|
|
|
Indian Pediatr 2010;47:
537-538 |
 |
Consensus Statement on Tuberculosis: Queries? |
|
Syed Ahmed Zaki and Preeti Shanbag,
Department of Pediatrics, Lokmanya Tilak Municipal
General Hospital, Sion, Mumbai 400022, India.
Email: [email protected]
|
|
We read with interest the "Consensus Statement on Childhood Tuberculosis"
developed by the Working Group on Tuberculosis of the IAP(1). We
appreciate the efforts of the expert committee in formulating the
guidelines. However, we have a few queries which we would like clarified.
1. Isolated tuberculoma has not been classified in
either severe or less severe form of extra-pulmonary tuberculosis.
Kindly advise regarding management of a child with isolated tuberculoma.
2. The Directly Observed Treatment Short-course
(DOTS) strategy is applicable to all patients with tuberculosis,
including children. As per DOTS, 6 months treatment is sufficient for
the treatment of TBM(2). Studies in adults and children have also found
that 6-month treatment is sufficient for the treatment of TBM with fully
susceptible mycobacteria(3,4). We work in a municipal general hospital
with many of our patients being unable to afford anti-tuberculous
therapy. Most of our children with TBM are therefore referred to DOTS
for their treatment. We have treated more than 100 children with TBM
using the 6-month regimen in the last five years. We have not had
treatment failure or relapse in any patient who has complied with
therapy. Deaths in these patients have been in the acute phase and all
related to shunt malfunction or infection. The guidelines mention that
lesions in TBM, miliary and spinal TB may take longer to sterilize and
that relapse in such cases is associated with serious morbidity and
hence a recommendation has been made to prolong the continuation phase
to 6-7 months(1). It is not clear on what basis this recommendation has
been made. Are there any studies which support the above statement? We
feel that extending the duration of the continuation phase for the
above-mentioned forms of TB without any definite evidence will also
extend the duration for which the child will be exposed to the side
effects of antituberculous drugs.
3. Paradoxical reactions are fairly common during the
treatment of tuberculosis and steroids have been found to be useful in
their treatment(5). This has not been mentioned in the guidelines while
describing the role of steroids in tuberculosis.
4. As per the World Health Organisation guidelines
(2003) for the treatment of tuberculosis, BCG vaccination of the newborn
should be postponed until the end of isoniazid prophylaxis(2). The
expert committee in the article have mentioned that "Vaccination with
BCG appears to decrease the risk of tuberculosis in exposed infants, but
the effect is variable"(1). We feel that it should be clearly
spelt out in the guidelines that BCG vaccine should be administered only
after INH prophylaxis has been completed.
References
1. Working Group on Tuberculosis, Indian Academy of
Pediatrics. Consensus statement on childhood tuberculosis, 2008. Indian
Pediatr 2010; 47: 41-55.
2. World Health Organization. Treatment of
tuberculosis. Guidelines for National Programmes, 3rd ed. Geneva: World
Health Organization; 2003.
3. van Loenhout-Rooyackers JH, Keyser A, Laheij RJ,
Verbeek AL, van der Meer JW. Tuberculous meningitis: is a 6-month
treatment regimen sufficient? Int J Tuberc Lung Dis 2001; 5: 1028-1035.
4. Jacobs RF, Sunakorn P, Chotpitayasunonah T, Pope S,
Kelleher K. Intensive short course chemotherapy for tuberculous
meningitis. Pediatr Infect Dis J 1992; 11: 194-198.
5. Lee LPY, Chiu WK, Chan HB. Enlarging tuberculous
lymph node despite treatment: Improving or Deteriorating? Hong Kong J
Paediatr 2009; 14: 42-45.
|
|
Reply
1. Isolated tuberculoma being a part of neuro-tuberculosis
is a severe form of extrapulmonary tuberculosis and should be treated with
category 1 regimen with steroids, similar to TBM.
2. It is clearly mentioned that there are studies to
suggest adequacy of 6 months treatment in TBM and military TB. However, in
case of delayed response to assigned therapy in category 1 and 2, it is
recommended to prolong intensive phase by 1 month and continuation phase
by 3 months in such patients. This is based on observation that in few
patients, standard regimen falls short of desired outcome that is achieved
by extension of therapy(1). We note with interest that authors of this
letter have data of 100 cases of TBM treated with standard 6 months of
therapy and followed up to confirm cure and no relapse. It is worth
publishing this data in peer-reviewed journal and we are sure that
guidelines can be subsequently modified accordingly.
3. While paradoxical reactions do occur, we feel that
they cannot be considered as "fairly common". In any case, such reactions
are in the form of pleural effusion, tuberculoma or increase in size and
number of existing tuberculomas or lymphnode enlargement. Tuberculoma and
mediatinal compressive lymphadenopathy are mentioned as indications for
steroids and it holds true irrespective whether such lesions represent
initial disease manifestation or paradoxical reaction. Superficial
lymphnode enlargement or pleural effusion are not indications of steroid
therapy.
4. As such protective effect of BCG vaccine is variable
and administration of INH does not have any significant effect on take up
of BCG vaccine. Moreover, BCG vaccine is routinely administered at birth
and diagnosis of tuberculosis in mother is often made thereafter.
YK Amdekar
Email: [email protected]
Reference
1. Kabra SK, Lodha R, Seth V. Category based treatment of tuberculosis
in children. Indian Pediatr 2004; 41: 927-937.
|
|
|
 |
|
