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Essentials Of Tuberculosis In Children 4th Edition
Vimlesh Seth Digital Instant Download
Author(s): Vimlesh Seth
ISBN(s): 9789350252529, 935025252X
Edition: 4
File Details: PDF, 17.31 MB
Year: 2011
Language: english
 Essentials of
TUBERCULOSIS IN CHILDREN
 Essentials of
TUBERCULOSIS IN CHILDREN
4th Edition

Vimlesh Seth MD FAMS FCAI FISCD

Senior Consultant
Formerly, Senior Professor and Head
Department of Pediatrics and
Chief Division of Tuberculosis, Pulmonology
Rheumatology and Intensive Care Unit
All India Institute of Medical Sciences (AIIMS)
New Delhi, India

SK Kabra MD DNB
Professor and Incharge
Division of Tuberculosis and Pulmonology
All India Institute of Medical Sciences (AIIMS)
New Delhi, India

Foreword
Peter R Donald

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • St Louis • Panama City • London
Published by
Jaypee Brothers Medical Publishers (P) Ltd

Corporate Office
4838/24, Ansari Road, Daryaganj, New Delhi 110 002, India
Phone: +91-11-43574357, Fax: +91-11-43574314

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Essentials of Tuberculosis in Children

© 2011, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and
the publisher.

This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any
dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition : 1997

Second Edition : 2001
Third Edition : 2006
Fourth Edition : 2011
ISBN 978-93-5025-252-9
Typeset at JPBMP typesetting unit
Printed at
 Dedicated to
My husband
Professor SD Seth
for his constant encouragement
and moral support
My grandchildren Ushmita and Udbhav
for helping me proactively
to become computer friendly
for easing my editorial
work for the book
 Contributors

AK Gupta MD Ashok Rattan MD BN Upendra MS

Professor and Head Chief Executive Assistant Professor
Department of Radiodiagnosis Fortis Clinical Research Ltd Department of Orthopedics
All India Institute of Medical Advisor, Religare SRL, Fortis All India Institute of Medical
Sciences Escorts, Delhi and NCR Sciences, New Delhi, India
New Delhi, India E-mail:
E-mail: [email protected] [email protected], BR Thapa MD
[email protected] Professor and Chief
Division of Pediatric
Alexey Kruk MD
Ashu Seith Bhalla MD Gastroenterology Hepatology and
Department of Public Health
Associate Professor Nutrition
Oxford University
Department of Radiodiagnosis Postgraduate Institute of Medical
United Kingdom Education and Research (PGIMER)
All India Institute of Medical
E-mail: [email protected] Chandigarh, India
Sciences
New Delhi, India E-mail: [email protected]
A Maheshwari MD
E-mail: [email protected]
Assistant Professor Daphne Ling
Department of Pediatrics Department of Epidemiology
Atin Kumar MD
Kalawati Saran Children Hospital and Biostatistics
Assistant Professor
Lady Hardinge Medical College Radiodiagnosis MC Gill University , Quebec, Canada
New Delhi, India JPNA Trauma Centre
E-mail: [email protected] All India Institute of Medical Donald A Enarson MD, FRCP (Edin)
Sciences International Union Against
Alka Beotra PhD New Delhi, India Tuberculosis and Lung Disease
Scientific Director E-mail: [email protected] 68 boulvard Saint-Michel
National DOPE Testing Laboratory Paris 75006 France
JN Stadium, Lodi Road E-mail: [email protected]
Bansidhar Tarai MD
New Delhi, India Formerly Chair in Clinical
Lab Manager
E-mail: [email protected] Pharmacology
Microbiology, Immunology and
Indian Council of Medical Research
Molecular Biology
and Professor and Head
Anju Seth MD Quest Diagnostics India Private
Department of Pharmacology
Professor Limited
All India Institute of Medical Sciences
Division of Endocrinology Gurgaon
New Delhi, India
Department of Pediatrics Haryana, India
E-mail: [email protected]
Kalawati Saran Children Hospital E-mail: [email protected]
[email protected]
Lady Hardinge Medical College
New Delhi, India Ben J Marais MRCP FCP M (Med) H Simon Schaaf MBChB (Stell) MMed
E-mail: [email protected] Professor Ped (Stell) DCM (Stell) MD Ped (Stell)
Department of Pediatrics and Child Professor of Pediatrics
Arvind Bagga MD FIAP FAMS Health Desmond Tutu TB Centre
Professor Faculty of Health Sciences, Department of Pediatrics and Child
Department of Pediatrics Tygerberg Hospital Health, and Tygerberg Children’s
All India Institute of Medical Health Sciences, Stellenbosch Hospital, Faculty of Health Sciences
University Stellenbosch University
Sciences
PO Box No. 19063 PO Box 19063, 7505 Tygerberg
New Delhi, India
7505 Tygerberg, South Africa South Africa
E-mail: [email protected]
E-mail: [email protected] E-mail [email protected]
viii
Essentials of Tuberculosis in Children

Harleen MS Grewal MD PhD DTMH LS Chauhan MD Neena Khanna MD

Professor and Senior Consultant Senior Dy Director-General (TB) Professor
The Grade Institute Section for Central TB Division Department of Dermatology and
Microbiology and Immunology Directorate General of Health Venereology
University of Bergen, Norway Services and Family Welfare All India Institute of Medical Sciences
E-mail: [email protected] Government of India New Delhi, India
Nirman Bhawan, New Delhi, India E-mail: [email protected]
Heidi Syre PhD E-mail: [email protected]
Scientist, The Grade Institute Section Nimrat Bawa
for Microbiology and Immunology Madhukar Pai MD PhD Diplomat of American Boards
University of Bergen, Norway Assistant Professor and CIHR New (Pathology)
E-mail: [email protected] Investigator Director Technical Affairs
Department of Epidemiology and Auroprobe Laboratories
J Cunningham MD FRCP Biostatistics C-229, Defence Colony
McGill University 1020 Pine Ave New Delhi, India
Medical Officer, WHO/CDS/TDR/PRD
West E-mail: [email protected],
Unicef/UNDP/World Bank/WHO
Montreal, QC H3A IA2, Canada [email protected]
Special Program for Research in
E-mail: [email protected].
Tropical Diseases, 20 Appia Ave
Nulda Beyers MBChB(Stell) FCP(SA)
Geneva-27, Switzerland
Madhulika Kabra MD PhD(Stell) MSc(Med)(UCT)
E-mail: [email protected] Professor TB/Community Project
Additional Professor
Department of Pediatrics International Union Against
JB Sharma MD DNB FRCOG All India Institute of Medical Tuberculosis and Lung Disease
Associate Professor Sciences 68 boulevard Saint-Michel
Department of Obstetrics and New Delhi, India Paris, France
Gynecology E-mail: E-mail: [email protected]
All India Institute of Medical Sciences [email protected]
New Delhi, India OP Semwal MBBS DCH
E-mail: [email protected] Manju Ghosh PhD Former, Research Associate
Research Scientist Department of Pediatrics
JL Stanford MD Division of Genetics All India Institute of Medical Sciences
Head, Division of Bacteriology Department of Pediatrics New Delhi, India
School of Pathology All India Institute of Medical Now: Senior Consultant Pediatrics
University College and Sciences E-mail: [email protected]
Middlesex School of Medicine New Delhi, India
63-67, Riding House Street E-mail: Pawan Rawal MD DM
London WIP 7PP, UK [email protected] Senior Research Associate
Division of Pediatric
K Gopinath PhD Md Khurshid Alam Hyder Gastroenterology Hepatology and
Scientist Medical Officer (TB) Nutrition
Division of Clinical Microbiology Tuberculosis Control Postgraduate Institute of Medical
World Health Organization Education and Research (PGIMER)
Department of Laboratory Medicine
Regional Office for South-East Asia Chandigarh, India
All India Institute of Medical Sciences
World Health House E-mail: [email protected]
New Delhi, India
Indraprastha Estate
E-mail: [email protected]
Mahatma Gandhi Marg PK Dave MS
New Delhi, India Senior Consultant
Kusum Verma MD E-mail: [email protected] Department of Orthopedics and
Senior Pathologist
Director
Sir Ganga Ram Hospital, New Delhi Nani Nair MD Rockland Hospital, New Delhi
Formerly Dean, Professor and Head Regional Adviser TB Former Director and Professor of
Department of Pathology World Health Organization Orthopedics
All India Institute of Medical Sciences Regional Office for South-East Asia All India Institute of Medical Sciences
New Delhi, India New Delhi-110002, India Ansari Nagar, New Delhi, India
E-mail: [email protected] E-mail: [email protected] E-mail: [email protected]
 ix
Contributors
Contents

PM Udani (Late) MD DCH Rakesh Lodha MD S Rasool MBBS

Professor Emeritus Assistant Professor Research Officer
Department of Pediatrics Department of Pediatrics Regional Research
Institute of Child Health, JJ Group All India Institute of Medical Institute of Unani Medicine
of Hospitals Sciences Jamia Nagar
Mumbai, Maharashtra, India New Delhi, India New Delhi, India
E-mail: [email protected]
PP Kotwal MS Sandeep R Mathur MD
Professor and Head Ravi Angara MD Assistant Professor
Department of Orthopedics Senior Resident Department of Pathology
All India Institute of Medical Sciences Division of Pediatric All India Institute of Medical Sciences
New Delhi, India Gastroenterology Hepatology and New Delhi, India
E-mail:
E-mail: [email protected] Nutrition
[email protected]
Postgraduate Institute of Medical
PR Donald MBChB (Stell) DCH (Glasg) Education and Research
Sangeeta Sharma MD
DTM&H (Lond) FCP(SA) FRCP (Edin) MD Chandigarh, India
Specialist and Head
(Stell) E-mail: [email protected]
Emeritus Professor of Pediatrics Department of Pediatrics
Desmond Tutu TB Centre LRS Institute of TB and Respiratory
Robert P Gie MD
Department of Pediatrics and Child Desmond Tutu TB Center and Diseases
Health Department of New Delhi, India
and Tygerberg Children’s Hospital Pediatric and Child Health
Faculty of Health Sciences Faculty of Health Sciences Sarman Singh MD
Stellenbosch University Stellenbosh University Professor
PO Box 19063 South Africa Clinical Microbiology Division
7505 Tygerberg, South Africa E-mail: [email protected] Department of Laboratory Medicine
E-mail: [email protected] All India Institute of Medical
Rohit Sarin DTCD MD Sciences
Prashant Mathur DCH DNB PhD Head New Delhi, India
Scientist ‘D’ Department of TB Control and E-mail- [email protected]
Division of Noncommunicable Training
Diseases Lala Ram Sarup Institute of
Indian Council of Medical Research Tuberculosis and Related Diseases S Aneja MD
New Delhi, India Sri Aurobindo Marg Director Professor
E-mail: [email protected], New Delhi, India Department of Pediatrics
[email protected] E-mail: [email protected] Kalawati Saran Children Hospital
Lady Hardinge Medical College
Rachna Seth DCH DNB Roli Mathur PhD New Delhi, India
Scientist ‘C’ E-mail: [email protected]
Assistant Professor
Division of Basic Medical Sciences
Department of Pediatrics
Indian Council of Medical Research
All India Institute of Medical Sciences SD Seth MD
New Delhi, India
New Delhi, India Advisor Clinical Trials Registry –
E-mail: [email protected],
E-mail: India
[email protected]
[email protected] National Institute of Medical Statistics
Ruchi Sood PhD Indian Council of Medical Research
Rajni Sharma Research Scientist-Infectious New Delhi, India
Assistant Professor Diseases
Division of Endocrinology New Drug Discovery Research Seemab Gulati MD
Department of Pediatrics Ranbaxy Research Laboratories Associate Professor
Kalawti Saran Children Hospital Plot No. 20, Sector 18 Department of Pediatrics
Lady Hardinge Medical College Udyog Vihar, Industrial Area All India Institute of Medical Sciences
New Delhi, India Gurgaon, Haryana, India New Delhi, India
E-mail: [email protected] E-mail: [email protected] Email: [email protected]
x
Essentials of Tuberculosis in Children

S Mukhopadhyaya MD S Kumar IP Apollo Hospital

Senior Radiologist Head of Laboratories Sarita Vihar, New Delhi
Formerly Professor and Head Auroprobe Laboratories Email: [email protected]
Department of Radiodiagnosis E-mail: [email protected]
All India Institute of Medical Sciences Vimlesh Seth MD
New Delhi, India S Kuhn MD Senior Consultant in Pediatrics
E-mail:[email protected] Consultant in Pediatrics Formerly Senior Professor and
Infectious diseases at Head
Alberta Children’s Hospital Department of Pediatrics
SK Kabra MD DNB 1820 Richmond Road SW All India Institute of Medical
Professor Calgargy, Alberta, Canada Sciences
Department of Pediatrics E-mail: New Delhi, India
All India Institute of Medical Sciences [email protected] E-mail: [email protected],
New Delhi, India [email protected]
E-mail: [email protected] Tahmeed Ahmed MBBS PhD
Senior Scientist and Head YK Amdekar MD
Suneeta Mittal MD FRCOG Nutrition Programm Senior Consultant Pediatrics
Professor and Head Dhaka, Bangladesh 151, Tushar, 14th Road
Department of Obstetrics and E-mail: [email protected] Chembur, Mumbai, Maharashtra,
Gynecology India
All India Institute of Medical Sciences V Kalra MD E-mail: [email protected]
New Delhi, India Senior Consultant
E-mail: [email protected] Pediatric Neurology
 Foreword

The epidemic proportions of tuberculosis in many countries was identified as a global emergency in 1993. Despite a
considerable increase in international efforts aimed at tuberculosis control and investment in tuberculosis research,
the perverse influence of HIV-infection combined with the effects of poverty and economic recession have combined
to ensure that the failure to control tuberculosis remains a cause for concern for National Tuberculosis Control
Managers in many countries. The magnitude of the problem is daunting and has been exacerbated by the appearance
of an increasing proportion of MDR-TB and the threat of XDR TB; under the lengthening shadow of HIV, the dream
of controlling, not to speak of eradicating TB has moved far into the future. Against this background, childhood
tuberculosis may appear to be a minor problem, but the percentage of tuberculosis occurring in children is estimated
to vary between 15% in low income countries to below five percent in United States and European countries, while
in high density peri-urban slums, the proportion may rise to much more than 20% in some cases. Even in developed
countries, MDR and XDR tuberculosis are an ever-present threat due to the increasing mobility of people across
international boundaries.
The problem of the diagnosis of tuberculosis in children remains a significant obstacle and is worsened in
severe forms of extrapulmonary diseases such as osteoarticular disease and meningeal tuberculosis. The lack of
standard case definitions and low priority accorded to childhood tuberculosis in the public health agendas of many
countries are persistent problems. Nonetheless, it is pleasing that the problems of childhood tuberculosis have recently
received increasing attention from the various agencies including the World Health Organization (WHO).
The belief that tuberculosis in children is not a significant cause of transmission of infection is also not true if
viewed from a long-term perspective; a significant proportion of children in the younger and vulnerable age group
who are infected by an adult source case will very often not receive preventive therapy and will later develop
infectious adult-type tuberculosis, especially during adolescence and this is particularly likely to happen in
communities with a high incidence of HIV-infection. Globally, it is estimated that 1.5 million new cases and 130,000
deaths due to tuberculosis per year occur in young children. Of the total deaths due to tuberculosis, 95% occur in
developing countries. It has been rightly emphasized that tuberculosis control programs should recognize tuberculosis
as a disease of the family and community rather than only the individual and that tuberculosis infection and disease
in children of all ages should be managed simultaneously with the evaluation and management of other family
members and members of the extended family and household and not in isolation.
It is thus pleasing that children are now specially included in the Revised National Tuberculosis Control
Programme (RNTCP) and that antituberculosis agents will become available on a weight-for-age basis. Suboptimal
dosing still remains possible and the lack of child-friendly preparations makes the accurate treatment of under-five-
year-old children difficult and it is this group that is subject to more serious forms of disseminated disease. Within
financial constraints, active contact tracing of under-five-year-old children is now recommended and will be facilitated
by a family or household-orientated approach.
In addition to these welcome innovations, the early diagnosis and management by directly observed short-
course treatment (DOTS) of all sputum microscopy smear-positive patients, whether children, adolescents or adults,
remains an important cornerstone of any tuberculosis control program as does the administration of BCG to infants.
Although BCG vaccination has a limited effect and prevents mainly disseminated forms of tuberculosis, efforts to
develop a new improved vaccine are gathering momentum.
One of the characteristics of tuberculosis in children, in contrast to adults, is the wide spectrum of manifestations
and there is a great need to create a greater understanding of this spectrum to fully appreciate the specific problems of
childhood tuberculosis. This book should thus be welcomed by the childhood tuberculosis community throughout the
world. In this book, Vimlesh Seth, herself a well-known international figure in this field, has brought together
63 eminent scientists and clinicians who have contributed 44 outstanding chapters that address most of the manifestations
of childhood tuberculosis. Dr Seth has made a considerable contribution to the better management of childhood
tuberculosis; included in her many activities are participation in two consensus reports (1997 and 2004) and a third that
appears in this book that summarizes the deliberations of pediatricians, program managers and laboratory workers
relating to childhood tuberculosis.
xii
Essentials of Tuberculosis in Children

In addition, attention is drawn to the neglected areas of tuberculosis in girls at adolescence and in children with
cancer and two chapters discuss pitfalls in diagnosis and management of childhood tuberculosis, and lacunae and
experience of managing children under the National Program (DOTS). The place of contact surveillance has been
highlighted and forms of extrapulmonary tuberculosis, such as neurotuberculosis, have been illustrated with a large
number of clinical pictures from children of various ages in the different stages of disease. The chapter on imaging
is exhaustive and based on data of pediatric TB clinic over five decades at All India Institute of Medical Sciences
(AIIMS), New Delhi, India.
The book is a valuable resource not only for the pediatric fraternity but also for all practitioners who treat children;
and it should find a place not only in libraries of medical colleges but also in Pediatric and Community Medicine
Departments. It is very reader-friendly and organized for easy consultation by both undergraduates and postgraduates
who need to know more about childhood tuberculosis. Appropriately in an age when the epidemic of HIV continues
to spread, there is a chapter on the organization of a pediatric and HIV clinic in the pediatric department of medical
college and how this can contribute to the collection of information about tuberculosis and HIV for the National Data
Base about disease in children and so influence the design of future policies for diagnosis and management. Frequently
asked questions relating to childhood tuberculosis and BCG are addressed and this is of great practical value. Dr Seth
is to be congratulated on the successful compilation of a formidable compendium of information about childhood
tuberculosis which will be of value, throughout the world wherever tuberculosis is a significant problem.

Peter R Donald
MBChB (Stell) DCH (Glasg) DTM&H (Lond) FCP(SA) FRCP (Edin) MD (Stell)
Emeritus Professor of Pediatrics
Desmond Tutu TB Centre
Department of Paediatrics and Child Health
and Tygerberg Children’s Hospital
Faculty of Health Sciences
Stellenbosch University
Tygerberg, South Africa
 Preface to the Fourth Edition

Tuberculosis (TB) continues to be the world’s most important infectious cause of morbidity and mortality among
adults. Nearly nine million people develop tuberculous disease each year and 1.7 million die every year (WHO,
2007). Detection rates are low and morbidity and mortality is high in children also. Over the last five years, the
incidence and prevalence of TB in children has not decreased. The reason is that on the preventive front, the same
strategies: (i) diagnosis and treating sputum smear-positive cases in adults and (ii) mass BCG vaccination of newborns
and infants are being practised. These have not proved effective to a significant extent because of the concurrent
addition of HIV/AIDS infection, MDR-TB and even XDR-TB. The latter two conditions need aggressive treatment in
children along with their source cases, which are usually adults in the family.
On the diagnostic front, with the significant advances at molecular level, there has not emerged a single test for
diagnosis, that too are not cost-effective requiring huge finances and high level of technical expertise. At best, they
are categorized only supportive tests.
In the contact survey, addition of IGRAs, with the basis of release of interferon – γ after incubation of whole
blood or separated T-cells with CFT 10 peptides and ESAT-609 antigen of tubercle bacilli has been well researched.
The two tests are quantiFERON-γ. TB and T-SPOT.TB; ELISPOT. These again cannot be used as the tests for diagnosis
as they emphasize that they are only comparable to the existing tuberculin test, the advantages over tuberculin test
are: (i) require only one visit of the patient, (ii) previous BCG vaccination does not interfere and, (iii) presence of
nontuberculous mycobacteria in the environment does not vitiate the results. However, their main advantage is
their use in contact tracing for which they have been extensively used.
In the basic format of the book there are seven sections. In each section a number of new chapters have been
added, contributed by specialists in their respective field. In total there are 44 chapters with 63 contributors from
India and abroad. In the 1st three sections namely history, epidemiology and microbiology and immunopathogenesis,
the chapters have been updated including the latest details at the molecular level in all aspects. In the clinical spectrum,
for TB and HIV coinfection there are two chapters with one giving detailed dosage schedule of antiretroviral drugs.
The other significant additions are tuberculosis at adolescence, particularly in female children in whom it can
be a prelude to the development of sterelity later in life. Chapters on cutaneous and endocrine manifestations are the
other additions. The chapter on TB in children with cancer has highlighted the point why TB is not a scurge in these
children. However, one should be in the lookout for this, particularly when the presentation of complications in
cancer are unusual and do not improve with conventional antibiotics used for the commonly occurring superadded
infections. In the management section, the chapters on antituberculosis drugs have been completely revised and
updated to facilitate the readers to understand various regimens used in the clinical spectrum of TB in children
specially HIV/TB coinfection and MDR-TB. Pharmacokinetics of all antituberculosis drugs have been updated from
literature review along with the experience at Pediatric department of All India Institute of Medical Sciences (AIIMS)
with 1st-line agents. Chapter on lacunae and experience of DOTS in the management of children has been included.
The Indian Academy of Pediatrics (IAP) in the third Consensus Statement has highlighted some reservations about
management of HIV and TB coinfection and MDR-TB by general pediatricians. They have emphasized that these
two aspects need management by experts in the field. Advances up to 2010 have been included making all the
chapters well referenced with the latest literature.
The book will be useful to both undergraduates and postgraduates. Departments of Community Medicine of
Medical colleges and Tuberculosis Hospital will also benefit from the efforts of the authors. It will be a useful reference
book for Program Managers of the Tuberculosis Division of Ministry of Health and Family Welfare, Government of
India; Departments of Health Research and Indian Council of Medical Research, Biotechnology of the Government
of India. Chapters on research priorities and ethics involved in clinical trial will facilitate pediatricians to write high
quality scientific projects on TB in children to have research grant from funding agencies. Details of how to get
National Data Base of TB and its coinfection with HIV/AIDS are necessary. This will help in making changes in
policies in their management from time to time. Further, it will help to make some facilities exclusively for children
such as medicine boxes in the four to five weight categories as per age. A chapter exclusively for how to organize a
TB/HIV clinic for pediatrics has been elucidated with detailed case record forms and instruction for the junior
doctors attending the clinic to achieve goal in this direction. In toto, this book will serve as a very useful treatise
regarding all aspects of TB in children.
Vimlesh Seth
SK Kabra
 Preface to the First Edition

The prevalence of active tuberculosis in India is 15 to 25 per 1,000 population, of which 25 percent are infectious.
About 3.4 million children in the country have tuberculosis of which 94 million are at risk of infection. Nearly 40
percent of the children by the age of 6 years and 80 percent by the age of 16 years develop tubercular infection. The
annual rate of infection is 3 percent.
There is resurgence of tuberculosis both in the developed and developing countries due to the increasing
occurrence of HIV/AIDs, even children being not spared. With the availability of effective chemotherapeutic agents,
a large number of children with pulmonary primary complex are overtreated and badly planned regimens are given
to children with tuberculous meningitis, as there are no specific guidelines for the management of tuberculosis in its
varied clinical spectrum. Ultimate control of tuberculosis rests on the development of shorter courses of chemotherapy,
and availability of vastly improved diagnostic methods.
Trinity of functions of the faculty of All India Institute of Medical Sciences is patient care, teaching and research.
For all this, there is always a need to have literature on the latest developments about epidemiology, diagnosis
(newer investigations) and treatment of any disease. Tuberculosis is one of the world’s most neglected health crises.
In this treatise, attempt has been made to address the problem of tuberculosis stating from epidemiology in
various settings (hospital and community), review of recent diagnostic methods, particularly the role of nonculture
techniques in the diagnosis of paucibacillary tuberculosis of children. Based on my work in the immunology in
children having tuberculosis, a clinico-immunoradiological profile has been defined. Work on the pharmacokinetics
conducted in my laboratory has helped me to design antituberculosis drug regimens for varied clinical spectrum on
sound scientific basis. The chapters on BCG vaccination and tuberculin test have exhaustively reviewed. There is a
chapter on practical problems in the form of questions and their answers. There is a whole lot of data on Indian
children practically about all aspects of tuberculosis in this book.
The book is intended to be used by general practitioners treating children, pediatricians in practice, faculty of
pediatrics and community medicine of medical colleges, postgraduate students and the policy makers of the
Government of India for its National Tuberculosis Control Program. Specific guidelines on diagnosis and management
of the children of an infectious adult can be formulated which should be incorporated in the National Tuberculosis
Control Program of Government of India and other developing countries.
My most sincere and grateful thanks are due to all the contributors from India and abroad for having presented
the various topics in a comprehensive and authoritative manner. My special thanks are due to Dr OP Semwal for his
painstaking effort and assistance in giving finishing touch to the book.
Able secretarial assistance of Miss Rita Sharma, Mrs Kanta Chawla and Mr Ashok Kumar is gratefully
acknowledged.
Thanks are also due to Shri JP Vij, Chairman and Managing Director of M/s Jaypee Brothers Medical Publishers
Pvt. Ltd., for the publication of this book. I gratefully acknowledge the sincere efforts of Mr Ghuman, Production
Manager, for ensuring a very high quality of the book and bringing it out in such a short-time.

Vimlesh Seth
 Acknowledgments

I owe my gratitude to all the contributors for their painstakingly written chapters in an excellent, simple and lucid
style, very well referenced and updated with thorough illustrations.
We acknowledge the efforts of Shri Jitendar P Vij, Chairman and Managing Director of M/s Jaypee Brothers
Medical Publishers (P) Ltd, for publishing the book. We also acknowledge the meticulous work and sincere efforts
of Mr Tarun Duneja (Director–Publishing) and Mrs Samina Khan, for ensuring quality of this edition. We are thankful
to Mr Bir Singh for his untiring secretarial assistance. He worked even on weekends to meet the deadline.
 About the Review of the Previous
Edition of the Book

The appearance of the book and contents are really outstanding.

Peter R Donald
Emeritus Professor of Pediatrics
Faculty of Health Sciences
Stellenbosch University
7505 Tygerberg, South Africa
E-mail: [email protected]

No Western books on pediatrics have provided a comprehensive update on the subject of childhood tuberculosis,
especially in the context of the developing world.
Professor Vimlesh Seth herself has written most of the early chapters on epidemiology, diagnosis,
immunopathogenesis, and the immunology of BCG vaccination and the tuberculin test. These chapters are readable,
comprehensive, and well referenced. There have been many recent advances in mycobacterial immunology and it is
to Professor Seth's credit that she has managed to be so concise. This is an excellent book.

Anthony Costello
Senior Lecturer
Archives of Disease of Children 1991; 66: 1006
Other documents randomly have
different content
 Astronomy - Revision Notes
Spring 2023 - Research Center

Prepared by: Researcher Williams

Date: August 12, 2025

Summary 1: Experimental procedures and results

Learning Objective 1: Practical applications and examples
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 2: Case studies and real-world applications
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
[Figure 2: Diagram/Chart/Graph]
Learning Objective 3: Learning outcomes and objectives
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Learning Objective 4: Statistical analysis and interpretation
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Learning Objective 5: Statistical analysis and interpretation
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Example 5: Fundamental concepts and principles
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 6: Practical applications and examples
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
[Figure 7: Diagram/Chart/Graph]
Note: Statistical analysis and interpretation
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Experimental procedures and results
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 9: Learning outcomes and objectives
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Summary 2: Experimental procedures and results
Remember: Research findings and conclusions
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Literature review and discussion
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Historical development and evolution
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Theoretical framework and methodology
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Assessment criteria and rubrics
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Interdisciplinary approaches
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Research findings and conclusions
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 17: Key terms and definitions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 18: Study tips and learning strategies
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Best practices and recommendations
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Exercise 3: Historical development and evolution
Example 20: Research findings and conclusions
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 21: Practical applications and examples
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Problem-solving strategies and techniques
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Ethical considerations and implications
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Interdisciplinary approaches
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Assessment criteria and rubrics
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 26: Diagram/Chart/Graph]
Important: Best practices and recommendations
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Example 27: Critical analysis and evaluation
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Current trends and future directions
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Interdisciplinary approaches
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Introduction 4: Key terms and definitions
Note: Experimental procedures and results
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 31: Experimental procedures and results
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Practical applications and examples
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 33: Critical analysis and evaluation
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 34: Statistical analysis and interpretation
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 35: Experimental procedures and results
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 36: Diagram/Chart/Graph]
Key Concept: Theoretical framework and methodology
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
[Figure 37: Diagram/Chart/Graph]
Important: Theoretical framework and methodology
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 38: Research findings and conclusions
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Critical analysis and evaluation
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Introduction 5: Key terms and definitions
Definition: Current trends and future directions
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Current trends and future directions
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 42: Assessment criteria and rubrics
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Learning outcomes and objectives
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Ethical considerations and implications
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 45: Diagram/Chart/Graph]
Definition: Learning outcomes and objectives
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Practical applications and examples
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Learning outcomes and objectives
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 48: Theoretical framework and methodology
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 49: Learning outcomes and objectives
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Review 6: Learning outcomes and objectives
Remember: Case studies and real-world applications
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Experimental procedures and results
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Key Concept: Problem-solving strategies and techniques
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Interdisciplinary approaches
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 54: Diagram/Chart/Graph]
Important: Assessment criteria and rubrics
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Problem-solving strategies and techniques
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Interdisciplinary approaches
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 57: Current trends and future directions
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Theoretical framework and methodology
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Case studies and real-world applications
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Review 7: Ethical considerations and implications
Remember: Comparative analysis and synthesis
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Study tips and learning strategies
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 62: Diagram/Chart/Graph]
Definition: Best practices and recommendations
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 63: Diagram/Chart/Graph]
Important: Statistical analysis and interpretation
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 64: Key terms and definitions
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 65: Diagram/Chart/Graph]
Practice Problem 65: Problem-solving strategies and techniques
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Practical applications and examples
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Current trends and future directions
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Practical applications and examples
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 69: Diagram/Chart/Graph]
Definition: Study tips and learning strategies
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Quiz 8: Experimental procedures and results
Important: Problem-solving strategies and techniques
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Study tips and learning strategies
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Interdisciplinary approaches
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 73: Diagram/Chart/Graph]
Example 73: Assessment criteria and rubrics
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 74: Fundamental concepts and principles
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Definition: Literature review and discussion
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Best practices and recommendations
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Interdisciplinary approaches
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Problem-solving strategies and techniques
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 79: Diagram/Chart/Graph]
Note: Current trends and future directions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Chapter 9: Case studies and real-world applications
Key Concept: Statistical analysis and interpretation
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Comparative analysis and synthesis
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 82: Diagram/Chart/Graph]
Example 82: Practical applications and examples
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 83: Diagram/Chart/Graph]
Definition: Fundamental concepts and principles
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 84: Diagram/Chart/Graph]
Practice Problem 84: Experimental procedures and results
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Note: Practical applications and examples
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Key terms and definitions
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Literature review and discussion
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Research findings and conclusions
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 89: Fundamental concepts and principles
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 90: Diagram/Chart/Graph]
Module 10: Experimental procedures and results
Remember: Interdisciplinary approaches
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 91: Practical applications and examples
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Comparative analysis and synthesis
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 93: Problem-solving strategies and techniques
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
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