TB: Introduction

Contents
• Cases

Objectives

  1. To know how to do targeted tuberculin skin testing
  2. To know how to evaluate and treat a child with a positive TST
  3. To know what to do with a child who has had BCG vaccination
  4. To know what determines a contact, source case and  associate case investigation and how they are managed
  5. To know what to do with a baby whose mother has a positive TST during pregnancy

Pediatric Tuberculosis Case Questionnaire

  1. Mrs. Rodriquez comes to your office and insists that you test her 6 year old son for tuberculosis. He was supposed to start first grade that day, at a new school, but was refused entry because of lack of testing. What do you want to know about the child? What would you do?
  2. Mrs. Rodriguez then tells you that her younger son, who is with her, has just returned from Mexico where he was visiting his paternal family for 2 weeks. He  returned yesterday. Could he be registered today for tuberculosis testing. For that matter could he also get his WIC form and 1 year old shots done as he is behind in his immunizations? What do you tell her?
  3. Mrs. Sonogo has just returned from the Ivory Coast after a 1 ½ year visit with her now 2 year old child. You see from his well documented immunization card that he has received all his vaccines, including BCG. You tell the mother that you would like to place a TST (tuberculosis skin test) at this visit. She refuses, tells you that he had a vaccine against tuberculosis and that the vaccine will cause the result to be positive. What do you tell her?
  4. Mrs Ramirez brings her child for a routine visit to your Monday clinic. You get a history that that her child spent the summer in the Dominican Republic with family. You check with the mother to make sure that she can return with the child in 48-72 hours to have the TST (tuberculin skin test) read. She assures you there is no problem and that she can return on Wednesday. You place the TST and the mother returns on Friday with the usual excuses. You look at the PPD anyway. If it is 6mm do you do anything? If it is 12 mm do you do anything?
  5. Your 8 year old patient has a positive TST. His  risk factor for placing the TST is travel to a high risk country. What do you do next? What do you tell the family? What do you do with the results that you obtain and how do you follow this patient?
  6. During a source case investigation the Department of Health contacts you for assistance. A 35 year old male was recently admitted to the hospital with cavitary TB with a sputum stain positive for AFB (acid fast bacilli). He has been living with his sister’s family for the past year, which includes her 2 children ages 3 years old and 7 weeks old. The mother wants to have you follow the boys. You place a TST on both children. The TST of the 3 year old is read as 6 mm induration. He is well with no symptoms and is sent for a CXR that shows hilar adenopathy. The 7 week old has a negative TST and a negative CXR. What do you do with this family?
  7. A mother comes to you with her 9 day old child. The mother has a history of a positive TST during her third trimester of pregnancy with a negative CXR. She is 22 years old. She tells you she might have had a +TST as a child and might have been treated. What should the mother do? What would you do about the 9 day old?
  8. A mother comes to you with her 4 month old child. She tells you that the child’s Aunt, who lives in the same apartment as the baby, has recently been diagnosed with LTBI ( latent tuberculosis infection). The aunt is 12 years old, was diagnosed at  school and the mother does not know why they tested her. You elicit no risk factors from the mother who had a negative PPD during her pregnancy. Do you need to test the 4 month old child? Do you need to do anything further for the family?

References

  1. Targeted Skin Testing and Treatment of Latent Tuberculosis Infection in Children and Adolescents, Pediatrics, Volume 114, Number 3, Part 3 of 3, supplement, June 6-7, 2002

Lisa Saiman MD, MPH supplement editor

An outstanding source of information. Also an excellent 3-4 page list/summary of what to do when at the end of the article.

2.  The Red Book

3. http://www.heartlandntbc.org/casestudies/cs3.pdf

Definitions

Associate- Person who shares a residence, who frequently sleeps in the residence, or is in Close contact with the index child with LTBI. Associates may be others children, Parents, grandparents, a babysitter, friend, or other realtives

Associate investigation- Associate investigations can be conducted by health departments or primary care providers for children with LTBI to identify the individual who may have infected the child. The household contacts (including other children, adolescents, adults) of a child with LTBI are evaluated by history, physical exam,TST,and/or chest radiograph to detect TB or LTBI.

Contact Investigation-Contact investigations are generally conducted by health departments to identify persons exposed to patients with infectious TB, promptly evaluate the exposed persons for LTBI or TB disease, and provide treatment if indicated.

LTBI- Infection with M tuberculosis is usually detected by a TST. Such persons have No signs or symptom of pulmonary or extrapulmonary TB disease have a chest  radiograph that is not suggestive of TB disease, or has evidence of healed TB disease (eg granulomas, calcification). Such persons are not infectious.

Source-case investigation-Source case investigations are generally conducted by health Depts for children with active TB to identify the individual who may have infected the child. The close contacts (including her children.)adolescents and adults) of a child with TB disease are evaluated by history, physical exam,TST, and/or chest radiograph to detect TB disease or LTBI

Targeted Skin Testing- Targeted skin testing uses a screening questionnaire to elicit risk factors for TB and LTBI and the selective use of the TST in children and adolescents with identified risk factors.

TB disease- Persons with TB disease may have signs and/or symptoms of illness caused by M tuberculosis, although children with TB disease may be asymptomatic.Disease may be pulmonary, extrapulmonary, or both. Children or adolescents with TB disease of the lungs or larynx may be infectious to others.