Some current concepts on childhood tuberculosis.

As children acquire infection with Mycobacterium tuberculosis from adults in their environment, the epidemiology of childhood tuberculosis (TB) follows that in adults. While global burden of childhood tuberculosis is unclear, in developing countries the annual risk of tuberculosis infection in children is 2- 5 per cent. Nearly 8-20 per cent of the deaths caused by tuberculosis occur in children. It has been suggested that BCG vaccination is responsible for decrease in the occurrence of disseminated and severe disease. Localized forms of illness, e.g., intrathoracic lymphadenopathy, and localized CNS disease have been reported to occur with greater frequency in vaccinated children. Human immunodeficiency virus (HIV) infected children are at an increased risk of tuberculosis, particularly disseminated disease. Diagnosis of TB in children presents special problems as the sputum is generally not available for examination. Diagnostic algorithms include scoring system utilizing clinical parameters and results of investigations. Various diagnostic techniques such as improved culture techniques, serodiagnosis, and nucleic acid amplification have been developed and evaluated to improve diagnosis of childhood tuberculosis. Serodiagnosis is an attractive investigation but till date none of the tests showed desirable sensitivity and specificity. Tests based on nucleic acid amplification are a promising development. Relatively less experience in children, need for technical expertise and high cost are the limiting factors for their use in childhood tuberculosis. Short-course chemotherapy for childhood tuberculosis is well established. Treatment with intermittent regimens is comparable to daily regimens. Directly observed treatment strategy (DOTS) has also shown encouraging results. Pattern of drug resistance among children with TB tends to reflect those found among adults in the same population. The rates of drug resistance to any drug vary from 20 to 80 per cent in different geographic regions.

Category based treatment of tuberculosis in children.

BACKGROUND: Childhood tuberculosis is treated with multiple regimens for different clinical manifestations. World Health Organization has suggested a category-based treatment of tuberculosis that focuses on adult type of illness. To include children as DOTS beneficiaries, there is a need to assess the feasibility of classification and treatment of various types of childhood tuberculosis in different categories. METHODS: The study was conducted in the Pediatric Tuberculosis (TB) Clinic of a tertiary care hospital in North India. All children registered in the TB clinic were classified in four categories, similar to the categorization in World Health Organization's guidelines for treatment of tuberculosis in adults. All children with freshly diagnosed serious form of tuberculosis were included in category I. Category II included patients who had treatment failure, had interrupted treatment, relapse cases and those who were suspected to have drug resistant tuberculosis. Patients with primary pulmonary complex (PPC), single lymph node tuberculosis, minimal pleural effusion and isolated skin tuberculosis were included in category III. Category IV included patients who did not improve or deteriorated despite administration of 5 drugs (as per Category II) for at least 2 months. Results: A total of 459 patients were started on antituberculosis drugs and were available for analysis. Pulmonary tuberculosis was the commonest followed by lymph node tuberculosis. Identification of AFB was possible only in 52 (11 percent) of the patients and was more commonly seen in lymph node tuberculosis. The mean age of the children was 93 months and sex distribution was almost equal. 323 patients were in category I, 12 in category II, 120 in category III and 4 in category IV. 365 (80 percent) children completed the treatment. Of these, 302 (82.7 percent) were cured with the primary regimen assigned to them in the beginning, 54 (14.8 percent) required extension of treatment for 3 months and 9 (2.5 percent) patients required change in the treatment regimen. Side effect in form of hepatotoxicity was observed in 12 (2.6 percent) patients and was significantly more in patients who were getting category IV treatment. Conclusion: It is feasible to classify and manage various types of tuberculosis in children in different categories similar to WHO guidelines for adult tuberculosis.

Tuberculosis in children--what has changed in last 20 years?

Several changes have been observed in the epidemiology, clinical manifestations, diagnostic modalities and treatment of tuberculosis. Emergence of HIV epidemic and drug resistance have posed significant challenges. With increase in number of diseased adults and spread of HIV infection, the infection rates in children are likely to increase. It is estimated that in developing countries the annual risk of tuberculosis infection in children is 2.5%. Nearly 8-20% of the deaths caused by tuberculosis occur in children. Lymph node tuberculosis has increased over last two decades. HIV infected children are at an increased risk of tuberculosis, particularly disseminated disease. In last two decades drug resistant tuberculosis has increased gradually. The rates of drug resistance to any drug varied from 20% to 80% in different geographic regions. Various diagnostic techniques such as improved culture techniques, serodiagnosis, and nucleic acid amplification have been developed and evaluated to improve diagnosis of childhood tuberculosis. Serodiagnosis is an attractive investigation but till date none of the tests have desirable sensitivity and specificity. Tests based on nucleic acid amplification are a promising advance. Relatively less experience in children, need for technical expertise and high cost are limiting factors for their use in children with tuberculosis. Short-course chemotherapy for childhood tuberculosis is well established. Treatment with intermittent regimens is comparable to daily regimens. Directly observed treatment strategy have shown encouraging result.

Factors associated with severe asthma.

OBJECTIVE:To study the role of various factors associated with development and severity of bronchial asthma in children between 5-15 years of age. SETTING: Tertiary Care Medical College Hospital. METHODS: A case control study was carried out during May 96 to April 98. Sixty children each suffering from mild (chronic) and severe asthma (chronic) and 60 controls were enrolled to study the association of various risk factors with development of asthma and for severe disease. RESULTS: On univariate analysis factors associated with significant risk for development of asthma included family history of asthma (p = 0.003), lack of exclusive breastfeeding (p = 0.05), past history of bronchiolitis (p = 0.02), associated allergic rhinitis (p = 0.04) and atopic dermatitis (p = 0.01). For development of severe asthma, associated factors were early onset of symptoms (p = 0.01), family history of asthma in grandparents (p = 0.04) and more than 10 cigarettes per day smoked by any family member. No significant effect of air pollution, overcrowding, pets and passive smoking were found on either development of asthma or it's severity. On multivariate analysis only age of onset below 48 months was associated with severe asthma (OR 2.13, 95% CI 1.00-4.54). Exclusive breastfeeding for more than 4 months was the most protective factor for development of asthma (OR 0.25, 95% CI 0.08-0.70). A strong association between development of asthma and past history of bronchiolitis or tuberculosis (OR 5.26, 95% CI 1.7-16.20) and presence of associated atopic dermatitis or rhinitis (OR 7.5, 95% CI 1.64-34.48) was observed. CONCLUSION: History of associated allergic diseases and past history of bronchiolitis were significantly associated with development of asthma. Exclusive breastfeeding for first 4 months of life was protective. The most significant factor associated with severe asthma was onset of illness before 48 months of age. There was no significant effect of air pollution, over crowding, pets at home or passive smoking on severity of asthma

Influence of dietary ginger (Zingiber officinales Rosc) on antioxidant defense system in rat: comparison with ascorbic acid.

Ginger (Z. officinale; 1% w/w) significantly lowered lipid peroxidation by maintaining the activities of the antioxidant enzymes--superoxide dismutase, catalase and glutathione peroxidase in rats. The blood glutathione content was significantly increased in ginger fed rats. Similar effects were also observed after natural antioxidant ascorbic acid (100 mg/kg, body wt) treatment. The results indicate that ginger is comparatively as effective as ascorbic acid as an antioxidant.

Diagnosis of tuberculosis.

Diagnosis of tuberculosis in children is usually based on clinical signs and symptoms, chest roentgenogram, tuberculin testing and history of contact with adult patients. The diagnostic tests for tuberculosis can be broadly divided into 2 groups: demonstration/isolation of Mycobacterium tuberculosis or one of its components [Ziehl Neelson (ZN) staining, special stains, cultures, polymerase chain reaction]; demonstration of host's response to exposure to M. tuberculosis (Mantoux test, serodiagnosis). The yield of tests used for demonstration of mycobacterium or its components is poor because of pauci-bacillary nature of disease in children. Diagnostic use of PCR is still experimental. Serodiagnosis does not have acceptable sensitivity and specificity hence, at present, does not have any role in diagnosis of tuberculosis in children. The diagnosis is suspected on history and a combination of imaging studies and Mantoux test still remains the most widely used investigation.

Clinico-immunological profile in juvenile rheumatoid arthritis--an Indian experience.

From a Pediatric Rheumatology Clinic 361 children diagnosed as juvenile rheumatoid arthritis (JRA) according to American Rheumatism Association-JRA criteria were studied retrospectively for their clinico-immunological profile. The mean age of onset in systemic, pauciarticular and polyarticular onset, JRA subtypes were 5.2, 6.8 and 7.2 years respectively. There was male preponderance in systemic and pauciarticular JRA. In seropositive polyarticular JRA, girls outnumbered boys. The frequency of occurrence of systemic, pauciarticular and polyarticular disease was 87 (24%), 108 (30%) and 166 (46%) respectively. The systemic onset disease was dominated by extra-articular manifestations in terms of fever (100%), rash (57%), hepatomegaly (51%) and lymphadenopathy (25%). The pauci- and polyarticular illnesses were commonly dominated by joint involvement, morning stiffness, and in few patients, by extra-articular manifestations also. The joints were involved symmetrically. Most commonly involved joints in order of decreasing frequency were knee, ankle, wrist and elbow in all the subtypes. Anemia and leucocytosis were observed in majority with higher frequency in systemic onset JRA. The rheumatoid factor (RF) was present in 15% of polyarticular JRA. RF was also present in 7 and 9% of patients with pauciarticular and systemic subtypes respectively. The antinuclear antibody was positive in only 3 out of 66 patients in whom the test was carried out. The demographic profile and trends in clinical features were similar to the studies reported on caucasian population with difference in the actual frequency of various clinical features.

Juvenile dermatomyositis.

The clinical profile of 7 children and their follow-up is described. There was female preponderance with mate to female ratio of 1:6. The median age of onset was 6 years. All the patients had skin rash, muscle weakness and abnormal enzyme profile. Muscle biopsy was performed in 6 and was abnormal in all of them. The electromyogram (EMG) was performed in 6 and was found abnormal in five. All the children responded well to corticosteroids. Two children received intravenous dexamethasone bolus and showed good response.

Tubercular lymphadenitis: clinical manifestations.

One hundred and thirteen children suffering from tubercular lymphadenitis proven histopathologically, were studied for clinical and laboratory features. Age distribution was equal in all age groups except during infancy when it was rare. Sex ratio indicates a male preponderance with male to female in the ratio of 1.5:1 (67:46). Family history of contact with known tuberculous patient was positive in 19 (17%) children, 44 (40%) had received BCG, and 98 (88%) were either normal nourished or had mild malnutrition. Cervical, axillary and inguinal nodes were found in 90 (80%), 14 (12%), and 8 (7%) children respectively. Epitrochlear node was found in only 1 child. 11 (10%) children had discharging sinus, all being in cervical group. The consistency of nodes was firm in 98 (87%), fluctuation was present in 15 (13%). In 87 (77%) lymph nodes were matted. Hepatomegaly of more than 2 cm was present in 13 (11%) and spleen was enlarged (> 2 cm) in 4 (4%) only: Mantoux test was positive in 96 (85%) children and chest X-ray was abnormal in 25 (22%) cases. Findings suggest that tubercular adenitis occurs in all age groups with equal frequency. It can occur in vaccinated children also. It may be a sole manifestation of tubercular infection. The cervical nodes are predominantly involved. There is no typical location of nodes in individual groups but multiplicity and matting of nodes are characteristic features of tubercular adenitis in children.

Hematological manifestations of congenital cytomegalovirus infection.

Nine infants suffering from congenital cytomegalovirus infection were studied for clinical features with special reference to hematological manifestations. The mean age of appearance of first clinical symptom of disease was 14 days and mean age at presentation was 58 days. Significant pallor, thrombocytopenia and evidence of hemolysis were present in 8 (89%), 4 (44%) and 4 (44%) patients respectively out of three bone marrow examination performed, paucity of erythroid and megakaryocytic cells were seen in two. The other clinical features included hepatomegaly in a (100%) splenomegaly in 6 (66%) each, petachial rash in 5 (55%), Hepatitis in 4 (44%) optic atrophy and corneal opacities in one patient each. Two patients died. Remaining patients showed symptomatic improvement without specific therapy.