- Email: [email protected]
Abdominal tuberculosis in children: case series
Posters / Paediatric Respiratory Reviews 12S1 (2011) S67–S100
N. Pediatric pulmonology in developing countries 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.
S93
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 yearold, 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 2 mg/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.
N. Pediatric pulmonology in developing countries 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.
S93
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 yearold, 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 2 mg/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.