Diagnosing childhood tuberculosis can be tricky

Diagnosing childhood tuberculosis can be tricky

Donya Betancourt, Pediatrician, drdonya@hotmail.com

For today's article I have very good updated information on TB
(tuberculosis) from a doctor who has vast experience of the
subject in Indonesia. However, he asked me to withhold his name
from publication.

Dear Dr. Donya

May I make some comments on your response regarding how to
deal with children and TB? I returned to Indonesia in 1983, after
seven years' service as a medical officer with the Amsterdam TB
Control Consultation Bureau. This bureau monitors all immigrants
to the Netherlands.

At the request of the Dutch overseas visitor police, my
colleagues and I used to examine many children who had been
diagnosed with and treated for TB in Indonesia.

After careful investigation and questioning, most of them had
never had TB! Thus is really a pitiful situation for children in
Indonesia, to say the least. And this has still been my personal
experience, whenever I have been confronted with the many child
TB diagnoses in Jakarta or anywhere else in this country (as far
as East Timor).

When a child has a long-standing or recurrent cough or is
deemed as "failing to thrive", eventually a CXR (Chest X-Ray) is
necessary.

Although, in my opinion, the lungs are without abnormalities,
the diagnosis is almost always reported as bronchopneumonia,
bronchitis. Or, dubious statements are made, like, "a specific
process is likely to be present" or "a specific process cannot
yet be excluded", leaving the referring doctor totally in the
dark.

In this context, I must inform you that I have more than 40
years of experience in TB control in several countries, and while
in the Netherlands, I was also engaged in training Dutch doctors
to read CXRs, preparing them to detect lung TB among the mass-
radiographed population.

The Skin Test

In Indonesia, especially in larger cities, 100 percent of
children have had a BCG vaccination. According to the world's
most outstanding TB epidemiologists (Dr K. Styblo and Dr A.
Rouillon) the Mantoux test (or the extent of its induration)
cannot differentiate between BCG vaccination and natural
infection with TB bacilli. Hence a skin test will not be useful
after BCG vaccination.

The skin test (PPD, Tuberculin, Mantoux, etc.) is obviously
not useful in a country with a high TB prevalence like Indonesia.

The examination of contacts is a tricky business. If the child
really has TB (who, for heaven's sake, could be in a position to
make such diagnosis?), then a centripetal investigation should be
made, regarding whom is the source of infection (i.e. a person
who is producing TB bacilli, a person with definite TB of the
lungs). In practice, is there anyone in the family with chronic
cough, anyone who should be suspected of spreading the germs, and
who is also in close contact with the child?

A centrifugal investigation should be made if a source of
infection is diagnosed in the family, i.e. someone who is
excreting TB bacilli (as shown by microscopic examination). Then
all children with or without symptoms of TB must have a CXR (but
no skin test is needed after a BCG vaccination).

Adults are recommended to have a CXR, starting with those who
have symptoms consistent with active TB.

It is interesting to note that adults with active TB usually
have symptoms, whereas children with TB (or childhood TB) do not
show symptoms. Childhood TB is a self-limiting disease. However,
the serious complications of childhood TB (miliary and or
meningitis TB) invariably cause very distinct and severe
symptoms.