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.