Multidrug-resistant tuberculosis in children from 2003 to 2005: A brief report

CT Appearances in Treated Abdominal Tuberculosis: A Radiologist's Dilemma

Objective To study the CT appearances of the abdomen after completion of antitubercular therapy (ATT) in adult patients.

Methods Multidetector CT scan abdomen was done in 20 adults within 1 month of completing ATT. CT appearances were compared with pretreatment scans which were available in 7 cases.

Results We found that residual ileocecal wall thickening and enhancement was significant (p < 0.05) after treatment in cases of ileocecal tuberculosis (TB). Mild decrease in wall thickness and diameter of the involved dilated small bowel loops was seen. Numerous large, matted nodes with necrosis persisted in the mesentery and retroperitoneum in treated TB, but reduction in the size of nodes was appreciated.

Conclusion Our results help to fill the vacuum in the database of CT appearances in treated abdominal TB. Persistence of bowel changes and lymph nodes should not be mistaken for recurrence of TB or residual disease.

Childhood multidrug-resistant tuberculosis in the European Union and European Economic Area: an analysis of tuberculosis surveillance data from 2007 to 2015

Confirming tuberculosis (TB) in children and obtaining information on drug susceptibility is essential to ensure adequate treatment. We assessed whether there are gaps in diagnosis and treatment of multidrug-resistant (MDR) TB in children in the European Union and European Economic Area (EU/EEA), quantified the burden of MDR TB in children and characterised cases. Methods: We analysed surveillance data from 2007 to 2015 for paediatric cases younger than 15 years. Results: In that period, 26 EU/EEA countries reported 18,826 paediatric TB cases of whom 4,129 (21.9%) were laboratory-confirmed. Drug susceptibility testing results were available for 3,378 (17.9%), representing 81.8% of the confirmed cases. The majority (n = 2,967; 87.8%) had drug-sensitive TB, 249 (7.4%) mono-resistant TB, 64 (1.9%) poly-resistant TB, 90 (2.7%) MDR TB and eight (0.2%) had extensively drug-resistant (XDR) TB. MDR TB was more frequently reported among paediatric cases with foreign background (adjusted odds ratio (aOR) = 1.73; 95% confidence interval (95% CI): 1.12–2.67) or previous TB treatment (aOR: 6.42; 95% CI: 3.24–12.75). Successful treatment outcome was reported for 58 of 74 paediatric MDR TB cases with outcome reported from 2007 to 2013; only the group of 5–9 years-olds was significantly associated with unsuccessful treatment outcome (crude odds ratio (cOR) = 11.45; 95% CI: 1.24–106.04). Conclusions: The burden of MDR TB in children in the EU/EEA appears low, but may be underestimated owing to challenges in laboratory confirmation. Diagnostic improvements are needed for early detection and adequate treatment of MDR TB. Children previously treated for TB or of foreign origin may warrant higher attention.

Changing prevalence and resistance patterns in children with drug-resistant tuberculosis in Mumbai

BACKGROUND

The prevalence of drug-resistant (DR) tuberculosis (TB) in children is increasing. Although, in India, multi-drug-resistant (MDR) TB rates have been relatively stable, the number of children with pre-extensively drug-resistant and extensively drug-resistant (XDR) TB is increasing.

AIM

To determine whether the prevalence of DR TB in children in Mumbai is changing and to study the evolving patterns of resistance.

METHODS

A retrospective study was undertaken in 1311 paediatric patients referred between April 2007 and March 2013 to the Paediatric TB clinic at B. J. Wadia Hospital for Children, Mumbai. Children were defined as having DR TB on the basis of drug susceptibility testing (DST) of Mycobacterium tuberculosis grown on culture of body fluids (in the case of extra pulmonary TB) or from gastric lavage/bronchi-alveolar lavage/sputum in patients with pulmonary TB or from DST of the contacts. The prevalence of DR TB was calculated and the type of DR was evaluated yearly and in the pre-2010 and post-2010 eras.

RESULTS

The overall prevalence of DR TB was 86 (6.6%) with an increase from 23 (5.6%) patients pre-2010 to 63 (7%) post-2010 (P = 0.40). Nine (10.4%) patients were diagnosed on the basis of contact with a parent with DR TB. Overall fluoroquinolone resistance increased from 9 (39.1%) pre-2010 to 59 (93.7%) post-2010 (P = 0.0001): moxifloxacin resistance increased from 2 (8.7%) to 29 (46%) (P = 0.0018) and ofloxacin resistance increased from 7 (30.4%) to 30 (47.6%) (P = 0.14). Ethionamide resistance also increased from 6 (26.1%) to 31 (49.2%) (P = 0.04), aminoglycoside resistance was one (4.3%) pre-2010 and 12 (19%) post-2010 (P = 0.17) and resistance remained virtually the same for both amikacin [0 pre-2010 and 6 (9.5%) after 2010] and kanamycin [one (4.3%) pre- and 6 (9.5%) post-2010]. Of the first-line drugs, resistance remained the same for isoniazid [23 (100%) to 61 (96.8%)], rifampicin [22 (95.7%) to 51 (80.9%),P = 0.17], pyrazinamide [15 (65.2%) to 35 (55.6%), P = 0.47], ethambutol [14 (60.9%) to 38 (60.3%), P = 1.00] and streptomycin [19 (82.6%) to 50 (79.4%), P = 1.00]. Resistance to PAS remained unchanged [2 (8.7%) to 5 (7.9%), P = 1.00].

CONCLUSION

There is increasing resistance to second-line anti-tuberculosis (ATT) drugs, particularly flouroquinolones and ethionamide. Hence, there is an urgent need to avoid the use of ATT drugs for non-tuberculous infection and to increase surveillance for DR TB in adults as MDR TB in children is usually through contact with an adult with infectious MDR TB.

Drug-resistant tuberculosis and advances in the treatment of childhood tuberculosis

Over the last 10 years, interest in pediatric tuberculosis (TB) has increased dramatically, together with increased funding and research. We have a better understanding of the burden of childhood TB as well as a better idea of how to diagnose it. Our appreciation of pathophysiology is improved and with it investigators are beginning to consider pediatric TB as a heterogeneous entity, with different types and severity of disease being treated in different ways. There have been advances in how to treat both TB infection and TB disease caused by both drug-susceptible as well as drug-resistant organisms. Two completely novel drugs, bedaquiline and delamanid, have been developed, in addition to the use of older drugs that have been re-purposed. New regimens are being evaluated that have the potential to shorten treatment. Many of these drugs and regimens have first been investigated in adults with children an afterthought, but increasingly children are being considered at the outset and, in some instances studies are only conducted in children where pediatric-specific issues exist.

Childhood abdominal tuberculosis: Disease patterns, diagnosis, and drug resistance

OBJECTIVE

Childhood abdominal tuberculosis may be difficult to diagnose with certainty. Drug resistance adds to the challenge. We present our experience in children with this condition.

METHODS

The case records of all children <18 years of age and diagnosed as abdominal tuberculosis from January 2000 to April 2012 were reviewed. The clinical details; investigative profile (imaging, ascitic fluid analysis, upper gastrointestinal (GI) endoscopy, colonoscopy, and laparotomy); histopathology; microbiology; and response to antitubercular therapy was noted.

RESULTS

Thirty-eight children (median age 11, range 4-16 years) were diagnosed. Multiple intraabdominal sites were involved in 12 (32 %), peritoneal alone in 9 (24 %); isolated intestinal and isolated lymph nodal in 6 (16 %) each. Three children had atypical presentations with gastric outlet obstruction, acute lower GI bleeding, and duodenal perforation, respectively. Overall, definitive bacteriological diagnosis was possible in 47 % (18/38). In others, diagnosis was supported by histopathology (19 %) or other supportive investigations (34 %) along with a response to treatment without relapse. Drug-resistant disease was diagnosed in three (8 %, two multidrug resistant, one extended drug resistant) all of whom presented with a similar clinical picture of large abdominal lymph node masses.

CONCLUSION

Abdominal tuberculosis is still a challenging diagnosis with microbiological confirmation possible only in half of the cases. Atypical presentations and emergence of drug resistance should be kept in mind while managing these patients.