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The clinical diagnosis of tuberculosis depends on the following five steps:
Always suspect tuberculosis if one or more of the following are present:
Having a high index of suspicion that the child has been in close contact with someone with tuberculosis in a community, especially if they live in the same household, is often the most important step in making the diagnosis. A high index of suspicion is very important in the early diagnosis of tuberculosis, as tuberculosis may present in many different ways and may be confused with a wide range of other diseases.
Suspecting tuberculosis is important in making the diagnosis.
Symptoms are what the child or parent complains of, while signs are what you observe.
Children with tuberculosis have usually been unwell for a few weeks when they first present. Unlike the sudden onset in acute bacterial or viral infections, the symptoms and signs of tuberculosis usually develop over a number of days or weeks.
There are often no clinical signs on examination in the early stages of tuberculosis.
A detailed history is very important when considering a diagnosis of tuberculosis as the history is often the most important clue to the correct diagnosis. Therefore always consider tuberculosis in a child with a chronic cough, weight loss, failure to thrive or unexplained fever for more than two weeks, especially if there is an adult with a chronic cough or known pulmonary tuberculosis in the family.
A careful history is very important in the diagnosis of tuberculosis.
These symptoms and signs are important as pulmonary tuberculosis is the commonest form of tuberculosis in children and adults.
A persistent cough lasting longer than two weeks is an important symptom of pulmonary tuberculosis.
Commonly there are no clinical signs on chest examination in children with pulmonary tuberculosis.
Children with tuberculosis may also have symptoms and signs of HIV infection.
This depends on whether TB bacilli spread to only one organ (e.g. the meninges), or to two or more organs at the same time.
Enlarged lymph nodes (lymphadenopathy) due to tuberculosis occur most commonly in the neck (cervical nodes).
Enlarged cervical lymph nodes may be due to tuberculosis.
Often the mother first notices that the child has lumps in the neck. At first the nodes are typically firm and non-tender on examination. Later they may feel matted (stuck together). Enlarged tuberculous lymph nodes may lead to complications.
The lymph nodes may become tender and soft due to inflammation and the breakdown of tissue in the node (lymphadenitis) to form a lymph node abscess. Later lymph nodes may become attached to the skin and discharge the soft (caseous) material onto the skin. This results in a fistula. With healing, tuberculous fistulas leave scars.
Enlarged lymph nodes in the axilla (arm pit) are common a few weeks or months after a BCG immunisation on the upper arm on the right side. This is not caused by tuberculosis but results from the BCG immunisation in young children. Complications of enlarged axillary lymph nodes due to BCG are common in children with HIV infection.
Infection of the membranes which cover the brain (the meninges) by TB bacilli.
The symptoms and signs of tuberculous meningitis are:
A depressed level of consciousness is an important sign of tuberculous meningitis.
It is important to suspect tuberculous meningitis in any child with drowsiness, headache and vomiting. The onset of symptoms and signs are often slow over a number of days. A depressed level of consciousness, convulsions and paralysis are late and dangerous signs.
It depends on whether the diagnosis is made early or late. Full recovery is possible after an early diagnosis. However children who present late with depressed level of consciousness and signs of a stroke often die despite treatment. Children who survive after the development of late signs may survive with permanent disability (blindness, deafness, cerebral palsy, mental retardation and hydrocephalus).
It is very important to suspect TB meningitis in any child with unexplained drowsiness, headache or vomiting so that an early diagnosis can be made and immediate treatment started.
Tuberculosis of one or more organs in the abdomen. It is usually due to the spread of TB bacilli from the lungs. Newborn infants may have abdominal tuberculosis as a result of TB bacilli spreading from the infected placenta.
The most common presentation of abdominal tuberculosis is:
The most common sites are the spine (spinal tuberculosis) and large joints such as the hip, knee or ankle. However, any bone or joint can be infected.
Bone tuberculosis (tuberculous osteitis) usually develops months to years after the primary TB infection. It is due to reactivation of TB bacilli that have been dormant in the bone ever since they were first carried there by blood spread from the lungs. Therefore it is uncommon in young children and usually seen in older children and adolescents.
Tuberculous osteitis of the spine usually occurs in the lower thoracic or upper lumbar vertebrae with:
Any child with local pain and tenderness over the spine must be suspected of having spinal tuberculosis. A rapid onset of a gibbus (‘hump back’) is almost always due to tuberculosis.
Spinal tuberculosis presents with local pain and tenderness.
Disseminated tuberculosis occurs when TB bacilli spread throughout the body via the bloodstream as the immune system cannot contain them in the lung. This leads to tuberculosis in a number of organs other than the lungs, such as the meninges, abdominal lymph nodes, liver, spleen, bones and joints.
Disseminated tuberculosis is most often seen in infants.
Because these children become extremely ill and may die if not diagnosed and treated rapidly and correctly.
Miliary tuberculosis is the spread of TB bacilli throughout both lungs. It is seen in some cases of disseminated tuberculosis and can be diagnosed on chest X-ray.
Scoring methods are available, but they are not very accurate in children, especially if HIV infection is also present. However, they are useful in identifying children who are at high risk of having tuberculosis and need to be referred for further evaluation and special tests.
A grandmother presents at a primary-care clinic with her 3 year old granddaughter. She gives a history that the child has a poor appetite, weight loss and fever for the past three weeks. The local general practitioner prescribed amoxicillin for a respiratory tract infection but this has not helped. The mother died of HIV infection a few months ago.
Because the child has a number of the general symptoms which suggest tuberculosis (poor appetite with weight loss and prolonged fever). Failure to respond to the antibiotic treatment given for a bacterial respiratory tract infection also suggests tuberculosis.
It would be important to know if anyone in the home has tuberculosis or a chronic cough which may be due to undiagnosed tuberculosis. You should also ask about overcrowding and poverty.
She might have died of tuberculosis complicating HIV infection. If the child is HIV infected this would greatly increase the risk of tuberculosis.
Often there are very few clinical signs early in tuberculosis. It would be important to weigh the child and plot the weight in the Road-to-Health booklet to assess weight loss. Signs of malnutrition and HIV infection should also be looked for.
It would be more accurate to identify children who are at high risk of tuberculosis and need further investigation.
A 4 year old child presents with a chronic cough for the past month, together with feeling weak and tired. As the examination of the chest is normal, the medical officer assures the parents that the child does not have pulmonary tuberculosis.
Yes. A chronic cough, especially if not improving, should always suggest tuberculosis. There is not enough information to exclude tuberculosis.
No, as children with pulmonary tuberculosis often do not have abnormal chest signs on examination.
If the child had no previous history of wheezing, it would be important to think of an enlarged hilar lymph node pressing on a large airway. If this were correct, the wheeze would not respond to an inhaled bronchodilator.
A pleural effusion. This might also cause shortness of breath.
Further investigations are indicated to confirm or exclude a clinical diagnosis of tuberculosis.
A 10 year old girl is seen in the outpatient department of a district hospital with a swelling in her neck. Examination suggests enlarged cervical lymph nodes. There is no history of tuberculosis in the home.
Cervical lymph node enlargement is common in children with tuberculosis.
Usually the lymph nodes are firm and painless, but may feel matted (stuck together).
The nodes may become painful and soft (lymphadenitis) and form an abscess or fistula which drains onto the skin.
BCG immunisation on that side.
By lymphatic spread from lymph nodes in the chest.
An ill six-month-old child presents with a two-week history of fever, poor feeding, drowsiness and irritability. A few hours back the child had a convulsion. The father started on TB treatment a month before.
Tuberculous meningitis. The father is almost certainly the source of the infection.
They get there via the bloodstream. Tuberculous meningitis is usually seen in infants and young children, and occurs soon after the primary infection.
Yes, as this is a late and serious sign of tuberculous meningitis and increases the risk of death or permanent disability. Therefore it is important to make the diagnosis as soon as possible.
Disseminated tuberculosis with widespread involvement of both lungs. These children are seriously ill.
Abdominal pain and distension. Sometimes an enlarged liver and spleen may be palpated.