Jeena P M, Pillay P, Pillay T, Coovadia H M
Department of Paediatrics & Child Health, Nelson R Mandela School of Medicine, University of Natal, Congella, South Africa.
Int J Tuberc Lung Dis. 2002 Aug;6(8):672-8.
Diagnosis of tuberculosis (TB) in childhood is difficult and is compounded by HIV-1, as both diseases often co-exist and have many similar features. Most studies from developing countries have included subjects in whom the diagnosis of TB is suspected but not proven. We therefore compare the findings in HIV-infected and non-HIV-infected children with culture-proven TB.
Records were obtained from the laboratory at King Edward VIII Hospital, Durban, South Africa, between January 1998 and December 1999. Children aged 0-12 years with proven pulmonary tuberculosis (sputum, gastric washing or endotracheal aspirate culture for Mycobacterium tuberculosis) from the paediatric medical wards and intensive care unit were included in the study. A retrospective chart review of demographic data, clinical presentation, diagnostic modalities for TB, HIV-1 result, management and outcome were evaluated.
Of 138 culture-proven cases of TB identified during the study period, the medical records of 118 (86%) could be traced. Of these, 57 (48%) were HIV-1 infected, 44 (37%) non-HIV-1-infected, and in 17 (14%) HIV-1 status was not determined. In contrast to previous studies, this study has shown that TB-HIV co-infection in children is common (48% of all culture-proven cases), the presentation of tuberculosis may be acute (43%), and supportive tests are individually only reliable in confirming a diagnosis in a third of cases. All culture evaluations for M. tuberculosis were positive by 8 weeks. Where other diseases often co-exist with TB and HIV infection and the pressure for hospital in-patient admissions are excessive, the diagnosis of tuberculosis could easily be missed (21.2%). Clubbing and age over 2 years were the most reliable indicators of underlying HIV-1 disease in a child with tuberculosis, while clinical features, radiology and supportive tests were found to be similar between HIV-infected and non-HIV-infected TB cases. Hospital-related mortality, all causes, was higher (17.5%) in the HIV-1-infected than the non-infected group (11.4%).
The changing pattern of presentation of childhood tuberculosis and the high prevalence of TB in HIV endemic areas has made it imperative to maintain a high index of suspicion, with culture evaluation being an important part of clinical practice.
儿童结核病的诊断较为困难，而HIV-1感染使其更加复杂，因为这两种疾病常同时存在且有许多相似特征。大多数来自发展中国家的研究纳入的是疑似患有结核病但未经证实的受试者。因此，我们比较了经培养证实患有结核病的HIV感染儿童和未感染HIV儿童的研究结果。
获取了1998年1月至1999年12月期间南非德班爱德华八世国王医院实验室的记录。该研究纳入了来自儿科病房和重症监护病房、年龄在0至12岁且经证实患有肺结核（痰、洗胃或气管内吸出物结核分枝杆菌培养阳性）的儿童。对人口统计学数据、临床表现、结核病诊断方法、HIV-1检测结果、治疗及转归进行回顾性病历审查评估。
在研究期间确定的138例经培养证实的结核病病例中，118例（86%）的病历可追溯。其中，57例（48%）感染了HIV-1，44例（37%）未感染HIV-1，17例（14%）未确定HIV-1感染状态。与以往研究不同，本研究表明儿童结核病合并HIV感染很常见（占所有经培养证实病例的48%），结核病表现可能为急性（43%），且各项辅助检查单独用于确诊时仅在三分之一的病例中可靠。所有结核分枝杆菌培养评估在8周时均呈阳性。在其他疾病常与结核病和HIV感染并存且住院压力过大的情况下，结核病很容易漏诊（21.2%）。杵状指和2岁以上是患有结核病儿童潜在HIV-1感染最可靠的指标，而HIV感染和未感染HIV的结核病病例在临床特征、放射学表现及辅助检查方面相似。HIV-1感染组的全因医院相关死亡率（17.5%）高于未感染组（11.4%）。
儿童结核病表现形式的变化以及HIV流行地区结核病的高患病率使得必须保持高度的怀疑指数，培养评估是临床实践的重要组成部分。
