Adolescents comprise one-third of pediatric tuberculosis (TB) cases in the United States, but there are few specific data on the epidemiology and clinical course in this population.
This was a ...retrospective review of adolescents (12-18 years old) seen at a Children's Tuberculosis Clinic in Houston, TX, from 1987 to 2012.
One hundred forty-five adolescents were identified; median age was 15.4 years: 50% female, 55% were Hispanic, 26% black, 13% Asian and 1% white; 54 were born abroad. Diagnoses were made after symptomatic presentation in 79%, during contact investigations in 14% and after screening tuberculin skin testing in the remainder. The most common symptoms were fever (63%), cough (60%) and weight loss (30%), but 21% were asymptomatic at diagnosis. Only 8% of adolescents with intrathoracic TB had hemoptysis. One hundred fourteen (78.6%) had isolated intrathoracic TB, 4 (2.8%) had intra- and extrathoracic TB and 27 (18.6%) had extrathoracic TB. The most common sites of extrathoracic TB were peripheral lymphadenopathy (10) and meningitis (6). The most common radiographic findings were infiltrates (34%), lymphadenopathy (27%), cavitary lesions (26%), pleural effusions (19%) and miliary disease (10%). Acid-fast bacillus smears and mycobacterial cultures were attempted for 97 of 118 adolescents with intrathoracic and 22 of 27 with extrathoracic disease, respectively, resulting in smear/culture positivity in 25% and 54% and 18% and 45%, respectively. Two patients died, 2 had relapse, 7 had significant sequelae and 92% recovered without complication. Seventy three percent of cases potentially were preventable.
The clinical, radiologic and microbiologic findings in adolescents with TB have features seen in both younger children and adults; most cases were preventable.
For testing immigrant children, research supports using interferon-gamma release assays rather than tuberculin skin tests.
US guidelines have recommended testing children emigrating from high ...tuberculosis-incidence countries with interferon-gamma release assays (IGRAs) or tuberculin skin tests (TSTs). We describe the Harris County (Texas) Public Health Refugee Health Screening Program’s testing results during 2010–2015 for children <18 years of age: 5,990 were evaluated, and 5,870 (98%) were tested. Overall, 364 (6.2%) children had ≥1 positive test: 143/1,842 (7.8%) were tested with TST alone, 129/3,730 (3.5%) with IGRA alone, and 92/298 (30.9%) with both TST and IGRA. Region of origin and younger age were associated with positive TST or IGRA results. All children were more likely to have positive results for TST than for IGRA (OR 2.92, 95% CI 2.37–3.59). Discordant test results were common (20%) and most often were TST+/IGRA– (95.0%), likely because of bacillus Calmette-Guérin vaccination. Finding fewer false positives supports the 2018 change in US immigration guidelines that recommends using IGRAs for recently immigrated children.
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.
Abstract
While interferon-gamma release assays (IGRAs) are widely used for detecting tuberculosis (TB) infection, tuberculin skin tests (TSTs) remain preferred for children under the age of 2 years. ...The preference for TST stems from concern over IGRA sensitivity in young children. However, TSTs are susceptible to false-positive results following Bacille Calmette-Guérin (BCG) vaccination, which is common in infancy, and exposure to nontuberculous mycobacteria. We reviewed available data for IGRA performance in children under age 2 years. Across four cohorts of high-risk children under age 2 (mostly case contacts or those born in tuberculosis endemic regions), 0 of 575 untreated children with negative IGRA test results progressed to tuberculosis disease—including 0 of 70 who were TST positive but IGRA negative. While neither TSTs nor IGRAs are perfectly sensitive for the diagnosis of tuberculosis infection, IGRAs are an acceptable alternative to TST in children <2 years of age.
Fever of unknown origin (FUO) in children is frequently caused by infectious diseases. Angiostrongylus cantonensis, while a primary cause of eosinophilic meningitis, is rarely a cause of FUO. We ...present 2 pediatric cases of FUO caused by Angiostrongylus cantonensis acquired in Houston, Texas, outside its usual geographic distribution.
Clostridium difficile-associated diarrhea (CDAD) is increasingly diagnosed in children in community settings. This study aims to assess recent antibiotic use and other risk factors in children with ...community-associated (CA-) CDAD compared with children with other diarrheal illnesses in a tertiary care setting.
Children with CA-CDAD evaluated at Texas Children's Hospital (Houston, TX) from January 1, 2012 to June 30, 2013 were identified. Two control subjects with community-associated diarrhea who tested negative for C. difficile were matched to case subjects. Data on demographics, medication exposure and outpatient healthcare encounters were collected from medical records. Multivariate logistic regression was performed to identify predictors of pediatric CA-CDAD.
Of 69 CA-CDAD cases, most (62.3%) had an underlying chronic medical condition and 40.6% had antibiotic exposure within 30 days of illness. However, no traditional risk factor for CDAD was identified in 23.2% and 15.9% of CA-CDAD cases within 30 and 90 days of illness onset, respectively. Outpatient healthcare encounters within 30 days were more common among CA-CDAD cases than control subjects (66.7% vs. 48.6%; P = 0.01). In the final multivariate model, CA-CDAD was associated with cephalosporin use within 30 days odds ratio: 3.32; 95% confidence interval: 1.10-10.01 and the presence of a gastrointestinal feeding device (odds ratio: 2.59; 95% confidence interval: 1.07-6.30).
Recent use of cephalosporins and the presence of gastrointestinal feeding devices are important risk factors for community- associated CDAD in children. Reduction in the use of outpatient antibiotics may decrease the burden of CA-CDAD in children.
childhood tuberculosis is a fundamentally different disease from adult tuberculosis. Most children who develop disease do so rapidly, within weeks or a few months of acquiring the infection, so time ...is critical. Childhood tuberculosis is often not difficult to diagnose clinically when chest X-ray is available and the child can be linked to a recently diagnosed case of contagious tuberculosis. This link is most often within the family, and just a few questions about ill family members can usually show that an ill child is at risk for having tuberculosis. However, this link requires an integrated and functional health care system that is lacking in many high burden areas. Children with tuberculosis have far fewer bacteria than adults and, as a result, detecting the germ using a microscope or a culture is difficult, positive, at best, 30% of the time, making tuberculosis in children difficult to confirm microbiologically. Several decades ago, it was decided to make microbiologic confirmation the main basis for tuberculosis case reporting in all ages; unfortunately, doing this ensured the exclusion of most children from tuberculosis reporting and demonstrated yet again why vulnerable groups need to have a seat at the table when policy is made.
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