Symptoms of tuberculosis in children

When collecting anamnesis, it is necessary to find out all the factors that contribute to the infection and development of the disease. Special attention should be paid by pediatricians of general practice to infected children and adolescents with factors that increase the risk of tuberculosis:

• often ill with ARI (influenza, parainfluenza, adenovirus, rhinovirus, RS-infection);
• children with chronic, often relapsing diseases of various parts of the respiratory tract (chronic rhinopharyngitis, sinusitis, chronic tonsillitis, chronic bronchitis and pneumonia);
• children and adolescents who have other chronic nonspecific diseases, including diabetes mellitus:
• children and adolescents receiving treatment with glucocorticoids.

The most significant increase in the risk of infection and tuberculosis is a combination of two or more of the above risk factors.

If there is a history of contact with a patient with tuberculosis, its duration, nature and presence of bacterial excretion should be clarified. Also, in the presence of bacterial excretion, the sensitivity of MBT to anti-tuberculosis drugs should be clarified. In connection with the emergence of a large number of migrants from the countries of the near abroad with a high incidence of tuberculosis, it is recommended to specify the place of residence of the examinee, the possibility of contact with sick or unexplored people. Of great importance is the contact of the child with the unopened adults who have returned from places of deprivation of liberty. It is necessary to clarify the living and living conditions of a child or adolescent, the family budget, the quality and regularity of nutrition, the presence of bad habits among parents.

When analyzing the patient's complaints, special attention should be paid to slowing the dynamics of a child's physical development, a violation of appetite, loss or slowing of weight gain, behavioral changes (tearfulness, capriciousness), sweating, subfebrile body temperature, shortness of breath, weakness, "volatile" joint pains , cough with separation of mucous or whitish sputum.

The reason for appealing to doctors of the general medical network is most often only changes in the behavior of the child, signs of tuberculosis intoxication.

Intoxication syndrome accompanies all active forms of the tuberculosis process (the phase of infiltration). It is especially pronounced in tuberculous exudative pleurisy, active disseminated process (miliary tuberculosis). The 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 the violation of thermoregulation (small subfebrile condition lasting from several weeks to 3-4 months), irritability (tearfulness, touchiness) for no apparent reason, fast fatigue, decreased attention, memory and, as a result, a decline in school performance. In girls, menstrual irregularities are possible.

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

Cough with sputum separation occurs only with progressive, neglected forms of active tuberculosis, first it appears mainly in the morning, then, as the endo- and peribronchitis develops, it becomes unproductive, intrusive. Young children are usually swallowed phlegm. With a significant increase in bronchopulmonary and bifurcation lymph nodes in young children (tumorous form), there are so-called compression symptoms: sonorous bitonal cough, compulsive pertussis cough with a metallic tinge, expiratory stridor (a sharp noisy exhalation with unchanged inspiration).

In the task of the pediatrician of the general medical network, when addressing them with certain complaints from children at risk for development of tuberculosis, the differential diagnosis of specific tuberculosis intoxication with intoxication syndrome occurs with the following diseases commonly 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, consult the relevant narrow specialists, take into account the data of laboratory and instrumental research methods.

Physical examination should begin with the definition of the child's physical development, physique. In tuberculosis, specific anthropometric indices (Erismana, Chulicka, etc.) can change, thinning of long tubular bones, a decrease in muscle and subcutaneous fat layers are noted. On examination, it is possible to identify the lag of the affected side with participation in the act of breathing, the marbling and pallor of the skin and mucous membranes, periorbital cyanosis and cyanosis of the nasolabial triangle, the severity of the subcutaneous venous network, paraspecific changes in the form of keratoconjunctivitis, flushing, mild hyperemia of the mucous membranes of the throat and nose, exacerbations of rhinopharyngitis. Often with active tuberculosis infection on the skin in the symmetrical areas of the shins, on the thighs, rarely on other sites appears erythema nodosum - crimson-red moderately painful spots (infiltrates).

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

Changes in the hemogram vary depending on the degree of activity and severity of the tuberculosis process. With tubercular intoxication, characteristic changes are usually not detected (moderate lympho- and monocytosis, moderate increase in ESR, hypoalbuminemia). With active tuberculosis, a leukocytosis of varying severity is detected. For subacute, uncomplicated forms, a normal or slightly elevated number of leukocytes (6-10 × ^{10 9} / L) is characteristic , with acute severe forms up to 15 × ^{10 9} / L. Along with the definition of the total number of leukocytes, the leukocyte formula should be evaluated. With active tuberculosis in adults and children older than 7 years, there is an increase in the number of stab neutrophils (shift of the leukocyte formula to the left), with extensive destructive processes, the number of stab neutrophils reaches 20%, sometimes with the appearance of young forms (promyelocytes and metamyelocytes). It is possible to detect the pathological granularity of neutrophils, especially in the prolonged course of the tuberculosis process (up to 90% of neutrophils), after the activity of the tuberculosis process subsides, this sign persists longer than the other shifts. Favorably flowing, uncontrolled forms of tuberculosis are characterized by a small eosinophilia; hypo- and aneosinophilia is noted in the severe course of the tuberculosis process. For the early period of primary tuberculosis infection lymphocytosis is characteristic, with the progression of the process lymphopenia occurs (10% and below). The number of monocytes in patients with tuberculosis is normal or slightly elevated. Persistent monocytosis occurs with fresh hematogenous dissemination. Reduction in the number of monocytes occurs in children with severe primary tuberculosis, caseous pneumonia.

Tuberculin diagnostics serves as the main method in detecting infection and tuberculosis, it is divided into mass and individual (the description of the tuberculin diagnostics technique is reflected in a separate section of the manual).

• Mass tuberculin diagnostics is carried out with Mantoux sample with 2 TE purified protein derivative Linnikova (PPD-L). It is implemented by the establishment of a common medical network. Mass tuberculin diagnostics is designed to achieve the following goals:
  • identification of a risk group for tuberculosis (primary infection with MTBT, increased sensitivity to tuberculin and hyperergic sensitivity to tuberculin);
  • selection of a contingent for immunization with BCG vaccine;
  • Determination of the level of infection of the ILO with children.
• Individual (clinical) tuberculin diagnostics can be carried out only for the purpose of phthisiatric surgery in children's somatic hospitals. Tuberculosis dispensaries, consulting and diagnostic centers, tuberculosis hospitals and sanatoriums. Such diagnostics has the following objectives:
  • clarification of the degree of activity of tuberculosis infection and the appropriateness of prescribing chemoprophylaxis;
  • determination of tuberculosis activity;
  • definition of the localization of the tuberculosis process;
  • evaluation of the effectiveness of anti-tuberculosis treatment.

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

For individual diagnosis, use a Mantoux sample with 2 TE purified tuberculin in standard dilution, a cutaneous graduated test, intra-cutaneous Mantoux samples with various dilutions of dry purified tuberculin, determination of an intradermal tuberculin titer. The technique for carrying out these diagnostic techniques is reflected in the instructions for the use of the allergen of tubercular purified dry.

Microbiological methods for diagnosing tuberculosis. The detection of MBT in the study of pathological material is the "gold standard" in the diagnosis of tuberculosis. In children with tuberculosis, the diagnosis at the bacteriological level can be verified only in 5-10% of cases, in adolescents - in 50%. In connection with this, any pathological material is used for microbiological research: sputum, gastric lavage, bronchial tubes, urine, exudate, biopsy (punctate), spinal fluid.

Histological and cytological methods of research are used in patients with clinical and radiological syndrome, characteristic of tuberculosis, in the absence of bacteriological confirmation of the diagnosis. For the study, you can use any biopsy specimens: lymph nodes, skin, soft tissues, lungs, pleura, mucous membranes of the bronchi, as well as punctate lymph nodes, cerebrospinal fluid, pleural or pericardial exudate when involved in the pathological process of the relevant organs and tissues. These studies can be performed both in hospitals of the general medical network, and in specialized tuberculosis institutions.

In extrapulmonary forms of the disease, mycobacteria can affect almost any organ, so a variety of materials are suitable for the study, including various tissue fluids (spinal cord, pleural, pericardial, synovial, ascitic, blood, pus), bone marrow punctate, resected tissue or other organ obtained from biopsies or surgical interventions, purulent necrotic masses, granulations, scrapings of synovial membranes, lymph nodes or punctata of their contents.

The radiation methods of research used for the diagnosis of tuberculosis in conditions of an anti-tuberculosis institution include the following:

• fluorography (including digital);
• fluoroscopy and radiography (using both traditional film technique and digital imaging methods);
• Tomography (including computer);
• Ultrasound.