Pulmonary Tuberculosis in Severely-malnourished or HIV-infected Children with Pneumonia: A Review

Abstract

Presentation of pulmonary tuberculosis (PTB) as acute pneumonia in severely-malnourished and HIV-positive children has received very little attention, although this is very important in the management of pneumonia in children living in communities where TB is highly endemic. Our aim was to identify confirmed TB in children with acute pneumonia and HIV infection and/or severe acute malnutrition (SAM) (weight-for-length/height or weight-for-age z score <-3 of the WHO median, or presence of nutritional oedema). We conducted a literature search, using PubMed and Web of Science in April 2013 for the period from January 1974 through April 2013. We included only those studies that reported confirmed TB identified by acid fast bacilli (AFB) through smear microscopy, or by culture-positive specimens from children with acute pneumonia and SAM and/or HIV infection. The specimens were collected either from induced sputum (IS), or gastric lavage (GL), or broncho-alveolar lavage (BAL), or percutaneous lung aspirates (LA). Pneumonia was defined as the radiological evidence of lobar or patchy consolidation and/or clinical evidence of severe/very severe pneumonia according to the WHO criteria of acute respiratory infection. A total of 17 studies met our search criteria but 6 were relevant for our review. Eleven studies were excluded as those did not assess the HIV status of the children or specify the nutritional status of the children with acute pneumonia and TB. We identified only 747 under-five children from the six relevant studies that determined a tubercular aetiology of acute pneumonia in children with SAM and/or positive HIV status. Three studies were reported from South Africa and one each from the Gambia, Ethiopia, and Thailand where 610, 90, 35, and 12 children were enrolled and 64 (10%), 23 (26%), 5 (14%), and 1 (8%) children were identified with active TB respectively, with a total of 93 (12%) children with active TB. Among 610 HIV-infected children in three studies from South Africa and 137 SAM children from other studies, 64 (10%) and 29 (21%) isolates of M. tuberculosis were identified respectively. Children from South Africa were infected with HIV without specification of their nutritional status whereas children from other countries had SAM but without indication of their HIV status. Our review of the existing data suggests that pulmonary tuberculosis may be more common than it is generally suspected in children with acute pneumonia and SAM, or HIV infection. Because of the scarcity of data, there is an urgent need to investigate PTB as one of the potential aetiologies of acute pneumonia in these children in a carefully-conducted larger study, especially outside Africa.

Integration of childhood TB into guidelines for the management of acute malnutrition in high burden countries

“…29 Among children with severe malnutrition, respiratory symptoms, and CXR findings consistent with pneumonia, TB was diagnosed microbiologically in 7%, and clinically in an additional 16% of children; 30 one review reported TB in 21% of children with SAM and pneumonia. 31 This highlights the need to evaluate specifically for TB among children with malnutrition and respiratory symptoms. 28,31 Over one third of guidelines reviewed specify that TB medications can have toxic effects in children with acute malnutrition.…”

“…31 This highlights the need to evaluate specifically for TB among children with malnutrition and respiratory symptoms. 28,31 Over one third of guidelines reviewed specify that TB medications can have toxic effects in children with acute malnutrition. Children with malnutrition have altered drug metabolism; 32 however, based on a systematic review of the efficacy, safety, and pharmacokinetics of antibiotics in children with SAM, further research is needed to guide optimal antibiotic treatment for these children.…”

Improving Tuberculosis Care for Children in High-Burden Settings

“…8 Pulmonary TB in young children often presents as pneumonia, but the diagnosis is usually not considered even in high-burden countries until the disease is far advanced. Chisti et al 9 prospectively investigated causes of pneumonia in severely malnourished children aged ,5 years in a hospital in Bangladesh. Of 1482 children with severe malnutrition, 405 had respiratory symptoms and an abnormal chest radiograph; TB was confirmed microbiologically in 10 reviewed TB screening at nutritional rehabilitation centers in Karnataka, India, and found that a standardized TB diagnostic algorithm was followed for only 37% of the children.…”

Influência da L-glutamina sobre aspectos imunomodulatórios de células tronco mesenquimais medulares em situação de desnutrição proteico-energética

“…Portanto, a associação desnutrição-infecção é responsável pelos altos índices de morbidade e mortalidade (CHISTI et al, 2013).…”

“…Em resumo, a falência de tecidos e órgãos decorrente da DPE modifica a produção de células que orquestram a resposta imune e altera as respostas específicas e não-específicas do organismo de diversas formas (NOVA et al, 2002), comprometendo o sistema imune do indivíduo desnutrido e aumentando a sua susceptibilidade à infecções (CHISTI et al, 2013;HICKMAN et al, 2014;PAPIER et al, 2014). …”