MINISYMPOSIUM

Point-of-care ultrasound: a simple protocol to improvediagnosis of childhood tuberculosis

Sabine Bélard & Tom Heller & Martin P. Grobusch &

Heather J. Zar

Received: 25 November 2013 /Accepted: 10 March 2014# Springer-Verlag Berlin Heidelberg 2014

Childhood tuberculosis (TB) accounts for a considerableburden of morbidity and mortality in many resource-limitedsettings [1]. Because of the nonspecific clinical signs andsymptoms, the paucibacillary nature of TB and thedifficulty in obtaining good specimens for microbiologicaltesting, diagnosing pulmonary and extrapulmonary tuber-culosis in children can be challenging. Extrapulmonary TBis a special concern in children infected with human im-munodeficiency virus (HIV).

The value of US imaging in diagnosing extrapulmonaryTB has long been recognized. Pericardial or pleural effu-sions, ascites, abdominal nodes and focal lesions in theliver or spleen are likely to be features of extrapulmonaryTB in settings where TB is highly endemic. However,access to US examination is often limited in these settings;US imaging is usually unavailable in primary care clinics,where most TB patients present, because of a lack of equip-ment and radiologic expertise. Even in referral hospitals,

where US is among the most requested specialist examina-tions [2], long waiting times are common. Now, however,high-quality, affordable portable US machines are availablefor use outside of imaging departments.

Today the concept of point-of-care US is used by vari-ous medical disciplines for diagnostic and procedural ap-plications [3]. A clinician-performed bedside US protocolfor HIV/TB called FASH, or focused assessment withsonography for HIV/TB [4], has been developed for usein adults in South Africa. This protocol can be taught inshort courses to practitioners [5] and is now one of themost applied point-of-care US modules in adult emergencyrooms in the country [6]. Examples of extrapulmonary TBfindings by FASH are presented in Figs. 1 and 2.

Point-of-care sonography in children is particularlyattractive because it does not expose the child to ioniz-ing radiation and does not require sedation. Moreover,the high proportion of extrapulmonary TB manifesta-tions in children, especially in young children, translatesinto a high yield of US findings, which are easilyrecognizable with basic US training. Further, imagescan be relayed to radiologists anywhere in the world,enabling expert assessment of such images if they can-not be interpreted on-site [7]. Bedside sonography as adiagnostic tool within the pediatric TB workup has,however, not been systematically assessed. Currently,FASH is being successfully piloted in a pediatric TBcohort in Cape Town. Besides the incremental diagnos-tic value of bedside sonography for childhood TB, ad-ditional possible benefits require further research. Theseinclude reduction of time to diagnosis and treatmentinitiation; use as a monitoring tool for response totreatment; extension to pulmonary, mediastinal and men-ingeal assessment; and, importantly, implementation atadmission wards and the primary care level.

S. Bélard (*) :H. J. ZarDepartment of Paediatrics and Child Health,Red Cross War Memorial Children’s Hospital,University of Cape Town, Cape Town, South Africae-mail: sabinebelard@yahoo.de

S. Bélard :M. P. Grobusch :H. J. ZarInstitute of Infectious Disease and Molecular Medicine,University of Cape Town, Cape Town, South Africa

S. Bélard :M. P. GrobuschCentre of Tropical Medicine and Travel Medicine,Division of Internal Medicine, Academic Medical Centre,University of Amsterdam, Amsterdam, The Netherlands

T. HellerDepartment of Internal Medicine, Infectious Diseases,Klinikum München-Perlach, Munich, Germany

Pediatr Radiol (2014) 44:679–680DOI 10.1007/s00247-014-2971-7

Conflicts of interest None

References

1. Detjen A, Gale M, Garcia Baena I et al (2013) Roadmap for childhoodtuberculosis: towards zero deaths. World Health Organization. http://apps.who.int/iris/bitstream/10665/89506/1/9789241506137_eng.pdf.Accessed 4 Feb 2014

2. De Vries E, Raubenheimer P, Kies B et al (2011) Acute hospitalisationneeds of adults admitted to public facilities in the Cape Town Metrodistrict. S Afr Med J 101:760–764

3. Moore CL, Copel JA (2011) Point-of-care ultrasonography. N Engl JMed 364:749–757

4. Heller T, Wallrauch C, Goblirsch S et al (2012) Focused assessmentwith sonography for HIV-associated tuberculosis (FASH): a shortprotocol and a pictorial review. Crit Ultrasound J 4:21

5. Heller T, Wallrauch C, Lessells RJ et al (2010) Short coursefor focused assessment with sonography for human immuno-deficiency virus/tuberculosis: preliminary results in a ruralsetting in South Africa with high prevalence of human im-munodeficiency virus and tuberculosis. Am J Trop Med Hyg82:512–515

6. Van Hoving DJ, Lamprecht HH, Stander M et al (2013)Adequacy of the emergency point-of-care ultrasound core cur-riculum for the local burden of disease in South Africa. EmergMed J 30:312–315

7. Janssen S, Grobusch MP, Heller T (2013) ‘Remote FASH’ tele-sonography—a novel tool to assist diagnosing HIV-associatedextrapulmonary tuberculosis in remote areas. Acta Trop 127:53–55

Fig. 1 Images recorded by aclinician-performed bedsideUS examination FASH(Focused assessment withsonography for HIV/TB).Findings are suggestive ofextrapulmonary tuberculosis (TB)in settings where tuberculosis ishighly endemic. (a) Image of a12-year-old girl shows theabdominal nodes (arrows) in thesplenic hilum and (b) image in a12-year-old boy shows splenicmicroabscesses (arrows)

Fig. 2 Clinician-performedbedside US examinationof an 11-year-old girl confirmspleural effusion (PE) and allowsimmediate decision-making ondiagnostic tap or therapeuticdrainage. Sonogram (a) confirmsthe pleural effusion suspected byanteroposterior chest radiograph(b)

680 Pediatr Radiol (2014) 44:679–680