Tuberculosis exposure, infection and disease in children: a systematic diagnostic approach

Pneumonia

Table 5 Clinical case definitions and management of TB exposure, infection, and disease in children

Diagnostic classification	Step 1		Step 2			Step 3
	Step 4
	Findings suggestive of TB disease?		Findings supportive of TB as the likely etiology?			Risk factors? (Management)
	Clinical^a	CXR^b	TB exposure (TST/IGRA)	M. tb detected	TB treatment response	Risk factors? (Management)
TB exposure	None	Normal	Yes (Negative or unavailable)	No	Not applicable	None (no PEP) Yes (consider PEP)
TB infection	None	No signs suggestive of TB disease^c	Likely (Positive)	No	Not applicable	None (consider LTBI treatment) Yes (provide LTBI treatment)
Presumptive TB	Clinical findings^d and/or radiological findings compatible with TB disease		Likely (Positive, may be false negative)	No	Yes	Not applicable (TB treatment)
Confirmed TB			Likely (Positive, may be false negative)	Yes	Yes	Not applicable (TB treatment)

Adapted from C.M. Perez-Velez. Diagnosis of Intrathoracic Tuberculosis in Children. In: Handbook of Child and Adolescent Tuberculosis (p. 168), J.R. Starke and P.R. Donald (Eds.), 2016, New York, NY: Oxford University Press. Copyright by Oxford University Press [15]. Adapted with permission
Dx diagnostic, IGRA interferon-gamma release assay, NAAT nucleic acid amplification test, PEP post-exposure prophylaxis, TB tuberculosis, TST tuberculin skin test, LTBI latent TB infection
^aSee “Clinical evaluation” section in text for clinical manifestations suggestive of TB ; ^bChest radiograph findings suggestive of TB disease (Fig. 2); ^cRadiological findings suggestive of inactive TB in a healthy child without symptoms or physical signs compatible with TB include (a) non-enlarged, homogenously calcified regional (parahilar/mediastinal or peripheral) lymph nodes; (b) calcified nodules with round borders in the lung parenchyma; (c) fibrotic scar or discrete linear opacity in the lung parenchyma (±: calcifications within the lesion; or, volume lost, or retraction); and (d) pleural scarring (thickening or calcification). Compare changes with previous imaging studies to ensure that they are radiologically stable; ^dWith TB disease up to 50% of older children with pulmonary TB may have a normal physical exam

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