Received 2022 Feb 24; Accepted 2022 May 27; Collection date 2022.

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• It is essential to recognize the signs and symptoms of pediatric TB early for effective management.
• Common symptoms of pediatric pulmonary TB include cough, fever, lymphadenopathy, and contact history.
• Analysis of retrospective and prospective cases can help in identifying warning signs and improving diagnostic strategies.
• In low-endemic areas, contact history and lymphadenopathy play a crucial role in diagnosing pediatric TB.
• Creating a diagnostic score for regions with low TB prevalence may be challenging due to the lack of significant risk factors.
• For additional resources, refer to the online version of the study at 10.1186/s13052-022-01288-5.

Understanding Tuberculosis in Children

Tuberculosis remains a leading cause of global mortality, primarily affecting the lungs. Early detection and preventive measures are vital in combating the disease. Children are particularly vulnerable to TB, often contracting it from close contact with infected adults.

Key Diagnostic Factors for TB

Diagnosing TB in children is challenging due to the lack of specific symptoms at the onset. Clinical judgment, risk assessment, and imaging play crucial roles in early detection.

Preventive Measures for TB in Children

Preventing TB in children involves several key strategies:

• Screening high-risk groups, such as family members of TB patients
• Providing preventive therapy for children exposed to TB
• Promoting vaccination with the Bacille Calmette-Guérin (BCG) vaccine
• Improving overall hygiene and living conditions to reduce transmission

By implementing these measures, we can help protect children from the devastating effects of tuberculosis and reduce its prevalence worldwide.

Study Setting and Methodology

Research Site

The research took place at Bambino Gesu Pediatric IRCCS in Rome, a tertiary pediatric hospital. Ethics approval was obtained following the Helsinki Declaration.

Study Details

Retrospective analysis included pediatric pulmonary TB cases between 2005-2017, while a prospective study focused on patients presenting to the Emergency Department with TB symptoms from 2018-2020. Data collection encompassed demographics, symptoms, risk factors, and diagnostic results.

Comparative Analysis

Comparison between retrospective and prospective TB cases shed light on identifying early warning signs. Statistical analysis was conducted utilizing STATA software, highlighting key differences between TB and non-TB patients.

Findings

The retrospective analysis revealed that pediatric pulmonary TB cases had a higher incidence among children under the age of 5, with common symptoms including cough, fever, and weight loss. On the other hand, the prospective study showed an increase in TB cases presenting to the Emergency Department with respiratory symptoms such as cough and difficulty breathing. The most significant risk factor for TB infection was household exposure to an active TB case.

Recommendations

Based on the findings of the study, early identification and prompt diagnosis of pediatric TB cases are crucial in preventing the spread of infection. Targeted screening strategies for high-risk populations, such as children under 5 and those with household exposure, should be implemented to improve case detection and management.

Demographics and Symptoms

Retrospective Findings

A total of 226 pediatric TB cases were examined, with an average age of 5.6 years. Male patients were more prevalent in this group.

Detailed demographic information, risk factors, and symptoms at the disease onset were evaluated in the retrospective cohort.

TB Diagnosis and Clinical Presentation

In this study, various diagnostic tools such as IGRA, Mantoux, and microbiological tests (culture, bacterioscopic, PCR) were utilized. Nearly all patients had positive results from Mantoux (92.9%) and IGRA (95.6%). Additionally, a significant percentage showed positive microbiological cultures, PCR, and bacterioscopic findings.

Key Findings from Prospective Study

An analysis of 85 patients (14 with TB and 71 non-TB) revealed interesting insights. Patients with TB were older compared to non-TB cases. Notably, persistent cough for ≥ 10 days was more prevalent in non-TB patients. Symptoms such as chest pain and hemoptysis showed variations between TB and non-TB cases.

Demographics and Symptoms Comparison

The study compared TB and non-TB cases based on demographics, risk factors, and symptoms. It was observed that age and symptoms like persistent cough and fever differed significantly between the two groups. Antibiotic therapy efficacy, contact history, and lymphadenopathy were identified as important factors in diagnosing pulmonary TB.

Assess for the presence of fever for 10 days or more, cough for 10 days or more, swollen lymph nodes, history of contact with infected individuals, and unexplained weight loss.

Discussion

Diagnosing tuberculosis in children can be difficult due to vague initial symptoms and lack of exposure to known cases of the disease. The methods used for diagnosis do not always give immediate results. Our research compared different clinical manifestations and risk factors in countries with low tuberculosis rates to those with high rates by studying two distinct groups. Contact with a person diagnosed with tuberculosis is a major risk factor among patients with the disease. Additionally, having parents from countries with high tuberculosis rates also contributes to the likelihood of developing the infection.

Although antibiotics are commonly prescribed, their effectiveness varies between cases of tuberculosis and other respiratory illnesses. Symptoms such as cough and fever, typically associated with the disease, may not consistently indicate tuberculosis in our particular situation. Swollen lymph nodes and weight loss present at different rates in cases of tuberculosis compared to non-tuberculosis cases.

Other symptoms like fatigue and chest pain are less significant in diagnosing tuberculosis. Distinguishing tuberculosis from other respiratory diseases based solely on symptoms can be a challenge. These findings underscore the complexities involved in diagnosing tuberculosis in children and the importance of considering various risk factors.

In our retrospective study, hemoptysis and night sweats were rarely reported symptoms (2.6% and 1.8% of cases, respectively), in line with previous Italian studies (hemoptysis 2.7%, night sweats 1% of cases) [20] as well as international ones [10, 47]. Night sweats were absent in tuberculosis cases in the prospective group, but were present in 33.8% of non-tuberculosis cases, potentially linked to fever. Therefore, these symptoms may not be clinically relevant for early diagnosis.

In a larger retrospective sample of 226 patients, both Mantoux and IGRA tests were positive in the majority of cases (92.9% and 95.6%, respectively), while culture was positive in only 42.2% of cases. Despite being the gold standard, a negative culture result should not delay the diagnostic process, especially in children who are at risk of disease progression after exposure. The limited sensitivity and specificity of microbiological tests are due to the low levels of bacteria present in pediatric tuberculosis cases, with only 20-50% of pulmonary cases showing a positive culture. Bacterioscopic tests were positive in only 18% of cases, reflecting their low sensitivity, while PCR was positive in 37.6% of patients, consistent with results from other studies (30.4-32%) [20, 35].

Our research in a country with low tuberculosis prevalence revealed a different clinical presentation of pulmonary tuberculosis. Persistent cough and fever were less common, while risk factors such as contact with known tuberculosis cases and swollen lymph nodes were significant. Furthermore, a poor response to antibiotic treatment in tuberculosis patients raised suspicion. Gathering details about the child’s and parents’ origins also proved to be crucial in suspecting the disease. To create a clinical scoring system for pulmonary tuberculosis in Italy, it is important to review the key risk factors. In a population with low rates of HIV and tuberculosis, criteria for inclusion could consist of a fever lasting ≥ 10 days, cough lasting ≥ 10 days, poor response to antibiotics, swollen lymph nodes, positive Mantoux and/or IGRA results, abnormal chest X-ray, and a history of contact with a known tuberculosis case.

Expanding the study to involve more medical centers is necessary to validate the clinical scoring system for early diagnosis and reduce unnecessary testing. Initial analysis has shown promise, with variations in criteria for inclusion and the questionnaire (detailed in Additional File 1).

Lastly, comparing tuberculosis and non-tuberculosis cases on a larger scale will help confirm or identify key indicators for suspecting tuberculosis to reduce transmission risks, particularly in crowded places like emergency department waiting rooms.