Tuberculosis in children and adolescents

The collapse of the USSR led to a drastic change in the socioeconomic situation, a rapid deterioration in the living standards of the population in virtually all former republics. These changes have led to an equally rapid deterioration of the epidemiological situation of tuberculosis. The incidence of tuberculosis among migrants has grown catastrophically, it was practically not controlled. Preventive measures to combat tuberculosis in a number of "hot spots" not only among adults, but also among children, almost did not. Speaking of tuberculosis, one can not ignore the fact that in the last decade the manifestations of tuberculosis in the adult population have changed significantly. So, according to the data of a number of authors, more than half of the patients noted an acute course with a hectic body temperature and marked changes in the peripheral blood. Cases of complications of pulmonary tuberculosis in children have become more frequent. The massiveness of bacterial release and the drug resistance of mycobacteria tuberculosis to the main antituberculosis drugs have sharply increased. All this leads to a decrease in the effectiveness of treatment and disability of patients.

As a result of untimely detection of tuberculosis in adults, the risk of infection of children increased. The infection of children living together with patients is several times higher than that of children from a healthy environment. Since 1990 there has been an increase in the incidence of children. The incidence of children in the outbreaks has increased more than threefold (from 0.16 to 0.6%) in Russia, exceeding the overall incidence of children by 50 times. In the structure of newly ill children in Russia, respiratory tuberculosis prevails (78%). The main form is tuberculosis of the intrathoracic lymph nodes. In children, the incidence of bacterial excretion in the pathology of respiratory organs is 3.0%. Against this background, in teenagers the tendency of the spread of the tuberculosis process approaches that of adults, with the predominant lesion of the pulmonary tissue in the form of infiltrative forms with bacterial excretion in 80% of cases. Prevention and early detection of the disease are of primary importance for the fight against tuberculosis in children. Immediately after the diagnosis is made, it is necessary to start treatment in time, its basis is antibacterial therapy.

To date, phthisiatricians of the country have accumulated significant experience in the prevention, timely detection and treatment of tuberculosis. The monographs and scientific articles fully reflect the successes of the fight against tuberculosis among the adult population. At the same time, it is known that the first meeting with a tuberculosis infection, ending with infection, and in some cases with a disease, happens in childhood and adolescence. Therefore, the main measures for the prevention of tuberculosis must be carried out in these age groups. More than 50 years of specific prevention of tuberculosis caused significant changes in the clinical course of tuberculosis in children and adolescents, affecting the pathomorphism of the disease. The defeat of the lymphatic system, pronounced bronchoadenitis, developed both in the pre-antibacterial period and in the first years of antibacterial treatment. However, due to various reasons, the lymphatic system could not serve as a barrier and delay the spread of infection, the lungs and other organs were affected. Spreading the process into the lungs, developing complications became leading in the picture of the disease. Now, in the conditions of systematic tuberculosis vaccination, increasing the overall resistance of the children's organism, the protective role of the lymphatic system is more clearly revealed, the infection in it is prolonged for a long time. In some cases, local forms of the disease do not develop, in others, lymph node lesions of various degrees are detected, and in recent years, small forms of bronchoadenitis are increasingly encountered. Despite the great successes, there are still a number of unresolved issues in the problem of child tuberculosis. In particular, the percentage of irreversible residual changes that complicate the complete cure of the patient is still significant. Against this background, the decline in the prevalence of tuberculosis in the 70-80s of the last century among the population, especially among children and adolescents, led to a decrease in alertness towards this infection among doctors, especially young people.

Causes, pathogenesis and morphology of primary tuberculosis

The causative agent of tuberculosis is mycobacterium tuberculosis. Although "consumption" as a disease was known in ancient times, for a long time a persistent struggle of opinions of various scientists on the etiology of the disease continued before the causative agent of tuberculosis was discovered. The infectious character of tuberculosis was experimentally proved long before the discovery of the causative agent of the disease. The French scientist Wilmen in 1865 infected rabbits with tuberculosis by subcutaneous administration of tissues of affected organs and by inhalation of sputum smear of tuberculosis patients.

In 1882, Robert Koch succeeded in detecting a rod in the tubercle foci when the drug was stained with methylene blue and obtaining a pure culture of the pathogen. Scientists have established that mycobacterium tuberculosis is highly resistant to the effects of any physical, chemical and biological agents. Having found themselves in conditions favorable for their development, mycobacterium tuberculosis can long remain viable and virulent. They tolerate prolonged cooling and drying.

[1], [2], [3], [4], [5], [6], [7], [8],

Features of tuberculosis in children and adolescents

Due to the changed situation on tuberculosis in Russia and a number of other countries of the world, the risk of infection of children has increased. Infection of children living together with patients is 2 times higher than that of children from a healthy environment. Since 1990, the growth of childhood morbidity in Russia has been increasing: in the outbreaks it increased more than 3-fold (from 0.16 to 0.56%), exceeding the total morbidity of children by 50 times. Among tuberculosis-affected children, in contact with patients in the family, a significant number of young children with disseminated forms of tuberculosis are noted. In the structure of newly ill children in Russia, respiratory tuberculosis prevails (78%). The main form is tuberculosis of the intrathoracic lymph nodes. In children, the incidence of bacterial excretion in the pathology of respiratory organs is 3.0%. In adolescents, the tendency of the spread of the tuberculosis process approaches that of adults, the predominantly pulmonary tissue is lesioned as infiltrative forms with bacterial excretion in 80% of cases.

Prevention and early detection of the disease are of primary importance for the fight against tuberculosis in children. Immediately after the diagnosis is made, it is necessary to start treatment in time, the basis of which is antibacterial therapy.

The specific prevention of tuberculosis for a long time (more than 50 years) caused significant changes in the clinical course of tuberculosis in children and adolescents, affecting the pathomorphism of the disease. In the conditions of systematic antituberculous vaccination, increasing the overall resistance of the children's organism, the protective role of the lymphatic system is more clearly manifested. Infection in it is long delayed; in some cases, local forms of the disease do not develop, in others - there is a different degree of involvement of the lymph nodes, and in recent years, more and more often diagnose small forms of bronchoadenitis. Despite the great successes, there remain a number of unresolved issues in the problem of child tuberculosis. In particular, the percentage of irreversible residual changes that complicate the complete cure of the patient is still significant. Against this background, the decline in the prevalence of tuberculosis in the 70-80s of the last century among the population, especially among children and adolescents, led to a decrease in alertness towards this infection among doctors, especially among young people.

In younger children, mainly primary forms of tuberculosis are detected. In older children and adolescents, secondary tuberculosis is found in more than 50% of cases.

Tuberculosis in different age categories has certain features, which contributes to the formation of residual changes after the transferred disease of varying severity.

In newborns and young children, tuberculosis is less favorable. Than in older children, and is characterized by a tendency to generalize the infection, its spread predominantly by lymphohematogenous pathway with the formation of extrapulmonary foci, to the defeat of the lymphatic apparatus, which sometimes determines the severity of the disease. At this age, forms such as the primary tuberculosis complex, tuberculosis meningitis and miliary tuberculosis predominate. At preschool and school age, tuberculosis is favorable, generalization of the process is rare, and the so-called little-expressed forms of tuberculosis in the form of tuberculosis of the intrathoracic or peripheral lymph nodes are at the forefront, especially at the present time.

Critical is also adolescence, when infiltrative changes in the lungs are relatively frequent, hematogenous dissemination of the infection occurs, and serous membranes are affected. The predominant forms are infiltrative and disseminated pulmonary tuberculosis. In adolescents, there is a significant restructuring of the neuroendocrine apparatus, which has a particularly negative effect on the course of tuberculosis with massive superinfection.

The features of the development of the disease in different age periods are determined by the anatomical and physiological and immunobiological properties of the organism.

[9], [10], [11], [12], [13], [14],

Tuberculosis in young children

Anatomical and physiological features of young children:

• immaturity of cellular and humoral immunity;
• slowed and reduced the migration of blood cells to the site of inflammation:
• incomplete phagocytosis (developed absorption phase, reduced digestion phase);
• deficiency of the basic components of complement;
• the upper respiratory tract and trachea are short and wide, the remaining airways are narrow and long (ventilation of the lungs is impaired);
• relative dryness of bronchial mucosa due to lack of mucous glands, low viscosity of secretions;
• acini poor in elastic fibers;
• an insufficient amount of surfactant leads to easy atelectasis formation;
• the intersegmental pleura is practically not developed, the interlobar pleura is poorly developed; not all layers of the pleura are formed;
• poorly developed cough reflex;
• in the lymph nodes there is little lymphoid tissue, weak valvular apparatus, it is possible to reverse lymph flow;
• many anastomoses between the lymph nodes of the mediastinum:
• many anastomoses between the blood and lymphatic vessels;
• immaturity of the thermoregulation center.

Tuberculosis in children of early age is detected mainly on the basis of treatment (most often diagnosed with pneumonia, ineffectiveness of nonspecific antibacterial therapy causes differential diagnostics with tuberculosis). In patients with tuberculosis of children under the age of 1 year, tubercular contact is detected in 100% of cases, from 1 to 3 years - in 70-80% of cases (the old saying is known: "Small children do not become infected, but fall ill"); 2/3 of tuberculosis patients of young children are not vaccinated with BCG or do not have a postvaccinal sign of the sign.

The most frequent complications are bronchopulmonary lesions, hematogenous dissemination into the lungs and meninges, and the disintegration of the lung tissue.

Late diagnosis and progressive course lead to death.

Clinical forms of tuberculosis in children and adolescents

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.

[15], [16],

Survey of children with tuberculosis of children and adolescents

Tuberculosis in children is characterized by a pronounced polymorphism of clinical manifestations, the absence of strictly specific symptoms, which creates significant difficulties in diagnosis. There is not a single clinical sign, characteristic only for tuberculosis. Often in children, the initial manifestations of tuberculosis infection are expressed only in behavioral changes, common symptoms of intoxication. Therefore, the main condition for timely and correct diagnosis is a comprehensive examination.

Survey of patients with tuberculosis

Semiotics of tuberculosis

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.

Symptoms of tuberculosis

Methods for detecting tuberculosis

Mass tuberculin diagnostics is carried out with the help of RM with 2 tuberculin units (RM with 2 TE) to children and adolescents vaccinated against tuberculosis, once a year, starting from 1 year; children and adolescents not vaccinated against tuberculosis - every 6 months, from the age of 6 months to receiving the vaccination.

Fluorography is carried out by teenagers, students (in schools, higher and secondary special educational institutions), working, unorganized. The survey is conducted at the place of work or study, for working in small businesses and unorganized - in polyclinics and anti-tuberculosis dispensaries.

Methods for detecting tuberculosis

Tuberculin Diagnosis

Tuberculin diagnostics is a set of diagnostic tests to determine the specific sensitization of the body to the MBT using tuberculin. Since the establishment of tuberculin to the present day, tuberculin diagnostics has not lost its importance and remains an important method of examination of children, adolescents and young people. When meeting with mycobacteria (infection or vaccination of BCG) the body responds with a certain immunological reaction and becomes sensitive to the subsequent administration of antigens from mycobacteria, that is, sensitized to them. This sensitivity, which is delayed in nature (that is, a specific reaction manifests itself after a certain time - 24-72 hours), was called delayed-type hypersensitivity. Tuberculin has a high specificity, acting even in very large dilutions. Intradermal administration of tuberculin to a person whose body is previously sensitized by both spontaneous infection and as a result of BCG vaccination causes a response-specific reaction that is of diagnostic significance.

Tuberculin Diagnosis

Preventive (preventive) treatment of tuberculosis

Preventive treatment in order to prevent tuberculosis appoints a phthisiopaediatrician. This section of work should be a priority in the work of the phthisiopaediatric service. Preventive treatment is given to children and adolescents who have been infected for the first time with an MBT (a turn, an early period of latent tuberculosis infection), and also from high-risk groups for tuberculosis.

When the bend is established, the child is sent to the TB specialist who is observing the patient for 1 year. After an early period of primary tuberculosis infection, the child remains infected with MBT (if there are no risk factors for tuberculosis, provided timely chemoprophylaxis is provided) or local tuberculosis develops at different times after primary infection (depending on the massiveness, virulence of the MTBT and the state of the macroorganism).

Preventive treatment of tuberculosis

Vaccine prophylaxis of tuberculosis

In childhood, the main method of preventing tuberculosis is vaccination with the vaccine BCG and BCG-M. According to the current Russian vaccination schedule for childhood infections, BCG vaccine is administered to all healthy newborns on the 3rd-7th day of life. Children aged 7 and 14 years with a persistently negative PM with 2 TE are subject to revaccination, and children infected with MBT are not subject to revaccination. At the age of 15 years, regardless of the results of tuberculin diagnostics, vaccination against tuberculosis is not performed. All measures for vaccine prophylaxis are carried out according to the calendar of vaccine prophylaxis of childhood infections.

Vaccination, aimed at the formation of artificial immunity to various infectious diseases, has become the most massive preventive measure of medicine in the XX century. Depending on the virulence of microorganisms, the role of the immune system in the pathogenesis of infectious diseases caused by them and the specificity in some cases, vaccination prevents the occurrence of the disease (smallpox, tetanus, poliomyelitis), in others, mainly influences its course. The main criterion in determining the method of mass immunization against a disease is its biological expediency in specific epidemiological conditions. The less the specific effectiveness of the vaccine, the greater the importance attached to the negative consequences of its use (complications). As a result, the improvement of the epidemiological situation naturally leads to a revision of vaccination tactics.

Vaccine against tuberculosis (BCG)