Academic journal article Journal of Health Population and Nutrition

Pulmonary Tuberculosis in Severely-Malnourished or HIV-Infected Children with Pneumonia: A Review

Academic journal article Journal of Health Population and Nutrition

Pulmonary Tuberculosis in Severely-Malnourished or HIV-Infected Children with Pneumonia: A Review

Article excerpt


According to the WHO global tuberculosis report 2012, there were an estimated 8.7 million new cases of TB (13% co-infected with HIV) and 1.4 million people died of TB, including 9,90,000 deaths among HIV-negative individuals and 430,000 among people who were HIV-positive in 2011 (1). However, among the overall global estimates, the incidence of active TB in children (defined as those aged <15 years) was estimated at 490,000 cases, and the total number of deaths from TB among HIVnegative cases was estimated at 64,000 in 2011 (1). Data from recently-published articles (2,3) suggest that, with accurate diagnosis and good reporting system, children younger than 15 years are likely to contribute 10-20% of the total disease burden due to TB in endemic areas, with a TB incidence estimated at around 50% of that recorded in adults (2). Mortality from pulmonary TB (PTB) is high among children who present with acute pneumonia and severe acute malnutrition (SAM) (4) with or without HIV infection (5). The co-morbidities from acute pneumonia with SAM or acute pneumonia with HIV are a serious problem among under-five children in developing countries (5-7). The duration of symptoms in PTB presenting as acute pneumonia, with cough, fever, anorexia, and failure to thrive, are often less than two weeks. A recentlypublished systematic review reported that, in addition to the usual respiratory bacterial aetiology in community-acquired acute pneumonia in severelymalnourished children, there are other important causes that remain mostly unexplored, and one of these causes is TB (8). Yet, presentation of PTB as acute pneumonia in severely-malnourished and HIV-infected children has received very little attention, although this is important in the management of pneumonia in children living in communities where TB is highly endemic (8).

Epidemiology and stratification of risks

The epidemiology of childhood TB with acute pneumonia, irrespective of nutritional or HIV status, has not been well-addressed in medical literature (8,9). In general, children have paucibacillary disease and reduced strength of coughing and rarely contribute to disease transmission compared to adults (10,11). Children with acute pneumonia and severe malnutrition and/or HIV infection may not be different in these characteristics. The natural history of the disease suggests age as the most important risk factor (12). The risk of disease after primary infection with TB is as high as 50% in infants below the age of one year, 10-20% in children aged 1-2 year(s), 5% in children aged 2-5 years, and only 2% in children aged 5-10 years. The risk increases to 10-20% for children older than 10 years (11,13). As in infants, severe malnutrition and HIV infection are also serious risk factors in children (5,14). All of these risk factors are associated with poor cell-mediated immune responses resulting in severe forms of disease after infection with TB (15-17). Of the infected children who progress to disease, approximately 95% will develop disease within 12 months of infection (18). Thus, on the basis of the high exposure rates of TB in endemic countries, all under-five children with SAM and/or HIV infection with acute pneumonia should be categorized as a high-risk group in terms of developing PTB.

In this review, we aimed to examine the aetiologic role of PTB in children with SAM and/or HIV infection presenting with features of acute pneumonia.


We conducted a literature search, limited to the English language, to identify reports focusing on tuberculosis in children with SAM and/or HIV infection with acute pneumonia. Severe malnutrition was defined as weight-for-age or weight-for-height z score <-3 of the median of the National Center for Health Statistics (NCHS) (19). We have also included the children with marasmus, or kwashiorkor, or marasmic-kwashiorkor defined according to the Wellcome classification (20). Acute pneumonia was defined as the radiological evidence of lobar or patchy consolidation (6) and/or clinical evidence of severe/very severe pneumonia according to the WHO criteria of acute respiratory infection (21). …

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