Diagnostic Challenges in Childhood Pulmonary Tuberculosis-Optimizing the Clinical Approach

Abstract

The management of childhood tuberculosis (TB) is hampered by the low sensitivity and limited accessibility of microbiological testing. Optimizing clinical approaches is therefore critical to close the persistent gaps in TB case detection and prevention necessary to realize the child mortality targets of the End TB Strategy. In this review, we provide practical guidance summarizing the evidence and guidelines describing the use of symptoms and signs in decision making for children being evaluated for either TB preventive treatment (TPT) or TB disease treatment in high-TB incidence settings. Among at-risk children being evaluated for TPT, a symptom screen may be used to differentiate children who require further investigation for TB disease before receiving TPT. For symptomatic children being investigated for TB disease, an algorithmic approach can inform which children should receive TB treatment, even in the absence of imaging or microbiological confirmation. Though clinical approaches have limitations in accuracy, they are readily available and can provide valuable guidance for decision making in resource-limited settings to increase treatment access. We discuss the trade-offs in using them to make TB treatment decisions.

Keywords: children; diagnosis; paediatric; symptom-based; tuberculosis.

Figure 1

Suggested algorithm to manage (A) HIV-negative child tuberculosis contacts and (B) children living with HIV when chest X-rays and tests of infection are not readily available; adapted from and consistent with World Health Organization guidance [14]. CXR—chest X-ray, IGRA—interferon-gamma release assay, TB—tuberculosis, TPT—TB preventive treatment, TST—tuberculin skin test. # Evidence is limited regarding the benefits and risks of TPT in asymptomatic child TB contacts ≥5 years of age without a TST or IGRA to document infection and without a CXR or other sensitive test to rule out TB disease and among children ≥10 years for whom higher bacillary load is disease is more common. * If evaluation definitively rules out TB disease, then TPT should be started.

Figure 2

Tuberculosis treatment decision algorithm in children less than 10 years of age with symptoms suggestive of pulmonary tuberculosis, reproduced from the operational handbook accompanying the 2022 consolidated guidelines on the management of TB in children and adolescents [31]. Scores associated with features from clinical history and physical exam and chest X-ray translate to risk of TB and are developed from analysis of diagnostic evaluations. TB—tuberculosis, HIV—human immunodeficiency virus, mWRD—molecular WHO-recommended rapid diagnostic test, CLHIV—children living with HIV, LF-LAM—lateral flow urine lipoarabinomannan assay, CXR—chest X-ray.