PECULIARITIES OF THE COURSE TUBERCULOSIS INFECTION IN CHILDREN IN MODERN CONDITIONS


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Abstract

Relevance. Tuberculosis is one of the most significant problems for modern society. Epidemiological situation with this disease remains unstable, with children being particularly at risk. According to Federal State Statistics Service number of TB cases per 100 thousand people aged 0 to 17 years in the period from 2010 to 2021 decreased by 2.5 times, but in spite of this the problem of TB incidence remains acute.
Objective. To present a clinical case of exudative pleurisy as a manifestation of childhood tuberculosis infection.
Materials and methods. Analysis of case histories of the patient treated at the department for children with respiratory tuberculosis of the VOKPTD named after N.S. Pokhvisneva in the period from April till October, 2022.
Results. The present work presents a clinical case of exudative pleurisy in a 9-year-old child against the background of infiltrative pulmonary tuberculosis. The patient was registered by a phthisiatrician for tuberculosis contact with a parent. At the next examination, the diascintest was positive, after which an MSCT was prescribed. The child was referred to the ward for children with TB of the respiratory organs for clarification of the diagnosis and further treatment. The child was examined by narrow specialists, then anti-tuberculosis therapy was prescribed. A few months later, the condition worsened, MSCT showed negative dynamics, fluid in the right pleural cavity. It was decided to consult a thoracic surgeon for a therapeutic and diagnostic pleural puncture. The patient tolerated the intervention satisfactorily. Within the next four days, the patient felt better and his body temperature decreased to normal values. During the next 4 months, the child received daily anti-tuberculosis therapy and was examined by specialists. The subsequent MSCT showed positive dynamics. Taking into account the positive dynamics, by the decision of the referral board after six months of in-patient treatment, the patient was transferred to out-patient treatment.
Conclusion. At the analysis of the case it is possible to draw a conclusion that the timely revealing of the patients with tuberculosis in the epidemiological centers as well as timely started anti-tuberculosis therapy, taking into account morphofunctional and immunologic features of a child organism, promote development of positive dynamics and the quickest cure.

 

Full Text

Relevance. To date, tuberculosis is one of the most significant problems for modern society. The epidemiological situation for this disease remains unstable, especially the greatest threat falls on the share of the child population. The reasons are untimely diagnosis of tuberculosis, infection from parents, frequent morbidity among children from risk groups, especially from foci of tuberculosis infection [1].
Many authors note that the development of complications in tuberculosis is characteristic of childhood at the present time [2].
According to Rosstat, the number of tuberculosis cases per 100,000 people aged 0 to 17 years in the period from 2010 to 2021 decreased by 2.5 times, but despite this, the problem of the spread of this disease remains relevant [3].
Goal. To present a clinical case of the development of exudative pleurisy as a manifestation of tuberculosis infection in childhood.
Materials and methods. Analysis of the medical history of a patient who was in the department for children with tuberculosis of the respiratory organs of the KUZ VOKPTD named after N.S. Pokhvisneva in the period from April to October 2022.
Examination of the provided medical documentation, anamnesis data, conclusions of specialist doctors. The results of computed tomography, ultrasound examination, and laboratory data are analyzed.
Results. Patient E., 9 years old, was admitted to the children's department of the N.S. Pokhvisneva Children's Hospital with a diagnosis of community-acquired, unspecified, bilateral polysegmental pneumonia on the left, complicated by destruction on the right. Respiratory failure of the 1st degree.
Anamnesis of life (according to the mother): he grew and developed according to his age. He is not registered with other specialists at the dispensary. Of the transferred diseases, chickenpox in 2018. Allergic history: food allergy to citrus fruits and sweets.
Anamnesis of the disease: the child is registered with a phthisiologist for tuberculosis contact with a parent. The father was diagnosed with infiltrative pulmonary tuberculosis, decay phase and insemination, respiratory failure of the 1st degree, MBT+, MDR (H,R,S,Pt). The father is on outpatient treatment, lives with his family.
Anti-tuberculosis therapy was not prescribed to the child during this period. At the next examination, diaskintest is positive (papule 14 mm). After that, MSCT was appointed. On the MSCT on the right in S3 there are single foci of medium intensity, in S6 there is an infiltrate with a decay cavity up to 6 mm in diameter, along its periphery there are multiple polymorphic foci, as well as foci in the basal parts of the lower lobe of the right lung. On the left in S3 and lingual segments there are polymorphic foci of a drain character, in S8 there is a group of foci of medium intensity. He was sent to the department for children with tuberculosis of the respiratory system to clarify the diagnosis and further treatment.
Objectively, upon admission: the condition of moderate severity, temperature 36.60 C, heart rate 104 beats per minute, BPD 20, the skin is clean, pale, without pathological rashes. There is weakened breathing in the lungs, scattered wet wheezing. The heart tones are clear, rhythmic. No pathology was detected on the part of other organs and systems.
During laboratory tests at admission, the following changes were revealed: UAC: increased ESR (28 mm / h) and thrombocytosis. In the biochemical analysis of blood, an increase in alkaline phosphatase is noted. Sputum examination: microscopy - CUM +, seeding - MBT +, PCR-DNA MBT +.
Examination of upper respiratory flushes: seeding - MBT +, PCR – DNA MBT+, drug resistance to Isoniazid, Rifampicin, Protionamide and Streptomycin. Urine culture on MBT: negative.
Conclusion of specialists at the time of admission and in dynamics: ophthalmologist: healthy, ethambutol is not contraindicated. Surgeon: bilateral flat feet of the second degree. Neurologist: transistor tic disorder. Neurogenic bladder. Migraine. Pulmonologist: community-acquired unsatisfied, bilateral, polysegmental pneumonia S3, S8 on the left, complicated by the destruction of S6 on the right. Infiltrative pulmonary tuberculosis with S6 decay on the right?
Taking into account the data of the examination, treatment was prescribed: Bacperazoni 0.9 x 2p / day No. 28 intramuscularly, Cetirizini 10 drops x 2 r / day (10mg) No. 14, ACC (Acetylcysteini) per os 100 mg x 3p / day. Bedaquiline 0.2, Moxifloxacin 0.4, Capriomycin 0.6, Linezolid 0.3, Pyrazinamide 0.75.
While on this therapy, the general condition of the child remained stable, his well-being improved. After a month of inpatient treatment, the patient's temperature rose to 38.20 C. During auscultation, wet wheezing and weakened breathing were heard on the right. The general condition of the child remained of moderate severity, the state of health worsened.
During this period, negative dynamics was observed on the MSCT of the OGC: single foci of medium intensity on the right in C3, an infiltrate with a decay cavity, 9 mm in diameter, in C6. In the right pleural cavity, fluid appeared with an axial cross-section of up to 60 mm. On the left in C3 and lingual segments there are polymorphic foci of a drain character, in C8 there is a group of foci of medium intensity.
The following changes were detected in the general blood test: leukocytosis, eosinophilia, lymphopenia, increased ESR up to 38 mm/h.
Taking into account the deterioration of the patient's condition and the data of computed tomography and laboratory data, it was decided to consult with a thoracic surgeon about performing a therapeutic and diagnostic pleural puncture. Drainage of the right pleural cavity was performed under local anesthesia, 700 ml of serous exudate was removed. The patient underwent the intervention satisfactorily. The results of the study of the obtained exudate by luminescent microscopy: KUM-, seeding on MBT- , PCR-DNA MBT +.
Taking into account the deterioration of the patient's condition and laboratory data, treatment was prescribed: Bedaquiline 0.2, Moxifloxacin 0.4, Amikacin 0.6, Linezolid 0.3, Pyrazinamide 0.75. Pathogenetic treatment: ACC, Ursofalk, Sirtura, Glutoxim, Vit B1, B6, B12, Omeprazole, Drotaverine, Linex, Bifidumbacterin.
During the next four days, the state of health improved, a decrease in body temperature to normal figures was noted.
The results of repeated diaskintest: positive (papule 5 mm).
Over the next 4 months, the child received daily anti-tuberculosis therapy, was examined by narrow specialists. At subsequent MSCTS, positive dynamics was noted. After six months of hospital treatment: infiltrate remains on the right in C6, which has decreased in size, the decay cavity has ceased to be determined, multiple polymorphic foci along the periphery, as well as foci in the basal parts of the lower lobe of the right lung, which have partially resolved. On the left, polymorphic foci of a drain character remain in the C3 lingual segments. The pleural cavities are free. Local thickening of the costal hymen in the anteroposterior parts of the right lung after undergoing right-sided exudative tuberculous pleurisy. During the same period: UAC, OAM and biochemical parameters are normal, sputum examination: KUM –; seeding: MBT –, PCR-DNA MBT– . Taking into account the positive dynamics, by the decision of the commission, after six months of inpatient treatment, the patient was transferred to the outpatient stage to continue treatment.
The patient was clinically diagnosed with infiltrative pulmonary tuberculosis, resorption phase, closure of the decay cavity. The condition after exudative tuberculous pleurisy on the right in the form of a local area of thickening of the costal pleura, MET (+) by term, MDR (H, R, S, Eto), I gr DN, A15 and recommendations are given after discharge: observation of the district phthisiologist, continue treatment according to RCT IV, continuation phase (Lzd 0.3, Tzd 0.5, Mfx 0.3, Z 1.0) up to 60 doses. Supervision of a pediatrician, orthopedist, ophthalmologist and neurologist at the place of residence. Control of MSCT OGK after 2 months, used blood, UAC, OAM, urine by Nechiporenko 1 time per month. Sputum control by luminescent microscopy, sputum seeding (one sputum sample) 1 time per month. ECG monitoring 1 time per month. Diaskintest control after 6 months.
Discussion: The presented clinical case demonstrates the peculiarities of the course of tuberculosis infection in childhood. Such physiological features as immaturity of cellular and humoral immunity, incomplete phagocytosis and many other causes cause rapid generalization of the inflammatory process and the development of complications in children [4]. In this case, infiltrative tuberculosis was aggravated by the development of exudative pleurisy due to the existing morpho-functional and immunological features of the child's body.
Conclusion: After analyzing this clinical case, it can be concluded that timely detection of tuberculosis patients in epidemiological foci, as well as timely anti-tuberculosis therapy, taking into account morpho-functional and immunological characteristics of the child's body, contribute to the development of positive dynamics and speedy cure.

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About the authors

Julia Sergeevna Ignatova

Voronezh State Medical University named after N.N. Burdenko

Author for correspondence.
Email: julia.ignatova00@mail.ru
ORCID iD: 0000-0002-8092-0477
SPIN-code: 9296-6706

student

Russian Federation, Voronezh, Studentskaya str., 10.

Nikita Olegovich Kasymov

Voronezh State Medical University named after N.N. Burdenko

Email: nikita-kasimov1@inbox.ru
ORCID iD: 0000-0002-6073-2065

student

Russian Federation, Voronezh, Studentskaya str., 10.

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  2. Цыганкова, Е.А. Возрастные проявления туберкулеза у детей / Е. А. Цыганкова, А. В. Мордык, А. А. Турица // Туберкулез и болезни легких. – 2014. - № 8. – С.111-112.
  3. Федеральная служба государственной статистики [Электронный ресурс]. URL:https://rosstat.gov.ru/folder/13721 (дата обращения 10.01.2023)
  4. Авдеева Т.Г Руководство участкового педиатра / Авдеева Т.Г — 4-е изд.. — : ГЭОТАР-Медиа, 2022 — 664 c.

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