¿Es la tuberculosis ganglionar una verdadera enfermedad tuberculosa? / Is lymph node tuberculosis a true tuberculosis disease?

Introducción: La presencia de adenopatías intratorácicas es el patrón característico de la tuberculosis pediátrica. Puede interpretarse como una infección o una enfermedad tuberculosa, con las consiguientes diferencias terapéuticas. El objetivo de este estudio fue determinar si los pacientes con adenopatías intratorácicas aisladas presentan diferencias clínicas, diagnósticas y microbiológicas respecto a los pacientes con otras formas de enfermedad tuberculosa. Material y métodos: Se estudiaron todos los pacientes menores de 14 años diagnosticados de enfermedad tuberculosa en Cantabria entre 2005 y 2014. Se clasificaron en dos grupos: pacientes con adenopatías intratorácicas exclusivamente y pacientes que presentaron otras formas de tuberculosis. Se compararon entre ambos grupos los síntomas clínicos, la velocidad de sedimentación globular, el resultado de la prueba de la tuberculina (PT) y el aislamiento microbiológico. Resultados: Se diagnosticaron 81 pacientes con enfermedad tuberculosa. El 38,3% presentó tuberculosis ganglionar intratorácica y el resto otras formas de tuberculosis. La media de edad ± desviación estándar en el momento del diagnóstico fue de 70,46 ± 43,6 meses. Los pacientes con tuberculosis ganglionar resultaron asintomáticos con mayor frecuencia y presentaron diámetros de induración de la PT significativamente mayores. El aislamiento microbiológico se consiguió en un 25,9% del total. No se observaron diferencias significativas en el aislamiento microbiológico entre ambos grupos (el 35,5 frente al 16,13%; p= 0,074). En ningún paciente con adenopatías detectadas mediante tomografía computarizada se aisló Mycobacterium tuberculosis. Discusión: El aislamiento de M. tuberculosis constituye el gold standard para el diagnóstico de enfermedad tuberculosa, estableciendo el diagnóstico diferencial con la infección. En este estudio, los pacientes con tuberculosis ganglionar presentaron un porcentaje de aislamiento microbiológico similar a los pacientes con otras formas de tuberculosis. Según estos resultados, el aislamiento microbiológico de las tuberculosis ganglionares no sería un hallazgo casual, por lo que las formas ganglionares deberían considerarse una enfermedad en lugar de una infección tuberculosa

Introduction: The presence of intrathoracic lymph nodes is the characteristic pattern of pediatric tuberculosis but can be interpreted as infection or tuberculosis disease with different therapeutic approaches. The aim of this study was to determine if patients with isolated intrathoracic lymph nodes had clinical, diagnostic and microbiological features compared with patients diagnosed with other forms of tuberculosis disease. Material and methods: All patients younger than 14 years of age diagnosed with tuberculosis in Cantabria between 2005 and 2014 were included in the study. They were classified into two groups: patients with exclusively intrathoracic adenopathies and those with other forms of tuberculosis. Clinical symptoms, erythrocyte sedimentation rate, tuberculin skin test (TST) results and microbiological isolation between the two groups were compared. Results: A total of 81 patients were diagnosed with tuberculosis, 38.3% had nodal tuberculosis and the rest other forms of tuberculosis. The mean age at diagnosis was 70.46 ± 43.6 months. Patients with nodal tuberculosis were more frequently asymptomatic and had significantly higher TST induration diameters. Microbiological isolation was achieved in 25.9% of the patients and no significant differences in microbiological isolation between the two groups were observed (35.5 vs. 16.13%; p= 0.074). No Mycobacterium tuberculosis was isolated in any patient with lymphadenopathies detected by computed tomography. Discussion: The microbiological isolation is the gold standard of tuberculosis disease. Isolation of M. tuberculosis was not significantly superior in the group of patients with exclusive lymph node tuberculosis suggesting that lymph node tuberculosis should be considered a true tuberculosis disease

[Results of the implementation of a protocol for outpatient management of the paediatric patient with tuberculosis]. / Resultados de la implantación de un protocolo para el manejo ambulatorio del paciente pediátrico con enfermedad tuberculosa.

OBJECTIVE: To assess the results of the implementation of a protocol for the outpatient management of paediatric patients with tuberculosis, and to compare it with the previous approach. MATERIAL AND METHODS: All patients younger than 14 years of age diagnosed with tuberculosis in Cantabria between 2005 and 2014 were included in the study. The pre-implementation period included patients admitted for gastric aspirate collection and to start treatment until 2010 (Pre-group). The post-implementation period was from 2010 onwards, using a protocol established for the outpatient management of these patients, with admission only being for clinical or social reasons, post-implantation period (Post-group). RESULTS: A total of 82 patients were studied: 29 from the Pre-group and 53 from Post-group. The median age was 61 months (IQR 32.5-97.75). All patients in the Pre-group were systematically admitted, compared to 26.4% of the Post-group (P<.001). The mean hospital stay was higher (7.27±7.1 days) in the Pre-group than in Post-group (3.4±11.46 days) (P<.0001). Only in 6.9% of patients from Pre-group were the 3 microbiological samples recommended for diagnosis following the international guidelines were provided, whereas they were provided by 73.58% patients from Post-group (P<.001). Of the cultures performed, 26.6% were positive for Mycobacterium tuberculosis, 37.5% of the Pre-group and 21.6% of the Post-group (P=.121). No significant differences were observed between the groups in other parameters related to treatment such as, therapeutic adherence, treatment not adjusted to the guidelines, treatment withdrawal or relapse.. DISCUSSION: Although guidelines recommend three microbiological samples for culture, no superior microbiological isolation was detected despite the increased number of samples collected. The management in hospital clinics of patients with suspected tuberculosis with stable clinical situation show similar or better clinical and microbiological results to the previous management, with lower hospital admission rate and with the subsequent cost savings.

Neumotórax recidivante como forma de presentación de tuberculosis pulmonar postprimaria / Recurrent pneumothorax presenting as post-primary pulmonary tuberculosis

Introducción: La tuberculosis postprimaria se produce por una reactivación de la enfermedad años después del contacto inicial. Es infrecuente en la infancia. Afecta a los lóbulos pulmonares superiores produciendo cavitaciones, y habitualmente cursa sin adenopatías. Caso clínico: Se presenta el caso de una paciente de 11 años de edad, con un neumotórax recidivante secundario a una tuberculosis cavitada. La fiebre persistió durante 2 meses tras el inicio de tratamiento. La paciente precisó una resección parcial del lóbulo superior izquierdo debido a una fístula broncopleural. Tras 6 meses de tratamiento tuberculostático presentó una recidiva. Conclusiones: La tuberculosis postprimaria puede aparecer en adolescentes y causar lesiones pulmonares graves que precisen resección quirúrgica. Los enfermos tienen una gran capacidad infectante. La respuesta al tratamiento es lenta debido a la elevada concentración bacilífera de las cavernas. La baciloscopia puede tardar meses en negativizarse. El tratamiento tuberculostático debe administrarse durante, al menos, 9 meses, y puede ser necesario prolongar la fase de inducción (AU)

Introduction: Post-primary tuberculosis is caused by reactivation of the disease years after the initial contact. It is rare in childhood. Affects upper lung lobes producing cavitations and usually presents without lymphadenopathy. Case report: We report the case of an eleven years-old patient with recurrent pneumothorax secondary to cavitated tuberculosis. The fever persisted two months after initiation of treatment. Partial resection of the left upper lobe was required due to bronchopleural fistula. After completing six months of tuberculosis treatment the infection relapsed. Conclusions: Post-primary tuberculosis can occur in adolescents and cause severe lung injury requiring surgical resection. Patients have a high capacity of spread disease. Treatment response is slow due to the high bacilliferous concentration on the caves. The baciloscopy may take months to become negative. Tuberculostatic treatment should be administered for at least, nine months and may be necessary to extend the induction phase (AU)

Descripción de un brote de tuberculosis y utilidad de la ecografía mediastínica / Description of tuberculosis outbreak and usefulness of mediastinal ultrasound

Objetivos: Describir un brote escolar de tuberculosis y comparar las características con otros brotes. Proponer la ecografía mediastínica como ayuda en el diagnóstico y seguimiento. Pacientes y métodos: Estudio descriptivo retrospectivo de la transmisión de la infección tuberculosa en microepidemia. Criterios de infección: Mantoux ≥ 5 mm, paciente asintomático, estudio radiológico, microbiológico y analítico normal. Criterios de enfermedad: Mantoux ≥ 5 mm y alguno de los estudios anteriores patológico. Se utilizó la ecografía mediastínica como método complementario de la radiografía de tórax (RxT). Se realizó una tomografía computarizada (TC) cuando el resultado combinado de la ecografía y la RxT no fue concluyente. Resultados: De los 412 alumnos, 17 presentaron infección y 16 enfermedad tuberculosa. Además, 4 contactos extraescolares resultaron enfermos. Manifestaciones clínicas: un eritema nudoso, una púrpura de Schönlein-Henoch, 12 con tos y 9 con fiebre. RxT en enfermos: 3 normales, 7 no concluyentes y 10 con los siguientes hallazgos: 2 neumonías, 2 atelectasias, 2 complejos primarios y 4 pacientes exclusivamente con adenopatías. Todos los enfermos con RxT normal o indeterminada presentaron adenopatías mediastínicas visualizadas en la ecografía, excepto en 3 demostradas por TC. Aislamiento microbiológico: 6 casos (31%). Conclusiones: El número de enfermos respecto a infectados fue superior a otros brotes. Existe una gran variabilidad en el enfoque diagnóstico de las microepidemias de tuberculosis. Resulta compleja la diferenciación entre infección y enfermedad. La clínica, analítica y la RxT son inespecíficas. Existen enfermos con RxT normal, ecografía patológica y aislamiento microbiológico. La ecografía mediastínica puede tener un papel importante en el diagnóstico y el seguimiento de enfermedad tuberculosa (AU)

Objectives: Describe a school outbreak of tuberculosis and compare the features with other outbreaks. Propose mediastinal ultrasound as an aid in its diagnosis and monitoring. Patients and methods: Retrospective descriptive study of the transmission of tuberculosis infection in a micro-epidemic. Infection criteria: Mantoux≥5 mm, asymptomatic patient, with normal radiological, microbiological and analytical studies. Disease criteria: Mantoux ≥5 mm and any of the above pathological studies. Mediastinal ultrasound was used as a complementary method of chest radiography (CXR). Computed tomography (CT) as the combined result of ultrasound and CXR was inconclusive. Results: Seventeen out of 412 students were infected and 16 with tuberculosis disease. In addition, 4 out-school contacts were diagnosed of tuberculosis. Clinical manifestations: one erythema nodosum, one Henoch-Schönlein purpura, twelve with cough and fever nine. CXR results in patients: 3 normal, 7 inconclusive, and 10 with the following findings:2 pneumonia, 2 pulmonary atelectasis, 2 primary complexes, 4 patients only with lymphadenopathy. All patients with normal or indeterminate CXR showed mediastinal lymphadenopathy visualized on ultrasound but 3 demonstrated by CT. Microbiological isolation: 6 cases (31%).Conclusions: The number of infected patients was higher compared to other outbreaks There is great variability in the diagnostic approach to tuberculosis micro-epidemics. It is complex to differentiate between infection and disease. The clinical, laboratory and CXR are nonspecific. There are patients with normal CXR, pathological ultrasound and microbiological isolation. Mediastinal ultrasound can play an important role in the diagnosis and management of tuberculosis disease (AU)

[Description of tuberculosis outbreak and usefulness of mediastinal ultrasound]. / Descripción de un brote de tuberculosis y utilidad de la ecografía mediastínica.

OBJECTIVES: Describe a school outbreak of tuberculosis and compare the features with other outbreaks. Propose mediastinal ultrasound as an aid in its diagnosis and monitoring. PATIENTS AND METHODS: Retrospective descriptive study of the transmission of tuberculosis infection in a micro-epidemic. Infection criteria: Mantoux ≥ 5mm, asymptomatic patient, with normal radiological, microbiological and analytical studies. Disease criteria: Mantoux ≥ 5mm and any of the above pathological studies. Mediastinal ultrasound was used as a complementary method of chest radiography (CXR). Computed tomography (CT) as the combined result of ultrasound and CXR was inconclusive. RESULTS: Seventeen out of 412 students were infected and 16 with tuberculosis disease. In addition, 4 out-school contacts were diagnosed of tuberculosis. CLINICAL MANIFESTATIONS: one erythema nodosum, one Henoch-Schönlein purpura, twelve with cough and fever nine. CXR results in patients: 3 normal, 7 inconclusive, and 10 with the following findings: 2 pneumonia, 2 pulmonary atelectasis, 2 primary complexes, 4 patients only with lymphadenopathy. All patients with normal or indeterminate CXR showed mediastinal lymphadenopathy visualized on ultrasound but 3 demonstrated by CT. Microbiological isolation: 6 cases (31%). CONCLUSIONS: The number of infected patients was higher compared to other outbreaks There is great variability in the diagnostic approach to tuberculosis micro-epidemics. It is complex to differentiate between infection and disease. The clinical, laboratory and CXR are nonspecific. There are patients with normal CXR, pathological ultrasound and microbiological isolation. Mediastinal ultrasound can play an important role in the diagnosis and management of tuberculosis disease.