Diagnosing childhood tuberculosis can be tricky<\/p>\n
Donya Betancourt, Pediatrician, drdonya@hotmail.com<\/p>\n
For today's article I have very good updated information on TB
\n(tuberculosis) from a doctor who has vast experience of the
\nsubject in Indonesia. However, he asked me to withhold his name
\nfrom publication.<\/p>\n
Dear Dr. Donya<\/p>\n
May I make some comments on your response regarding how to
\ndeal with children and TB? I returned to Indonesia in 1983, after
\nseven years' service as a medical officer with the Amsterdam TB
\nControl Consultation Bureau. This bureau monitors all immigrants
\nto the Netherlands.<\/p>\n
At the request of the Dutch overseas visitor police, my
\ncolleagues and I used to examine many children who had been
\ndiagnosed with and treated for TB in Indonesia.<\/p>\n
After careful investigation and questioning, most of them had
\nnever had TB! Thus is really a pitiful situation for children in
\nIndonesia, to say the least. And this has still been my personal
\nexperience, whenever I have been confronted with the many child
\nTB diagnoses in Jakarta or anywhere else in this country (as far
\nas East Timor).<\/p>\n
When a child has a long-standing or recurrent cough or is
\ndeemed as "failing to thrive", eventually a CXR (Chest X-Ray) is
\nnecessary.<\/p>\n
Although, in my opinion, the lungs are without abnormalities,
\nthe diagnosis is almost always reported as bronchopneumonia,
\nbronchitis. Or, dubious statements are made, like, "a specific
\nprocess is likely to be present" or "a specific process cannot
\nyet be excluded", leaving the referring doctor totally in the
\ndark.<\/p>\n
In this context, I must inform you that I have more than 40
\nyears of experience in TB control in several countries, and while
\nin the Netherlands, I was also engaged in training Dutch doctors
\nto read CXRs, preparing them to detect lung TB among the mass-
\nradiographed population.<\/p>\n
The Skin Test<\/p>\n
In Indonesia, especially in larger cities, 100 percent of
\nchildren have had a BCG vaccination. According to the world's
\nmost outstanding TB epidemiologists (Dr K. Styblo and Dr A.
\nRouillon) the Mantoux test (or the extent of its induration)
\ncannot differentiate between BCG vaccination and natural
\ninfection with TB bacilli. Hence a skin test will not be useful
\nafter BCG vaccination.<\/p>\n
The skin test (PPD, Tuberculin, Mantoux, etc.) is obviously
\nnot useful in a country with a high TB prevalence like Indonesia.<\/p>\n
The examination of contacts is a tricky business. If the child
\nreally has TB (who, for heaven's sake, could be in a position to
\nmake such diagnosis?), then a centripetal investigation should be
\nmade, regarding whom is the source of infection (i.e. a person
\nwho is producing TB bacilli, a person with definite TB of the
\nlungs). In practice, is there anyone in the family with chronic
\ncough, anyone who should be suspected of spreading the germs, and
\nwho is also in close contact with the child?<\/p>\n
A centrifugal investigation should be made if a source of
\ninfection is diagnosed in the family, i.e. someone who is
\nexcreting TB bacilli (as shown by microscopic examination). Then
\nall children with or without symptoms of TB must have a CXR (but
\nno skin test is needed after a BCG vaccination).<\/p>\n
Adults are recommended to have a CXR, starting with those who
\nhave symptoms consistent with active TB.<\/p>\n
It is interesting to note that adults with active TB usually
\nhave symptoms, whereas children with TB (or childhood TB) do not
\nshow symptoms. Childhood TB is a self-limiting disease. However,
\nthe serious complications of childhood TB (miliary and or
\nmeningitis TB) invariably cause very distinct and severe
\nsymptoms.<\/p>",
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