Drug-resistant abdominal tuberculosis in children: dilemmas and difficulties

Drug-resistant abdominal tuberculosis (DR-ATB) is suspected in subjects with non-response to standard therapy despite good compliance. Literature is scarce in children. We studied symptoms, yield of investigations, management and outcome of DR-ATB in children. The electronic database of children (<18 years) diagnosed with DR-ATB over last 15 years was analysed retrospectively and clinical profile, investigations, treatment and outcome were noted. Samples were subjected to microscopy, Xpert MTB/RIF Ultra assay, culture, second-line drug susceptibility test (SL-DST) by line probe assay and histology. DR-TB was classified as per guidelines. Thirteen girls (median age: 15 years) presented with anorexia (12, 92%), fever (11, 85%), weight-loss (11, 85%), abdominal pain (11, 85%), lump (6, 46%), intestinal obstruction (5, 38%) and perforation (6, 46%). Imaging showed necrotic lymph-nodes (11, 85%), bowel thickening (9, 69%), ascites (8, 62%), omental thickening (5, 38%), visceral involvement (4, 31%) and tubo-ovarian mass (3, 23%). All had multiple site involvement in abdomen and had received anti-tubercular therapy (ATT) previously. Eight (62%) cases had extra-abdominal tuberculosis. Eleven (85%) cases were rifampicin-resistant (one was pre-extensively drug resistant [pre-XDR]) and 1 (7%) case each was isoniazid mono-resistant and probable XDR-TB. ATT was given for 24 (10-42) months, 11 (85%) responded, one succumbed and one was lost to follow-up. Adverse events occurred in five (38%) cases. In conclusion, rifampicin-resistance accounted for 85% of all DR-ATB. Majority of the patients with DR-ATB were adolescent females with past history of ATT, large necrotic lymph-nodes and multiple site involvement in abdomen. Majority showed good response to therapy.