TB in pediatric patients is not so wee

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“Yes, I lost the year…I had to leave my vocational [school] and the dedicate myself to the health center.”

“I spent 4 years with tuberculosis. I wanted to study more, become a teacher. This disease has taken an important part of my life.”

In the session “Not so wee TB: addressing disease in pediatric patients,” an expert panel that included Andrea T. Cruz, MD, MPH, Baylor College of Medicine, Houston, Texas; Anja Reuter, MBChB, MPH, Sentinel Project on Pediatric Drug Resistant Tuberculosis, Cape Town, South Africa; Silvia S. Chiang, MD, ScM, Alpert Medical School of Brown University, Providence, Rhode Island; and Lisa Armitige, MD, PhD, Heartland National TB Center/University of Texas Health Science Center at Tyler, San Antonio, Texas, discussed the challenges and proposed solutions in pediatric TB.

In the United States, pulmonary TB comprises most disease in children, but it is particularly difficult to diagnose in infants and young children. For what Armitige called “little lungs and an ugly disease,” Cruz described that symptoms may be minimal, amounting only to a cough, prolonged symptoms, or persistent pneumonia.

In other cases, obtaining at chest x-ray in an at-risk infant may instead make the diagnosis. Another challenge lies in the limitations of available diagnostic methods, though Cruz celebrated an upcoming Redbook guideline that is prepared to recommend interferon-gamma release assay testing for all infants and children (rather than only those older than 2 years of age).

Further, in border states like Texas, where the uninsured population is 11.8% and many lack a medical home, early detection is even more difficult. Immigrants and refugees face variable pre-arrival testing, with tourists having no such requirements. As violence continues to drive migration from countries like El Salvador, Guatemala, Honduras, and Mexico, the incidence of TB among unaccompanied minors is alarmingly high.

Reuter shared insights from Cape Town's Khayelitsha region, a highly endemic peri-urban slum with high rates of rifampicin resistance and HIV coinfection. There, challenges include limited socioeconomic support, challenges obtaining a bacteriological diagnosis, children left out of research, and overburdened facilities with limited resources. However, capacitating doctors and RNs, implementing GeneXpert Ultra stool PCR testing, introducing child-friendly counseling, and introducing pediatric medication formulations are beginning to bridge diagnostic and treatment gaps.

A less often-discussed consequence of TB is its long-term impact on a child’s health. Chiang highlighted how post-TB lung disease manifests as chronic respiratory abnormalities like bronchiectasis (14/25 in one study) or obstructive lung disease that can substantially limit quality of life. When considering the isolation during treatment or medication side effects like hearing loss, TB also impacts the educational or emotional well-being of children.

Lastly, Armitige emphasized the importance of early diagnosis, sharing a harrowing journey of 2 sisters, each with TB meningitis. While a younger, asymptomatic sister was diagnosed by lumbar puncture indicated only due to her age of 5 months and proximity to a sister with seizures and a stroke due to TB meningitis, her primary care provider didn’t want to treat because “she looked too good.” Armitige reminded attendees (and the providers) that children are at a heightened risk of high mortality (up to 19.3%) and neurological sequelae (53.9%). Anyone with spinal fluid studies suggestive of TB meningitis should be treated, and when intolerance arises, Armitige sticks to her mantra – “keep treating.”

Pediatric TB is an intricate challenge that demands continued attention and funding. While the resilience of children offers hope, it is important to remember that "TB in pediatric patients is not so wee. There is still much work to do."

Reference
Cruz AT, Reuter A, Chiang SS, Armitage L. State of TB among pediatric patients. IDWeek 2023. October 12, 2023. Boston, Massachusetts.