Symptoms of tuberculosis in children

When collecting anamnesis, it is necessary to identify all factors that contribute to infection and development of the disease. At the same time, general pediatricians should pay special attention to children and adolescents infected with MBT with factors that increase the risk of tuberculosis:

• frequently suffering from acute respiratory infections (flu, parainfluenza, adenovirus, rhinovirus, RS infection);
• children with chronic, frequently recurring diseases of various parts of the respiratory tract (chronic nasopharyngitis, sinusitis, chronic tonsillitis, chronic bronchitis and pneumonia);
• children and adolescents with other chronic non-specific diseases, including diabetes mellitus:
• children and adolescents receiving glucocorticoid treatment.

The risk of infection and tuberculosis is most significantly increased by a combination of two or more of the risk factors described above.

If there is a history of contact with a patient with tuberculosis, its duration, nature and the presence of bacterial excretion should be clarified. Also, if bacterial excretion is present, the sensitivity of MBT to anti-tuberculosis drugs should be clarified. Due to the emergence of a large number of migrants from neighboring countries with a high incidence of tuberculosis, it is recommended to clarify the place of residence of the person being examined, the possibility of contact with sick or unexamined people. Of great importance is the child's contact with unexamined adults who have returned from places of imprisonment. It is necessary to clarify the living conditions of the child or teenager, the family budget, the quality and regularity of nutrition, the presence of bad habits in the parents.

When analyzing the patient's complaints, special attention should be paid to the slowdown in the child's physical development, loss of appetite, loss or slowing of weight gain, changes in behavior (tearfulness, capriciousness), sweating, subfebrile body temperature, shortness of breath, weakness, "flying" pain in the joints, cough with the separation of mucous or whitish sputum.

The reason for contacting general practitioners is most often only changes in the child’s behavior and signs of tuberculosis intoxication.

Intoxication syndrome accompanies all active forms of the tuberculosis process (infiltration phase). It is especially pronounced in tuberculous exudative pleurisy, active disseminated process (miliary tuberculosis). General symptoms of specific intoxication in the form of symptoms of neurovegetative dystonia and neuroendocrine dysfunctions are noted in varying degrees of severity in all forms of primary tuberculosis. This is expressed in a violation of thermoregulation (low subfebrile temperature lasting from several weeks to 3-4 months), irritability (tearfulness, touchiness) without an apparent reason, rapid fatigue, decreased attention, memory and, as a result, decreased academic performance at school. In girls, menstrual irregularities are possible.

The temperature reaction in children and adolescents with various forms of tuberculosis infection is characterized by pronounced variability due to age-related features of the neuroendocrine and central nervous systems. In children with tuberculosis of the intrathoracic lymph nodes, the primary tuberculosis complex of uncomplicated course and tuberculosis intoxication is the body temperature, mainly subfebrile, with rises in the evening hours and after physical exertion. In children with active forms of primary tuberculosis, subfebrile temperature may occur only 2-3 times a week in the evening. The hectic nature of the temperature curve is characteristic of caseous processes, with suppuration of exudate. Constant febrile body temperature occurs with tuberculous meningitis, exudative pleurisy, miliary tuberculosis. It should be noted that children usually tolerate high body temperature in tuberculosis well, unlike fever and intoxication syndrome of non-tuberculous genesis. This serves as an important differential diagnostic sign.

Cough with sputum production occurs only in progressive, advanced forms of active tuberculosis, at first it appears mainly in the morning, then as endo- and peribronchitis develops it becomes unproductive and obsessive. Young children usually swallow sputum. With a significant increase in bronchopulmonary and bifurcation lymph nodes in young children (tumorous form), so-called compression symptoms occur: sonorous bitonal cough, obsessive whooping cough-like cough with a metallic tint, expiratory stridor (sharp noisy exhalation with unchanged inhalation).

The task of a general pediatrician when children from risk groups for developing tuberculosis come to them with certain complaints is to conduct a differential diagnosis of specific tuberculosis intoxication with intoxication syndrome in the following diseases that are often encountered in childhood and adolescence:

• chronic tonsillitis, sinusitis; o rheumatism;
• hepatocholecystopathy;
• diseases of the genitourinary system;
• hyperthyroidism;
• helminthic invasions.

To exclude each of the above pathologies, if necessary, consultations with relevant specialists are carried out, and data from laboratory and instrumental research methods are taken into account.

Physical examination should begin with determining the child's physical development and build. In tuberculosis, specific anthropometric indices (Erisman, Chulitskaya, etc.) may change, thinning of long tubular bones, reduction of muscle and subcutaneous fat layers are noted. During examination, it is possible to detect a lag of the affected side in participation in the act of breathing, marbling and pallor of the skin and mucous membranes, periorbital cyanosis and cyanosis of the nasolabial triangle, severity of the subcutaneous venous network, paraspecific changes in the form of keratoconjunctivitis, phlycten, moderate hyperemia of the mucous membranes of the pharynx and nose, exacerbations of nasopharyngitis. Often, with an active tuberculosis infection, erythema nodosum appears on the skin in symmetrical areas of the shins, thighs, and less often in other areas - purple-red moderately painful spots (infiltrates).

If there is a cough, you should pay attention to its nature - tuberculosis is characterized by a dry cough with the release of a small amount of sputum, with tuberculosis of the intrathoracic lymph nodes there may be a bitonal cough, less often - whooping cough-like, and with destructive forms of tuberculosis hemoptysis occurs.

Changes in the hemogram vary depending on the activity and severity of the tuberculosis process. In tuberculosis intoxication, characteristic changes are usually not detected (moderate lymphocytosis and monocytosis, moderate increase in ESR, hypoalbuminemia are noted). In active tuberculosis, leukocytosis of varying degrees of severity is detected. Subacute non-common forms are characterized by a normal or slightly increased number of leukocytes (6-10x10 ⁹ /l), in acute severe forms - up to 15x10 ⁹ /l. Along with determining the total number of leukocytes, the leukocyte formula should be assessed. In active tuberculosis in adults and children over 7 years of age, the number of band neutrophils increases (leukocyte formula shifts to the left); in extensive destructive processes, the number of band neutrophils reaches 20%, sometimes with the appearance of young forms (promyelocytes and metamyelocytes). Pathological granularity of neutrophils may be detected, especially in the case of a protracted course of the tuberculosis process (up to 90% of neutrophils); after the tuberculosis process activity subsides, this sign persists longer than other shifts. Favorably progressing, uncommon forms of tuberculosis are characterized by slight eosinophilia; hypo- and aneosinophilia are noted in severe tuberculosis. Lymphocytosis is characteristic of the early period of primary tuberculosis infection; lymphopenia (10% and below) occurs as the process progresses. The number of monocytes in patients with tuberculosis is normal or slightly increased. Persistent monocytosis occurs with fresh hematogenous dissemination. A decrease in the number of monocytes occurs in children with severe primary tuberculosis, caseous pneumonia.

Tuberculin diagnostics is the main method for identifying infection and tuberculosis disease; it is divided into mass and individual (a description of the tuberculin diagnostics method is reflected in a separate section of the manual).

• Mass tuberculin diagnostics are carried out using the Mantoux test with 2 TE of purified protein derivative of Linnikova (PPD-L). It is carried out by institutions of the general medical network. Mass tuberculin diagnostics is intended to achieve the following goals:
  • identification of a risk group for tuberculosis (primary infection with MBT, increasing sensitivity to tuberculin and hyperergic sensitivity to tuberculin);
  • selection of a contingent for immunization with BCG vaccine;
  • determination of the level of MBT infection in the child population.
• Individual (clinical) tuberculin diagnostics can be performed only by prescription of a phthisiatrician in children's somatic hospitals, anti-tuberculosis dispensaries, consultative and diagnostic centers, tuberculosis hospitals and sanatoriums. Such diagnostics pursue the following goals:
  • clarification of the degree of activity of tuberculosis infection and the appropriateness of prescribing chemoprophylaxis;
  • determination of the activity of the tuberculosis process;
  • determination of the localization of the tuberculosis process;
  • evaluation of the effectiveness of the anti-tuberculosis treatment.

Indications for clinical tuberculin diagnostics are the presence of chronic diseases of various organs and systems with a torpid, wave-like course with the ineffectiveness of traditional treatment methods and the presence of additional risk factors for infection with MBT and tuberculosis (contact with a patient with tuberculosis, lack of vaccination against tuberculosis, social risk factors, etc.).

For individual diagnostics, the Mantoux test with 2 TE of purified tuberculin in standard dilution, cutaneous graduated test, intradermal Mantoux tests with various dilutions of dry purified tuberculin, and determination of intradermal tuberculin titer are used. The technique for carrying out these diagnostic methods is reflected in the instructions for use of purified dry tuberculosis allergen.

Microbiological methods of diagnosing tuberculosis. Detection of MBT during examination of pathological material is the "gold standard" in diagnosing tuberculosis. In children with tuberculosis, it is possible to verify the diagnosis at the bacteriological level only in 5-10% of cases, in adolescents - in 50%. In this regard, any pathological material is used for microbiological examination: sputum, gastric lavage, bronchial, urine, exudate, biopsy (puncture), cerebrospinal fluid.

Histological and cytological methods of examination are used in relation to patients with clinical and radiological syndrome characteristic of tuberculosis, in the absence of bacteriological confirmation of the diagnosis. Any biopsy specimens can be used for examination: lymph nodes, skin, soft tissues, lungs, pleura, bronchial mucosa, as well as lymph node punctures, cerebrospinal fluid, pleural or pericardial exudate when the corresponding organs and tissues are involved in the pathological process. These studies can be performed both in general medical network hospitals and in specialized tuberculosis institutions.

In extrapulmonary forms of the disease, mycobacteria can affect almost any organ, so a wide variety of material is suitable for research, including various tissue fluids (cerebrospinal, pleural, pericardial, synovial, ascitic, blood, pus), bone marrow punctures, resected tissues of one or another organ obtained during biopsies or surgical interventions, purulent-necrotic masses, granulations, scrapings of synovial membranes, lymph nodes or punctures of their contents.

The following are among the radiation research methods used to diagnose tuberculosis in the conditions of an anti-tuberculosis institution:

• fluorography (including digital);
• fluoroscopy and radiography (using both traditional film techniques and digital image recording methods);
• tomography (including computed tomography);
• Ultrasound.