Clinical forms of tuberculosis in children and adolescents

Tuberculosis infection, penetrating the child's body, can affect all organs and systems of the body, the tubercle bacillus does not penetrate only the hair, nails and teeth. Therefore, they meet different forms of tuberculosis. In childhood, primary forms of tuberculosis predominantly develop. In older children and adolescents, secondary tuberculosis occurs in more than 50% of cases. According to the international classification, tuberculosis is divided into respiratory tuberculosis, tuberculosis of the nervous system, tuberculosis of other organs and systems, and miliary tuberculosis.

In the ICD-10 tuberculosis is indicated by codes A15-A19.

Advances in theoretical and methodological immunology allowed researchers to characterize systemic and local changes in immunological reactivity in the tuberculosis process quite fully. Primary infection with tuberculosis causes immunologic reorganization: the body becomes sensitive to tuberculin, develops a tuberculin allergy. It is now recognized that a delayed-type hypersensitivity, the main component of cellular immunity, is the leading factor in immune mechanisms in tuberculosis.

The clinical period of primary tuberculosis infection takes 6-12 months from the moment of infection with tuberculosis, at this time the risk of development of the disease is highest. Distinguish usually asymptomatic pre-inflammatory period - the time from the moment of penetration of MBT into the body of the child before the appearance of a positive tuberculin reaction, which averages 6-8 weeks. As well as the turn of tuberculin reactions - the transition of a negative reaction to a positive one. Essential to understanding tuberculosis is the unique nature of immunobiological changes, characterized by the development against a background of high sensitivity to tuberculin of nonspecific allergic inflammatory processes in various organs and systems with weakening of cellular immunity.

The early period of primary tuberculosis infection is the initial phase of the interaction of the causative agent of tuberculosis and the macroorganism. The MBT during this period is rapidly spreading lymphogenous and hematogenous throughout the body (latent microbism), causing specific sensitization and paraspecific tissue changes. Paraspecific reactions disrupt the functions of various organs, cause a variety of clinical symptoms, often causing diagnostic difficulties (masks of tuberculosis). Currently, the early period of primary tuberculosis infection in most children is almost asymptomatic.

Identify the early period of primary tuberculosis infection allows a systematic formulation of the Mantoux reaction with 2 TE. The change in sensitivity to tuberculin due to the recent infection with MW is called a turn of tuberculin reactions. The intermediate form of the tuberculosis process before the development of the local tuberculosis process is tuberculosis intoxication. In the future, primary or secondary forms of tuberculosis develop.

Anatomical and physiological features of the adolescent period:

• there is a reorganization of the neuroendocrine apparatus;
• intensively growing segments of the lungs;
• the level of metabolism and the level of energy costs change;
• elastic fibers in the alveoli and interalveolar spaces intensively develop;
• there is a discrepancy between the anatomical structure of the organs (incomplete development of the functioning part, weakness of the connective structures) and the increased functional needs of the organism;
• there is a psychological restructuring, the stereotype of a child's life breaks down, a new social situation is formed, many new contacts arise, the diet changes, new habits are acquired, including harmful ones (smoking, alcohol, drug addiction).

The peculiarity of tuberculosis in adolescence is a tendency to progressive flow, alterative necrotic reactions. Pulmonary tissue disintegration is relatively frequent and rapid (the tendency to decay is more pronounced than in adults); Secondary forms of tuberculosis, characteristic of adults (infiltrative, focal, cavernous tuberculosis) develop with the preservation of the features of the primary period (high general sensitization). Adolescents living in tuberculosis contact develop tuberculosis twice as often as children of other ages (except for young children); late diagnosis, inadequate treatment, missed "turn", the lack of preventive treatment in the period of "bend" lead to the chronicization of the tuberculosis process.

Tuberculosis in children with HIV infection

The clinical course of HIV infection in children with tuberculosis and the prognosis of the disease appear to be related to the pathway of HIV infection. Early infection during fetal development can lead to fetal death, which is what. May be indicated by a higher number of spontaneous abortions, fetal defects and stillbirths in HIV-infected women. Infection during childbirth, apparently, leads to a later appearance of signs of infection. Finally, parenteral infection causes a longer progression of the disease. According to I.A. Popova, the most significant factor determining the survival of HIV-infected children in the foci of infection, was their age at the time of infection. In the group with a rapid progression of the disease, the age of children at the time of infection ranged from 1 to 11 months, and in the group with a slow progression, from 18 months to 11 years.

The main feature of the clinical course of tuberculosis and HIV infection in children, especially those infected by HIV-infected mothers, is the delay in psychomotor development associated with the defeat of the HIV brain. Which morphologically manifests itself atrophy of brain structures. For children, the development of lymphoid interstitial pneumonitis and lymphadenopathy is characteristic, which makes differential diagnosis of hilar lymph nodes difficult with tuberculosis. Children, unlike adults, are more likely to suffer from secondary bacterial infections: otitis, sinusitis, urinary tract infections, pneumonia, etc.

Morphological manifestations and the course of the tuberculosis process depend on the age and the state of immunity at the time of the disease. In young children, tuberculosis is difficult: with a tendency to dissemination, generalization of the process with CNS damage. The prevalence of tuberculosis lesions is associated not only with the state of the immune system as a whole, but also with the absence of anti-tuberculosis immunity, since children born from HIV-infected mothers are not vaccinated with BCG vaccine until the age of 18.

When organizing early detection of tuberculosis in children with HIV infection, one should not limit oneself to traditional methods of testing for tuberculosis. Given that the immunopathogenesis of tuberculosis changes against the background of HIV infection, the reaction to standard tuberculin at a dose of 2 TE is very negative in tuberculosis infected with mycobacteria of children, which makes early diagnosis of tuberculosis difficult.

To improve the detection of tuberculosis or tuberculosis of HIV-infected children, especially those at risk for tuberculosis, it is necessary:

• systematic monitoring of children's health;
• constant monitoring by the phthisiatrician;
• Mantoux test with 2 TE of purified tuberculin PPD-L 2 times a year;
• timely appointment of preventive treatment (according to indications);
• use of a Mantoux sample with a higher dose of tuberculin - 5 or 10 TE for detection of infection with Mycobacterium tuberculosis; use of new diagnostic methods - detection of antibodies to mycobacterium tuberculosis by ELISA;
• determination of the genetic material of mycobacterium tuberculosis by PCR;
• along with traditional X-ray tomography methods (chest X-ray) - X-ray computed tomography.

Primary tuberculosis

Primary tuberculosis complex

The primary complex is identified in different age groups; most often - in young children. Considering that. That at present, along with a decrease in infection in children, its shift toward older age groups occurs, and the primary tuberculosis complex is also detected in adolescents.

Inflammatory changes in primary tuberculosis depend to some extent on the child's age. Particularly pronounced propensity to the extensive processes in the primary period in children aged 0 to 7 years. This circumstance is explained by the fact that during this period the differentiation of the pulmonary tissue has not yet been completed, in which wide lumens of lymphatic fissures are preserved, loose connective tissue septums rich in lymphatic vessels, which contributes to the spread of inflammatory changes. Clinical manifestations of the primary tuberculosis complex in young children are expressed to the greatest extent and are characterized by widespread and complicated forms. In cases where the size of the primary focus is small, the perifocal infiltration zone is not visible or blurred, the changes in the intrathoracic lymph nodes are limited, the clinical manifestations of the primary complex are erased and are not highly symptomatic. In a number of cases, the primary complex has an asymptomatic course and is detected already in the phase of reverse development - calcification. The evolution of the primary pulmonary focus can be different. A small focus with a predominance of infiltrative, and not necrotic, changes can completely resolve. In other cases, lime is deposited in the outbreak with the formation of the so-called Gon focus. However, in such cases, resorption of lime and a significant decrease, and in some cases, complete disappearance of the source, are possible.

Tuberculosis of the intrathoracic lymph nodes

The first place among the clinical forms of primary tuberculosis in children and adolescents currently occupies tuberculosis of the intrathoracic lymph nodes: it accounts for 75-80% of all cases of tuberculosis in children. The frequency of this clinical form is increased mainly by improving the methods of diagnosing little-expressed specific changes.

The course depends on the prevalence of specific inflammation, on the one hand, and the state of immunological reactivity of the organism, on the other. The nature of the course of the process and its outcome are also determined by the timely detection of the disease and the usefulness of tuberculostatic therapy. In young children who are not vaccinated or ineffectively vaccinated with BCG in close bacillary contact, tuberculosis of the hilar lymph nodes, even with a limited nature of the initial process, can proceed violently and become generalized. In most cases, bronchoadenitis proceeds favorably. Timely identified processes with limited lesion of the intrathoracic lymph nodes with full tuberculostatic therapy usually give a positive dynamics with a gradual transition from the phase of infiltration to the phase of resorption.

Tumor, or tumor, the form of tuberculosis of the intrathoracic lymph nodes, as a rule, has a more severe clinical course. This form is more common in young children, it is accompanied by a more vivid clinical picture, it is often accompanied by the development of complications. This form is characterized by hyperergic sensitivity to tuberculin on the background of a "bend".

Tuberculosis of the intrathoracic lymph nodes must be differentiated from pathological changes in the mediastinum and root of the lungs of nontuberculous etiology. Most often in young children, problems arise that require an additional radiological examination of education in the anterior mediastinum. The main cause is thymus gland. Carrying out a lateral radiograph of the thoracic organs allows excluding lymph node involvement.

Secondary Tuberculosis

Secondary forms of tuberculosis in children are found only at the senior school age, coinciding with the puberty period (13-14 years). For adolescents, secondary forms of primary genesis are characteristic (on the background of the widespread pulmonary process, there are tuberculosis infected with intrathoracic lymph nodes). The predominant form is infiltrative and focal pulmonary tuberculosis.

Disseminated tuberculosis of the lungs

Currently, in childhood and adolescence, hematogenically disseminated tuberculosis is rare.

The development of disseminated forms of tuberculosis is preceded by the period of primary tuberculosis infection and the breakthrough of the tuberculosis focus into the bloodstream while simultaneously sensitizing the vascular system. For the onset of the disease, it is important to reduce immunity under the influence of adverse effects (insolation, eating disorders, intercurrent infections during the bending period, etc.).

In young children, the disease often takes the form of miliary tuberculosis. When along with the lungs are affected and other organs. The source of dissemination in secondary forms of tuberculosis can be lungs, bones, kidneys and other organs. The subacute form occurs very rarely in older children and adolescents, often occurs during the period of primary infection, but may also appear as a secondary form of tuberculosis, together with foci of extrapulmonary localization

In the absence or insufficiently intensive treatment, the adolescent's disease progresses steadily in most cases; enlarged and merged scattered foci in the lungs, new cavities of decay appear, and later the development of lobular caseous pneumonia. This unfavorable course of subacute dissemination in adolescents can be explained by the transitional age, when hormonal changes occur, an unstable state of immunobiological processes occurs with regard to tuberculosis infection.

With chronic disseminated tuberculosis, the process acquires features of fibrous-cavernous tuberculosis with exacerbation in the spring-autumn period and an unfavorable outcome.

Tuberculous pleurisy

In children and adolescents pleurisy can occur as a complication of tuberculosis of the intrathoracic lymph nodes and the primary tuberculosis complex, and also as an independent disease.

If a clinical and radiological examination of the tuberculosis picture is clearly visible, pleurisy is regarded as a complication. In the same cases, when no changes are detected, pleurisy is treated as an independent form of tuberculosis.

Distinguish pleurisy dry (fibrinous) and exudative. Dry pleurisy of children and adolescents can be a manifestation of active, and most often primary or disseminated pulmonary tuberculosis as a result of lymphohematogenous spread of infection.

Clinical manifestations and symptoms of exudative pleurisy are largely determined by its localization. The effusion can be free or coagulated. Topography distinguishes apical pleurisy, costal, interlobar, mediastinal, diaphragmatic panpleuritis.

Interdollar pleurisy in children is more often a complication of tuberculosis of the intrathoracic lymph nodes. Mediastinal pleurisy is most often seen as a complication of the primary tuberculosis complex or bronchoadenitis in young children.

Extrapulmonary tuberculosis in children and adolescents

Extrapulmonary forms of tuberculosis in children, as a rule, serve as a manifestation of lymphogenous or hematogenous dissemination, the condition of which is the massive nature of the infection against the background of poor vaccination of BCG or its absence, adverse socioeconomic factors and various concomitant diseases.

Comparison of the nature of manifestations of extrapulmonary forms of the disease in the structure of newly diagnosed tuberculosis in children over the past 15 years has shown that, despite the worsening epidemiological situation in the country as a whole, the total number of extrapulmonary forms of the disease has decreased. A decrease in the incidence of tuberculosis meningitis, osteoarticular tuberculosis was noted. The number of children with tuberculosis of the genitourinary system, peripheral lymph nodes and eyes, on the contrary, tends to increase. It is established that there are no any differences in age in the incidence rates of pulmonary and extrapulmonary forms. In young children, the lesion of the osteoarticular and central nervous system predominates, indicating the generalization of the process characteristic of this age. The remaining children are more often affected by peripheral lymph nodes and urogenital organs.

Tuberculosis of peripheral lymph nodes

Clinical manifestations of tuberculosis of peripheral lymph nodes in children are similar to those in adults.

Tuberculous meningitis

Tuberculosis of meninges mostly affects children under 5 years old. Most often the disease develops during the first years after infection with mycobacterium tuberculosis.

In young children, parents can pay attention to such initial symptoms as decreased appetite, increasing drowsiness, adynamia. In the first days of the disease, convulsions, frustration of consciousness and focal symptoms of the CNS lesion appear as a violation of the functions of the cranial nerves, paresis or paralysis of the limbs. Meningeal symptoms can be expressed weakly, a bradycardia is absent. The chair becomes more frequent 4-5 times a day, which, in combination with vomiting (2-4 times), resembles dyspepsia. At the same time there is no excision, a large fontanel is tense, bulging. Hydrocephalus is developing rapidly. Sometimes the clinical picture of tuberculous meningitis in a nursing baby is so rubbish that nothing else can be noticed, other than a rise in temperature, increasing drowsiness and adynamia. The swelling and tension of the fontanel become decisive in these cases. If the diagnosis is not timely delivered, the disease progresses and after 2, a maximum of 3 weeks leads to death. From the meningeal symptoms in children of early age, the symptom of "hanging" (Lesage) is characteristic: the child lifted by the armpits pulls the legs to the stomach, keeping them in a bent position, and the "tripod" symptom is a peculiar pose in which the child sits on the hands behind the buttocks . In the second period of the disease, meningeal symptoms appear and grow, signs of cranial nerve damage (more often III and VI pairs).

In older children, tuberculous meningitis proceeds in the same way as in adults.

Clinical manifestations of the disease depend on the degree of damage to the internal organs, the age-related reactivity of the organism, the virulence of the microbe and its sensitivity to the drugs used, and on the start of treatment. The prognosis of a child under the age of 3 years is worse compared to the older age. With a timely (before the 10th day) long-term comprehensive treatment, the prognosis is favorable in more than 90% of cases.

Brain tuberculosis in children in most cases remains very small and does not cause an increase in intracranial pressure, but may cause a characteristic local symptomatology with signs of volume lesion.

It is necessary to diagnose tubercular meningitis before the 7th-10th day of the disease, even during the exudative phase of inflammation. In these cases, you can hope for a complete cure.

It is important to consider the following:

• anamnesis (information on contact with tuberculosis patients):
• the nature of tuberculin samples, the timing of revaccination (given that in case of a child's severe condition, tuberculin tests may be negative);
• clinical manifestations (the nature of the onset and development of meningitis, the state of consciousness, the severity of meningeal symptoms);
• chest X-ray: detection of active tuberculosis or residual changes of the transferred tuberculosis (at the same time, their absence does not allow to reject the tuberculosis etiology);
• lumbar puncture with the study of cerebrospinal fluid is the decisive factor in elucidating the etiology of meningitis:
• examination of the fundus: the detection of tubercular tubercles on the retina indicates with certainty the tubercleous etiology of meningitis. Stagnant discs of the optic nerves reflect an increase in intracranial pressure. It should be borne in mind that with a pronounced stagnation in the fundus, an axial dislocation is possible with lumbar puncture. In this case, the cerebrospinal fluid should be released. Do not remove the mandrana from the needle;
• bacteriological study of cerebrospinal fluid: detection of mycobacterium tuberculosis is an indisputable proof of the tubercular nature of meningitis.

Principles of treatment of tuberculosis of meninges, a combination of drugs, duration of their reception are similar to those for adult patients, except for calculating the daily dose of drugs per 1 kg of the body weight of the child. An adequate dose of isoniazid is 30 mg / kg per day. The younger the child, the higher the dose should be. Assign a strict bed rest for 1,5-2 months. After 3-4 months they allow movement through the ward.

Reconvalvesentam in the first 2-3 years spend anti-relapse courses for 2 months in the spring and autumn in the conditions of a specialized sanatorium.

Tuberculosis of bones and joints

Tubercular lesions of the skeleton in children and adolescents are characterized by extensive destruction of bones and joints, which in the absence of adequate treatment leads to an early and steadily progressing disability.

Diagnosis of osteoarticular tuberculosis in children is carried out in parallel in two directions:

• determination of the activity and prevalence of tuberculosis infection;
• Determination of the prevalence of local lesions and its complications. The evaluation of the activity and prevalence of tuberculosis infection in a child with osteoarticular tuberculosis is carried out in specialized anti-tuberculosis institutions: they establish the fact of infection with mycobacteria of tuberculosis, the clinical form of tuberculosis of respiratory organs, the degree of sensitivity to tuberculin; reveal other organ damage. For diagnosis, traditional criteria are used:
• anamnestic and epidemiological - information on contact with a patient with tuberculosis, its duration, vaccination and revaccination of BCG, the nature of the postvaccinal reaction, the dynamics of tuberculin samples:
  • data from X-ray tomography or CT of thoracic organs;
  • laboratory data - clinical blood analysis (absolute number of leukocytes and leukocyte formula, ESR value), urine, proteinogram (content of α ₂ and γ-globulins, C-reactive protein):
  • data of tuberculin samples - Mantoux reactions with 2 TE PPD-L and advanced tuberculin diagnostics;
  • serological and immunological parameters;
  • results of bacteriological examination of sputum, urine, as well as pathological contents of abscesses and fistulas on mycobacterium tuberculosis and concomitant bacterial flora.

Diagnosis of local lesions of bones and joints is carried out on the basis of clinical and radiation methods of investigation. Clinically assess the appearance of the affected skeleton, the presence of abscesses, fistulas, the amount of deformities, contractures, the degree of restriction of the function of the organs, neurological symptoms. The basic method of radial assessment is the standard radiography of the affected skeleton in two projections. To clarify the diagnosis using special techniques - X-ray tomography, CT, MRI. Each of these methods is used according to the indications, depending on the localization of the process and the diagnostic tasks. In the presence of abscesses, fistulas, material of previous operations or biopsies, a bacteriological, cytological and / or histological examination is performed.

The general state of children with tuberculous ostitis usually does not suffer, the symptoms of intoxication are revealed either with multiple bone foci, or with an active intrathoracic tuberculosis process.

To the peculiarities of clinical manifestations of tubercular arthritis in children, their polymorphism should be attributed. On the one hand, the disease can be accompanied by severe clinical manifestations, characteristic of acute nonspecific inflammatory lesions, on the other hand, pathology can be hidden and diagnosed only at the stage of already arising orthopedic complications - vicious situation and contractures. The late diagnosis of tubercular arthritis is usually associated with an underestimation of the epidemiological situation and clinical and radiological signs of the disease. In young children, arthritis usually develops on the background of pronounced general changes caused by disseminated tuberculosis, in adolescents - more often on the background of overall health. Patients are observed for a long time in the primary medical network with diagnoses: hematogenous osteomyelitis, infectious-allergic or purulent arthritis, transient arthralgia, Perthes disease. Suspicion of a specific lesion usually occurs when there is an extensive destruction of the joint on the background of apparent adequate treatment.

For tuberculous spondylitis in children, late diagnosis is associated with an underestimation of early symptoms of the disease. Unfortunately, the first complaint, on the basis of which suspicion of pathology usually arises, is the deformation of the spine. A retrospective analysis shows that in younger children, the general clinical symptoms appear much earlier: behavior change, anxiety in sleep, decreased appetite and motor activity, subfebrile condition, usually considered as manifestations of rickets or banal infections. The development of the disease is characterized by an increase in the symptoms of intoxication. The appearance of neurological disorders and an increase in the deformation of the spine, which is usually the reason for a primary radiographic examination. In school-age patients, at the onset of the disease, local clinical symptoms predominate: back pain, fatigue, posture disorder and gait. When examined, local soreness and stiffness of the back muscles, moderate deformation of the spine are revealed. The presence of pain in the absence of severe symptoms of intoxication and rough deformation leads to an unjustified diagnosis of "spinal osteochondrosis". X-ray examination is usually carried out because of increasing pain in the back, increasing kyphosis or with the appearance of neurological disorders.

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