TB & HIV

Question 1

What is the most common causative organism of tuberculosis in children?

Answer 1

Mycobacterium tuberculosis is the primary causative agent in pediatric TB. Less commonly, Mycobacterium bovis may be implicated, especially in areas where unpasteurized dairy is consumed.

Question 2

How is TB most commonly transmitted to children?

Answer 2

Through inhalation of airborne droplets from an infectious adult with active pulmonary TB. Children rarely transmit TB due to low bacillary load and less forceful coughing.

Question 3

What factors increase the risk of TB infection and disease progression in children?

Answer 3

Close contact with an adult TB case, HIV infection, severe malnutrition, age <5 years, immunosuppressive therapy (e.g., steroids), no BCG vaccination.

Question 4

What are the hallmark clinical features of pulmonary TB in children?

Answer 4

Chronic cough (>2–3 weeks), fever, weight loss or failure to thrive, fatigue, night sweats, lymphadenopathy (esp. hilar or cervical).

Question 5

How is latent TB infection (LTBI) diagnosed in children?

Answer 5

Positive Tuberculin Skin Test (TST) or Interferon-Gamma Release Assay (IGRA), no symptoms of active TB, normal chest X-ray, no microbiologic evidence of TB.

Question 6

What defines primary TB in children?

Answer 6

Initial infection post-exposure, often asymptomatic or with mild symptoms. Includes Ghon focus, regional lymphadenopathy, risk of progression to miliary or meningeal TB in high-risk children.

Question 7

What is the Ghon focus and Ghon complex in TB?

Answer 7

Ghon focus: Primary granulomatous lesion in lung; Ghon complex: Ghon focus + regional lymphadenopathy (typically hilar nodes).

Question 8

What is the typical radiographic presentation of pediatric pulmonary TB?

Answer 8

Hilar or mediastinal lymphadenopathy (most common), segmental/lobar consolidation, miliary pattern (disseminated), rarely cavitation.

Question 9

What are extrapulmonary forms of TB commonly seen in children?

Answer 9

TB meningitis, lymph node TB (esp. cervical), miliary TB, TB of bones/joints (Pott’s disease), abdominal TB.

Question 10

What diagnostic tools are recommended for pediatric TB diagnosis?

Answer 10

Clinical assessment, Chest X-ray, TST or IGRA, Gastric aspirate or sputum AFB smear/culture, GeneXpert MTB/RIF.

Question 11

What is the role of GeneXpert MTB/RIF in pediatric TB diagnosis?

Answer 11

GeneXpert MTB/RIF detects Mycobacterium tuberculosis DNA and rifampicin resistance within 2 hours. It is recommended by WHO for use in children with suspected TB, especially in extrapulmonary or smear-negative cases.

Question 12

What are the features of miliary tuberculosis in children?

Answer 12

Disseminated TB with hematogenous spread; presents with prolonged fever, weight loss, hepatosplenomegaly, respiratory distress, and a miliary pattern on chest X-ray.

Question 13

How does TB meningitis typically present in children?

Answer 13

Insidious onset with fever, vomiting, irritability, altered sensorium, signs of raised intracranial pressure, and focal neurological deficits. May follow primary TB infection after 1–6 months.

Question 14

What are the stages of TB meningitis in children?

Answer 14

Stage I: Nonspecific symptoms (fever, malaise); Stage II: Neurological signs (meningeal signs, lethargy); Stage III: Severe neurological deficits (coma, seizures, decerebration).

Question 15

What are the indications for starting empirical anti-TB treatment in children?

Answer 15

Strong clinical suspicion (symptoms + contact + radiological signs), inability to confirm diagnosis microbiologically, and high-risk cases (e.g., <5 years, HIV+, malnourished).

Question 16

What is the treatment regimen for drug-sensitive TB in children?

Answer 16

2 months of intensive phase with HRZE (isoniazid, rifampicin, pyrazinamide, ethambutol), followed by 4 months continuation phase with HR (isoniazid, rifampicin).

Question 17

What are the common side effects of anti-TB drugs in children?

Answer 17

Isoniazid: hepatotoxicity, peripheral neuropathy; Rifampicin: hepatotoxicity, orange discoloration of secretions; Pyrazinamide: hepatotoxicity, arthralgia; Ethambutol: optic neuritis (rare in children).

Question 18

How is TB prevented in high-risk pediatric contacts?

Answer 18

BCG vaccination at birth; Isoniazid preventive therapy (IPT) for 6 months in children <5 years or immunocompromised contacts after ruling out active TB.

Question 19

What is the role of BCG vaccine in TB prevention?

Answer 19

BCG provides protection against severe forms of TB (e.g., miliary TB and TB meningitis) in infants and young children. Its efficacy against pulmonary TB is variable.

Question 20

How is treatment adherence monitored in pediatric TB cases?

Answer 20

By direct observed therapy (DOT), weight-based drug dosing review, clinical follow-up, symptom resolution, and weight gain. Sputum/gastric aspirate conversion is rare in children.

Question 21

When is corticosteroid therapy indicated in pediatric TB?

Answer 21

Steroids are indicated in TB meningitis, miliary TB with respiratory distress, pericardial TB, and severe pleural effusion to reduce inflammation and complications.

Question 22

What are the key differences between TB and community-acquired pneumonia in children?

Answer 22

TB: chronic symptoms, weight loss, hilar lymphadenopathy, positive TST/IGRA; CAP: acute onset, lobar consolidation, rapid response to antibiotics.

Question 23

What is the significance of a positive TST in a BCG-vaccinated child?

Answer 23

A positive TST may still indicate TB infection, especially if induration is ≥10 mm; interpretation must consider exposure history and risk factors.

Question 24

How is multidrug-resistant TB (MDR-TB) managed in children?

Answer 24

Requires second-line drugs (e.g., fluoroquinolones, injectables, linezolid) for 18–24 months, with strict monitoring. Regimen is guided by drug susceptibility testing (DST).

Question 25

What are the prognostic factors in pediatric TB?

Answer 25

Poor prognosis is associated with young age (<2 years), HIV co-infection, severe malnutrition, drug resistance, and delayed diagnosis or treatment.

Question 26

What are the main modes of HIV transmission in children?

Answer 26

Vertical transmission is the most common, which includes in utero, intrapartum (during delivery), and postpartum (mainly via breastfeeding). Other less common routes include contaminated blood transfusions, needle sticks, and sexual abuse.

Question 27

What are the WHO clinical staging criteria for pediatric HIV?

Answer 27

WHO stages: Stage 1 – Asymptomatic or persistent generalized lymphadenopathy. Stage 2 – Hepatomegaly, splenomegaly, dermatitis, recurrent URTIs. Stage 3 – Unexplained moderate malnutrition, chronic diarrhea >14 days, oral candidiasis, pulmonary TB. Stage 4 – Severe wasting, PCP, esophageal candidiasis, HIV encephalopathy, extrapulmonary TB.

Question 28

What are common clinical manifestations of pediatric HIV?

Answer 28

Growth failure, developmental delay, recurrent bacterial infections (e.g., pneumonia, otitis media), oral thrush, chronic diarrhea, generalized lymphadenopathy, hepatosplenomegaly, and increased risk of malignancy (e.g., lymphomas).

Question 29

What are the recommended diagnostic tests for infants <18 months?

Answer 29

Virologic tests such as HIV DNA PCR or HIV RNA PCR are used. These can detect viral nucleic acids within 4–6 weeks of age. Serologic tests (antibody-based) are not reliable due to maternal antibodies.

Question 30

How is HIV diagnosed in children >18 months?

Answer 30

HIV is diagnosed using two positive HIV antibody tests (e.g., rapid diagnostic test, ELISA) based on different principles. A confirmatory test is essential before starting ART.

Question 31

What is the role of cotrimoxazole prophylaxis in pediatric HIV?

Answer 31

Prevents Pneumocystis jirovecii pneumonia, toxoplasmosis, malaria, and bacterial infections. Start at 4–6 weeks of age in HIV-exposed infants and continue until HIV is excluded. In confirmed HIV cases, continue long-term based on clinical and immunological status.

Question 32

When should ART be initiated in HIV-infected children?

Answer 32

WHO recommends initiating ART in all children with confirmed HIV infection, regardless of WHO clinical stage or CD4 count, as soon as possible after diagnosis.

Question 33

What are the preferred first-line ART regimens in pediatric HIV?

Answer 33

Children <3 years: 2 NRTIs (e.g., abacavir + lamivudine) + a PI (lopinavir/ritonavir). Children ≥3 years: 2 NRTIs + an NNRTI (e.g., efavirenz). Newer regimens may include integrase inhibitors like dolutegravir where available.

Question 34

What are the goals of ART in pediatric HIV?

Answer 34

Suppress HIV viral load to undetectable levels, restore and preserve immune function (increase CD4 counts), improve growth and neurodevelopment, reduce HIV-related morbidity and mortality, and prevent transmission.

Question 35

How is ART response monitored in HIV-infected children?

Answer 35

Monitor clinical improvement (growth, infections), CD4 count/percentage every 6 months, viral load every 6 months (or 3–6 months after starting/changing ART), and assess adherence regularly.

Question 36

What are key side effects of antiretroviral drugs in children?

Answer 36

Zidovudine: anemia, neutropenia Lamivudine: well-tolerated Efavirenz: vivid dreams, dizziness Nevirapine: hepatotoxicity, rash Lopinavir/ritonavir: diarrhea, lipodystrophy Monitor liver enzymes and CBC regularly.

Question 37

What is IRIS and when does it occur in pediatric HIV?

Answer 37

Immune Reconstitution Inflammatory Syndrome (IRIS) is a paradoxical worsening of existing infections (like TB or CMV) after starting ART due to immune recovery. Typically occurs within weeks to 6 months of initiating ART. Managed by treating the underlying infection and continuing ART.

Question 38

How is immunosuppression classified using CD4 in children?

Answer 38

<12 months: Severe if CD4 <1500/mm³ or <25% 1–5 years: Severe if CD4 <750/mm³ or <20% >5 years: Severe if CD4 <350/mm³ or <15% CD4 monitoring helps guide prophylaxis and assess treatment response.

Question 39

What are common OIs in pediatric HIV and their prophylaxis?

Answer 39

Common OIs: PCP, TB, candidiasis, chronic diarrhea (cryptosporidiosis), CMV, HSV, bacterial pneumonia. Prophylaxis: Cotrimoxazole for PCP and toxoplasmosis; INH for TB exposure; antifungals in select cases.

Question 40

What are strategies for PMTCT (Prevention of Mother-to-Child Transmission)?

Answer 40

Initiate lifelong ART in all pregnant women (regardless of CD4). Provide neonatal ART prophylaxis (e.g., nevirapine). Exclusive breastfeeding with maternal ART or exclusive formula feeding. Early infant diagnosis at 6 weeks and continued follow-up.