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A 2 year old boy is seen with a mild productive cough of 2 weeks' duration. There has been an intermittent low-grade fever, and mild anorexia. There has been no foreign travel, but a grandmother lives in the same house and she has a chronic productive cough. You have some concern that this boy could have tuberculosis (TB). A TB skin test (Mantoux test) is performed, and you decide to get a chest x-ray which shows a right upper lobe infiltrate with right hilar adenopathy. Which one of the following would apply?
A. Await results of the TB skin test for further action.
B. Admit to the hospital for sputum collection for acid fast bacilli (AFB).
C. Start the patient on isoniazid (INH) pending further evaluation.
D. Admit to the hospital for nasogastric (NG) aspirate collection for AFB.
E. Continued observation and follow-up chest x-ray in 1 month
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B?
ppd test is only a screening test--meaning its not used to diagnose acutely ill patients, but *Asymptomatic* ones.... so waiting for ppd doesnt make sense.
do AFB to confirm tb and then start him on INH.
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would he need to be *Admitted* for sputum collection? hmm.....
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D. Admit to the hospital for nasogastric (NG) aspirate collection for AFB.
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It doesn't say on the vignette if PPD is + right. What I know is if PPD is + but neg. X-ray in person with HIV, or recent converter from neg a year ago, and those in close contact, and less than 35y/o should start isonia +b6 right away. Also, px here has + X-ray. What do you think guys?
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s_star, you are right.. sputum collection is difficult in a child 
encargon... what you say applies to asymptomatic people... thats the only time we consider ppd at all. its just used for screening.
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I just viewed the video highlights of Kaplan regarding this, and I'm positive that patient who's PPD+ and NORMAL chest xray should receive iso + b6 for 9 mo in the ff: immunocompromised(dm, HIV), <35, recent converter 2 years, in addition BCG does NOT alter this.......a positive PPD and all the more a (+) X-ray as in thisw case should be started on treatment. Kaplan books say same. I respect your opinions guys. Goodluck
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att, what is the correct answer?
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D. Admit to the hospital for nasogastric (NG) aspirate collection for AFB.
The x-ray demonstrates a rather typical TB primary complex with a parenchymal infiltrate and regional lymphadenopathy. There is a right upper lobe infiltrate with right hilar adenopathy. This is suspicious for primary TB infection and the child should be admitted to the hospital for AFB collection. In younger children who do not have a productive cough, the collection of early morning NG aspirates upon awakening on 3 consecutive days should be performed.
The treatment of TB is with multidrug therapy. The use of INH alone is reserved for patients with TB exposure who have a positive PPD and negative chest x-ray.
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