Id/01(P) Prevalence of Tuberculous Infection & Disease Among Children Under 5 Years In

ID/01(P) PREVALENCE OF TUBERCULOUS INFECTION & DISEASE AMONG CHILDREN UNDER 5 YEARS IN CONTACT WITH AN OPEN CASE OF TUBERCULOSIS

Devendra Sareen, Nishtha Sareen, Dharam Singh, Abhishek Ojha, K.K. Agarwal

27-F New Fatehpura, Udaipur-313 001

A major fraction of our population is constituted by children. Tuberculosis is still one of the major health hazard in them. The present study was planned to determine the prevalence of tuberculous infection and disease among children below 5 years of age exposed to an open case of tuberculosis in the family and to find out its co- relation with various variables. After obtaining a detailed history of 100 such children, each of them was subjected to detailed physical examination with special reference to nutritional status and signs of tuberculosis. These children were further investigated by a combined BCG & Tuberculin testing. Children showing a positive BCG or MT test were further evaluated by radiological examination and these findings were co-related.Most of the children were asymptomatic (83%). Prevalence of tuberculous infection was 76% with positive BCG test in 72% and positive MT in 27% cases. 55^ of them showed radiological evidences of the disease. The positivity of BCG test was high in children suffering from various grades of malnutrition in comparison to MT test. Prevalence of Tuberculous disease was 55% and was almost equal in BCG vaccinated and unvaccinated children. The disease was more prevalent in poor socio-economic class (67.4%), living in over crowded houses (60.8%) with poor environmental conditions (64%). Hence, whenever a sputum positive case of tuberculosis is diagnosed, all children living in close contact must be screened thoroughly for tuberculosis at earliest and if disease is detected in them, they should be given anti-tubercular drugs for proper duration to avoid severe sequelae of disease.

ID/02(P) SPECTRUM OF FALCIPARUM MALARIA IN LUCKNOW

Col Mukti Sharma, Col Uma Raju

Dept of Pediatrics, Command Hospital (Central Command), Lucknow Cantt - 226002

Background :Malaria is a major disease in tropical climates causing high rates of mortality. A rising incidence of falciparum malaria in Eastern UP has given rise to diagnostic difficulties in children admitted with fever. Unless treated early the disease has a high mortality. We present our experience in diagnosis and treatment of children with falciparum malaria. Patients & MethodsForty eight children were diagnosed to have MT malaria in the last 3 years (Oct 2003 to Jun 2007). Mean age 6.5 (range-14 months to10) years. Diagnosis was based on clinical features, presence of splenomegaly and confirmed on presence of MT rings on peripheral smear or a positive serum immuno-chromatographic test (ICT). All these children were treated with quinine, and those who did not respond in 72 hours were administered artesunate alone or in combination depending on severity of symptoms. Results: Clinical presentation was varied; the commonest being diarrhoea and low grade fever and headache (n=19). Seventeen mimicked meningitis with headache, high grade fever and vomiting. The others were jaundice (n=7), florid urticaria (n=2). Two presented as acute renal failure and one with haemoglobinuria. Diagnosis confirmed by presence of MT rings on peripheral smear (n=17) and a positive serum immuno-chromatographic test (ICT) in the rest (n=31). Being an endemic area for malaria, chloroquin had been exhibited to 41 patients prior to hospitalisation, however this had not altered the course of the disease. Forty three patients responded to parenteral quinine. Five had to be given artesunate alone or in combination with quinine. All children recovered and are on follow up. Conclusions:Falciparum malaria in children can mimic a number of common clinical entities and diagnosis on peripheral smear is only in about 30% and the rest need a serum ICT for confirmation. Majority do not respond to chloroquin but do to quinine. Those resistant to quinine respond to artesunate.

ID/03(P) SAFETY AND EFFICACY OF Β ARTEETHER IN CHILDREN WITH UNCOMPLICATED FALCIPARUM MALARIA.

B.D.Gupta, Pramod Sharma, Randeep Singh, Manish Parakh, Anil Arora.

Department of Pediatrics, Umaid Hospital for Women & Children, Dr.S.N. Medical College, Jodhpur.

INTRODUCTION : Malaria has an annual incidence of 300 to 500 cases. Rajasthan has faced recent out breaks of malaria with over 7 lakh cases reported in 2003. Arteether, a semi synthetic product, an ethyl derivative of dihydro artemesinin is available as an oil based preparation for intra muscular administration. It is efficacious against chloroquine resistant uncomplicated and even severe malaria. It has an advantage of rapid Schizonticidal action, early defervescence and rapid parasite clearance time.

OBJECTIVE : To evaluate the efficacy of B arte ether in uncomplicated falciparum malaria and study its side effect profile.MATERIAL AND METHODS : Open propspective study, clearance obtained from Ethical committee and Drug controller of India and written consent from parents. Patients of complicated malaria were excluded. Clinically suspected malaria cases confirmed on stained peripheral blood smear were included. Cases were hospitalized for a period of 7 days and evaluated on 14, 21 and 28 days. Symptom score was assigned to each case. Percentage parasite count was derived for each patient and arteether used in dose of 3 mg/Kg. ODx3 consecutive days by deep intra muscular injection.RESULTS :Most common symptom was fever without rigors seen in 73.8% cases followed by weakness, pain abdomen and vomiting in 40.4%, 28.5% and 28% cases. Mean symptom score on day 0 was 24.4 ±1.8 which came down to 22.1±0.4 by day 7. Splenomegaly was seen in 66.6% cases and ring forms of parasite were seen in 50% cases and ring and gametes in 35.7% cases. Parasite count was < 2% in 71.4% cases while on day 4, 10 cases (23.8%) had parasitemia < 2%. Reduction in the parasite load on day 4 was statistically significant (p < 0.02). Fever cleared in 38% cases by 48 hours with mean fever clearance time of 36+12.3 hours. Spleen regression by day 4 was seen in 30.95 patients. Parasite clearance time was 24-48 hours in 52.3% cases. Sensitivity to Arteether was noted to be 97.6% with resistance (R-II) seen only in 1 cas CONCLUSION: Β-arteether is efficacious in uncomplicated falciparum malaria and was well tolerated without any major side effects.

ID/04(P) INDUCED SPUTUM VS GASTRIC LAVAGE FOR MICROBIOLOGICAL CONFIRMATION OF PULMONARY TUBERCULOSIS IN CHILDREN”

Ashok K.Gupta,Umar Amin Qureshi , Bella Mahajan

Prof.& Head Deptt. Of Pediatrics Govt. Medical College, S.M.G.S. Hospital, Jammu(J&K) 180 001

doc_ ashokg @ yahoo.co.in

INTRODUCTION: Of the estimated 8.3 million new T.B. cases reported to the WHO in 2000 ,884019 were children. Although childhood T. B. contributes to only 3-6% of total case load in industrialized countries , it makes up a large proportion(15-20%) of all T. B. cases in developing countries. Microbiological confirmation of tuberculosis is however desireable for definitive diagnosis. Gastric lavage has its limitations: needs overnight fasting ,is time consuming,unpleasant both for mother and child,repeated specimens and hospitalization is reguired and the yield may range from 28-40% although rates can rise to75% in infants. Sputum induction is better than Gastric lavage and the yield is twice and one sample yield from induced sputum is equivalent to that from three sequential Gastric lavages. The present study was designed to compare INDUCED SPUTUM with GASTRIC LAVAGE for yield of M.Tuberculosis in children with suspected Pul. Tuberculosis as very few such studies are available in children MATERIAL & METHODS: Children admitted in the deptt. of Pediatrics Govt. Medical College S.M.G.S. Hospital Jammu over a period of one year from oct.2005 to oct.2006 and suffering from suspected Pul.Tuberculosis on the basis of ch. Cough >28 days; failure to gain wt. or loss of wt. with in the previous 3 months; recurrent chest infections >2 in previous 1 month or >3 in preceding 3 months or>6 in last 1 year ; prolonged fever and one of the following criteria were enrolled (contact with in past two years; +ve mantoux test ;chest radiography suggestive ).Children were excluded ,if on treatment or has completed treatment past 2 weeks or on chemoprophylaxis or having signs of upper airway obstruction or cyanosis.Gastric lavage was done on 3 cosecutive mornings according to a strandard protocol. Sputum induction was done with a jet nebulizer attached to oxygen on 3 consecutive days. Tuberculosis was diagnosed when a stain for AFB was +ve, or was cultured from induced sputum or gastric lavage specimens. OBSERVATIONS AND RESULTS: Atotal of 65 children were initially included, successful sputum induction was possible in 60 children and all also under went gastric lavage on 3 cnsecutive days. Th youngest patient was 6 months old, oldest 16 years. 60% age <5 years and 50% 1-5 years. 72% rural,52% had malnutrition. 35% had history of cough>4weeks,18% history of recurrent chest infections, 53%BCG scar, contact 66%, +ve mantoux test 45% and chest skiagram suggestive 79%. A positive stain was obtained in 9 cultures,7 were smear positive and 9 were culture positive , but all the samples which were smear positive were also culture positive.From 9 cultures 3more cases were identified from induced sputum than from gastric lavage. The yield of M.Tuberculosis was maximum 50% in both induced sputum and gastric lavage in the age group of 6 months to 1 year. The child in whom M.Tuberculosis was identified from induced sputum was6 months old. The only child who was positive on induced ssutum in 10-18 years age group had a cavity. The difference between yield for M.Tuberculosis from AFB smears/cultures on induced sputum or gastric lavage is statistically insignificant (p=0.99) on application of Chi Square test. This is probably due to small study and less number of cases. SUMMARY & CONCLUSION: Sputum induction can be effectively performed even in infants. Induced sputum is better than Gastric lavage for the isolation of M. Tuberculosis particularly in children >5yrs.It is less invasive, does not need overnight fasting and can be done as OPD procedure. Use of induced sputum should be considered as a first line investigation in children suspected of having pulmonary tuberculosis, especially in circumstances in which a culture confirmed diagnosis is vigorously sought(Such as when source case is unknown or cutaneous anergy arises ).The important clinical usefulness of SI for the diagnosis of TB in this study raises possibility for its use in primary care and for diagnosis of other respiratory diseases in infants and young children.

ID/05(O) SPUTUM CULTURE FOR MICROBIOLOGICAL CONFIRMATION OF PULMONARY TUBERCULOSIS IN CHILDREN ON LOWENSTEIN JENSON MEDIUM VS MIDDELBROOK

Ashok K.Gupta,Umar Amin Qureshi , Bella Mahajan.

50 B/D Gandhi Nagar ,Jammu (J&K)180004

Introduction: Of the estimated 8.3 million new T.B. cases reported to the WHO in 2000 ,884019 were children. Although childhood T. B. contributes to only 3-6% of total case load in industrialized countries , it makes up a large proportion(15-20%) of all T. B. cases in developing countries. Microbiological confirmation of tuberculosis is however desireable for definitive diagnosis. Isolation of mycobacterium is also essential for drug sensitivity testing, epidemiological surveys, case finding and assessment of tuberculosis control programme.For the isolation of M.tuberculosis conventional egg based media require up to 8-10 weeks of inoculation.Thus there is a great need for developing rapid,sensitive,simple and economic culture methods.In the present study we have evaluated the use of Lowenstein Jenson vesus Middlebrook medium. MATERIAL & METHODS: Children admitted in the deptt. of Pediatrics Govt. Medical College S.M.G.S. Hospital Jammu over a period of one year from oct.2005 to oct.2006 and suffering from suspected Pul.Tuberculosis on the basis of ch. Cough >28 days; failure to gain wt. or loss of wt. with in the previous 3 months; recurrent chest infections >2 in previous 1 month or >3 in preceding 3 months or>6 in last 1 year ; prolonged fever and one of the following criteria were enrolled (contact with in past two years; +ve mantoux test ;chest radiography suggestive ).Children were excluded ,if on treatment or has completed treatment past 2 weeks or on chemoprophylaxis or having signs of upper airway obstruction or cyanosis.Sputum was collected ethier fromGastric lavage done on 3 cosecutive mornings according to a strandard protocol or Sputum induction was done with a jet nebulizer attached to oxygen on 3 consecutive days. Samples from gastric lavage and induced sputum were cultured singly after decontamination by PETROFF,S method. A 0.5ml of the treated specimens was inoculated simultaneously on L J & Middelbrook 7H9 media.Presence of growth was confirmed by making a smear from the colonies/culture media; stained by ZN stain and examined for the presence of AFB.Tuberculosis was diagnosed when a stain for AFB was +ve, or was cultured from induced sputum or gastric lavage specimens. OBSERVATIONS AND RESULTS: A total of 60 children in whom sputum could be colleted by sputum induction on 3 consecutive days were included, and all also underwent gastric lavage on 3 cnsecutive days. Th youngest patient was 6 months old, oldest 16 years. 60% age <5 years and 50% 1-5 years. 72% rural,52% had malnutrition. 35% had history of cough>4weeks,18% history of recurrent chest infections, 53%BCG scar, contact 66%, +ve mantoux test 45% and chest skiagram suggestive 79%. Out of total 360 samples overall smear positivity was 7.77%, on induced samples 8.44% and 6.1% on gastric lavavge .Culture positivty from induced was(23/180=12.77%) and from gastric lavage(14/180=7.7%). 10.3%(37cases out of 360) was overall positivity on culture, 20% on LJ &9.4% on Middelbrook.. The difference between yields for M.Tuberculosis from AFB smears and from cultures on induced sputum and gastric lavage is statistically insignificant (p=0.99 ) on application of chi-square test. However culture positivity was more( 36/180= 20%) with LJ medium than Middlebrook(17/180= 9.4%) though Middlebrook detected one additional case which was negative on LJmedium. No child was smear positive but culture negative. "CHI-SQUARE TEST APPLIED TO COMPARE THE EFFICACY OF TWO MEDIA REVEALED SUPERIORITY OF LJ MEDIUM OVER THE OTHER --MIDDELBROOK MEDIUM WITH HIGHLY SIGNIFICANT RESULTS--(P value<0.005) SUMMARY & CONCLUSION: In conclusion, we observed in this study that culture on old traditional LJ medium continues to be superior though it takes more time than the newely introduced Middlebrook medium which is costilier also and most laboratories are not able to affofd. Sputum induction can be effectively performed even in infants. Induced sputum is better than Gastric lavage for the isolation of M. Tuberculosis .