1. Dr. Sumit Kumar is right in highlighting the need for category four in DOTS. We agree that with DOTS, resistant TB can be decreased significantly. However, it will not disappear completely. Drug resistant TB in children is reflection of drug resistant TB in adult patients. As long as there are adults with multi drug resistant tuberculosis, there will be cases of MDR tuberculosis in children and that justifies need for category 4 in the treatment strategies(1).

2. Possibility of increasing subcarinal adenopathy in intrathoracic tuberculosis has been suggested and increasing BCG coverage has been attributed to this phenomenon(2). There are not documented studies to support this hypothesis.

It is difficult to identify subcarinal adenopathy on plain CXR. Even hilar and paratracheal nodes may be missed on plain CXR in 15-20% of proven intrathoracic tuberculosis(3,4), There is definite radiation hazards and high cost involved with chest CT scan, hence it cannot be done in all suspected cases of tuberculosis. Therefore it is advisable to keep a high index of suspicion of tuberculosis and before asking for CT chest look for other supporting evidence in form of recent contact with adult patients with tuberculosis, positive tuberculin test or suspicion of nodes on CXR.

3. In scoring systems more weightage is given to laboratory test i.e., acid-fast bacilli, tubercles in biopsy suggestive radiology and tuberculin test >10 mm induration. These scoring systems need validation in individual countries. There is definite need for a scoring system based on clinical features for making a diagnosis of tuberculosis in children; however, feasibility of achieving the same remains doubtful.

S.K. Kabra,
Rakesh Lodha,
Department of Pediatrics,
All India Institute of Medical Sciences,
New Delhi 110 029,
India.  

1. Kabra SK, Lodha R. DOTS in Pediatric patients. Indian Pediatr 2005; 42: 299- 300.

2. Udani PM. BCG Vaccination in India and tuberculosis in Children. Indian J Pediatr 1994; 61: 451-462.

3. Swaminathan S, Raghvan A, Datta M, Paramasivan CN, Sarvanan KC. Computerized Tomography detect pulmonary lesions in children with normal radiographs diagnosed to have tuberculosis. Indian Pediatr 2005; 42: 258-261.

4. Miller WT, Muler WT Jr. Tuberculosis in the normal host: radiologic findings. Semin Roentgenol 1993, 28: 109-118.