Pediatric emergency medicine trisk 2309 2309
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Intrathoracic tuberculosis (pulmonary parenchymal disease, intrathoracic lymphadenopathy, and
pleural disease) and peripheral lymphadenopathy account for over 90% of all cases of childhood
tuberculosis.
Most children with tuberculosis have negative acid-fast sputum smears and cultures; the diagnosis is
instead based on a triad of findings: a positive TST or TB blood test (interferon gamma release
assays [IGRAs]); compatible radiographic and clinical findings; and contact with a person known to
have tuberculosis disease.
Preadolescent children with pulmonary tuberculosis without cavitary findings on radiography rarely
are contagious; however, providers should utilize airborne precautions because in many instances,
the child is brought to the ED by the person from whom they acquired tuberculosis, and that adult is
by definition contagious.
Current Evidence
The most common sites of infection are intrathoracic (pulmonary parenchymal, intrathoracic adenopathy, and/or
pleural effusions) and peripheral lymphadenopathy. Together, these account for over 90% of all childhood TB
cases. Meningeal tuberculosis comprises 1% to 2% of all childhood TB cases, and is most common in children in
the first 2 years of life.
Latent tuberculosis infection (LTBI) is defined as a positive TST ( e-Table 94.16 ) or IGRA in a child who
lacks TB symptoms and has a normal chest radiograph and physical examination. While LTBI will rarely be an
ED-based diagnosis, clinicians may see children with LTBI for nontuberculosis concerns or for medication adverse
events. Children with LTBI are not contagious and have no specific infection control considerations. As most
tuberculosis medications are hepatically metabolized, the clinician should be aware of potential hepatotoxicity if a
child receiving tuberculosis medication presents with abdominal pain, vomiting, anorexia, or icterus. Isoniazid
(INH) can also cause peripheral neuropathy and can cause benzodiazepine-refractory seizures in cases of overdose
(the antidote is pyridoxine, administered as a gram-to-gram dose based on the estimates of the INH dose ingested).
Goals of Treatment
The goal of treatment is to recognize which children with pulmonary, meningeal, or lymphadenitis may have
tuberculosis as opposed to other diagnoses.
Clinical Considerations
Clinical recognition: Tuberculosis disease ( e-Table 94.17 ) should be included in the differential diagnosis of
children with fever of unknown origin; pneumonia refractory to therapy for community-acquired pneumonia;
cavitary pneumonia/lung abscesses; hilar or mediastinal adenopathy; miliary pattern on chest radiograph; freeflowing pleural effusions with or without consolidation; chronic nontender adenopathy; chronic otorrhea or
chronic otitis media; and meningitis with an elevated CSF protein. Children with pulmonary tuberculosis often
have chest radiographs that look far worse than the child. Weight loss in combination with pneumonia should lead
the provider to broaden the differential diagnosis outside of the usual pathogens causing community-acquired
pneumonia. TB meningitis has an insidious onset, and in the early stages, children may have fever and
constitutional symptoms alone. Unexplained protracted vomiting (due to increased intracranial pressure) often is
identified only in retrospect. Given the nonspecific initial symptoms and the rarity of the diagnosis in
industrialized nations, many children with TB meningitis have had multiple healthcare encounters prior to
diagnosis.
Triage considerations: While prepubertal children with noncavitary chest radiographs rarely are contagious, the
person bringing the child to medical attention may be the person who transmitted tuberculosis to the child. As
such, airborne precautions should be used more to protect healthcare workers and other patients from the
caregivers, as opposed to from the patient him/herself.
Clinical assessment: The diagnosis of tuberculosis in a child infrequently is made based upon microbiologic
confirmation. Acid-fast cultures of respiratory secretions are positive in a minority of children; the highest culture
yield occurs in children with peripheral lymphadenopathy or skeletal disease. Instead, children usually are
diagnosed based on a triad of findings: epidemiologic links to a person with known or suspected tuberculosis
disease; a positive TST or IGRA; and compatible clinical or radiographic findings. A chest radiograph should be
performed in all children in whom TB is suspected; the most common findings include parenchymal infiltrates,
