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 tuberculosis bacillus does not penetrate only the hair, nails and teeth. Therefore, there are various forms of tuberculosis. In childhood, primary forms of tuberculosis mainly develop. In older children and adolescents, secondary tuberculosis occurs in more than 50% of cases. According to the international classification, tuberculosis is divided into tuberculosis of the respiratory organs, tuberculosis of the nervous system, tuberculosis of other organs and systems and miliary tuberculosis.

In ICD-10, tuberculosis is designated by codes A15-A19.

Theoretical and methodological advances in immunology have enabled researchers to characterize systemic and local changes in immunological reactivity in the tuberculosis process quite fully. Primary tuberculosis infection causes immunological restructuring: the body becomes sensitive to tuberculin, and tuberculin allergy develops. It is now recognized that 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 lasts 6-12 months from the moment of contracting tuberculosis, during which time the risk of developing the disease is highest. A distinction is usually made between an asymptomatic preallergic period - the time from the moment MBT enters the child's body until a positive tuberculin reaction appears, which averages 6-8 weeks. As well as a turn in tuberculin reactions - the transition of a negative reaction to a positive one. Of significant importance for understanding tuberculosis is the peculiarity of immunobiological shifts, characterized by the development of nonspecific allergic inflammatory processes in various organs and systems against the background of high sensitivity to tuberculin with weakening of cellular immunity.

The early period of primary tuberculosis infection is the initial phase of interaction between the tuberculosis pathogen and the macroorganism. During this period, MBT quickly spreads through the lymphogenous and hematogenous pathways 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 (tuberculosis masks). Currently, the early period of primary tuberculosis infection is almost asymptomatic in most children.

The early period of primary tuberculosis infection can be identified by systematically setting the Mantoux reaction with 2 TE. The change in sensitivity to tuberculin due to recent infection with MBT is called a turn in tuberculin reactions. The intermediate form of the tuberculosis process before the development of the local tuberculosis process is tuberculosis intoxication. Subsequently, primary or secondary forms of tuberculosis develop.

Anatomical and physiological characteristics of adolescence:

• the neuroendocrine apparatus is being restructured;
• lung segments grow intensively;
• the level of metabolism and the level of energy expenditure change;
• elastic fibers in the alveoli and interalveolar spaces develop intensively;
• a discrepancy arises between the anatomical structure of organs (incomplete development of the functioning part, weakness of connective structures) and the increased functional needs of the body;
• a psychological restructuring occurs, the child’s life stereotype is broken, a new social status is formed, many new contacts arise, the diet changes, new habits are acquired, including harmful ones (smoking, alcohol, drug addiction).

A feature of tuberculosis in adolescence is a tendency to a progressive course, alterative-necrotic reactions. Lung tissue decay occurs relatively often and quickly (the tendency to decay is more pronounced than in adults); secondary forms of tuberculosis, typical for adults (infiltrative, focal, cavernous tuberculosis), develop while maintaining the features of the primary period (high general sensitization). Adolescents living in contact with tuberculosis develop tuberculosis 2 times more often than children of other ages (except for young children); late diagnosis, inadequate treatment, missed "turn", lack of preventive treatment during the "turn" period lead to the chronicity 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 are likely related to the route of HIV infection. Early infection during intrauterine development may result in fetal death, which may be evidenced by the higher rate of spontaneous abortions, fetal defects, and stillbirths in HIV-infected women. Infection during childbirth likely results in a later appearance of infection signs. 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 infection foci was their age at the time of infection. In the group with rapid disease progression, the age of children at the time of infection ranged from 1 to 11 months, and in the group with 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 a delay in psychomotor development associated with HIV-induced brain damage, which is morphologically manifested by atrophy of brain structures. Children are characterized by the development of lymphoid interstitial pneumonitis and lymphadenopathies, which complicates differential diagnosis with tuberculosis of the intrathoracic lymph nodes. Children, unlike adults, more often suffer from secondary bacterial infections: otitis, sinusitis, urinary tract infections, pneumonia, etc.

Morphological manifestations and the course of the tuberculosis process depend on age and the state of immunity at the time of the disease. In young children, tuberculosis is severe: with a tendency to dissemination, generalization of the process with damage to the central nervous system. 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 to HIV-infected mothers are not vaccinated with the BCG vaccine until the age of 18.

When organizing early detection of tuberculosis in children with HIV infection, one cannot limit oneself to traditional methods of examination for tuberculosis. Considering that the immunopathogenesis of tuberculosis changes against the background of HIV infection, very often the reaction to standard tuberculin at a dose of 2 TE in children infected with Mycobacterium tuberculosis is negative, which complicates the early diagnosis of tuberculosis.

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

• systematic monitoring of children's health;
• constant monitoring by a phthisiatrician;
• conducting the Mantoux test with 2 TE of purified tuberculin PPD-L 2 times a year;
• timely administration of preventive treatment (as indicated);
• use of the Mantoux test with a higher dose of tuberculin - 5 or 10 TE - to detect infection with Mycobacterium tuberculosis; use of new diagnostic methods - determination of antibodies to Mycobacterium tuberculosis by the ELISA method;
• determination of the genetic material of Mycobacterium tuberculosis using the PCR method;
• Along with traditional X-ray tomographic research methods (survey chest X-ray), X-ray computed tomography is performed.

Primary tuberculosis

Primary tuberculosis complex

Primary complex is detected in various age groups; most often - in young children. Considering that at present, along with a decrease in infection in children, there is a shift towards older age groups, primary tuberculosis complex is also detected in adolescents.

Inflammatory changes in primary tuberculosis depend to a certain extent on the child's age. The tendency to extensive processes in the primary period is especially pronounced in children aged 0 to 7 years. This circumstance is explained by the fact that during this period the differentiation of the lung tissue is not yet complete, in which wide lumens of lymphatic clefts, loose connective tissue septa rich in lymphatic vessels are preserved, 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 lesion is small, the perifocal infiltration zone is absent or poorly represented, changes in the intrathoracic lymph nodes are limited, the clinical manifestations of the primary complex are erased and have few symptoms. In some cases, the primary complex is asymptomatic and is detected already in the phase of reverse development - calcification. The evolution of the primary pulmonary focus may be different. A small focus with a predominance of infiltrative rather than necrotic changes may completely resolve. In other cases, lime deposition occurs in the focus, forming the so-called Ghon focus. However, even with such variants, lime resorption and a significant reduction, and in some cases, complete disappearance of the focus are possible.

Tuberculosis of the intrathoracic lymph nodes

The first place among the clinical forms of primary tuberculosis in children and adolescents is currently occupied by 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 increasing mainly due to the improvement of diagnostic methods for mild specific changes.

The course depends on the prevalence of specific inflammation, on the one hand, and the state of the body's immunological reactivity, on the other. The nature of the process and its outcome are also determined by timely detection of the disease and the adequacy of tuberculostatic therapy. In young children who are not vaccinated or ineffectively vaccinated with BCG and who have come into close bacillary contact, tuberculosis of the intrathoracic lymph nodes, even with a limited nature of the initial process, can proceed rapidly and turn into a generalized form. In most cases, bronchoadenitis proceeds favorably. Timely detected processes with limited damage to the intrathoracic lymph nodes with adequate tuberculostatic therapy usually give positive dynamics with a gradual transition from the infiltration phase to the resorption phase.

Tumorous, or tumorous, 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 against the background of a "virage".

Tuberculosis of the intrathoracic lymph nodes must be differentiated from pathological changes in the mediastinum and lung root of non-tuberculous etiology. Most often, young children have problems that require additional radiographic examination of the formation in the anterior mediastinum. The main cause is the thymus gland. Carrying out a lateral chest X-ray allows you to exclude damage to the lymph nodes.

Secondary tuberculosis

Secondary forms of tuberculosis in children are found only in senior school age, coinciding with puberty (13-14 years). Secondary forms of primary genesis are typical for adolescents (against the background of a widespread pulmonary process, there are intrathoracic lymph nodes affected by tuberculosis). The predominant form is infiltrative and focal pulmonary tuberculosis.

Disseminated pulmonary tuberculosis

Currently, hematogenous disseminating tuberculosis is rarely encountered in children and adolescents.

The development of disseminated forms of tuberculosis is preceded by a period of primary tuberculosis infection and a breakthrough of the tuberculosis focus into the bloodstream with simultaneous sensitization of the vascular system. For the development of the disease, a decrease in immunity under the influence of unfavorable effects (insolation, malnutrition, intercurrent infections during the turn, etc.) is important.

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

In the absence of or insufficiently intensive treatment, the disease in adolescents in most cases steadily progresses; scattered foci in the lungs enlarge and merge, new cavities of decay appear, and lobular caseous pneumonia may develop in the future. Such an unfavorable course of subacute dissemination in adolescents can be explained by the transitional age, when hormonal changes in the body occur, and an unstable state of immunobiological processes in relation to tuberculosis infection occurs.

In chronic disseminated tuberculosis, the process takes on the features of fibrous-cavernous tuberculosis with an 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 primary tuberculosis complex, as well as as an independent disease.

If the clinical and radiological examination clearly reveals the picture of tuberculosis, pleurisy is considered a complication. In those cases where no changes are detected, pleurisy is considered an independent form of tuberculosis.

A distinction is made between dry (fibrinous) and exudative pleurisy. Dry pleurisy in 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 may be free or encapsulated. Topographically, apical pleurisy, costal, interlobar, mediastinal, and diaphragmatic panpleurisy are distinguished.

Interlobar pleurisy in children is most often a complication of tuberculosis of the intrathoracic lymph nodes. Mediastinal pleurisy is most often encountered 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, are a manifestation of lymphogenous or hematogenous dissemination, the conditions for the occurrence of which are the massiveness of the infection against the background of poor-quality BCG vaccination or its absence, unfavorable socio-economic factors and various concomitant diseases.

A 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 deterioration of the 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 tuberculous meningitis and osteoarticular tuberculosis in children has been noted. The number of children with tuberculosis of the genitourinary system, peripheral lymph nodes and eyes, on the contrary, tends to increase. It has been established that there are no differences by age in the incidence of pulmonary and extrapulmonary forms. In young children, lesions of the osteoarticular and central nervous systems predominate, indicating the generalization of the process characteristic of this age. In other children, peripheral lymph nodes and genitourinary organs are more often affected.

Tuberculosis of the peripheral lymph nodes

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

Tuberculous meningitis

Tuberculosis of the meninges mainly affects children under 5 years of age. Most often, the disease develops during the first years after infection with Mycobacterium tuberculosis.

In young children, parents may notice initial symptoms such as decreased appetite, increasing drowsiness, and adynamia. In the first days of the disease, convulsions, impaired consciousness, and focal symptoms of CNS damage in the form of cranial nerve dysfunction, paresis, or paralysis of the limbs appear. Meningeal symptoms may be mild, bradycardia is absent. Stool frequency increases to 4-5 times a day, which, combined with vomiting (2-4 times), resembles dyspepsia. There is no exsicosis, the large fontanelle is tense and bulging. Hydrocephalus develops quickly. Sometimes the clinical picture of tuberculous meningitis in an infant is so blurred that nothing else can be noticed except for an increase in temperature, increasing drowsiness, and adynamia. Bulging and tension of the fontanelle are of decisive importance in these cases. If the diagnosis is not made in a timely manner, the disease progresses and leads to death in 2, maximum 3 weeks. Meningeal symptoms in young children include the "suspension" symptom (Lesage): a child lifted by the armpits pulls his legs up to his stomach, keeping them in a bent position, and the "tripod" symptom - a peculiar pose in which the child sits, leaning on his hands behind his buttocks. In the second period of the disease, meningeal symptoms appear and increase, signs of damage to the cranial nerves (usually the III and VI pairs).

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

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

Brain tuberculomas in children in most cases remain very small and do not cause an increase in intracranial pressure, but can cause characteristic local symptoms with signs of a volumetric lesion.

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

It is important to consider the following:

• anamnesis (information about contact with patients with tuberculosis):
• the nature of tuberculin tests, timing of revaccination (taking into account that if the child is in a serious condition, tuberculin tests may be negative);
• clinical manifestations (nature of onset and development of meningitis, state of consciousness, severity of meningeal symptoms);
• chest X-ray data: detection of active tuberculosis or residual changes from previous tuberculosis (at the same time, their absence does not allow us to reject tuberculosis etiology);
• Lumbar puncture with examination of cerebrospinal fluid is a decisive moment in determining the etiology of meningitis:
• fundus examination: detection of tuberculous tubercles on the retina undoubtedly indicates tuberculous etiology of meningitis. Congested optic discs reflect increased intracranial pressure. It should be taken into account that with pronounced congestion in the fundus, axial dislocation is possible during lumbar puncture. In this case, the cerebrospinal fluid should be released without removing the mandrin from the needle;
• Bacteriological examination of cerebrospinal fluid: detection of Mycobacterium tuberculosis is indisputable proof of the tuberculous nature of meningitis.

The principles of treatment of meningeal tuberculosis, the combination of drugs, the duration of their administration are similar to those for adult patients, with the exception of calculating the daily dose of drugs per 1 kg of the child's body weight. An adequate dose of isoniazid should be considered 30 mg / kg per day. The younger the child, the higher the dose should be. Strict bed rest is prescribed for 1.5-2 months. After 3-4 months, movement around the ward is allowed.

During the first 2-3 years, convalescents undergo anti-relapse courses of 2 months in the spring and autumn in a specialized sanatorium.

Tuberculosis of bones and joints

Tuberculous 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 early and steadily progressive disability.

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

• determination of the activity and prevalence of tuberculosis infection;
• determining the prevalence of local lesions and their complications. The activity and prevalence of tuberculosis infection in a child with osteoarticular tuberculosis is assessed in specialized anti-tuberculosis institutions: the fact of infection with tuberculosis mycobacteria, the clinical form of tuberculosis of the respiratory organs, the degree of sensitivity to tuberculin are established; other organ lesions are identified. Traditional criteria are used for diagnosis:
• anamnestic and epidemiological - information about contact with a patient with tuberculosis, its duration, BCG vaccination and revaccination, the nature of the post-vaccination reaction, the dynamics of tuberculin tests:
  • X-ray tomography or CT scan data of the chest organs;
  • laboratory data - clinical blood test (absolute leukocyte count and leukocyte formula, ESR value), urine, proteinogram (content of α2- _and γ-globulins, C-reactive protein):
  • tuberculin test data - Mantoux reaction with 2 TE PPD-L and in-depth tuberculin diagnostics;
  • serological and immunological indicators;
  • results of bacteriological examination of sputum, urine, as well as pathological contents of abscesses and fistulas for Mycobacterium tuberculosis and associated bacterial flora.

Diagnostics of local lesions of bones and joints are carried out on the basis of clinical and radiological examination methods. The appearance of the affected skeletal section, the presence of abscesses, fistulas, the magnitude of deformations, contractures, the degree of limitation of organ function, and neurological symptoms are clinically assessed. The basic method of radiological assessment is standard radiography of the affected skeletal section in two projections. To clarify the diagnosis, special techniques are used - X-ray tomography, CT, MRI. Each of the specified methods is used according to indications depending on the localization of the process and the diagnostic tasks set. In the presence of abscesses, fistulas, material from previously performed operations or biopsies, bacteriological, cytological and/or histological examination is carried out.

The general condition of children with tuberculous ostitis usually does not suffer; symptoms of intoxication are detected either with multiple bone foci or in the presence of an active intrathoracic tuberculous process.

The peculiarities of clinical manifestations of tuberculous arthritis in children include their polymorphism. On the one hand, the disease may be accompanied by pronounced clinical manifestations characteristic of acute nonspecific inflammatory lesions, on the other hand, the pathology may proceed latently and be diagnosed only at the stage of already developed orthopedic complications - malposition and contractures. Late diagnosis of tuberculous arthritis is usually associated with underestimation of the epidemiological situation and clinical and radiological signs of the disease. In young children, arthritis usually develops against the background of pronounced general changes caused by the dissemination of tuberculosis, in adolescents - more often against the background of general health. Patients are monitored for a long time in the primary health care network with the following diagnoses: hematogenous osteomyelitis, infectious-allergic or purulent arthritis, transient arthralgia, Perthes disease. Suspicion of a specific lesion usually arises when extensive joint destruction is detected despite seemingly adequate treatment.

Tuberculous spondylitis in children is characterized by late diagnosis associated with underestimation of early symptoms of the disease. Unfortunately, the first complaint, on the basis of which a suspicion of pathology usually arises, is spinal deformation. Retrospective analysis shows that in young children, general clinical symptoms appear much earlier: behavioral changes, anxiety during sleep, decreased appetite and motor activity, subfebrile temperature, usually considered as manifestations of rickets or a banal infection. The development of the disease is characterized by an increase in intoxication symptoms, the appearance of neurological disorders and an increase in spinal deformation, which is usually the reason for the primary X-ray examination. In school-age patients, local clinical symptoms predominate at the onset of the disease: back pain, fatigue, impaired posture and gait. During examination, local pain and rigidity of the back muscles, moderate deformation of the spine are revealed. The presence of pain in the absence of pronounced symptoms of intoxication and gross deformation becomes the reason for an unfounded diagnosis of "osteochondrosis of the spine". X-ray examination is usually carried out due to increasing back pain, increasing kyphosis or the appearance of neurological disorders.

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