Secondary Logo

Point-of-care Ultrasound for Pulmonary and Extrapulmonary Tuberculosis in Children

Bélard, Sabine, MD; Heuvelings, Charlotte C., MD; Heller, Tom, MD; Andronikou, Savvas, PhD; Grobusch, Martin P., FRCP; Zar, Heather J., PhD

The Pediatric Infectious Disease Journal: May 2019 - Volume 38 - Issue 5 - p e110
doi: 10.1097/INF.0000000000002243
Letters to the Editor
Free

Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa, Centre of Tropical Medicine and Travel Medicine, Amsterdam Academic Medical Centers, Amsterdam, The Netherlands, Department of Pediatric Pneumology and Immunology, Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin Institute of Health (BIH), Berlin, Germany

Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa, Centre of Tropical Medicine and Travel Medicine, Amsterdam Academic Medical Centers, location AMC, Amsterdam, The Netherlands

Lighthouse Clinic, Lilongwe, Malawi

Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa, Department of Radiology, Children’s hospital of Philadelphia, Philadelphia, Pennsylvania

Centre of Tropical Medicine and Travel Medicine Amsterdam Academic Medical Centers, Amsterdam, The Netherlands

Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa

Supported by grants NIH RO1 HD058971, Medical Research Council South Africa, National Research Foundation South Africa.

S.B. and C.C.H. were funded by a Marie Curie People grant, and S.B. is currently participant in the BIH-Charité Clinician Scientist Program funded by Charité – Universitätsmedizin Berlin and the Berlin Institute of Health. H.Z. is funded by the MRC South Africa. The other authors have no conflicts of interest to disclose.

Address for correspondence: Sabine Bélard, MD, Department of Pediatric Pneumology and Immunology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail: sabine.belard@charite.de.

Back to Top | Article Outline

To the Editors:

We read with interest the letter by Buonsenso et al1 on their experience on lung ultrasound for pulmonary tuberculosis (PTB) in children in response to our study of point-of-care ultrasound (POCUS) in children. The authors indicate that POCUS of the lung is limited with regard to PTB. However, our article addresses POCUS for identification of concurrent extra-pulmonary tuberculosis (EPTB) in children with PTB2 but does not address lung ultrasound in children with PTB.

Childhood PTB is difficult to diagnose because clinical presentation is nonspecific, and microbiologic confirmation is only achieved in a minority of children. Imaging therefore plays an important diagnostic role. However, current imaging tools are limited by sensitivity and specificity, as well as availability and/or feasibility in children. The standard radiologic study in childhood tuberculosis (TB) is chest radiograph, which can show parenchymal disease or pleural effusion but may not accurately detect mediastinal lymphadenopathy, has poor interreader agreement and may not be affordable in resource-poor, highly endemic settings.3–5 Computed tomography (CT) may certainly demonstrate lymphadenopathy more often and may be more accurate for parenchymal disease, but it is not the “standard” technique because of radiation exposure and cost. CT or magnetic resonance imaging is even less accessible and require sedation in young children. New imaging approaches are urgently needed to improve diagnosis of childhood TB, and ultrasound emerges as promising noninvasive and cheap point-of-care tool.

Our work focused on POCUS for detection of EPTB because children are vulnerable to develop disseminated forms of TB. POCUS for EPTB was found to be valuable in the diagnostic work-up of HIV/TB coinfected adults who may also develop disseminated forms of TB.6–8 We showed that concurrent EPTB as detected by POCUS, that is, abdominal lymphadenopathy, pleural or pericardial effusion or splenic micro-abscesses, was prevalent in almost a third of children with PTB in our study in South Africa and that follow-up POCUS for EPTB was very useful for monitoring treatment response.2

In their letter, Buonsenso et al1 report lung ultrasound and CT findings from 9 pediatric TB cases from Sierra Leone (whether these cases had confirmed or unconfirmed PTB is not reported) and conclude that lung POCUS has limitations. We do not share their skepticism with regard to ultrasound for PTB, because in children PTB often presents with lung consolidation that may extend to the periphery and because ultrasound is better than chest radiograph in detecting small consolidation.9

Sabine Bélard, MD

Department of Paediatrics and Child Health

Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health

University of Cape Town

Cape Town, South Africa

Centre of Tropical Medicine and Travel Medicine

Amsterdam Academic Medical Centers

Amsterdam, The Netherlands

Department of Pediatric Pneumology and Immunology

Charité-Universitätsmedizin Berlin

Humboldt-Universität zu Berlin, and Berlin Institute of Health

Berlin Institute of Health (BIH)

Berlin, Germany

Charlotte C. Heuvelings, MD

Department of Paediatrics and Child Health

Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health

University of Cape Town

Cape Town, South Africa

Centre of Tropical Medicine and Travel Medicine, Amsterdam Academic Medical

Centers, location AMC, Amsterdam, The Netherlands

Tom Heller, MD

Lighthouse Clinic

Lilongwe, Malawi

Savvas Andronikou, PhD

Department of Paediatrics and Child Health

Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health

University of Cape Town

Cape Town, South Africa

Department of Radiology

Children’s hospital of Philadelphia

Philadelphia, Pennsylvania

Martin P. Grobusch, FRCP

Centre of Tropical Medicine and Travel Medicine Amsterdam Academic Medical Centers

Amsterdam, The Netherlands

Heather J. Zar, PhD

Department of Paediatrics and Child Health

Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health

University of Cape Town

Cape Town, South Africa

Back to Top | Article Outline

REFERENCES

1. Buonsenso D, Pezza L, Valentini P. Utility of point-of-care ultrasound in children with pulmonary tuberculosis. Pediatr Infect Dis J. 2018;37:e280–e281.
2. Bélard S, Heuvelings CC, Banderker E, et al. Utility of point-of-care ultrasound in children with pulmonary tuberculosis. Pediatr Infect Dis J. 2018;37:637–642.
3. Pedrazzoli D, Lalli M, Boccia D, et al. Can tuberculosis patients in resource-constrained settings afford chest radiography? Eur Respir J. 2017;49: 1601877
4. Swingler GH, du Toit G, Andronikou S, et al. Diagnostic accuracy of chest radiography in detecting mediastinal lymphadenopathy in suspected pulmonary tuberculosis. Arch Dis Child. 2005;90:1153–1156.
5. Berteloot L, Marcy O, Nguyen B, et al. Value of chest X-ray in TB diagnosis in HIV-infected children living in resource-limited countries: the ANRS 12229-PAANTHER 01 study. Int J Tuberc Lung Dis. 2018;22:844–850.
6. Heller T, Wallrauch C, Goblirsch S, et al. Focused assessment with sonography for HIV-associated tuberculosis (FASH): a short protocol and a pictorial review. Crit Ultrasound J. 2012;4:21.
7. van Hoving DJ, Lamprecht HH, Stander M, et al. Adequacy of the emergency point-of-care ultrasound core curriculum for the local burden of disease in South Africa. Emerg Med J. 2013;30:312–315.
8. Weber SF, Saravu K, Heller T, et al. Point-of-care ultrasound for extrapulmonary tuberculosis in India: a prospective cohort study in HIV-positive and HIV-negative presumptive tuberculosis patients. Am J Trop Med Hyg. 2018;98:266–273.
9. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr. 2013;167:119–125.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.