Challenges encountered in managing tuberculosis in children: a case report

The management of pediatric tuberculosis involves several challenges, as illustrated in these three cases. Challenges are numerous and each case demonstrates the difficulty and delay in diagnosis, social constraints that delay the diagnosis, and drug dosing schedules that cause serious side effects in children. All three cases received the Bacillus Calmette-Guérin vaccine at birth, and each has documented confirmation of vaccination.

A 1-year-old Sri Lankan Muslim baby was transferred to a tertiary care center with a week-long fever of unknown origin, accompanied by recent weight faltering. Investigations revealed anemia, elevated erythrocyte sedimentation rate, and chest X-ray showing miliary changes, with a positive GeneXpert® System for tuberculosis, though gastric aspirates were negative for acid fast bacilli. GeneXpert is a molecular diagnostic system that uses real-time polymerase chain reaction technology to detect specific genetic material (DNA or RNA) from pathogens in a biological sample for the rapid and accurate diagnosis of tuberculosis. The baby was treated with antituberculosis drugs and recovered fully, and contact tracing identified the grandmother as a possible source due to a chronic cough. A 4-month-old Sri Lankan Tamil baby with fever, cough, and shortness of breath developed convulsions and was initially treated for a lower respiratory infection and possible bacterial meningitis. After transfer to a tertiary hospital and investigation, high cerebrospinal fluid protein and lymphocyte count suggested a possible tuberculosis infection and antituberculosis drugs were started. The baby developed liver dysfunction after 6 days of treatment, which resolved after discontinuing the antituberculosis drugs, and she recovered fully without sequelae after appropriate management. A 2-year-old Sri Lankan Tamil child presented with difficulty walking for 2 weeks following an accidental fall, with localized swelling and tenderness over the L4-L5 region. The child showed signs of bilateral lower limb weakness, reduced power, and exaggerated knee jerks, and had a history of contact with a father diagnosed with pulmonary tuberculosis. X-rays were performed to investigate the spinal issue, and the child had previously defaulted on tuberculosis prophylaxis after receiving isonicotinic acid hydrazide. Magnetic resonance imaging showed destruction of the L4 and L5 vertebrae with caseous material tracking and causing secondary psoas abscess.

Clinicians must maintain a low threshold for diagnosing tuberculosis in young children, especially those under 1 year old with malnutrition, as tuberculosis can present subtly in this age group. Performing GeneXpert® when suspected is warranted. Parental education and challenging social circumstances hinder children from getting better. The cases identify the challenges faced by clinicians.