Sunday, 11 November 2012

A 3-year-old girl is admitted with the x-ray pictured. The child lives with her parents and a 6-week-old brother.

A 3-year-old girl is admitted with the x-ray pictured. The child lives with her parents and a 6-week-old brother. Her grandfather stayed with the family for 2 months before his return to the West Indies 1 month ago. The grandfather had a 3-month history of weight loss, fever, and hemoptysis. Appropriate management of this problem includes

a. Bronchoscopy and culture of washings for all family members
b. Placement of a Mantoux test on the 6-week-old sibling
c. Isolating the 3-year-old patient for 1 month
d. Treating the 3-year-old patient with isoniazid (INH) and rifampin
e. HIV testing for all family members

The answer is d. The key to controlling tuberculosis in children and eradicating the disease is early detection and appropriate treatment of adult cases; the child, once infected, is at lifelong risk for the development of the disease and for infecting others unless given isoniazid prophylaxis. The usual source of the disease is an infected adult. Household contacts of a person with newly diagnosed active disease have a considerable risk of developing active tuberculosis, and the risk is greatest for infants and children. Therefore, when tuberculosis is diagnosed in a child, the immediate family and close contacts should be tested with tuberculin skin tests and chest radiographs and treated appropriately when indicated. Bronchoscopy would be indicated only in unusual circumstances. Three to eight weeks is required after exposure before hypersensitivity to tuberculin develops. This means that the tuberculin test must be repeated in exposed persons if there is a negative reaction at the time that contact with the source of infection is broken. TB skin tests are usually negative in infants of this age, even when active disease is ongoing. A logical preventive measure is the administration of isoniazid to the baby for 3 months when a Mantoux (purified protein derivative, PPD) can then be placed. Transmission of tuberculosis occurs when bacilli-laden, small-sized droplets are dispersed into the air by the cough or sneeze of an infected adult. Small children with primary pulmonary tuberculosis are not considered infectious to others, and they are not capable of coughing up and producing sputum. Sputum, when produced, is promptly swallowed, and for this reason specimens for microbial confirmation can be obtained by means of gastric lavage from smaller children.


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