Childhood Tuberculosis

MCQ Quiz
Question 1

15yo MK was diagnosed with pulmonary tuberculosis 10 years ago.

He is currently here for a health-check. His parents are concerned on
reactivation of the disease. Which of the following statement is true?
A. His sputum smear and culture for tuberculosis and tuberculin skin
test is expected to be negative if he is currently asymptomatic.
B. His family members who were in contact with him before are all
considered latent TB.
C. Reactivation TB may affect other organs despite previous history of
pulmonary TB.
D. He can be reassured that reactivation TB only occurs later in life.
Answer: C
A. Latent TB usually have positive tuberculin skin test as the patient
has developed cell-mediated immune memory to the bacillus.
B. Latent TB are those who had primary TB but whose immune
system is able to contained the infection. Those with latent infection
are asymptomatic and not infectious to others. Children with primary
TB rarely affect other children and adults.
D. Reactivation TB can occur in immunocompromised states in any
age group, eg malnutrition, HIV co-infection, immunosuppresent
therapy (chemo, steroids etc)…
 Question 2

A five year old boy was diagnosed with disseminated tuberculosis and
currently under rifampicin, isoniazide and pyrazinamide. Which of the
clinical presentation is unlikely for this child?
A. Weight loss
B. Positive tuberculin test
C. Meninges and adrenal insufficiency
D. Fever
Answer: B
• Tuberculin skin test (mantoux test) with purified protein derivative
(PDD) often yields negative results in miliary Tb due to large number
or TB antigens throughout the body
• Weight loss (80%), fever (80%) and meninges (up to 25%) occurs in
miliary TB.
Question 3

Which physical sign is highly suggestive of extrapulmonary TB?

A) failure to thrive
B) bronchial breath sound
C) lymphadenopathy
D) wheezing
Answer: C
Pulmonary TB presents with abnormal breath sound (wheezing and
bronchial breath sound indicating lung consolidation)
Failure to thrive can present in all types of TB due to chronic
infection.
Lymphadenopathy is as result of infection of lymph node by
Mycobacterium TB
 Question 4

Which of the following is true regarding sputum smear microscopy in

investigations for tuberculosis (in children)
A . Most often sputum smear is positive
B . A child with retroviral disease, and previous immunization with
BCG vaccine would have a positive sputum smear
C. Once there is positive sputum smear, there is no need of culture and
sensitivity of tuberculosis
D. Sputum smear microscopy is a disease specific investigation
Answer : B
A. Compared to adults, The bacilli is sparse in the sputum of a child, hence it
is more frequently false negative in children
B. BCG vaccine is contraindicated in people with impaired immunity,
and WHO does not recommend BCG vaccination for children with
symptomatic HIV infection as there is higher risk of disseminated BCG
disease developing in children infected with HIV who are vaccinated at
birth and who later developed AIDS.
C. It is highly suggestive but not confirmatory . To confirm the diagnosis of
pulmonary TB, we should culture Mycobacterium tuberculosis from the
sputum. However, because mycobacterial culture requires expensive
equipment and the long turn-around time, AFB smear is still valuable.
D. Acid-fast bacilli (AFB) smear-positive sputum is usually an initial clue in
the diagnosis of pulmonary tuberculosis (TB); however, the test is not
disease-specific. Nontuberculous mycobacterium-related colonization or lung
disease often has AFB smear-positive sputum results
 Question 5

M. tuberculosis can be found in the sputum of patients with

tuberculosis. After digestion of the sputum, isolation is best
accomplished using:
a. Sheep blood agar
b. Löffler’s medium
c. Thayer-Martin agar
d. Thiosulfate citrate bile salts sucrose medium
e. Löwenstein-Jensen medium
Answer: E
• Sheep Blood agar: S. aureus nutrient base and 5 to 8% sheep blood;
selective and differential media, such as mannitol salt agar, also are
available for S. aureus.
• Loffler’s Medium: C. diphtheria, but suppresses the growth of most other
nasopharyngeal microflora colonies on this medium appear small, gray, and
granular and have uneven edges.
• Thayer –Martin Agar: Pathogenic Neisseriae TM agar is both a selective and
an enriched medium; it contains hemoglobin, the supplement Isovitalex,
and the antibiotics vancomycin, colistin, nystatin, and trimethoprim.
• Thiosulfate citrate bile salts sucrose medium : V. cholerae as well as other
vibrios, including V. parahaemolyticus and V. alginolyticus, although media
such as mannitol salt agar also support the growth of vibrios Maximal
growth occurs at a pH of 8.5 to 9.5 and at 37°C incubation.
• Löwenstein-Jensen M tuberculosis Nutrient base and egg yolk
 Question 6

Which of the following is the the best diagnostic clue of pulmonary

tuberculosis (TB) is:
1. Isolation of Mycobacterium tuberculosis
2. Positive chest x-ray results
3. Positive PPD test results
4. Mother has active TB
5. Father has active TB
Answer:
Diagnosing tuberculosis is quite difficult in children. Although they
may cough, they rarely produce sputum and may present in a non-
specific manner with failure to thrive or loss of weight, reduced
energy, and, perhaps, persistent fever. Contact with a relative with
tuberculosis is an important pointer. Tuberculin testing may be
helpful, and, when possible, a chest radiograph should be obtained
or laryngeal swabs or gastric washings taken for culture.
 The radiographic hallmark is the relatively
large size and importance of
lymphadenopathy. The chest radiograph
remains normal, and the child is
asymptomatic. In some children, the hilar
and mediastinal lymph nodes continue to
enlarge and are readily visible on chest
radiograph. External compression from the
enlarging nodes can cause air trapping,
hyperinflation, and even emphysema. As
the nodes attach to and infiltrate the
bronchial wall, caseum fills the lumen
causing complete obstruction. This results in
atelectasis that usually involves the lobar
segment distal to the obstructed lumen.
The resulting radiographic shadows are
usually called collapse-consolidation or
segmental lesions (Fig. 2). These findings
are similar to those caused by aspiration of
a foreign body; in essence, the lymph node
is acting as the foreign body. Multiple
segmental lesions in different lobes may be
apparent in 25% of children.[38]
Question 7

A 2-year-old boy present to ED with history of unresolved fever and

cough for 2 weeks. The baby looks malnourished, unwell and
lethargic. The father was diagnosed to have pulmonary TB one week
ago and currently on TB regime. Mantoux test was done and the
result is 6mm. Chest X-ray shows normal findings. What is the next
step of management?

A discharges the patient with follow up

B repeat the mantoux test after 2 weeks
C start the patient on TB regime
D start INH chemoprophylaxis
Question 7

Steroid is indicated in?

A. Miliary TB
B. TB meningtis
C. TB spine
D. Endobronchial TB
Answer: B
Tuberculous meningitis is a serious form of tuberculosis affecting the
meninges covering the brain and spinal cord. The clinical outcome is
poor even when treated with conventional antituberculous drugs.
Corticosteroids are commonly used in addition to antituberculous
drugs for treating the condition. They help reduce swelling and
congestion of the meninges, and thus decrease pressure inside the
brain and the attendant risk of death or disabling residual neurological
deficit among survivors.
Question 8

A mother brings an 8 year old child to the clinic who is on anti-

tuberculosis treatment. She complains that her child has been passing
red-orange urine for the last few days and that she is very worried.
Which of the following drug could be the cause of that condition?
A Streptomycin
B Rifampicin
C Ethambutol
D Pyrazinamide
Answer: B
Rifampicin is an intensely red solid and the small fraction which
reached body fluids is known for imparting a harmless red-orange
color to the urine and to a lesser extent to sweat and tears.
Question 9

What is the commonest complication of TB meningitis:

A. Tuberculoma
B. Diabetes insipidus
C. Hydrocephalus
D. Epileptic seizures
Answer: C
The most common complications were: hyponatraemia 49%,
hydrocephalus 42%, stroke 33%, cranial nerve palsies 29%, epileptic
seizures 28%, diabetes insipidus 6%, tuberculoma 3%,
myeloradiculopathy 3% and hypothalamic syndrome 3%.
Hydrocephalus is one of the most common complications of
tuberculous meningitis. It occurs in approximately 2/3rd of patients
with tuberculous meningitis and has an unfavorable impact on the
prognosis.