abdominal tuberculosis in children: case series
TRANSCRIPT
Posters / Paediatric Respiratory Reviews 12S1 (2011) S67–S100 S93
N. Pediatric pulmonology in developingcountries
N1
Abdominal tuberculosis in children: case series
W. Indawat. Faculty of Medicine, University of Indonesia, Department
of Child Health, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
Background: Abdominal tuberculosis is considered as rare disease.
Although it is the sixth most frequent site of extra pulmonary
involvement of tuberculosis, it is very difficult to be diagnosed. It
can have varied presentations, frequently mimicking other diseases.
Unfortunately, chest X-ray showing evidence of concomitant
pulmonary lesion only appears in less than 25 percent of cases.
Objective: We would like to report our experience with 12 cases of
abdominal tuberculosis regarding their clinical course, tuberculin
test and other important supporting findings.
Results: Subjects were twelve patients (8 boys and 4 girls) of mean
age 8.8 years old. All of them were suffered from undernourishment
while 6 of them were in severe malnutrition. Anorexia was found
in 10 patient as well as weight lost. Fever was seen on almost
all of them (11/12). All cases had abdominal pain but only half of
them had intra abdominal mass. Six out of 12 had ascites while 7
patients had abdominal distention. Only 4 patients were suffered
from diarrhea or constipation. Cervical or inguinal lymph nodes
enlargements were observed in 6 patients. The source of infection
was not well defined in half of patient as well as positive tuberculin
skin test. Chest X-ray reveals significant pleural effusion in 2 cases,
calcification in 1 case, normal in 1 case, while the rest showed
minimal infiltrates with hilar nodes enlargement. Abdominal TB
involved peritoneum in 9 cases, abdominal lymph nodes in 3 cases,
gastrointestinal tract in 2 cases and liver in 2 cases. Ascitic fluid
analysis only performed in 1 case which showed exudative fluid
with lymphocyte predominance. The diagnosis of abdominal TB was
confirmed by histopathology examination in 6 cases. The remaining
cases diagnosed by combination of history of exposure, ascitic fluid
diagnostic features, tuberculin skin test, abdominal imaging and
good response to anti tuberculosis drug.
Conclusion: Most of our abdominal TB patients were between 7–15
years old. Abdominal TB was usually found in late stage because
the symptoms are not specific. Many modalities were needed to
confirm the diagnosis. Our experiences showed many children with
abdominal TB also have abnormality in chest X-ray. In cases which
confirmatory investigation unavailable, treatment may be initiated
based on suggestive clinical course and other supportive findings.
Good response to therapy will confirmed the diagnosis in such
cases.
N2
BCG immunization in severe extrapulmonary TB in children
N. Kaswandani, B. Supriyatno. Faculty of Medicine, University of
Indonesia, Department of Child Health, Cipto Mangunkusumo Hospital,
Jakarta, Indonesia
Background: Extrapulmonary TB is a manifestation of TB that may
lead to mortality and permanent disability. Some previous studies
reported the efficacy of BCG to prevent the severe manifestation
of TB in children such as meningitis TB, bone TB and miliary TB.
The aim of this study was to know the prevalence of BCG scar and
identify the clinical features and supporting examination findings
in in extrapulmonary TB in children.
Methods: This was a retrospective study which evaluated all
children with extrapulmonary tuberculosis. Subjects were all
patients with extra pulmonary TB who were admitted to
Ciptomangunkusumo Hospital Jakarta Indonesia during 2008 to
2009. All data were taken from medical records.
Results: There were 28 children (15 males and 13 females)
diagnosed as extrapulmonary TB. The diagnosis of bone TB
(spondilitis, coxitis and osteomyelitis) was found in 14 (50%)
children while CNS TB (meningitis and tuberculoma) was found
in 9 (32.1%) children. The age of patients is mostly 1–5 years old
(42.9%); under 1 year-old patients and over 5 years old were 5
(17.9%) patients and 11 (39.3%) respectively. History of TB contact
was identified in 13 (46.4%) subjects. Tuberculin skin test (TST) was
performed to all subjects and the positive rate was 50%. The majority
of subjects (64.3%) were under-nourished. Eighteen (64.3%) parents
stated that their children were BCG immunized, but BCG scar was
identified in 12 (42.9%) subjects. Chest X-ray findings varied from
infiltrate and hillar lymphadenopathy to miliary.
Conclusions: The most common manifestation of extrapulmonary
TB was spondilitis TB. The majority of subjects were 1 to 5 year-
old, undernourished and TST positive. BCG scar was found in 42.9%
patients who suffered from severe extrapulmonary TB.
N3
Case report: Role of bronchoscopy in the management of
endobronchial TB and IRIS in HIV children
C.J. Mendoza Fox. Clinica Ricardo Palma, Clinica Anglo-Americana,
Hospital Hipolito Unanue, Lima, Peru
Introduction: Endobronchial tumors (ET) in children are extremely
rare, with real incidence unknown. The majority of reports
are small group of cases, with bronchial adenoma and
bronchogenic carcinoma representing 70–90% of the tumors.
Other frequent diagnosis are: papilloma, inflammatory polyps,
leiomyoma and hemangioma. The exact incidence of endobronchial
tuberculosis (ETB) is unknown. The role of bronchoscopy (FB) in the
evaluation of immune reconstitution inflammatory syndrome (IRIS)
has not been determined.
Aims: To review the role of FB in the investigation and management
of ETB and IRIS in HIV children.
Case: A 12 year old boy, HIV C3, with HAART since February 09.
In treatment since June 09 for multidrug resistent tuberculosis
(MDR TB), with clinical and radiological improvement. In
September 09 presents 5 days of fever, cough and a new
consolidation in the left upper lobe (LUL). Work-up included a
FB, finding two ETs with obstruction of >90% of the right main
bronchus and one obstructing 100% of 1–2 segment LUL. Results
of bronchoalveolar lavage revealed 3 colonies of mycobacterium TB
and biopsy showed chronic granulomatous inflammation with Ziehl
Neelsen +/+++.
Patient continued with anti-MDR TB treatment and received
prednisone 2mg/kg/d with a reduction of >90% of lesions at the
month control.
Discussion: The incidence of ETB is unknown, however studies
that investigated the results of FB in children with suspected
TB have shown bronchial involvement in 41–63% of cases. The
lesions described are: compression of the airways (42–59%),
granulation tissue (18–29%), caseating material(12–39%) and polyp
formation(6%). Airway involvement may be multifocal (41%) and
in both bronchial trees (12%). Lymphoma, Karposi sarcoma and
Cryptococcus neoformans cause lymph node enlargement in HIV that
can be confused with that of TB. Besides it is easy in this group, to
get confused between a failure of TB treatment, presentation of an
undiagnosed disease or IRIS. The last one is an exclusion diagnosis,
that has a 7% incidence in HIV with TB treatment and in >19% of
HAART patients. Most cases resolve spontaneously, but also can be
severe and letal.
Conclusion: The role of FB in the evaluation of ETB and IRIS has
not been determined yet; but we show that in this patient (after
7 months of HAART and 3 of anti-MDR TB) it was essential for the
diagnosis, management and follow-up.