eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Tuberculosis: Follow-up

Author: Vandana Batra, MD, Pediatrician, Department of Pediatrics, Division of General Pediatrics/Primary Care, Nemours Pediatrics
Coauthor(s): Jocelyn Y Ang, MD, Assistant Professor, Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Michigan and Wayne State University
Contributor Information and Disclosures

Updated: Nov 23, 2009

Follow-up

Further Outpatient Care

• Public health authorities should be notified of all cases of tuberculosis (TB).
• Directly observed therapy (DOT) is mandatory for the treatment of patients with coexistent HIV disease, those with multidrug-resistant (MDR) tuberculosis, and those who may be noncompliant.
• The WHO launched the Stop TB strategy in 2006 (modelled after the DOT strategy) and the core components include pursuing high-quality DOT expansion and enhancement; addressing tuberculosis and HIV, MDR tuberculosis, and other challenges; contributing to health system strengthening; engaging all care providers; empowering people with tuberculosis; and enabling and promoting research.³
• A regular follow-up appointment every 4-8 weeks should be scheduled to ensure compliance and to monitor the adverse effects of and response to the medications administered. Adherence to the regimen is of vital importance to its success. Therefore, every measure should be taken to provide language-specific and culturally appropriate material to ensure compliance. Clear and written instructions regarding the timing of medication and the quantity to be administered should be provided.
• Monitoring of liver function test results is not indicated routinely. However, it may be required in the treatment of patients with miliary tuberculosis, tubercular meningitis, and coexistence of other hepatic disorders or with concomitant hepatotoxic drug therapy. In the rare event the patient has symptoms of hepatitis, discontinue the regimen and evaluate liver function. If the tests are normal or return to normal, then a decision to restart the medications may be made. Re-introduce the drugs one by one.
• Follow-up chest radiography may be performed after 2-3 months of therapy to observe the response to treatment in patients with pulmonary tuberculosis. However, hilar lymphadenopathy may take several years to resolve. Thus, a normal chest radiography finding is not required for termination of therapy.

Transfer

• Patients with miliary tuberculosis, tubercular meningitis, or disseminated tuberculosis may need transfer to the ICU until their condition is stabilized.

Deterrence/Prevention

• Treatment of latent tuberculosis infection
  • Current recommendations for preventive therapy are based on a comparative analysis of the risk of administration of isoniazid (INH) versus the risk of acquiring the disease. Adults with a positive tuberculin skin test (TST) result and no clinical or radiographic manifestations who are receiving INH therapy have been demonstrated to have 54-88% protection against the development of the disease, whereas children have been shown to have 100% protection.
  • The risk of acquisition of tuberculosis is particularly high in very young children (<5 y) and in the adolescent population. Thus, patients in these age groups with a positive TST result and no other manifestations should receive INH therapy. Active tuberculosis should be carefully excluded prior to the initiation of preventive therapy.
  • For recent contacts of patients with contagious tuberculosis (ie, in the past 3 mo), INH therapy is indicated even if the TST result is negative. This is especially true for contacts who are infected with HIV or for household contacts younger than 5 years. Household contacts of any age should be considered for INH therapy if they are from a high-prevalence area, even if the TST result is negative.
  • The recommendations from the AAP are to administer 9 months of therapy. The drug of choice is INH. A period of treatment of 12 months is recommended for patients with HIV infection. For the management of contacts of INH-resistant cases, rifampin is recommended for 6 months in children.
  • In case of a high probability of infection with MDR-TB, observation is recommended since none of the other drugs have been evaluated for preventive therapy. Several drugs have been used in these circumstances, including pyrazinamide, fluoroquinolones, and ethambutol, depending on the susceptibility patterns.
• Vaccination
  • The bacille Calmette-Guérin (BCG) vaccine is available for the prevention of disseminated tuberculosis. BCG is a live vaccine prepared from attenuated strains of M bovis.
  • Although BCG vaccine has been in use since 1921 and approximately 3 billion doses have been administered, its efficacy continues to be debated. Several trials have been performed to assess the efficacy of the vaccine, and results vary. However, 2 meta-analyses of the various trials concluded that the vaccine is efficacious against miliary and meningeal tuberculosis.¹⁵ Controversy surrounds the efficacy of BCG vaccination against pulmonary tuberculosis.
  • The major role of BCG vaccination is the prevention of serious and life-threatening disease such as disseminated tuberculosis and tubercular meningitis in children. The BCG vaccine does not prevent infection with M tuberculosis.
  • The Expanded Program on Immunization of the WHO recommends the administration of BCG at birth. The vaccine is being used in more than 100 countries. In the United States, BCG vaccination is currently recommended only in certain situations, including the following:
    • Child has negative HIV and TST results, is exposed to persons with contagious MDR (resistant to INH and rifampin) pulmonary tuberculosis, and cannot be removed from the exposure
    • Child has negative HIV and TST results, is exposed to persons with untreated or ineffectively treated contagious pulmonary tuberculosis, and cannot be removed from the exposure or treated with antitubercular medication
  • From birth to age 2 months, administration of BCG does not require a prior TST. Thereafter, a TST is mandatory prior to vaccination.
  • Adverse reactions due to the vaccine include subcutaneous abscess formation and the development of lymphadenopathy. Rare complications, such as osteitis of the epiphyses of the long bones and disseminated tuberculosis, may necessitate administration of antitubercular therapy, except for pyrazinamide.
  • Contraindications to the administration of the vaccine include immunosuppressed conditions such as primary or secondary immunodeficiency, including steroid use and HIV infection. However, in areas of the world where the risk of tuberculosis is high, the WHO recommends using the BCG vaccine in children who have asymptomatic HIV infection.

Complications

• Miliary disease and tubercular meningitis are the earliest and most deadly complications of primary tuberculosis. A high index of suspicion is required for prompt diagnosis and management of these conditions. Pulmonary complications of tuberculosis include the development of pleural effusions and pneumothorax. Complete obstruction of a bronchus can result if caseous material extrudes into the lumen. This can lead to atelectasis of the involved lung. Bronchiectasis, stenosis of the airways, bronchoesophageal fistula, and endobronchial disease caused by penetration through an airway wall are other catastrophes that may occur with primary tuberculosis.
• Perforation of the small bowel, obstruction, enterocutaneous fistula, and the development of severe malabsorption may complicate tuberculosis of the small intestine.
• Pericardial effusion can be an acute complication or can resemble chronic constrictive pericarditis.
• Renal complications including hydronephrosis and autonephrectomy usually do not occur in children. Paraplegia may complicate Pott disease of the spine (ie, tubercular spondylitis).

Prognosis

• Prognosis of tuberculosis varies according to the clinical manifestation. Poor prognosis is associated with disseminated tuberculosis, miliary disease, and tubercular meningitis.
• The prognosis of tubercular meningitis varies according to the stage of the disease at the time treatment is started. Stage 1 has a good prognosis, whereas patients with stage 3 usually have sequelae such as deafness, blindness, paraplegia, mental retardation, movement disorders, and diabetes insipidus.
• Higher mortality rates occur in children younger than 5 years (20%) and in those with a illness lasting longer than 2 months (80%).

Patient Education

• Educate patients regarding compliance to therapy, adverse effects of medications, and follow-up care.
• For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education article Tuberculosis.

Miscellaneous

Medicolegal Pitfalls

• Tuberculosis (TB) presents a potential health hazard to the public.
• Legal measures have been initiated in several states in the United States allowing for civil or criminal detention of patients with active tuberculosis with persistent noncompliance with directly observed therapy (DOT).

Special Concerns

• Tuberculosis can cause significant morbidity in the pregnant woman and the fetus; hence, pregnant women must be carefully evaluated and be placed on prophylaxis or treatment as indicated. Hematogenous spread of the bacilli through the umbilical vein and the placenta to the fetal liver or aspiration of tubercle bacilli from infected amniotic fluid may lead to the development of congenital tuberculosis.
• First-line agents recommended by the AAP include isoniazid (INH), rifampin, and ethambutol. No significant teratogenicity on the fetus has been observed. Streptomycin is contraindicated because it may lead to the development of deafness in the fetus. Data regarding the use of pyrazinamide, cycloserine, and ethionamide are not available; avoid these drugs if possible. Treatment should be started as soon as the diagnosis of tuberculosis is confirmed or after the first trimester in women younger than 35 years with recent tuberculin skin test (TST) conversion. Strict adherence to the treatment protocol is essential to prevent the development of congenital tuberculosis and maternal morbidity.
• Breastfeeding should not be discouraged because the amount of drug in breast milk is very small, and no adverse effects have been documented. All pregnant women on INH therapy should receive pyridoxine.

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