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.