Pediatric TB , two doubts

One problem discussed by friend today .

Four year old kid ,Father diagnosed Sputum positive pulmonary tuberculosis.Child was symptomatic ,ill nourished. He was put on Cat I ATT . Next week he developed extensive skin rash .

Not sick, No jaundice.

LFT normal .

How to proceed.

Answer for the question was based on following thought. Here i share it to hear your views. Mine is not final comment

" Commonest situation we encounter following ATT in kids are alteration of liver function ,leading to varying levels of derangement and clinical features. Most of them reverse on stopping ATT .

When we take decision we consider two opposing arguments

On one side 1. How important is ATT in this case .
If i stop for short period will this cause major problems due to progression of TB. Most of the cases we see milder cases and few days or weeks of not giving ATT does not matter , So we stop it and there is a method to re introduce . But a situation of TB meningitis or miliary TB withholding ATT even for days is may tilt the balance.

In short how severe is the problem caused by TB

On the other side 2. If we continue any of the drug or all of the drug will it lead to problems.

That is how dangerous is the problem caused by the drug

Eg . Liver dysfunction ,can not be taken lightly . We should view any significant Liver dysfunction very seriously , eg Transaminase level rise more than Twice with or without other parameters or clinical ,We have to stop

But what about other drug related problems .

We occasionally encounter. INH related. psychosis or neurological problems ( peripheral neuropathy is least we encounter.)

Arthritis due to Pyrazinamide. Rashes due to pyrazinamide

Ethambutol causing rash . ( i have nt seen an optic neuritis so far in kids on ETB

We had rifampicin related thrombocytopenia

We had rifampicin related interstitial nephritis

So in these situations what ?

Eg we take a situation of Primary complex ( mild TB in the first argument ) and a Drug problem serious one like deranged LFT , No doubt . Stop all drugs. Put on SM , ETB , moniter Transaminase when it comes down below twice the normal value ,introduce INH and and RFP one by one weekly

But is there any guidelines when we encounter a situation of

Serious TB and a milder of the drug problem Eg drug rash . '

Here are we justified in Stopping all ATT , wait and re introduce ?

What should be the basis of re introduction of drug . ie when re introduce one of them , what should be the sequence?

If the rash disappearance take long and the TB is serious one ?

So considering the above points we discussed the following

" what is the seriousness of TB? how sick the kid is ?

" Ill nourished. Vitals stable, frequent respiratory symptoms , Now chest is clear .Xray , para hilar infiltrates.

So it is not a serious situation of TB. a few days of ATT stopping may not cause problem

"What is the type of reaction and what is the Liver function ?

"Skin lesion maculopapular rashes through t body , Itching. No jaundice. No lymph nodes. No fever . Other reasons for Skin rash thought of , and excluded.Possibility of drug related rash high

Liver function tests came as normal

Already all drugs is stopped since yesterday "

So final decision taken and advised

"So , let us not re introduce the drugs for few days . Normal LFT ,

Chances of skin lesion are more likely to be due to ETB ro PZN .

So let us wait for few days for rash to disappear.

Introduce INH and RFP first

Then introduce PZN , wait for one week. if tolerating it must be ETB .

Then introduce PZN , wait for one week. if tolerating it must be ETB the culprit .

in that case again one problem?

Should we re introduce ETB and see

Should we substitute SM ?

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One more Doubt

Sibling of this kid is two and half years.

Not symptomatic .

Mantauxe 25 mms positive .

What should be the advise

Guidelines say INH 10 mg for six months .

Below 6 years with contact. or mantauxe positivity guidelines say INH only

But strong positivity . of 25 mms , is there a need for doubt " whether to put him on Cat I ATT ?