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TB Indian Academy of Pediatrics IAP congenital
TB/01(O) INCIDENCE OF TUBERCULOSIS IN PERINATALLY AQUIRED HIV INFECTED CHILDREN Hemant kumar, Meenakshi sharma, Jagdish singh Department of Pediatrics ,SPMCHI, Jaipur HIV-TB coinfection has a cascading adverse impact on outcome of both HIV and TB.In view of paucity of studies on pediatric HIV-TB coinfection in India AIM of this study is to evaluate incidene of tuberculosis in perinatally aquired HIV infected children.DESIGN-case series study.MATERIALS and METHODS-study conducted at SPMCHI,Jaipur from 15-9-2004 to 15-9-2005.In this study perinatally aquired HIV infected children were subjected to a battery of investigations for diagnosis of tuberculosis based upon guidelines of consensus statement of IAP.Diagnosis of HIV infection was established by HIV DNA/RNA PCR before 18 months of age and by three ELISA’s after 18 months of age.Perinatally aquired infection was assumed when mother was HIV positive and no other alternative route of transmission could be established.RESULTS-out of 35 perinatally aquired HIV infected children , 11 had evidences of probable tuberculosis [Incidence-31.4%]. Four had miliary pulmonary TB,three had progressive pulmonary disease, four had CT chest based evidences of tuberculosis. Among these one had evidences of CNS TB and one had evidences of Abdominal TB .so only two had disseminated TB. Mantoux test was positive in only one case. None of the patients had culture proven mycobacterium tubercular disease.Six children received HAART along with antitubercular therapy[ATT].None of these six, had paradoxical reaction or any significant adverse effect.CONCLUSION-TB is quite common in perinatally aquired HIV infected children[Incidence- 31.4%] . As HIV-TB coinfection has cascading adverse impact on outcome of both ,TB should be actively searched and treated in these children. TB/02(P) NEUROTUBERCULOSIS: CAUSE OF OBESITY IN A CHILD Ravinder K. Gupta, Arjun Singh Department of Pediatrics, Acharya Shri Chander College of Medical Sciences and Hospital (ASCOMS), Sidhra, Jammu Case: An eleven year old male child presented with history of increased weight gain, sleepiness, pain in knees and ankles along with generalized body aches and pain abdomen off and on for past three months.There was history of excessive appetite along with decreased physical activity and lethargy. There was no history of fever, rash, swelling in knees or ankles. His bowel and bladder habits were normal. His milestones were consistent with age and birth history was uneventful. Before coming to this hospital, patient had taken ATT for nine months at a rural centre and he had stopped it about three months back. There was no history of similar complaints or any other significant illness in any of the family members. On examination child was conscious, cooperative and well oriented to time, space and person. Most of the time he used to be lethargic and sleeping. All his vitals were maintained. There was no pallor, icterus, cyanois, edema and lymphadenopathy. BCG scar was not present. Weight of the child was 40 kg., height 125 cms.,head circumference 53cms., chest circumference 77 cms.,mid-arm circumference 20 cms.,and his BMI was 25.64[ greater than 95th percentile] . Systemic examination including genitalia revealed no abnormality. Eye including fundus examination and ENT examination were also within normal limits. The child was subjected to investigations which revealed his Hb-13.0 gms / dl , TLC- 9000 / mm3 , DLC-P68 , L30 , E2 , PBF was normocytic normochromic , ESR was 22mm at 1st hr., urine and stool examination was normal and specific gravity of urine was 1.020. RFT, LFT, Blood sugar , lipid profile and thyroid profile were within normal limits. X-ray chest revealed prominent hilar shadows with surrounding parenchymal lesion on right side, consistent with pulmonary tuberculosis. USG abdomen revealed no abnormality; montoux test reading was 22mm.Contrast enhanced MRI study revealed the presence of multiple thick walled ring enhancing lesions in the brain surrounded by oedema and presence of a rounded non-enhancing cystic lesion in the supra –sellar region. The findings were highly suggestive of multiple granulomatous lesions (tuberculomas) Thus in view of clinical history including past history and laboratory profile with imaging study, a diagnosis of neurotuberculosis with obesity was made and child was put on ATT with steroids and supportive therapy. During the course of treatment in hospital child’s general activity improved, generalized body aches and lethargy was decreased and appetite became normal. To conclude, any child coming for evaluation of obesity, neurotuberculosis as the cause of obesity should be kept in mind and accordingly investigated. TB/03(P) EARLY DIAGNOSIS OF CNS TUBERCULOSIS WITH CSF PCR IN A PATIENT WITH NO ETIOLOGICAL OR BIOCHEMICAL EVIDENCE OF TUBERCULOUS MENINGITIS Tanmay Toteja,Vikas Bhambhani,Jacob Puliyel,Suman Lata Department of Pediatrics,St. Stephen's Hospital,Tis Hazari,Delhi-54 INTRODUCTION / BACKGROUND: In stage I of TBM no cytological or biochemical changes are seen in the CSF, though bacilli are present. Early diagnosis can be made by CSF PCR for TB. CSF PCR positivity for TB without evidence of TBM or systemic tuberculosis has been reported in 5 cases of HIV positive individuals. We here report a case of focal seizures, granuloma, a normal CSF picture and culture, HIV ELISA negative but PCR CSF for TB positive CASE REPORT: A 3 year 9 month old boy with left complex partial seizures ; no history of Koch’s contact ; an unremarkable clinical examination , no neurological deficit, no features of raised ICP and meningism. CECT HEAD – Ring-enhancing lesions with perilesional edema; no evidence of abnormal meningeal enhancement or hydrocephalus. ESR 8 mm in I hour, Mantoux test 15 x 10 mm CSF – Normal cytology and biochemistry; Gram’s and AFB staining and culture inconclusive HIV ELISA – negative; Chest X- ray – Normal; PCR ASSAY for TB - POSITIVE Treatment – ATT (2HRZE + 10 HRE) with steroids and anti-epileptics RESULTS: On follow up – No seizures and resolution of the granuloma over 1 year on CECT head. DISCUSSION: Granulomatous lesions are common findings in a patient with focal seizures. Neurocysticercosis and tuberculoma being the most common differential diagnosis of the above in the Indian sub-continent. Gold standard for diagnosis is stereotactic biopsy and histology. In early TBM diagnosis can be established by CSF PCR ASSAY before cytological or biochemical changes are seen in CSF thus preventing extensive damage and neurological sequale. CONCLUSION: Early diagnosis of tubercular etiology in Granulomatous lesions can be established by CSF PCR ASSAY TB/04(P) CONGENITAL TUBERCULOSIS Rajiv Kumar, Nomeeta Gupta Department of Pediatrics, Batra Hospital & Medical Research Centre, New Delhi-110062. Congenital tuberculosis is a rare disease with a high mortality and less than 300 cases have been reported so far in the literature. Only about 10 cases reported so far in India. A timely diagnosis is difficult because the symptoms in the infants are often non-specific and mothers are often asymptomatic. A primary complex in the liver can be regarded as strong evidence of congenital tuberculosis.We report a case of congenital tuberculosis diagnosed by liver biopsy in a 2 months old infant presented with acute abdomen. Case Report: A 8 weeks old infant presented with fever, excessive cry, vomiting, gradual abdominal distension and refusal of feeds for five days. The child was sick, toxic-look, irritable and had mild pallor with no icterus or superficial lymphadenopathy. Systemic examination revealed abdominal distension, hepatosplenomegaly, reducible umbilical hernia and right hydrocele. Late onset septicemia, intrauterine congenital infections and intestinal obstruction with paralytic ileus were considered in the differential diagnosis. Laboratory investigations revealed Hb 8.1 gm%, TLC 16600/mm3 with 73% neutrophils, 24% lymphocytes, 2% monocytes and 1% eosinophil, ESR 58mm and platelet count 80,000/mm3. PT and PTT were normal. Liver enzymes were elevated. Serological tests for TORCH, syphilis and HIV were negative. Alpha- fetoprotein was normal. Hepatitis B surface antigen and hepatitis C antibody were negative. Chest X-ray showed ill-defined homogenous opacity in the right paracardiac region. Abdominal X-rays revealed gaseous distension of bowel loops. Abdominal ultrasound revealed hepatosplenomegaly, portal adenopathy and minimal free fluid in the Morrison’s pouch. CT abdomen revealed ascites with hepatosplenomegaly with mutiple hypodense lesions in liver and spleen with necrotic retroperitoneal or intra-abdominal lymphadenopathy. Early morning gastric aspirate smear for AFB on consecutive three days and tuberculin test were negative. Miniexploratory laparotomy was done because of his worsening clinical status on 7th day of admission. Liver and retroperitoneal lymph nodes biopsy showed multiple epitheloid cell granulomas with occasional Langhans’ giant cells and central necrosis in few of them. Antituberculous treatment was started on 8th day of admission. The family screening for tuberculosis was negative. Endometrial biopsy in the asymptomatic mother confirmed the source of infection and the perinatal onset of illness. TB/05(P) CALVARIAL TUBERCULOSIS Neeraj Awasthy 123, Anandkunj, Vikaspuri, New Delhi, 110018 Calvarial tuberculosis is a very rare entity scantily described in literature. It forms 0.2-1.3% of the bone tuberculosis. This entity is rare even in the endemic areas for tuberculosis thus necessitating the awareness of the lesion so as to enable diagnosis. Primary Calvarial tuberculosis with no evidence of tuberculosis is still rarer of these cases. We describe six cases of Calvarial tuberculosis. The relevant clinicoradiological features and management are discussed. A high index of suspicion and awareness of this condition may lead to more cases being diagnosed early. TB/06(O) PEDIATRIC MDRTB – FOUR CASE REPORTS FROM BELUR ESI TB HOSPITAL Sumit Kumar, Amit Kumar Poddar, Kunal Dutta, Pradip Bhattacharya Belur ESI TB Hospital, Sapuipara, Bally, Howrah, West Bengal – 711227 Introduction: MDRTB is a ticking time bomb which is not being treated by RNTCP. Out of 200 beds in our hospital we have 16 in 3 wards reserved for MDRTB. These beds are always occupied. Materials and Methods: After sputum is persistently AFB positive for 5 months, sample is sent for culture in LJ Media and MDR Regimen is started. Drugs available are: Kanamycin, PAS, Cycloserine, Ethionamide, Sparfloxacin/Levofloxacin/Ciprofloxacin. Case Reports: Four Children below 18 years were treated successfully between 1999-2005. Sahazad (14 years) admitted for 5 years was initially treated by Streptomycin PZA, Ciprofloxacin and Ethionamide for 2yrs 4mths. Then due to fall and rise of Sputum positivity, he was treated with Kanamycin, Sparfloxacin, Cycloserine, Dapsone and Clofozimine for 2yrs 2mths and cured. Nityananda (10 yrs) admitted for 2yrs 4mths, Robin (17yrs) admitted for 2yrs 6mths, Pavan (16yrs) still admitted, were treated with Kanamycin, PAS, Ethionamide, Cycloserine, Sparfloxacin/Levofloxacin/Ciprofloxacin. All the cases were HIV and HBsAg negative. ADR encountered were hypothyroidism, psychosis and gastritis. Conclusion: MDRTB should be treated institutionally and under supervision to prevent an epidemic if not a global pandemic. TB/07(P) MILIARY TB – AN UNUSUAL PRESENTATION Lalitha Kailas, B. Vijayakumar, Kiron S. Professor & HOD, Dept. of Pediatrics, SAT Hospital, Medical College, Trivandrum Miliary TB usually presents in infants and yound children with fever and respiratory symptoms and signs. We present a 6 ½ year old child who presented with PUO but no respiratory complains. The fundus examination showed choroid tubercles and the repeat Xray showed miliary mottling.
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