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Correspondence

Indian Pediatr 2017;54: 164-165

Need for Revision of Guidelines for Management of DR-TB in Children

 

*Manju Kumari and Ira Shah

Pediatric TB Clinic, Department of Pediatrics, BJ Wadia Hospital for Children, Mumbai, India.
Email: [email protected]

  


Overall prevalence of drug resistant tuberculosis (DR-TB) in pediatric patient is increasing [1]. The Directly Observed Treatment, Short Course (DOTS) strategy has emerged as a possible solution to the rising number of tuberculosis (TB) cases and has been incorporated in India’s Revised National Tuberculosis Control Programme (RNTCP) as well. RNTCP multidrug resistant (MDR) TB treatment regimen consist of 6 drugs [kanamycin (km), levofloxacin (lvx), ethionamide (eto), pyrazinamide (Z), ethambutol (E) and cycloserine (cs) during 6-9 months of an intensive phase and 4 drugs (lvx, eto, E and cs) during the 18 months of the continuation phase [2]. In recent studies it has been found that there is increasing fluoroquinolone and ethionamide resistance [1].

At our institute, we had a 10-year-old boy who was diagnosed with rifampicin-resistant (RR) miliary tuberculosis with pneumothorax by GenXpert on sputum sample. We started the child on second-line anti-tubercular therapy (ATT) consisting of moxifloxacin, amikacin, PAS, cs and clofazimine along with prednisolone, based on our previous experience with prevailing DR-TB in Mumbai and the sensitivity pattern [1]. Child improved on above regimen and was discharged with advice to follow-up with drug sensitivity testing (DST) report. After 15 days of above regimen, during a visit to a DOTS center for the medicines, drug regimen was changed to lvx, eto, Z, E, cs and km. After one week of above regime, child’s condition deteriorated, and he developed fever, headache and altered sensorium with signs of raised intracranial pressure. On neuroimaging, he had multiple tuberculomas with communicating hydrocephalus. Child was started on previous ATT regimen that we had put him on initially, and he was treated with dexamethasone along with 3% sodium chloride for his raised intracranial tension. Subsequently, his DST report arrived which showed resistance to rifampicin, isoniazid, km, ofloxacin, E and eto with sensitivity to moxifloxacin, Z, linezolid, PAS, amikacin, clofazimine and capreomycin. Thus as per the medicines that he was receiving from DOTS, the child would be receiving only two drugs (Z and km) to which the DST showed sensitivity with all the other drugs being resistant. This could have led to worsening of his clinical condition. Though it may be argued that appearance of tuberculomas may suggest a paradoxical reaction, the child even after one month of hospitalization was bed ridden, and needed a ventriculoperitoneal shunt for his hydrocephalus suggesting that he developed CNS TB as part of his worsening of TB.

Thus, there is a need for revision of national guidelines for management of DR-TB patients to avoid worsening of the disease condition.

References

1. Shah I, Shah F. Changing prevalence and resistance patterns in children with drug-resistant tuberculosis in Mumbai. Paediatr Int Child Health. 2016:1-4 [Epub ahead of print].

2. Central TB Division. Programmatic Management for Drug-resistant Tuberculosis guidelines-Ma version, Directorate General of Health Services, Ministry of Health and Family Welfare. 2012. Available From: http://www.tbcindia.nic.in/pdfs/Guidelines%20for%20PMDT%20in%20India%20-%20May%202012.pdf. Accessed November 28, 2016.

 

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