Mini-symposium: Childhood tuberculosis
Clinical manifestations of tuberculosis in children

https://doi.org/10.1016/j.prrv.2007.04.008Get rights and content

Summary

The natural history and clinical manifestations of tuberculosis in children differ significantly from those of the disease seen in adults. The two main factors determining the risk of progression to disease are patient age and immune status. Neonates have the highest risk of progression to disease, and in infancy miliary and meningeal involvement is common. Children from 5 to 10 years of age are less likely to develop disease than other age groups, and adolescent patients can present with progressive primary tuberculosis or cavitary disease. Immunocompromised patients are more likely both to progress to tuberculous disease and to have extrapulmonary manifestations; diagnostic tests are also of lower yield in this population. The most common sites of disease in children are intrathoracic disease and superficial lymphadenopathy. Clinical manifestations are often due to a profound inflammatory response to a relatively low burden of organisms. This is reflected in the low yield of diagnostic tests; consequently, the diagnosis of tuberculosis is often based upon a positive skin test, epidemiological information, and compatible clinical and radiographic presentation.

Section snippets

Pulmonary TB

Pulmonary parenchymal disease and associated intrathoracic adenopathy are the most common clinical manifestations of TB in children. Most have a positive tuberculin skin test (TST); however, skin test anergy is common in immunocompromised or malnourished patients. Inhalation of bacilli into a terminal airway can result in a Ghon complex, comprising the initial focus of infection, the draining lymphatic vessels and enlargement of the regional lymph nodes (Fig. 1). There are four potential

Superficial lymph nodes

Superficial lymphadenopathy, occurring in 10–15% of children, accounts for almost 50% of extrapulmonary disease. Historically, it has been caused by drinking unpasteurised milk infected with Mycobacterium bovis, but now the most common route is haematogenous infection with M. tuberculosis. Symptoms generally present 6–12 months after initial infection, and the mean age at diagnosis tends to be higher than children diagnosed with non-tuberculous mycobacterial (NTM) infections. Most

Miliary/disseminated TB

Miliary TB accounts for 1–2% of all cases of TB. It is more commonly seen in infants and children under 5 years of age and in immunocompromised hosts, including patients with rheumatological conditions receiving tumour necrosis factor-α agents.33 Miliary TB is due to lymphohaematogenous spread, and multiorgan involvement is common. Organs that receive the greatest vascular supply are at highest risk. The onset is usually 2–6 months after the initial infection; however, disease progression can

Conclusion

The spectrum of paediatric TB disease is influenced by host factors such as age and immunological status. Although the most common presentation is with thoracic disease, the possibility of disseminated or focal extrathoracic disease must be considered in neonatal and immunocompromised populations. Due to limitations in diagnostic modalities and low culture yield in paediatric patients, the diagnosis of TB often rests upon a positive TST, chest radiograph findings, compatible clinical findings,

Practice points

  • Only 5–10% of immunocompetent children progress from tuberculosis infection to disease.

  • Risk of progression to disease and risk of extrapulmonary tuberculosis are dependent upon host factors such as patient age and immune status.

  • The most common sites of infection are the lung and superficial lymph nodes, together accounting for approximately 90% of disease in children.

  • Rapidly progressive forms of disease include central nervous system involvement and disseminated (miliary) tuberculosis; later

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