Pediyatrik Tüberküloz: Bir Üniversite Hastanesinin Beş Yıllık Deneyimi

Abstract

Amaç: Bu çalışmanın amacı, 2008-2013 yılları arasında merkezimizdeki pediatrik tüberküloz ve latent tüberküloz vakalarının klinik, radyolojik, mikrobiyolojik, laboratuvar sonuçlarını içeren demografik özelliklerini ve tedavi karakteristiklerini değerlendirmek olarak belirlenmiştir.Gereç ve Yöntem: Çalışmaya alınan 236 çocuğun yaş ortalaması 94.39±58.73 ay olan vakaların klinik özellikleri ve laboratuvar sonuçları retrospektif olarak incelendi. Tüberküloz hastalığı veya latent tüberküloz tanısı TDT, IGRA, PA akciğer grafisi, toraks BT, ARB ve kültür duyarlılık testleri kullanılarak konuldu.Bulgular: Yetmiş altı 33 kız/43 erkek TB vakasının 34’ü %44.7 akciğer TB, 26’sı %33.8 akciğer dışı TB ve 16’sı %21,5 hem akciğer hem de akciğer dışı TB tanısı aldı. Akciğer grafisi ve toraks BT görüntülemelerinde en sık görülen imajlar sırasıyla %30 ve %64 olarak lenfadenopatiydi. En yaygın akciğer dışı tutulum 12 %15.8 vaka ile lenf nodu TB’idi. Temas öyküsü, vakalarının 24’ünde %31.6 belirlendi. Mikrobiyolojik örnek alınabilen %54 vakanın %21’inde ARB ve %34’ünde kültür pozitifliği saptandı. İlaç dirençi ise vakaların 6’sında %7.9 mevcuttu. Takibi tamamlanan TB vakalarının tedavisi başarı ile tamamlandı, ancak izleminde, %11.8’inde sekel gelişti. Yüz altmış 63 kız/ 97 erkek latent TB tanısı alan vakanın %20’sinde aile taraması pozitif saptandı. TDT pozitifliği %91.9 saptanırken, IGRA testi %19.4 idi. Belirsiz IGRA sonuçları %0.6 saptandı.Sonuç: TB vakalarından temas öyküsü sıklığı LT vakalarından daha fazlaydı. Ev teması ve yapılan taramalar TB kontrolu için çok önemlidir. Mikrobiyolojik tanı oranı dünya ile benzer şekilde düşük saptandı ve ilaç direnci açısından çocukluk TB’si hakkında sınırlı veri elde edilebildi. Bu konu ile ilgili daha çok çalışmaya gereksinim vardır

Keywords

• Tüberküloz,çocuk,latent tüberküloz,IGRA

Pediatric Tuberculosis: A 5-Year Experience from a Turkish Tertiary Pediatric Hospital

Abstract

Objective: The aim of this study was to analyze the demographical attributes such as clinical findings; radiology, microbiology, and laboratory test results along with treatment characteristics of pediatric tuberculosis patients followed by our clinic from 2008 to 2013. Material and Method: Clinical features and laboratory test results of 236 children included in our study with mean age of 94.39±58.73 months were analyzed retrospectively. Tuberculosis or latent tuberculosis diagnosis were made via Mantoux tuberculin skin test, interferon-gamma release assay IGRA , posterior-anterior chest X-ray, thorax CT, sputum cultures for acid-fast bacilli and culture sensitivity tests.Results: Seventy-six 33 female/43 male cases with TB were diagnosed as pulmonary TB n=34; 44.7% , extrapulmonary TB n=26; 33.8% and both pulmonary and extrapulmonary TB n=16; 21,5% Chest X-ray and thorax BT demonstrated mostly lymphadenopathies in 30% and 64% of the cases, respectively. Most prevalent extrapulmonary involvement was lymph node TB with 12 cases 15.8% . History of contact with a TB patient was detected in 24 31,6% cases. Acid-fast bacilli and 34% culture sensitivity were detected in 21, and 34 % of the patients in 54 % of the cases from whom microbiological specimens were collected. Drug resistance was detected in 6 7.9% cases. Treatment of TB patients with completed follow-up was successful, however, 11,8% developed sequellae. Positive family screening results were obtained in 20% of 160 63 female / 97 male patients diagnosed as latent TB. TDT positivity was detected in 91,9%, and IGRA positivity in 19.4% of the patients. Indeterminate IGRA results were obtained in 0.6% of the cases.Conclusion: History of contact with a TB patient was more prevalent in active TB patients compared to latent TB patients. History of contact with a TB patient at home, and medical screenings had most importance in TB control. Rate of microbiological diagnosis was found to be low which was similar with global rates and the drug resistance data of childhood TB was limited. Further research should be conducted on this issue

Keywords

• Tuberculosis,child,latent tuberculosis,IGRA

References

1. Global tuberculosis report 2013. World Health Organization. Available from: URL: http://apps.who. int/iris/bitstre am/10665/91355/1/9789241564656_eng. pdf
2. Türkiye Ulusal Verem Savaş Dernekleri Federasyonu, Türkiye’de Verem Savaşı 2012 Raporu. Available from: URL: http://tüberküloz.thsk.saglik.gov.tr/ Dosya/ Dokumanlar/ raporlar/ turkiyede_verem_savasi_2012_ raporu.pdf
3. Hesseling aC, Schaaf HS, Gie rP, Starke Jr, Beyers N. A critical review of diagnostic approaches used in the diagnosis of childhood tuberculosis. Int J Tuberc Lung Dis 2002;6:1038-45.
4. Starke Jr. Tuberculosis in children. Current Opinition in Pediatrics 1995;7:268-77.
5. https://doi.org/10.1097/00008480-199506000-00005
6. Jentoft HF, Omenaas e, eide Ge, Gulsvik a. Tuberculin reactivity: prevalence and predictors in BCG-vaccinated young Norwegian adults. Respiratory Medicine 2002;96:1033-9.
7. https://doi.org/10.1053/rmed.2002.1386
8. lienhardt C, Fielding K, Sillah J, Tunkara a, Donkor S, Manneh K, et al. Risk factors for tubercu- losis infection in sub-Saharan Africa: a contact study in The Gambia. Am J Respir Crit Care Med 2003;168:448- 55.

9. https://doi.org/10.1164/rccm.200212-1483OC
10. Babayiğit-Hocaoğlu a, ölmez-erge D, anal ö, Makay B, Uzuner n, Karaman ö. Characteristics of children with positive tuberculin skin test. Tüberküloz ve Toraks Dergisi 2011;59:158-63.
11. https://doi.org/10.5578/tt.1761
12. Marais BJ. Well defined symptoms are of value in the diagnosis of childhood pulmonary tuberculosis. Arch Dis Child 2005;90:1162-5.
13. https://doi.org/10.1136/adc.2004.070797
14. Horsburgh Cr Jr. Priorities for the treatment of latent tuberculosis infection in the United States. N Engl J Med 2004;350:2060-7.
15. https://doi.org/10.1056/NEJMsa031667
16. Pai M, Zwerling a, Menzies D. Systematic review: T-cell-based assays for the diagnosis of latent tubercu- losis infection: An update. Ann Intern Med 2008;149: 177-84.
17. https://doi.org/10.7326/0003-4819-149-3-200808050-00241
18. WHO, editor. Global tuberculosis report: 2014. WHO Library Cataloguing-in- Publication Data.Fransa. 2014. (http://www.who.int/tb/features_archive/globaltb_ report2014/en/).
19. Chang SH, nahid P, eitzman Sr. Hepatotoxicity in children receiving isoniazid therapy for latent tubercu- losis infection. J Pediatr Infect Dis Soc 2014;3:221-7.
20. https://doi.org/10.1093/jpids/pit089
21. Donald Pr, Marais BJ, Barry Ce. Age and the epi- demiology and pathogenesis of tuberculosis. Lancet 2010;375:1852-4.
22. https://doi.org/10.1016/S0140-6736(10)60580-6
23. Buonsenso D, lancella l, Delogu G, Krzysztofiak a, Testa a, ranno o, et al. A twenty-year retrospecti- ve study of pediatric tuberculosis in two tertiary hospi- tals in Rome. Pediatr Infect Dis J 2012;31:1022-6.
24. Schaaf HS, Marais BJ, Whitelaw a, Hesseling aC, eley B, Hussey GD, et al. Culture confirmed childho- od tuberculosis in Cape Town, South Africa: a review of 596 cases. BMC Infect Dis 2007;7:140.
25. https://doi.org/10.1186/1471-2334-7-140
26. Cruz aT, Hwang KM, Birnbaum GD, Starke Jr. Adolescents with tuberculosis: a review of 145 cases. Pediatr Infect Dis J 2013;32:937-41.
27. https://doi.org/10.1097/INF.0b013e3182933214
28. nicol MP, Workman l, ısaacs W, Munro J, Black F, eley B, et al. Accuracy of the Xpert MTB/RIF test for the diagnosis of pulmonary tuberculosis in children admitted to hospital in Cape Town, South Africa: a descriptive study. Lancet Infect Dis 2011;11:819-24.
29. https://doi.org/10.1016/S1473-3099(11)70167-0
30. Mandalakas aM, Detjen aK, Hesseling aC, Benedetti a, Menzies D. Interferon-gamma release assays and childhood tuberculosis: systematic review and meta-analysis. Int J Tuberc Lung Dis 2011;15:1018- 32.
31. https://doi.org/10.5588/ijtld.10.0631
32. Kampmann B, Whittaker e, Williams a, Walters S, gordon a, martinez-alier N, et al. Interferon-γ rele- ase assays do not identify more children with active tuberculosis than the tuberculin skin test. Eur Respir J 2009;33:1374-82.
33. https://doi.org/10.1183/09031936.00153408
34. Sun l, Tian Jl, Yin QQ, Xiao J, li JQ, Guo YJ, et al. Performance of the interferon gamma release assays in tuberculosis disease in children five years old or less. PLoS One 2015;10:10143820.
35. https://doi.org/10.1371/journal.pone.0143820
36. Haustein T, ridout Da, Hartley JC, Thaker U, Shingadia D, Klein nJ, et al. The likelihood of an indeterminate test result from a whole-blood interferon- gamma release assay for the diagnosis of Mycobacterium tuberculosis infection in children correlates with age and immune status. Pediatr Infect Dis J 2009;28:669- 73.
37. https://doi.org/10.1097/INF.0b013e3181a16394
38. Diel r, Goletti D, Ferrara G, Bothamley G, Cirillo D, Kampmann B, et al. Interferon-γ release assays for the diagnosis of latent Mycobacterium tuberculosis infection: a systematic review and meta-analysis. Eur Respir J 2011;37:88-99.
39. https://doi.org/10.1183/09031936.00115110
40. Delacourt C, Mani TM, Bonnerot V, de Blic J, Sayeg n, lallemand D, et al. Computed tomography with normal chest radiograph in tuberculous infection. Arch Dis Child 1993;69:430-2.
41. https://doi.org/10.1136/adc.69.4.430
42. Boloursaz Mr, Khalilzadeh S, Baghaie n, Khodayari aa, Velayati aa. Radiologic manifestation of pulmo- nary tuberculosis in children admitted in pediatric ward-Massih Daneshvari Hospital: a 5-year retrospec- tive study. Acta Medica Iranica 2010;48:244-9.
43. Kim WS, Moon WK, Kim ıO, lee HJ, ım JG, Yeon Km, et al. Pulmonary tuberculosis in children: evalua- tion with CT. AJR Am J Roentgenol 1997;168:1005-9.
44. https://doi.org/10.2214/ajr.168.4.9124105
45. Cardinal l Parlatano D, Boccuzzi F, Onoscuri M, Volpicelli g, Veltri a. The imaging spectrum of pul- monary tuberculosis. Acta Radiologica 2015;56:557- 64.
46. https://doi.org/10.1177/0284185114533247
47. Tran ST, renschler JP, le HT, Dang HT, Dao TM, Pham an, et al. Diagnostic accuracy of microscopic observation drug susceptibility (MODS) assay for pediatric tuberculosis in Hanoi, Vietnam. PLoS One 2013;8:e72100.
48. https://doi.org/10.1371/journal.pone.0072100
49. Huang YF, nong Br, Chuang CM, Hsieh KS, liu YC. Ten-year experience of children with tuberculosis in southern Taiwan. J Microbiol Immunol Infect 2009;42:516-20.
50. Dodd le, Wilkinson rJ. Diagnosis of paediatric tuberculosis: the culture conundrum. Lancet Infect Dis 2013;13:3-4.
51. https://doi.org/10.1016/S1473-3099(12)70290-6
52. Maltezou HC, Spyridis P, Kafetzis Da. Extra- pulmonary tuberculosis in children. Arch Dis Child 2000;83:342-6.
53. https://doi.org/10.1136/adc.83.4.342
54. WHO, editor. Global tuberculosis report: 2014. WHO Library Cataloguing-in- Publication Data.Fransa. 2014. (http://www.who.int/tb/features_archive/globaltb_ report2014/en/).
55. Cakir e, erdem e, Ozlu n, Seber e, Gencer S, Kilicaslan Z. Demographic and microbial characteris- tics and drug resistance of childhood tuberculosis in Istanbul: analysis of 1,541 cases. J Infect Dev Cntries 2014;8:304-9.
56. https://doi.org/10.3855/jidc.3950
57. Starke Jr. Tuberculosis. In Jensen HB, Baltimore RS, eds. Pediatric infectious diseases: principles and practi- ces. Philadelphia: WB Saunders Press, 2002:396-419.
58. Marais BJ, Gie rP, Schaaf HS, Hesseling aC, enarson Da, Beyers n. The spectrum of disease in children treated for tuberculosis in a highly endemic area. Int J Tuberc Lung Dis 2006;10:732-8.
59. özkaya Ş, Onbaşıoğlu M. T.C. Sağlık Bakanlığı Verem Savaş Daire Başkanlığı. Türkiye’de Verem Savaşı 2013 Raporu. Ankara: Uzman Matbaacılık; 2013. Erişim:http://tüberküloz.thsk.saglik.gov.tr/ Dosya/Dokumanlar/raporlar/turkiyede_verem_ savasi_2013_raporu.pdf).
60. Gulec SG, Telhan l, Koçkaya T, erdem e, Bayraktar B, Palanduz a. Description of pediatric tuberculosis evaluated in a referral center in Istanbul Turkey. Yonsei Medical J 2012;53:1176-82.
61. https://doi.org/10.3349/ymj.2012.53.6.1176
62. Ormerod lP, Horsfield n. Frequency and type of reactions to antituberculosis drugs: observations in routine treatment. Tuber Lung Dis 1996;77:37-42.
63. https://doi.org/10.1016/S0962-8479(96)90073-8
64. Donald Pr. Antituberculosis drug-induced hepatotoxi- city in children. Pediatric Reports 2011;3:e16.
65. https://doi.org/10.4081/pr.2011.e16
66. Pekcan S, Tana aslan a, Kiper N, uysal g, gürkan F, Patıroğlu T, et al. Multicentric analysis of childho- od tuberculosis in Turkey. Turkish Journal of Pediatrics 2013;55:121-9.
67. Chiang SS, Khan FA, Milstein MB, Tolman AW, Benedetti A, Starke JR, et al. Treatment outcomes of childhood tuberculous meningitis: a systematic review and meta-analysis. Lancet Infect Dis 2014;14:947-57.
68. https://doi.org/10.1016/S1473-3099(14)70852-7
69. Turgut M. Spinal tuberculosis (Pott’s disease): its cli- nical presentation, surgical management, and outcome. A survey study on 694 patients. Neurosurgical Review 2001;24:8-13.
70. https://doi.org/10.1007/PL00011973
71. Veedu PT, Bhalla aS, Vishnubhatla S, Kabra SK, arora a, Singh D, et al. Pediatric vs adult pulmonary tuberculosis: A retrospective computed tomography study. World J Clin Pediatr 2013;2:70-6.
72. https://doi.org/10.5409/wjcp.v2.i4.70