The contact
investigation examining those persons close to a suspected case of
tuberculosis with a tuberculin skin test, chest radiograph, and physical
examination is the most important activity in a community to prevent
tuberculosis in children. The most frequent setting for exposure of a
child is the household, but it can occur in a school, day care center, or
other closed setting. In this stage, the tuberculin skin test result is
negative, the chest radiograph appears normal, and the child lacks
signs or symptoms of disease. Some exposed children may have
inhaled droplet nuclei infected with M. tuberculosis and have early
infection, but the clinician cannot know it because it takes up to 3
months for delayed hypersensitivity to tuberculin a positive skin test
result to develop.
Transmission
Children usually are infected by an adult or adolescent in the
immediate household, most often a parent, grandparent, or
household employee. Casual extrafamilial contact is the source of
infection much less often, but babysitters, schoolteachers, music
teachers, school-bus drivers, parishioners, nurses, gardeners, have
been implicated in individual cases and in hundreds of mini-epi
demics within limited population groups. Within the household of an
infectious adult, the infants and toddlers almost always are infected.
Also at high risk are the older children and teenagers who help the
ailing adult. Adults with pulmonary disease who are receiving regular,
appropriate chemotherapy probably rarely infect children; much more
dangerous are those with chronic tuberculous disease that is
unrecognized, inadequately treated, or in relapse because of
development of resistance.
Children with tuberculosis rarely, if ever, infect other children.
Many children with the disease have tuberculin-negative parents.
PATHOGENESIS IN CHILDREN
Primary tuberculosis is always result of exogenous infection.
The infection penetrates into organism by:
- aerogenic (the most often way of penetration)
- alimentary;
- contact way.
1. The primary complex of tuberculosis consists of local disease at the
portal of entry and the regional lymph nodes that drain the area of the
primary focus. In more than 95% of cases the portal of entry is the
lung. M. tuberculosis within particles larger than 10 (xm usually are
caught by the mucociliary mechanisms of the bronchial tree and are
expelled. Small particles are inhaled beyond these clearance
mechanisms. However, primary infection may occur anywhere in the
body.
2. Ingestion of milk infected with bovine tuberculosis can lead to a
gastrointestinal primary lesion.
3. Infection of the skin or mucous membrane can occur through an
abrasion, cut, or insect bite.
Clinical manifestations.
Complaints on aggravation of appetite, sweating, not
constant subfebrile body temperature, emotional instability,
decreasing of memory.
Objectively: paleness, decreasing of skin turgor,
micropoliadenitis (increasing of quantity and sizes of periferal
lymphatic nodes more than five groups). During percussion
changes over the lungs are absant. Auscultation: sometimes
dry rales.
Laboratory and other methods of investigation.
In hemogram can be slight leukocytosis with an insignificant
shift to the left, lymphopenia, eosinophilia, monocytosis, ESR is
normal or increased.
Roengenological examination.
In reviewable roentgenogram and tomogram of lungs there
are no changes usually. Sometimes it can be strengthen of
lungs picture.
Differential diagnosis.
It is necessery to exclude diseases accompanied by
intoxication: chronical sourses of infection of oral cavity and
epipharynx: chronical tonsillitis, pielonephritis, rheumatism,
hepatocholecystitis, helminthic invasions.
Main diagnostic criterions of tuberculous intoxication are:
- tuberculin intensifier
- symptoms of intoxication
- absence of roentgenological changes
- excluding of intoxication with different ethiology
Treatment.
Isoniazidum 10mg/kg of weight + rifampicinum10 mg/kg or
etambutol 20mg/kg for 4-6 months, vitamins B1, B6, C.
Clinical manifestations.
Asymptomatic course of disease can be present under little specific
changes in lungs. Complaints: subfebrile temperature, decrease of
body weight, bad appetite, quick tiredness. Coughing happens seldom.
Inspection: paleness, decrease of skin turgor, paraspecific changes,
micropolyadenitis. These changes can be absent.
Percussion: dullness over lung component with a big size.
Weakend breathing with streached exhale.
Hemogram: Leucocytosis 10-13 T/l, insignificant shift to the left,
lymphopenia, monocytosis, SSE 20-25 mm/h.
Tuberculin test - intensivity of tuberculin reaction, hyperergic reaction.
MBT are rarely to be found.
X-ray diagnostics:
Phases: 1) infiltrative or pneumonic;
2) resorbtion (suction,bipolarities);
3) scarring
4) calcification.
fig. 2