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Intrathoracic tuberculosis (pulmonary parenchymal disease, intrathoracic lymphadenopathy, and pleural disease) and peripheral lymphadenopathy account for over 90% of all cases of childhood tuberculosis Most children with tuberculosis have negative acid-fast sputum smears and cultures; the diagnosis is instead based on a triad of findings: a positive TST or TB blood test (interferon gamma release assays [IGRAs]); compatible radiographic and clinical findings; and contact with a person known to have tuberculosis disease Preadolescent children with pulmonary tuberculosis without cavitary findings on radiography rarely are contagious; however, providers should utilize airborne precautions because in many instances, the child is brought to the ED by the person from whom they acquired tuberculosis, and that adult is by definition contagious Current Evidence The most common sites of infection are intrathoracic (pulmonary parenchymal, intrathoracic adenopathy, and/or pleural effusions) and peripheral lymphadenopathy Together, these account for over 90% of all childhood TB cases Meningeal tuberculosis comprises 1% to 2% of all childhood TB cases, and is most common in children in the first years of life Latent tuberculosis infection (LTBI) is defined as a positive TST ( e-Table 94.16 ) or IGRA in a child who lacks TB symptoms and has a normal chest radiograph and physical examination While LTBI will rarely be an ED-based diagnosis, clinicians may see children with LTBI for nontuberculosis concerns or for medication adverse events Children with LTBI are not contagious and have no specific infection control considerations As most tuberculosis medications are hepatically metabolized, the clinician should be aware of potential hepatotoxicity if a child receiving tuberculosis medication presents with abdominal pain, vomiting, anorexia, or icterus Isoniazid (INH) can also cause peripheral neuropathy and can cause benzodiazepine-refractory seizures in cases of overdose (the antidote is pyridoxine, administered as a gram-to-gram dose based on the estimates of the INH dose ingested) Goals of Treatment The goal of treatment is to recognize which children with pulmonary, meningeal, or lymphadenitis may have tuberculosis as opposed to other diagnoses Clinical Considerations Clinical recognition: Tuberculosis disease ( e-Table 94.17 ) should be included in the differential diagnosis of children with fever of unknown origin; pneumonia refractory to therapy for community-acquired pneumonia; cavitary pneumonia/lung abscesses; hilar or mediastinal adenopathy; miliary pattern on chest radiograph; freeflowing pleural effusions with or without consolidation; chronic nontender adenopathy; chronic otorrhea or chronic otitis media; and meningitis with an elevated CSF protein Children with pulmonary tuberculosis often have chest radiographs that look far worse than the child Weight loss in combination with pneumonia should lead the provider to broaden the differential diagnosis outside of the usual pathogens causing community-acquired pneumonia TB meningitis has an insidious onset, and in the early stages, children may have fever and constitutional symptoms alone Unexplained protracted vomiting (due to increased intracranial pressure) often is identified only in retrospect Given the nonspecific initial symptoms and the rarity of the diagnosis in industrialized nations, many children with TB meningitis have had multiple healthcare encounters prior to diagnosis Triage considerations: While prepubertal children with noncavitary chest radiographs rarely are contagious, the person bringing the child to medical attention may be the person who transmitted tuberculosis to the child As such, airborne precautions should be used more to protect healthcare workers and other patients from the caregivers, as opposed to from the patient him/herself Clinical assessment: The diagnosis of tuberculosis in a child infrequently is made based upon microbiologic confirmation Acid-fast cultures of respiratory secretions are positive in a minority of children; the highest culture yield occurs in children with peripheral lymphadenopathy or skeletal disease Instead, children usually are diagnosed based on a triad of findings: epidemiologic links to a person with known or suspected tuberculosis disease; a positive TST or IGRA; and compatible clinical or radiographic findings A chest radiograph should be performed in all children in whom TB is suspected; the most common findings include parenchymal infiltrates,
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