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Pulmonary tuberculosis in children
J THORAC
CARDIOV ASC SURG
80:221-224, 1980
Pulmonary tuberculosis in children A major change has occurred in the incidence and management of pulmonary tuberculosis in patients of all ages. This review emphasizes the effectiveness of drug therapy and the declining role of surgical management of pulmonary Tuberculosis in children. Surgical intervention was necessary in only two of 140 children (1.4%) with proved tuberculosis, one for a large tuberculoma and the other for refractory involvement of the chest wall. The remaining 138 children were treated successfully with anti-tuberculous drugs. Pulmonary tuberculosis in children is primarily a medical disease and only rarely is surgical intervention indicated.
James E. Lowe, M.D., Durham, N. C., Thomas M. Daniel, M.D., Richmond, Va., Charlotte Richer, M.D., McCain, N. C., and Walter G. Wolfe, M.D., Durham, N. C.
T
he incidence of pulmonary tuberculosis in children continues to decrease and the resultant need for surgical intervention has diminished concomitantly. In 1967 Lees and associates 1 reported that surgical intervention was required in 5% of their 1,954 cases of pulmonary tuberculosis in patients less than 16 years of age. In the present series, 140 children (aged 7 months to 16 years) with active pulmonary tuberculosis were treated from 1968 to 1978 and the incidence of surgical intervention was 1.4%. AIl patients received antituberculous medical therapy for an average of 1 year. Only two children (1.4%) required surgical treatment of their disease, whereas the remaining 138 children responded to medical therapy alone. Selected case reports
The foIlowing case reports include the only two patients requiring surgical intervention in our series. The two cases labeled "medical" illustrate the degree of disease which can be treated successfuIly without the need for surgical intervention. CAS E I (surgical). A 9-year-old girl was hospitalized because of an abnormal chest x-ray film taken after the finding of a positive tuberculin skin test. The chest film showed a 4 by 4 cm mass lying adjacent to the superior pole of the right hilum (Fig. I). The patient "felt sick" and had experienced a sore throat 3 months prior to admission. Sputa for acid-fast bacilli (AFB) were positive by smear and cul-
From the Department of Surgery, Duke University Medical Center, Durham, N. C. and the McCain Sanatorium, McCain, N. C. Received for publication Nov. 5, 1979. Accepted for publication Feb. 12, 1980. Address for reprints: WalterG. Wolfe, M.D., P.O. Box 3507, Duke University Medical Center, Durham, N. C. 27710.
ture. Treatment with isoniazid (INH), para-aminosalicylic acid (PAS), and streptomycin was begun in November of 1968. The mass persisted unchanged over the next 9 months, and in August of 1969 the child underwent a thoracotomy. A firm, hard, 6 em tuberculoma was removed from the anterior segment of the right upper lobe. Pathological examination showed the parenchyma to be completely replaced by yellowish gray caseous material. AFB were noted on special stains and subsequently were confirmed by culture. The patient's postoperative course was unremarkable. Antituberculous therapy was continued for I year postoperatively. CASE 2 (surgical). A 12-year-old girl was asymptomatic and had a normal chest x-ray film in March of 1968 when the diagnosis of active tuberculosis was made in her father. In October of that year, an oval 2 by 2 ern mass developed in the periphery of the left lung (Fig. 2). The purified protein derivative test was positive as were sputum smears, and she was begun on antituberculous therapy. Over the next 2 1;2 years there was no change in the size of the mass. In November of 1971, she underwent thoracotomy which demonstrated a 4 by 2 ern irregular, slightly fluctuant mass lying beneath the left seventh rib but external to the parietal pleura (chest wall abcess). Fibrous pleural adhesions were evident and a small tuberculoma was present in the adjacent lingula. Pathological examination showed caseous material with positive AFB smears and subsequent positive cultures. Follow-up sputum smears and cultures were negative and drug therapy was discontinued after I year. CASE 3 (medical). A l5-year-old boy was admitted in August of 1975, because of a cavitary lesion in the right midlung field (Fig. 3). He previously had been treated for 2 months with isoniazid and ethambutal and was discharged receiving those drugs. He presumably discontinued the medications. The latest x-ray film showed deterioration and he was readmitted because of the positive smear for AFB. Treatment at this time consisted of streptomycin, isoniazid, rifampin, and pyridoxine. He tolerated these medications well and the cavity cleared completely. Subsequent smears were negative, chest x-ray films were normal, and he returned to school. Follow-up chest roentgenograms have revealed no recurrence since therapy was discontinued.
0022-5223/80/080221+04$00.4010 © 1980 The C. V. Mosby Co.
221
The Journal of
222
Loweetal.
Thoracic and Cardiovascular Surgery
Fig. 1. Case 1. Preoperative x-ray film (A) and laminagram (B) of lesion in the anterior segment of the right upper lobe. C. Postoperative chest x-ray film.
Fig. 2. Case 2. A. Preoperative chest x-ray film demonstrating the mass in the periphery of the left lung involving the chest wall. B. Postoperative x-ray film. 4 (medical). A 15-year-old girl was admitted in December of 1972, after she had noticed a cough and poor appetite but denied chills, fevers, or night sweats at that time. On admission she was febrile and the chest film showed scattered disease throughout both lungs. A cavity was present on the left side along with a dense infiltrate along the cardiac border associated with mediastinal adenopathy (Fig. 4). The patient was treated with a combination of streptomycin, isoniazid, and ethambutal. Prior to discharge, streptomycin was discontinued (6 weeks). Sputum smears became negative, the chest roentgenogram cleared markedly, and the girl resumed moderate activities including school work while continuing her antituberculous therapy. CAS E
Discussion The presentation of primary pulmonary tuberculosis in children often differs from that in adults. Several distinct forms have been described. Neonatal tuberculosis presents a picture of disseminated pulmonary disease with occasional obstructive emphysema and is thought to be secondary to infected amniotic fluid or hematogenous transplacental passage from the mother. 2 Miliary tuberculosis has been reported in children and presents the picture of multiple small pulmonary lesions similar to that of the adult.
Volume 80
Pulmonary tuberculosis in children
Number 2
223
August, 1980
Fig. 3. Case 3. A , Pretreatment chest film. B. Post-treatment chest film.
Fig. 4. Case 4. A , Pretreatment x-ray film. B . Post-treatment x-ray film . Unilateral and/or bilateral hilar or paratracheal adenopathy with an associated small parenchymal infiltrate is the most common presentation for primary tuberculosis . Laminagraphy may be necessary to visualize the parenchymal component. The clinical manifestations reflect the basic pathological process in primary tuberculosis, which is one of an inflammatory response to the tubercle bacilli within the alveoli and a secondary spread of the inflammatory response through the regional lymphatics to the mediastinal lymph nodes. As illustrated by Case 4, mediastinal adenop-
athy , even when pronounced , is not an indication for surgical intervention. Less commonly, the clinical presentation may be one of a mass or large infiltrate with or without visible adenopathy. and often with little associated clinical illness. Miller and associates" suggest the term "segmental" for description of such lesions as seen on the chest film, for this would include the atelectatic lesion secondary to proximal endobronchial tuberculosis as well as a type similar in appearance but which does not involve the bronchi and which reflects an intraparen-
The Journal of
224 Lowe et al.
chymal mass lesion. The natural course of these segmental lesions in children is of interest because, in the present series, their persistence was the only indication for operation. In 117 patients with segmental lesions reported by Miller's group," tuberculous therapy for 1 year resulted in complete clearing in 68%, residual gross scarring in 17%, calcification in 10%, and no change in size of the mass in 5%. In 1970, Gerbeaux" reported a series in which only 10% of treated segmental lesions did not change in size over 18 months. Eight of his patients underwent operation, and caseation with acid-fast organisms was present on the smear but not on culture. In the present series, there were six patients with segmental lesions, four of which represented atelectatic masses that resolved on medical therapy. Two lesions remained unchanged after 9 months and 30 months of therapy, respectively. In both of these patients, surgical removal demonstrated the presence of large caseous masses which contained acid-fast organisms both by smear and by culture. Clinically prominent presenting features in pulmonary tuberculosis may represent complications of any of the aforementioned forms of the disease. These include pleural effusions, interlobar effusions, obstructive emphysema, and the development of chest wall abcesses. In the second patient discussed in the present series, a segmental lesion which did not resolve on medical therapy was discovered at thoracotomy to actually be a chest wall abscess adjacent to a small parenchymal tuberculoma. The lesions probably represented tuberculous involvement of a lateral intercostal node, as there was no evidence of overlying rib involvement. The discussion of presenting forms of childhood tuberculosis is not complete without including the clinical picture of an asymptomatic child with a normal roentgenogram and a recently positive skin test. It is perhaps the treatment of these patients, as recommended by the Medical Section of the National Tuberculosis and Respiratory Diseases Association, that has had a large part in reducing the need for surgical intervention in the course of treatment. Chronic pulmonary tuberculosis (also known as secondary, reinfection, or adult-type tuberculosis) may occur in the pediatric age group and has the charac-
Thoracic and Cardiovascular Surgery
teristic features of adult tuberculosis, with its higher incidence in the apical portion of the lung, its tendency toward cavity formation, and its less prominent adenopathy. Many authors have emphasized the increased likelihood for appearance of secondary tuberculosis during puberty, especially in girls. 5. 6 Although symptomatic bronchiectasis, bronchial stenosis, and tuberculous empyema are all accepted criteria for surgical intervention, there was no instance of the need for this in our group. Other indications for operation, such as destroyed lung and persistently positive cavitating lesions after 6 months of therapy, do occur occasionally in children and should be managed in the same manner as when present in adult patients. The present series shows that the overwhelming majority of children with pulmonary tuberculosis can be successfully managed medically. At our institution active parenchymal disease in children is currently treated with isoniazid, 10 mg/kg/day, combined with either rifampin, 10 mg/kg/day (not to exceed 600 mg), or PAS, 40 mg/kg/day. Streptomycin, 20 mg/kg/day, is administered for 4 to 6 weeks and then twice weekly for an additional 4 weeks. Ethambutal is used only in children older than 13 years. For conversion of a tuberculin skin test with no parenchymal disease by chest roentgenogram, isoniazid alone is administered for 9 to 12 months.
2
3
4 5
6
REFERENCES Lees WM, Fox RT, Shields TW: Pulmonary surgery for tuberculosis in children. Ann Thorac Surg 4:327-333, 1967 Singleton EB, Wagner ML: Radiologic Atlas of Pulmonary Abnormalities in Children, Philadelphia, 1971, W. B. Saunders Company Miller FJ, Seal RME, Taylor MD: Tuberculosis in Children. Evaluation, Control, Treatment. London, 1963, 1. & A. Churchill Ltd., Chap 10 Gerbeaux J: Primary Tuberculosis in Childhood, Springfield, Ill., 1970, Charles C Thomas, Publisher, pp. 87-88 Durfee ML, Nemir RL, Sewell EM, et al: The treatment of tuberculosis in children. Am Rev Respir Dis 99:304-307, 1969 Levine MI, Mascia A V: Pulmonary Diseases and Anomalies of Infancy and Childhood. Their Diagnosis and Treatment, New York, 1966, Harper & Row, Publishers, p. 234
CARDIOV ASC SURG
80:221-224, 1980
Pulmonary tuberculosis in children A major change has occurred in the incidence and management of pulmonary tuberculosis in patients of all ages. This review emphasizes the effectiveness of drug therapy and the declining role of surgical management of pulmonary Tuberculosis in children. Surgical intervention was necessary in only two of 140 children (1.4%) with proved tuberculosis, one for a large tuberculoma and the other for refractory involvement of the chest wall. The remaining 138 children were treated successfully with anti-tuberculous drugs. Pulmonary tuberculosis in children is primarily a medical disease and only rarely is surgical intervention indicated.
James E. Lowe, M.D., Durham, N. C., Thomas M. Daniel, M.D., Richmond, Va., Charlotte Richer, M.D., McCain, N. C., and Walter G. Wolfe, M.D., Durham, N. C.
T
he incidence of pulmonary tuberculosis in children continues to decrease and the resultant need for surgical intervention has diminished concomitantly. In 1967 Lees and associates 1 reported that surgical intervention was required in 5% of their 1,954 cases of pulmonary tuberculosis in patients less than 16 years of age. In the present series, 140 children (aged 7 months to 16 years) with active pulmonary tuberculosis were treated from 1968 to 1978 and the incidence of surgical intervention was 1.4%. AIl patients received antituberculous medical therapy for an average of 1 year. Only two children (1.4%) required surgical treatment of their disease, whereas the remaining 138 children responded to medical therapy alone. Selected case reports
The foIlowing case reports include the only two patients requiring surgical intervention in our series. The two cases labeled "medical" illustrate the degree of disease which can be treated successfuIly without the need for surgical intervention. CAS E I (surgical). A 9-year-old girl was hospitalized because of an abnormal chest x-ray film taken after the finding of a positive tuberculin skin test. The chest film showed a 4 by 4 cm mass lying adjacent to the superior pole of the right hilum (Fig. I). The patient "felt sick" and had experienced a sore throat 3 months prior to admission. Sputa for acid-fast bacilli (AFB) were positive by smear and cul-
From the Department of Surgery, Duke University Medical Center, Durham, N. C. and the McCain Sanatorium, McCain, N. C. Received for publication Nov. 5, 1979. Accepted for publication Feb. 12, 1980. Address for reprints: WalterG. Wolfe, M.D., P.O. Box 3507, Duke University Medical Center, Durham, N. C. 27710.
ture. Treatment with isoniazid (INH), para-aminosalicylic acid (PAS), and streptomycin was begun in November of 1968. The mass persisted unchanged over the next 9 months, and in August of 1969 the child underwent a thoracotomy. A firm, hard, 6 em tuberculoma was removed from the anterior segment of the right upper lobe. Pathological examination showed the parenchyma to be completely replaced by yellowish gray caseous material. AFB were noted on special stains and subsequently were confirmed by culture. The patient's postoperative course was unremarkable. Antituberculous therapy was continued for I year postoperatively. CASE 2 (surgical). A 12-year-old girl was asymptomatic and had a normal chest x-ray film in March of 1968 when the diagnosis of active tuberculosis was made in her father. In October of that year, an oval 2 by 2 ern mass developed in the periphery of the left lung (Fig. 2). The purified protein derivative test was positive as were sputum smears, and she was begun on antituberculous therapy. Over the next 2 1;2 years there was no change in the size of the mass. In November of 1971, she underwent thoracotomy which demonstrated a 4 by 2 ern irregular, slightly fluctuant mass lying beneath the left seventh rib but external to the parietal pleura (chest wall abcess). Fibrous pleural adhesions were evident and a small tuberculoma was present in the adjacent lingula. Pathological examination showed caseous material with positive AFB smears and subsequent positive cultures. Follow-up sputum smears and cultures were negative and drug therapy was discontinued after I year. CASE 3 (medical). A l5-year-old boy was admitted in August of 1975, because of a cavitary lesion in the right midlung field (Fig. 3). He previously had been treated for 2 months with isoniazid and ethambutal and was discharged receiving those drugs. He presumably discontinued the medications. The latest x-ray film showed deterioration and he was readmitted because of the positive smear for AFB. Treatment at this time consisted of streptomycin, isoniazid, rifampin, and pyridoxine. He tolerated these medications well and the cavity cleared completely. Subsequent smears were negative, chest x-ray films were normal, and he returned to school. Follow-up chest roentgenograms have revealed no recurrence since therapy was discontinued.
0022-5223/80/080221+04$00.4010 © 1980 The C. V. Mosby Co.
221
The Journal of
222
Loweetal.
Thoracic and Cardiovascular Surgery
Fig. 1. Case 1. Preoperative x-ray film (A) and laminagram (B) of lesion in the anterior segment of the right upper lobe. C. Postoperative chest x-ray film.
Fig. 2. Case 2. A. Preoperative chest x-ray film demonstrating the mass in the periphery of the left lung involving the chest wall. B. Postoperative x-ray film. 4 (medical). A 15-year-old girl was admitted in December of 1972, after she had noticed a cough and poor appetite but denied chills, fevers, or night sweats at that time. On admission she was febrile and the chest film showed scattered disease throughout both lungs. A cavity was present on the left side along with a dense infiltrate along the cardiac border associated with mediastinal adenopathy (Fig. 4). The patient was treated with a combination of streptomycin, isoniazid, and ethambutal. Prior to discharge, streptomycin was discontinued (6 weeks). Sputum smears became negative, the chest roentgenogram cleared markedly, and the girl resumed moderate activities including school work while continuing her antituberculous therapy. CAS E
Discussion The presentation of primary pulmonary tuberculosis in children often differs from that in adults. Several distinct forms have been described. Neonatal tuberculosis presents a picture of disseminated pulmonary disease with occasional obstructive emphysema and is thought to be secondary to infected amniotic fluid or hematogenous transplacental passage from the mother. 2 Miliary tuberculosis has been reported in children and presents the picture of multiple small pulmonary lesions similar to that of the adult.
Volume 80
Pulmonary tuberculosis in children
Number 2
223
August, 1980
Fig. 3. Case 3. A , Pretreatment chest film. B. Post-treatment chest film.
Fig. 4. Case 4. A , Pretreatment x-ray film. B . Post-treatment x-ray film . Unilateral and/or bilateral hilar or paratracheal adenopathy with an associated small parenchymal infiltrate is the most common presentation for primary tuberculosis . Laminagraphy may be necessary to visualize the parenchymal component. The clinical manifestations reflect the basic pathological process in primary tuberculosis, which is one of an inflammatory response to the tubercle bacilli within the alveoli and a secondary spread of the inflammatory response through the regional lymphatics to the mediastinal lymph nodes. As illustrated by Case 4, mediastinal adenop-
athy , even when pronounced , is not an indication for surgical intervention. Less commonly, the clinical presentation may be one of a mass or large infiltrate with or without visible adenopathy. and often with little associated clinical illness. Miller and associates" suggest the term "segmental" for description of such lesions as seen on the chest film, for this would include the atelectatic lesion secondary to proximal endobronchial tuberculosis as well as a type similar in appearance but which does not involve the bronchi and which reflects an intraparen-
The Journal of
224 Lowe et al.
chymal mass lesion. The natural course of these segmental lesions in children is of interest because, in the present series, their persistence was the only indication for operation. In 117 patients with segmental lesions reported by Miller's group," tuberculous therapy for 1 year resulted in complete clearing in 68%, residual gross scarring in 17%, calcification in 10%, and no change in size of the mass in 5%. In 1970, Gerbeaux" reported a series in which only 10% of treated segmental lesions did not change in size over 18 months. Eight of his patients underwent operation, and caseation with acid-fast organisms was present on the smear but not on culture. In the present series, there were six patients with segmental lesions, four of which represented atelectatic masses that resolved on medical therapy. Two lesions remained unchanged after 9 months and 30 months of therapy, respectively. In both of these patients, surgical removal demonstrated the presence of large caseous masses which contained acid-fast organisms both by smear and by culture. Clinically prominent presenting features in pulmonary tuberculosis may represent complications of any of the aforementioned forms of the disease. These include pleural effusions, interlobar effusions, obstructive emphysema, and the development of chest wall abcesses. In the second patient discussed in the present series, a segmental lesion which did not resolve on medical therapy was discovered at thoracotomy to actually be a chest wall abscess adjacent to a small parenchymal tuberculoma. The lesions probably represented tuberculous involvement of a lateral intercostal node, as there was no evidence of overlying rib involvement. The discussion of presenting forms of childhood tuberculosis is not complete without including the clinical picture of an asymptomatic child with a normal roentgenogram and a recently positive skin test. It is perhaps the treatment of these patients, as recommended by the Medical Section of the National Tuberculosis and Respiratory Diseases Association, that has had a large part in reducing the need for surgical intervention in the course of treatment. Chronic pulmonary tuberculosis (also known as secondary, reinfection, or adult-type tuberculosis) may occur in the pediatric age group and has the charac-
Thoracic and Cardiovascular Surgery
teristic features of adult tuberculosis, with its higher incidence in the apical portion of the lung, its tendency toward cavity formation, and its less prominent adenopathy. Many authors have emphasized the increased likelihood for appearance of secondary tuberculosis during puberty, especially in girls. 5. 6 Although symptomatic bronchiectasis, bronchial stenosis, and tuberculous empyema are all accepted criteria for surgical intervention, there was no instance of the need for this in our group. Other indications for operation, such as destroyed lung and persistently positive cavitating lesions after 6 months of therapy, do occur occasionally in children and should be managed in the same manner as when present in adult patients. The present series shows that the overwhelming majority of children with pulmonary tuberculosis can be successfully managed medically. At our institution active parenchymal disease in children is currently treated with isoniazid, 10 mg/kg/day, combined with either rifampin, 10 mg/kg/day (not to exceed 600 mg), or PAS, 40 mg/kg/day. Streptomycin, 20 mg/kg/day, is administered for 4 to 6 weeks and then twice weekly for an additional 4 weeks. Ethambutal is used only in children older than 13 years. For conversion of a tuberculin skin test with no parenchymal disease by chest roentgenogram, isoniazid alone is administered for 9 to 12 months.
2
3
4 5
6
REFERENCES Lees WM, Fox RT, Shields TW: Pulmonary surgery for tuberculosis in children. Ann Thorac Surg 4:327-333, 1967 Singleton EB, Wagner ML: Radiologic Atlas of Pulmonary Abnormalities in Children, Philadelphia, 1971, W. B. Saunders Company Miller FJ, Seal RME, Taylor MD: Tuberculosis in Children. Evaluation, Control, Treatment. London, 1963, 1. & A. Churchill Ltd., Chap 10 Gerbeaux J: Primary Tuberculosis in Childhood, Springfield, Ill., 1970, Charles C Thomas, Publisher, pp. 87-88 Durfee ML, Nemir RL, Sewell EM, et al: The treatment of tuberculosis in children. Am Rev Respir Dis 99:304-307, 1969 Levine MI, Mascia A V: Pulmonary Diseases and Anomalies of Infancy and Childhood. Their Diagnosis and Treatment, New York, 1966, Harper & Row, Publishers, p. 234