Tuberculosis
in the Pediatric
Population
of
Houston,
Texas
Jeffrey
R. Starke,
MD, and Kym
T. Taylor-Watts,
PA-C
From the Department of Pediatrics, Baylor College of Medicine, and Children’s
Tuberculosis Clinic, Jefferson Davis Hospital, Houston, Texas
ABSTRACT. From September 1984 to December 1987,
the children’s tuberculosis clinic in Houston, TX, cared for 110 children with active tuberculosis. The median age
was 24 months. Approximately one half of the cases were in Hispanic children, but one third were in black children.
Only 11% were foreign-born. Diagnosis resulted from
case contact investigation in 50% of cases, routine
tuber-culin screening in 6%, and evaluation of an ill child in
44%. Intrathoracic disease alone was present in 77% of cases, and extrathoracic disease in 23%, including
in-volvement of the cervical and supraclavicular lymph
nodes, meninges, brain, liver, and skin. Gastric aspirates yielded Mycobacterium tuberculosis from 39% of the chil-dren with pulmonary disease. Of six children infected with drug-resistant tuberculosis, two became critically ill before referral because the probability of resistance was not recognized by the referring physician. Presently, 94%
of patients have successfully completed therapy, which
has been shortened from 12 to 18 months to 6 to 9
months. However, 39% were noncompliant with treat-ment and required twice-weekly supervised therapy to
complete treatment. Tuberculosis remains a serious cause
of morbidity in children; specific expertise in obtaining cultures, selecting drugs, and assuring compliance is
cm-cial for adequate results. Pediatrics 1989;84:28-35; tuber-culosia, public health, drug resistance.
Tuberculosis remains an important cause of
mor-bidity, mortality, and health care expenditures in
the United States.1 In 1988, active tuberculosis developed in more than 22 000 people, and 1600
adults and children died of the disease.2’3 In some
areas of the United States, the incidence of
tuber-culosis is increasing, largely because of the influx
of foreign-born, high-risk individuals,4, and the
prevalence of infection with the human
immuno-deficiency virus.79
Received for publication Jun 8, 1988; accepted Jul 18, 1988.
Reprint requests to (J.R.S.) Dept of Pediatrics, Baylor College
of Medicine, One Baylor Plaza, Houston, TX 77030.
PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the
American Academy of Pediatrics.
Any program designed to control or eliminate tuberculosis must focus great effort on children,
because they are the future reservoir for the disease.
Tuberculosis cases in children are important public
health markers for a community because they
rep-resent ongoing transmission of tuberculosis and, at
least, a partial failure of current tuberculosis
con-trol efforts.
The number of cases of childhood tuberculosis in
the United States has changed little in recent years. In 1985, there were 1261 cases of tuberculosis in
children in the United States. Almost 80% occurred
in minority children: 344 (27.3%) were
white-His-panic, 456 (36.2%) were black, 47 (3.7%) were
na-tive American, 160 (12.7%) were Asian/Pacific
Islander, and 254 (20.1%) were white,
non-His-panic.1#{176}There were 221 (17.5%) cases in
foreign-born children. Only 12% of US counties reported
one or more tuberculosis cases in children.” There-fore, childhood tuberculosis tends to cluster in
cer-tam racial and ethnic groups and in certain
geo-graphic locales.
Houston, TX, consistently has had a high
tuber-culosis case rate, with an especially high proportion
of cases occurring in children. We reviewed 110 consecutive cases of “active” childhood tuberculosis to describe current trends in epidemiology, clinical findings, and response to therapy.
MATERIALS AND METHODS
Between September 1, 1984, and December 31,
1987, 110 children with active tuberculosis were
cared for at the children’s tuberculosis clinic at Jefferson Davis Hospital, Houston. These children
represented about 80% of the cases of childhood
tuberculosis diagnosed in the Houston metropolitan
area during this time.
directly at Jefferson Davis Hospital. Some children were transferred to our clinic after initial
in-hos-pital evaluation at another facility. In general,
chil-dren with suspected pulmonary tuberculosis were
hospitalized if they were significantly symptomatic
or if cultures could help determine appropriate
ther-apy. Parental education and case contact
investi-gation of the family also were stressed during the usual 3-day hospitalization. All costs of hospitali-zation and outpatient care were funded fully by the
state and city tuberculosis control programs.
The diagnosis of tuberculosis was confirmed if
Mycobacterium tuberculosis was isolated from any body site or if the clinical findings were consistent with tuberculosis and at least two of the following
three criteria also were met: (1) a Mantoux
5-tuberculin unit skin test result >10 mm of
indura-tion, (2) other disease entities were ruled out and the subsequent clinical course was consistent with tuberculosis, and (3) an adult source case with
contagious M tuberculosis disease was discovered.
Laboratory
Evaluation
The following laboratory values were determined at the time of diagnosis of tuberculosis for most children: complete blood cell count and differential, urinalysis, serum total bilirubin, serum aspartate
aminotransferase, serum alanine aminotransferase,
and serum alkaline phosphatase. If streptomycin were to be used, baseline values for blood urea nitrogen and serum creatinine also were obtained. When pyrazinamide was used, baseline serum uric acid was determined. These determinations were not repeated during treatment unless signs or
symptoms of drug toxicity or illness developed.
Other laboratory determinations were performed as indicated clinically. Children older than 5 years of age taking ethambutol had monthly vision tests in which a Snellen chart was used.
Specimens for mycobacterial culture were
ob-tamed whenever possible. In children with sus-pected pulmonary disease, early morning gastric
aspirates or lavage (with saline-free water) were
obtained on three consecutive mornings. Digestion and neutralization of pH were performed by stand-ard methods.’2”3 Other body fluids and tissues cul-tured at appropriate times included bronchial
la-vage fluid, pleural fluid, urine, cerebrospinal fluid,
lymph nodes, and skin. Cultures and tests for sus-ceptibility were performed using both standard Lowenstein-Jensen medium’3 and the Bactec radio-metric system.’4”5
Treatment and Outpatient Care
In the first year of this study, children with
thoracic tuberculosis received the then standard 12
to 18 months of isoniazid and rifampin. In early
1986, children with thoracic disease received
isoni-azid and rifampin for only 9 months. Since late
1986, all children with thoracic tuberculosis have
received isoniazid and rifampin for a total of 6 to 9
months, pyrazinamide being added during the first
2 months. Patients with meningitis, tuberculoma,
or miliary disease received isoniazid and rifampin for 12 months, and pyrazinamide and/or
strepto-mycin also were used for the first 2 months. The
10 patients with nondrug-resistant adenitis
re-ceived isoniazid and rifampin for 12 months, 5 with
and 5 without pyrazinamide used during the initial
2 months of treatment. Noncompliant patients were given twice-weekly supervised medications by a nurse or outreach worker after initial daily
ther-apy for 2 months.
Treatment for suspected or proven drug-resistant
tuberculosis was individualized using at least two
drugs active against the isolate for 12 to 18 months.
The daily doses of drugs used were: isoniazid, 10 to
15 mg/kg; rifampin, 10 to 20 mg/kg; pyrazinamide,
25 to 35 mg/kg; and streptomycin 20 to 25 mg/kg.
The twice-weekly doses were: isoniazid, 20 to 25
mg/kg; rifampin, 10 to 20 mg/kg. Because of drug
resistance, ethambutol (20 to 25 mg/kg per day)
was used in three patients, ethioniamide was used
in one patient, and kanamycin was used in one
patient.
Corticosteroids were used in all patients with
meningitis and in selected patients thought to have endobronchial disease as judged by chest
roentgen-ogram and/or presence of significant respiratory
signs or symptoms. All patients were followed up
monthly during treatment at the children’s
tuber-culosis clinic. Compliance with treatment was
judged by self-report, parents’ knowledge of the
medicines, pill counts, clinical improvement, and
compliance with clinic visits.
RESULTS
Epidemiology
The general epidemiologic characteristics of the
110 children are summarized in Table 1. There were
slightly more girls than boys. The median age of
the patients was 24 months, with a range of 3 months to 16 years. The vast majority (102 children
[93%]) were from minority populations. Twelve (11%) children were foreign-born. Several of the US-born children had lived for more than 6 months
in a foreign country with a high rate of tuberculosis.
TABLE 1. Epidemiologic Characteristics of 110 Chil-dren With Tuberculosis
Characteristic No. (%)
of Patients
Sex
Boys 50 (45)
Girls 60 (55)
Ethnicity/race
Hispanic 52 (47)
Black 40 (36)
White-non-Hispanic 8 (7)
Oriental 5 (5)
Other 5 (5)
Place of birth
Texas 95 (86)
Other US state 3 (3)
Foreign-born 12 (11)
Referral source
Contact investigation 55 (50)
Private physician 28 (25)
Harris County Hospital district clinics 27 (25)
State of health at initial visit
Symptomatic 48 (44)
Asymptomatic 62 (56)
the symptomatic children had extrathoracic disease
or were young infants with extensive pulmonary
disease. Of the 62 children who were asymptomatic
at the time diagnosis was made, 55 were found by
contact investigation, and seven were found
through routine tuberculin screening by private
physicians; therefore, such screening may be useful
for finding both tuberculous infection and “active”
disease in high-risk populations. Overall, an adult
source case was identified for 77 (70%) of the chil-dren.
The median size of induration in response to a
Mantoux tuberculin test was 15 mm. However, 10
(9%) children were totally anergic for the
5-tuber-culin unit skin test when their disease was
diag-nosed. The age range of these 10 children was 3
months to 15 years, but 7 children were <2 years
of age. Of the 10 children, 9 had extrapulmonary disease (3 meningitis, 2 tuberculoma, 2 pleural, and
2 cervical adenitis), and 8 children’s tuberculin tests converted to positive within 3 months of initiation
of treatment. Four children had selective anergy for
tuberculin with skin tests positive for Candida and/ or tetanus at the time of diagnosis.
Thoracic Disease
The anatomic locations of tuberculous disease in
the patients are listed in Table 2. There were 58
(53%) patients who had pulmonary parenchymal
disease as the only manifestation. All 58 children
also had hilar adenopathy. An additional 23
pa-tients (21%) had only hilar adenopathy, and 4 (4%)
had significant pleural effusion. Overall, 85 (77%)
TABLE 2. Location and Frequency of Tuberculosis in
110 Children
Anatomic Location
No. of Patients
Lung
As only site 58
With extrapulmonary site 16
R upper lobe only 14
R middle lobe only 15
R lower lobe only 11
L upper lobe only 10
L lower lobe only 5
More than one lobe 16
Miliary 3
Lymphatic
Hilar adenopathy 23
Cervical/supraclavicular 11
Central nervous system
Meningitis 8
Tuberculoma 2
Pleura 4
Skin 1
Disseminated/miliary 3
patients had thoracic disease alone, and an
addi-tional 16 (15%) had pulmonary abnormalities
as-sociated with extrathoracic disease. Only 9 children
with cervical adenitis had extrathoracic disease
without pulmonary manifestations.
Only 20 children with pulmonary parenchymal
disease had symptoms referable to the respiratory
tract, and 14 of these children were <1 year of age.
The most common symptoms were cough, fever of
3 to 10 days’ duration, and decreased appetite.
Several infants reportedly had night sweats. There
was physical evidence of abnormal air movement in 15 patients (8 had localized wheezing and 7 had
markedly decreased focal breath sounds). Five of
the children with wheezing were infants with
mod-erate to severe respiratory distress.
The majority of children with pulmonary disease
had segmental lesions associated with hilar
ade-nopathy. The four major lobes were involved almost
equally, and 16 children had involvement of more
than one lobe. Four children had cavitation within
a dense pulmonary infiltrate. Several infants had
segmental emphysema associated with hilar
ade-nopathy. In three cases, collapse of the involved
segment was observed in the hospital. These three
infants had severe respiratory distress which sub-sided as the segment collapsed.
Hilar adenopathy alone was observed in 23
pa-tients. None of these patients had significant
din-ical signs or symptoms. Twenty-two were
discov-ered through routine contact investigation of an
adult case, and one was discovered via routine
screening.
Four children had tuberculous pleurisy. Each had
Stage at Admission*
Induration Roentgenographic Findings
Results (Fluid)
1 21 II 0 mm Miliary Mycobacterium tuberculosis
(CSF)
Normal
2 19 III 25 mm RML pneumonia M tuberculosis (CSF) Profound retardation; died of aspiration 2 y after treatment
3 10 I 13 mm RUL and RML
collapse-consoli-dation
M tuberculosis (CSF) Normal
4 19 III 15 mm Hilar adenopathy M tuberculosis (CSF) Normal
5 19 III 0 mm RLL pneumonia Negative Mild L hemiparesis
6 15 III 11 mm RLL pneumonia Negative Profound retardation;
R hemiparesis
7 7 III 20 mm RML pneumonia Negative Seizures and L
hemi-paresis
8 12 II 0 mm LLL pneumonia M tuberculosis (CSF) Normal
* Stage I, general symptoms common to infection, ie, lethargy, irritability, headache, vomiting; stage II, general signs of meningeal irritation plus evidence of focal neurologic involvement; stage III, profound changes in sensorium.
chest pain, fever, and malaise. All four also had
pulmonary parenchymal disease but not hilar
ade-nopathy. Two children were initially anergic for
tuberculin. In both cases, the diagnosis of
tubercu-losis was not considered at first and a delay in
treatment of weeks to months ensued.
Extrathoracic Disease
There were 25 children (23%) with significant
extrathoracic manifestations of tuberculosis. All of
these children were evaluated because of a report
of a symptomatic illness.
The single largest group was 11 patients with
cervical or supraclavicular adenitis. In general,
these children were slightly older than the other
patients with a median age of 31 months. Bilateral
disease was present in only four children. The
an-tenor cervical and submandibular nodes were
af-fected most commonly. Two of these children also
had pulmonary abnormalities visible on chest
roentgenograms.
Ten children had tuberculosis ofthe central
nerv-ous system. Eight children had tuberculous
men-ingitis (Table 3). These children were young
(me-dian age 17 months) and all had pulmonary disease.
The clinical findings were not indolent, because all patients were ill for <10 days and several had clinical development during 72 hours or less. As expected, outcome correlated with clinical stage:
the three children with stages I and II were normal, but four of five children with stage III had signifi-cant residual deficits. Computed tomography of all
eight children demonstrated some degree of
hydro-cephalus initially. Five patients required placement of a ventriculoperitoneal shunt and a sixth required
temporary ventriculostomy placement.
TABLE 3. Children With Tuberculous Meningitis
Patient Age Clinical Mantoux Test Chest No. (mo)
Two children had tuberculomas of the brain. A 15-year-old Thai girl had a left temperoparietal
lesion discovered after onset of focal seizures. The
gross and histologic appearances of the lesion were
classic for tuberculoma. A computed tomographic
scan had shown a space-occupying lesion with some enhancement, and angiographic results were
indic-ative of an avascular mass. The second child with
a tuberculoma was a 1-year-old Hispanic girl who had a ring-enhancing lesion of the pons, which calcified throughout several months. The lesion
regressed with antituberculous medications. Both
children had known exposures to adults with
tuber-culous disease and abnormal findings on chest
roentgenograms.
One child had tuberculosis verrucosa cutis, or
warty tuberculosis, of the knee. Histologically, the
lesion was made up of caseating granulomas, and
culture of a gastric aspirate was positive for M tuberculosis. Three children had miliary
tuberculo-sis associated with hepatosplenomegaly and
ade-nopathy; their chest roentgenograms appeared typ-ical for the disease and there was mild elevation of
liver enzyme values. None had meningitis or other
forms of tuberculosis.
Culture Results
A summary of our culture results is shown in Table 4. Gastric aspirate cultures were positive for
M tuberculosis from 39% of children with pulmo-nary disease. In infants <1 year of age, gastric
aspirate cultures were positive for M tuberculosis in
75% of cases. Other positive culture results were
obtained from 50% of children with cervical
aden-itis, 67% with pleurisy, 33% with disseminated/
miliary disease, 61% with meningitis, and the one
child with tuberculosis verrucosa cutis. Although an adult source case was identified for 70% of the children, 53% of the children with positive culture
results had no source case identified, and the child’s
culture was the only guide for therapy.
Cultures may be of particular importance when drug resistance is an issue. Drug resistance was a
key element in designing a treatment regimen for
eight of our cases (Table 5). Six of our patients had
likely or proven resistance, and each had an
excel-lent response to appropriate medications. Two
pa-tients were thought initially to have drug-resistant
disease because of probable association with a
drug-resistant source case. However, the isolate obtained
from each of these two children was totally suscep-tible. Isolation of the organism from the child led to more standard, shorter, and less toxic treatment.
Treatment
In general, results of treatment have been excel-lent. Presently, 103 patients have successfully com-pleted treatment, and 7 moved away from Houston before therapy was completed.
Seventy-five patients with thoracic disease only
and no drug resistance completed treatment under
our supervision: 26 were treated for more than 9
months, 15 were treated for 9 months with only isoniazid and rifampin, and 22 were treated for 9
months total after an initial 2-month treatment
with isoniazid, rifampin, and pyrazinamide. An ad-ditional 12 patients have completed a 6-month reg-imen of isoniazid, rifampin, and pyrazinamide for
2 months, followed by 4 months of only isoniazid
and rifampin. The results of all regimens have been
TABLE 4. Culture Resul ts From 110 C hildren With Active Tuberculosis
Major Form of Infection
No. of Patients
No. of Patients in Whom Cultures Were Attempted*
No. (%) of Cultures
Positive for Mycobacterium
tuberculosis
Pulmonary
Hilar adenitis
Cervical adenitis Pleural
Disseminated Meningitis
Tuberculoma
Cutaneous
58
23 11 4 3 8
2
1
44
3 8 3 3 8
1
1
17 (39) 0 (0) 4 (50) 2 (67) 1 (33) 5 (61)
0 (0)
1 (100)
* Sources of cultures were pulmonary, hilar adenitis, cutaneous-gastric aspirate only; pleural-pleural effusion; cervical adenitis-aspiration or excisional biopsy oflymph node; disseminated-gastric aspirate, urine; meningitis-cerebral spinal fluid; tuberculoma-resected lesion.
TABLE 5. Drug-Resistance in Childhood Tuberculosis*
Patient
No.
Age Anatomic Location of Tuberculosis
Source Case and Sensitivity
Result
Child’s Culture Result!
Sensitivity
Child’s Treatment
Result
1 9 mo Disseminated Mother/resistant to INH, RIF
Neg INH, RIF, PZA, STM
2 9 y Pulmonary Mother/resistant to
INH, RIF
Neg INH, RIF, PZA, STM
3 4 y Hilar adenopathy Mother/resistant to INH, RIF
Neg INH, RIF, PZA, STM
4 14 mo Miliary Father/resistant to
INH, STM
Neg RIF, PZA, ETH, ET, KM
5 13 y Cervical adenopathy Unknown Pos/resistant
to INH
INH, RIF, PZA, STM, ETH
6 2 y Pulmonary Uncle/resistant to
INH
Neg RIF, PZA, STM
7t 1 y Meningitis Father/resistant to
INH
Pos INH, RIF, PZA, STM
8t 2 y Pulmonary Uncle/resistant to
INH
Pos INH, RIF, PZA
* Abbreviations: INH, isoniazid; RIF, rifampin; STM, streptomycin; PZA, pyrazinamide; ETH, ethambutol; ET, ethionamide; KM, kanamycin.
t Supposed source had drug-resistant Mycobacterium tuberculosis, but child’s organism was susceptible to all
comparable, although the time of follow-up for pa-tients treated with the 6-month regimen has been
<1 year. All patients with extrathoracic
tuberculo-sis did well on the regimens described. Significant
drug toxicity has not occurred. Six patients with
drug-resistant tuberculosis were treated for 12 to
18 months with at least two active drugs, with full
resolution and no toxicity.
In our entire series, only two children (one with miliary disease and one with supraclavicular aden-itis) had relapses. In both of these children, relapse occurred prior to referral to our clinic; both had
drug-resistant disease that was not recognized or
treated appropriately by the referring physician.
Both children subsequently did well on alternative
regimens. One patient died of aspiration pneumonia
2 years after completion of therapy for tuberculous
meningitis. The only pediatric death from tuber-culosis in Houston during the time of this study
was a patient not cared for in our clinic who had
tuberculous meningitis and was allowed to be non-compliant with treatment.
Compliance has been the major problem in
treat-ment. Using minimal criteria, we determined that
43 (39%) of our patients were significantly noncom-pliant with regard to treatment. Successful treat-ment was completed only because we had the ability to supervise twice-weekly administration of
medi-cations via visits to the home or school. In three
cases, treatment was maintained only after
inter-vention by Harris County Child Protective
Serv-ices. The disease in children treated twice weekly
resolved as quickly and completely as that in chil-dren given daily medication.
DISCUSSION
The common perception among both health care
professionals and the general public is that
pediat-rid tuberculosis is no longer a significant public
health threat in the United States. Although the
overall incidence has declined during the past 5ev-eral decades, the disease persists at fairly high rates in certain geographic and ethnic pockets.’#{176}”6
Tu-berculosis among children will persist as long as
contagious adults remain in their environment. Many of the epidemiologic characteristics of our patients are not surprising. Our median patient age of 24 months confirms that pediatric tuberculosis
is largely a disease of infants and young children,
less commonly causing disease in the “favored age”
of 5 to 14 years.’7 More than 90% of our cases occurred in minority children, with about one half being Hispanic and one third being black. Only 1 1% of our children were foreign-born, which is lower than might be expected considering the large
influx of foreign-born persons into Houston in the past decade.
Fifty-six percent of our patients were asympto-matic when the diagnosis was made, confirming that active tuberculosis occurring in the pediatric population, especially thoracic disease, often is din-ically silent in the early stages. The majority of
these children were discovered by contact
investi-gation of an adult with contagious tuberculosis.
This strongly emphasizes the need for diligent and
thorough household investigations of adults with
tuberculosis. Although the goal of routine tubercu-lin screening is to diagnose subclinical tuberculous infection, seven of our patients with tuberculous
disease were identified via routine screening.
The majority of children with symptoms were small infants with probable endobronchial
tuber-culosis and children with extrapulmonary disease.
A total of 23% of our patients had significant ex-trathoracic disease and 13 children had potentially life-threatening forms of infection (8 with
menin-gitis, 2 with tuberculoma, and 3 with miliary
dis-ease). The decline in reported cases of extrathoracic
tuberculosis in the United States has been much slower than that for thoracic disease during the
past two decades. Recent epidemiologic evidence
suggests that the changing demographics of the population with tuberculosis in the United States-a shift toward infants, older adults, the
foreign-born, and minorities-may be the responsible
fac-tor’8
Nine percent of our patients were anergic to
tuberculin, which is comparable to the 10% to 20%
incidence often noted in adults’9’2#{176} A previous study
of 200 children with culture-proven M tuberculosis
infection yielded an initial anergy rate of 14%.21 In
that study, 5.5% of children had persistently nega-tive tuberculin reactions after therapy was given, compared with only 2% in our series. Three factors implicate the disease rather than the host as the primary determinant of anergy in our patients: (1)
9 of the 10 anergic patients had extrapulmonary
disease. The anergy rate was 2% for children with
pulmonary disease alone vs 32% for those with
extrapulmonary manifestations; (2) 4 children had
anergy selective for tuberculin; and (3) all but two patients had positive tuberculin tests within 3 months of starting therapy. The anergic patients were not significantly younger nor did they differ in any epidemiologic characteristics from the other children with tuberculosis. Although we have not performed routine screening for human immuno-deficiency virus on our patients, no clinical evidence
of ongoing immunosuppression exists for any of
them. The presence of anergy did not correlate with
Culture results were important in establishing
the diagnosis in some patients and directing
treat-ment in others. They were especially helpful for
infants with pulmonary disease, because the yield
was high (75%) and diagnosis can be more difficult
in infants. For only 70% of our patients could we
determine the identity of the adult source. Because of the increasing rate of drug-resistant tuberculosis
in most areas of the world, it is essential that
cultures be obtained for children with suspected
tuberculous disease and no identified source case. Bacteriologic confirmation is not essential in chil-dren with primary tuberculosis if results of cultures
and susceptibility testing are available from an
adult source case,2’ unless the child is at high risk
for multiple exposures or drug-resistant
tuberculo-sis. Many adults with drug-resistant tuberculosis
really have partial resistance, ie, a proportion of
their organisms is drug-resistant and another pro-portion is fully susceptible. Children exposed to
these adults may become infected with either a
drug-resistant or a drug-susceptible organism. In
two of our children, the supposed source had
drug-resistant tuberculosis, but the isolate from the child
was susceptible to all medications. This knowledge
significantly changed our therapeutic regimen.
During the past decade, the recommended
dura-tion of treatment for tuberculosis in adults has been
shortened significantly. The American Thoracic
Society and Centers for Disease Control currently
recommend a total duration of 6 months of therapy
for adults with pulmonary tuberculosis if at least three drugs (usually isoniazid, rifampin, and
pyra-zinamide) are used for the first 2 months and
iso-niazid and rifampin are continued for an additional
4 months.24 The same regimen is recommended for
children,24’25 despite the fact that none of the
stud-ies cited used this regimen and the
pharmacoki-netics of pyrazinamide are unknown in children.
Our data support previous study findings26’27 that
total therapy durations of 9 months using isoniazid
and rifampin alone or with other drugs are effective for thoradic tuberculosis in children. We agree that
6-month regimens using three or more drugs
mi-tially should be effective in children, and our 12
patients who have completed this regimen have
done well. We have treated most of our children
with extrathoracic disease for 12 months with good
success. We think regimens of 6 to 9 months also should be effective for extrapulmonary tuberculosis in children.
There is no doubt that the major problem in
treatment of tuberculosis today is compliance. Our
clinic is designed specifically for the care and edu-cation of families with tuberculosis, yet 39% of our
patients were judged to be significantly
noncom-pliant with regard to their medication. This rate is
consistent with numerous studies of the treatment
of chronic diseases.28’2#{176} Our ability to give these
children twice-weekly supervised therapy by either
outreach workers or school nurses was the only
reason they completed treatment successfully. Our study and others have demonstrated the efficacy of twice-weekly therapy for tuberculosis in chil-then.25’26 The pediatrician caring for children with tuberculosis must have available the knowledge,
time, resources, and desire to ensure compliance
with treatment. Twice-weekly supervised therapy
is a necessary component of any program in which
children with tuberculosis are cared for.
ACKNOWLEDGMENTS
The authors thank Dr Katharine H.K. Hsu for her
help in caring for these patients. We also thank the
nurses, clerks, and housestaff of Jefferson Davis Hospital
who helped us care for these patients. We thank Teresa
Cieslewicz and Robin Dudley for their secretarial assist-ance.
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INTERNATIONAL
COURSE
ON NEONATAL
INTENSIVE
CARE
September
14-17,
1989
Sanremo, Italy
Guest Speakers
R. Ballard-California, USA D. Baum-UK
J_ Birnholz-Illinois, USA E. Cosmi-Italy
P. Crosignani-Italy
G. Duc-Switzerland J. Emery-UK J.I. Fournet-France L.A. Hanson-Sweden A. Huch-Switzerland
For details, contact:
G.E. Moro, MD
Dep1 of Perinatal Pathology Provincial Maternity Hospital Via M. Melloni, 52
20129 Milan, Italy
Telephone: (02) 7523251/2
Fax(02) 7523299
R. Huch-Switzerland
M. Klaus-California, USA S.B. Korones-Tennessee, USA J.F. Lucey-Vermont, USA G. Moro-Italy
F.A. Oski-Maryland, USA
N.C.R. R#{228}ih#{228}-Sweden
