Respiratory Archives - Page 2 of 3 - CHILD AND CHEST HEALTH CARE

Drug resistant Tuberculosis,What we know till beginning of 2021,DR.D.K.JHA,M.D.,Pediatric Pulmonologist,Delhi

DR DEV KUMAR JHA - 18 Feb, 2021 - INFECTIOUS DISEASES,Respiratory, - 0 Comment

Tuberculosis is very very old disease of human .

There has been many research in the field of diagnosis and treatment of tuberculosis.

Inspite of all the efforts worldwide,it is still the killer disease due to various reasons responsible for the emergence of drug resistant TB (Tuberculosis).

Chief responsible factors for the increased incidence of tuberculosis are poverty leading to undernutrition, and HIV infection.

Main causes of emergence of drug resistance is not completing the prescribed regimen of treatment and high burden of tuberculosis.

TERMINOLOGIES BEING USED:

Monoresistant tuberculosis-Resistance of tuberculosis to any first line drug-Rifampicin,Isoniazid,pyrazinamide,ethambutol

Polyresistant tuberculosis: Resistance of tuberculosis to more than one drug but not to both Rifampicin and Isoniazid

Multi drug resistant(MDR) tuberculosis: Resistance to both Rifampicin and Isoniazid with or without resistance to other drugs

Pre-extensively drug resistant(PRE-XDR) tuberculosis:Resistance to both Rifampicin and isoniazid with resistance to either fluoroquinilones or second line injectables but not to both fluoroquinolones and second line injectables(SLI)

Extensively drug resistant tuberculosis(XDR):Resistance to Rifampicin,Isoniazid,fluoroquinolones and second line injectables(SLI)

RR-TB:Resistance to Rifampicin with or without resistance to other antituberculous drugs

SECOND LINE INJECTABLES(SLI):Amikacin,Kanamycin and capreomycin

PRIMARY RESISTANCE:When a child or adult becomes infected with drug resistant strain of Mycobacterium tuberculosis

SECONDARY/ACQUIRED RESISTANCE:This is more common.The individual is infected with drug sensitive strain of Mycobacterium tuberculosis but it becomes drug resistant during treatment due to selection of resistant mutant strain.The cause of such resistance is incopmlete or suboptimal treatmen

TERMS USED IN DIAGNOSTIC PROCESSES

C-Tb skin test;This is a new test for the detection of tuberculosis infection.In this test ESAT6/CFP10 antigens are used.It is done in the same way as Tuberculin skin test(TST).Antigen is injected intradermally on the forearm and reaction is read after 48-72 hours with the ball pen-scale method.An induration of 5mm is taken as positive irrespective of age,BCG status and whether with HIV or non HIV.The sensitivity is comparable to TST(MANTOUX TEST) and IGRA(QUANTIFERON GOLD)

IGRA(QUANTIFERON TB GOLD IN TUBE TEST;QFT-GIT: AND T-SPOT TB TEST:T-SPOT):This test is based on the principle of white blood cells of individuals infected with mycobacterium release interferon gamma when mixed with antigens derived from Mycobacterium.In this test whole blood is taken from individual and then mixed to ESAT6/CFP10 antigens and result is available within 24 hours.It does not differentiate between active and latent Tb.This test is not affected by BCG vaccination and is specific for Mycobacterium tuberculosis but not reliable below 5 years of age.

TESTS TO DETECT MYCOBACTERIUM:

LAMP;Loop mediated isothermal amplification test is 15% more sensitive than Zeil Neilson microscopy(smear microscopy) which is most widely used traditional test to detect Mycobacterium in smear preparation of sample in the form of sputum or gastric aspirate. It is temperature independent test ,done manually for amplification of DNA and can be read by naked eye with ultraviolate light.The report is available within one hour.WHO has recommended it as an alternative to ZN microscopy as it can be used in periphery

LED-FM:Light emitting diode fluorescent microscopy is 10 % more sensitive than ZN microscopy.With proper training it can be used in periphery although its specificity is less.WHO has recommended it as an alternative to ZN microscopy.According to WHO policy paper its sensitivity is 86.3%

CBNAAT :Cartridge based nucleic acid amplification test is based on polymerase chain reaction for the ampilification of DNA.Report is available within 2 hours.It can detect live as well as dead tuberculous bacilli ,so it can not be a replacement for smear microscopy and culture based drug sensitivity test for folllow up.It is also known as GenXpert /Rif test.It also detects Rifampicin resistance.Its sensitivity is 89% and specificity is 99%

GenXpert ultra(CBNAAT ULTRA):It is an advance version of GenXpert which is ultrasensitive with main difference from GenXpert is ,it can detect Mycobacterium from sputum even if the number of bacilli per ml is as low as 16,whereas in GenXpert ,the number of bacilli should be 131/ml for detection

TRUENAT;It has been developed in India by Molbio Diagnostics Pvt.Ltd.Goa.Its sensitivity and specificity to detect Mycobacteria and Rifampicin resistance is similar to CBNAAT/GenXpert test.But it requires 0.5 ml of sample as compared to CBNAAT which requires 1 ml.It is battery operated and not fully automated so it does not require continuous power supply and can be used in periphery

LPA-Line probe assay is based on polymerase chain reaction with reverse hybridization technique.First line assay detects resistance to isoniazid while second line LPA detects resistance to Fluoroqinolones and SLI.Report is available within 24-48 hours.According to recent RNTCP guideline,if Rifampicin resitance is detected on CBNAAT,second sample is sent to detect isoniazid resistance by LPA.If isoniazid resistance is detected,second line LPA is done for Fluoroquinolones and SLI.If Rifampicin sensitivity is detected on CBNAAT,sample is sent for LPA to detect isoniazid resistance.

According to WHO,END TB Programme,all patients should be subjected to DST(Drug sensitivity test) and the reference standard for this test is either liquid or solid culture.The report becomes available in 12 weeks.

To meet the requirement of universal DST as recommended by WHO,rapid tests are being developed as-NEXT GENERATION SEQUENCING(NGS).It is a rapid molecular test to detect mutations responsible for drug resistance.These are of 3 types

Targeted NGS-it sequences the specific point on gene of Mycobacterium tuberculosis

Whole genome sequencing(WGS)It sequences the whole genome ,so it is better than TNGS.

Pyrosequencing-it is method of sequencing by synthesis.

DRUGS TO TREAT RESISTANT TUBERCULOSIS:

GROUP-A-Levofloxacin or Moxifloxacin,Bedaquiline,Linezolid

GROUP-B-Clofazimine,Cycloserine or Teridizone

GROUP-C-Ethambutol,Delamanid,Pyrazinamide,Imipenam-cilastin or Meropenam,Amikacin or Streptomycin,Ethionamide or Prothionamide,Para-Aminosalicylic acid(PAS)

There are TWO regimens for the treatment of drug resistant tuberculosis,Long course and Short course

Long course is for 18-20 months-According to WHO 2019 guideline, 2 drugs from Group A except Bedaquiline in children,1-2 drug from Group B along with Delamanid must be chosen and the list of at least 5 drugs is completed from Group C.After 6 months of continuation phase,Delamanid is withdrawn and at least 4 drugs should be continued for the rest of the period of treatment..

DELAMANID CAN BE GIVEN TO CHILDREN ABOVE 3 YEARS OF AGE

SHORT COURSE REGIMEN:It is given for a period of 9-12 months.Usually the intensive phase is of 4-6 months consisting of Moxifloxacin,high dose isoniazid,ethambutol,,pyrazinamide,clofazimine,ethionamide or prothionamid,Kanamycin or Amikacin(7 drugs) followed by a fixed period of 5 months of Moxifloxacin,clofazimine,pyrazinamide and ethambutol(4 drugs)

Drug resistance to Fluoroquinolones and second line injectables should be ruled out before initiating short course treatment.

Now a days it is being emphasised and WHO in June 2020 has recommended ,all oral drug regimen where injectables shuold be replaced by Bedaquiline.FDA has approved Bedaquiline above 12 years of age but in India it has been approved above 18 years in accordance to RNTCP guideline.

NOTE:High dose isoniazid- dose is 15-20 mg/kg/day-it can cause optic and peripheral neuritis,ANA positivity,agranulocytosis,vasculitis and thrombocytopenia.

Linezolid-Dose 15 mg /kg od for wt<15 kg and 10-12 mg/kg od,for >15kg.It causes Myelosuppression,peripheral and optic neuritis and lactic acidosis.It penetrates CNS well

Ethionamide/Prothionamide causes hypothyroidism

EPTB and CNS Tb should be treated with longer regimen

REFERENCES:

TB facts.GenXpert Test-TB diagnosis,TB resistance testing,CBNAAT.2018.Available at:http://www.tbfacts.org/genexpert/Accessed

2019

World Health Organisation(WHO).The use of next generation sequencing technologies for The detection of mutations Associated with drug resistance in Mycobacterium toberculosis Complex;Technical guide.Available at http://apps.who.int/iris/handle/10665/27443.Accessesd2019.

World Health Organisation.WHO consolidated guideline on Drug Resistasnt tuberculosis treatment 2019?Available at :https:apps.who.int/iris/bitstream/handle/10665/311389/9789241550529-eng.pdf.Accessed 2019

SISUNATOVIR,A PROMISING DRUG TO TREAT SEVERE RSV INFECTIONS INCLUDING BRONCHIOLITIS,Dr.D.K.JHA,M.D.,Pediatric Pulmonologist,Delhi,India

DR DEV KUMAR JHA - 13 Aug, 2020 - Respiratory, - 0 Comment

RSV(Respiratory syncytial virus) is the most common cause of bronchiolitis in children.

Bronchiolitis is usually mild but in infants between 3-6 months,it may become serious and sometimes life threatening.

It usually becomes serious in preterm infants and infants already having cardiac disease with significant shunt,infants having CLD(Chronic lung disease,previously known as BPD) and infants with primary immune deficiency.

There is no specific treatment other than Rivaverin which may or may not work.

So, the mainstay of treatment is only supportive and it has high morbidity and mortality.

In such situations,a new drug Sisunatovir may be life saving for many infants.

In a research ,66 adults were inoculated with RSV,then they were given treatment with this new drug Sisunatovir.It resulted in significant reduction in clinical symptoms with significant reduction in viral load,with no significant adverse effects.The new drug was well tolerated and there was no resistane to this new drug.It was Phase 2a study.

Sisunatovir binds to the surface protein F, of RSV and inhibits its replication.It is a fusion inhibitor which is administered orally.

REFERENCES:ReViral announces FDA Fast Track designation granted to sisunatovir for the treatment of serious respiratory syncytial virus infection. https://www.businesswire.com/news/home/20200804005065/en/ReViral-Announces-FDA-Fast-Track-Designation-Granted. Accessed August 4, 2020

Meaning of ground glass opacity on Chest CT,Dr.D.K.Jha,M.D.,Pediatric Pulmonologist,Delhi,India

DR DEV KUMAR JHA - 07 Aug, 2020 - Respiratory, - 0 Comment

Computed tomography of chest(Chest CT) has become an essential imaging modality to diagnose many chest conditions including some complicated Pneumonia.

As CT chest is time consuming,so children below 3 years should better be sedated for proper examination of chest by CT.

Ground glass opacity (GGO) may be seen in different chest conditions and its location may give some clue to the diagnosis.

In the time of widespread occurance of COVID 19 ,CT chest may be useful to point towards diagnosis when the serological tests are negative.

In COVID 19 Pneumonia typical findings on chest CT is bilateral ground glass opacity located peripherally in the subpleural regions and at lower lobes of lung.Later on there may be crazy pavy changes with architectural damage ,perilobular opacities superimposed upon ground glass lesions.

There may be consolidation in the lower lobes of the lung located in subpleural regions suggestive of COVID19 Pneumonia.

Atypical findings in COVID19Pneumonia may be ground glass opacity on the upper lobes of lung,peribronchovascular regions and,there may be cavitation,lymphadenopathy and pleural thickening.

Ground glass opacities are also seen in other viral pneumonia.It is seen in upto 75%cases of Adenovirus Pneumonia and more than 75%cases of cytomegalovirus(CMV) Pneumonia.It is also seen in approximately 25% cases of Herpes simplex Pneumonia.

It is also seen in Pneumonia due to Pneumocystis carini but in this case it is mainly located on the upper lobes.

GGO may be observed in interstitial lung diseases(ILD) but the pattern of distribution may differentiate it from infective origin.

GGO may be seen in lung injury caused by electronic cigarrette smokes,eosinophilic pneumonia,hypersensitivity Pneumonia,Pulmonary alveolar proteinosis,diffuse alveolar hemorrhage,and pulmonary edema.

Bacterial Pneumonia can be differentiated by the distribution of opacities in the focal ,segmental and lobar regions not predominantly in the lower lobes.Other findings also differentiate it from viral pneumonia, like cavitation,lymphadenopathy and lung abscess

REFERENCES;Cite this: Broad Differential Diagnosis of Chest CT Ground-Glass Opacities – Medscape – Jul 16, 2020.

childern usually do not transmit coronavirus19 infection,Dr.D.k.Jha,M.D.,Pediatric Pulmonologist,Delhi,India

DR DEV KUMAR JHA - 16 Jul, 2020 - INFECTIOUS DISEASES,Respiratory, - 0 Comment

Coronavirus 19 is a potential lethal virus causing Coronavirus disease 2019.

This disease has made realisation of its presence all over the world .

All age groups are being infected with this disease with varying morbidities and mortalities.

The disease has disrupted the educational and economic activities,all over the world.Schools are closed for a long time all over the world in the fear of spread of the disease among children and then in the household.

Researchers have studied 4130 cases through hospital surveillance network between 10,March 2020 to 10,April 2020.Among them 40 cases were children below 16 years of age.Household and parents were called for contact tracing .

It was observed that,in 79% of cases, the source were an adult in the household who were either diseased or infected prior to the infection in children.

In only 8% cases,children were primarily infected who then infected adults.

It was then concluded that,children, not only suffer from mild form of the disease in majority of cases,but they are also not the source of infection to othe children or adults in most of the cases.

The study was published in PEDIATRICS,the official journal of American Academy of Pediatrics.

In conclusion,there will be very little benefit from closing the schools, but it can adversely affects the academy of growing children.

REFERENCES:Pediatrics. 2020;146:e20201576, e2020004879

Famotidine is a promising drug to treat COVID19,Dr.D.k.JHA,M.D.,

DR DEV KUMAR JHA - 16 Jun, 2020 - Respiratory, - 0 Comment

Famotidine is H2 receptor antagonist which is out of fashion now,which has been widely used to treat gastritis in children as well as in adults.

According to a case series of 10 patients of COVID19, Famotidine was self administered at home as it is a over the counter drug,means anyone can purchase it from medical store without the prescription of a doctor.

The dose used was 80 mg three times daily for a median period of 11 days.

Patients were interviewed on telephone regarding ,demography,risk factors,temperature,oxygen saturation and general well being apart from commom symptoms related to COVID 19.

According to the National institute of health protocol,longitudinal severity scores of 5 symptoms were collected-headache,cough,fatigue,shortness of breath and ansomnia.

The demography and risk factors were wide in the patients.Symptomps started to improve after 24-48 hours of initiation of therapy and the patients came to premorbid condition 14 days after treatment.

Particularly airway related symptoms like cough and shortness of breath improved faster than general symptom like fatigue

The mechanism of action of this drug Famotidine has not been established,which needs further study.

REFERENCES:Janowitz T, Gablenz E, Pattinson D, et al. Famotidine use and quantitative symptom tracking for COVID-19 in non-hospitalised patients: a case series [published online June 4, 2020]. Gut. doi:10.1136/gutjnl-2020-321852

FeNO may help to diagnose cough variant asthma,DR.D.K.JHA,M.D.

DR DEV KUMAR JHA - 12 Nov, 2019 - Respiratory, - 0 Comment

Asthma,only as cough

Asthma is a leading cause of respiratory morbidity all over the world whether it be adult or children.In cough variant asthma,patients have only symptom of troublesome cough for a long period.They do not complaint of tightness of chest,difficulty in breathing,or wheezing any time in the course of their illness.On CHEST auscultation,there is no adeventitious sound in the form of wheeze.This type of cough presents a difficulty in front of treating physician for the accurate diagnosis.It may be asthma or other diagnosis which needs meticulous investigations.It is also difficult to convince to patients or parents that it may be asthma,because there is a common belief among patients and parents that asthma means difficulty in breathing.On the other hand,spirometry,which is a goldstandard diagnostic test for asthma, done on such type of asthma patients are usually normal.

FeNO(Fractional excretion of nitric oxide) is measured by a portable machine,which is hand held and subject is asked to exhale through the mouth piece connected to a hand held device.The measurement is in part per billion(ppb).The normal and abnormal levels have been validated in adults,not in children.But its level when it is high,well correlates with eosinophilic inflammation of airways in children and it can be performed easily in school going children.

In a study ,32 patients with an average age of 42.5 years were included.All had only cough for a long period(chronic cough),normal blood eosinophil count,normal chest X-Ray,normal spirometry results but abnormal ACT(Asthma control test) and positive skin prick test for environmental antigens.9 healthy persons were included for control with the mean age of 47 years.FeNO measurements were taken with the help of FeNO analyser.

FeNO were significantly elevated with the mean value of 64.4ppb in 91%(n29) of patients.The normal cut off value for adults is 25ppb.In healthy controls,the mean value measured was 16ppb.

REFERENCES:Nsouli T, Diliberto N, Nsouli S, Zamora S, Nsouli A, Bellanti J. Lack of concordance between FeNO and spirometry in patients with chronic cough. Presented at: American College of Allergy, Asthma, & Immunology Annual Scientific Meeting 2019; November 7-11, 2019; Houston, TX. Abstract A202

SPUTUM EOSINOPHIL COUNT CORRELATES WITH BLOOD EOSINIPHIL COUNT AND CAN DIFFERENTIATE ASTHMA AND COPD,DR.D.K.JHA.M.D.,

DR DEV KUMAR JHA - 02 Nov, 2019 - Respiratory, - 0 Comment

Sometimes ,it becomes difficult to differentiate asthma,COPD and asthma-COPD overlap

It is easy to take sputum sample in adult, but in children it is difficult

So,any sample can be used depending upon the age of patient,if both correlates well

Researchers from Japan retrospectively,evaluated 195 patients with Asthma(n95),COPD(n61) and asthma COPD overlap(n39) between 2015 to 2017

Sputum sample was centrifuged at 500g for 5 minutes,then transferred to a glass slide.It was then crushed with a rotatory motion with another glass slide.Cell counts were done after proper staining.

To assess whether the sputum eosinophil counts-/>3% correlates with blood eosinophil count,researchers constructed ROC(Receivers operative curve)

Patients with Asthma and asthma COPD overlap had significantly higher eosinophil count and lower neutrophil counts during stable period as compared to patients with COPD . But it was not so during exacerbations.

MEAN eosinophil and neutrophil counts: asthma, 17.4% and 78.8%, respectively; COPD, 1.8% and 95.6%, respectively; and asthma-COPD overlap, 11.8% and 84.2%, respectively).It was during stable period

But,during the periods of exacerbation, following was the results

MEAN eosinophil and neutrophil counts: asthma, 15.0% and 83.3%, respectively; COPD, 4.8% and 86.4%, respectively; and asthma-COPD overlap 17.7% and 79.9% respectively.

There was significant correlations between blood and sputum eosinophil percentage among all categories of patients both during stable and during the period of exacerbations

It was clear from the analysis of ROC curve, that the blood eosinophil can predict sputum eosinophil count3% during stable period as well as during the period of exacerbations.Following is the results.

During stable period (AUC, 0.75 [95% CI, 0.66-0.84]; cutoff, 235 µL; sensitivity, 75.4% and specificity, 71.3%) and during the exacerbation period (AUC, 0.80 [95% CI, 0.66-0.94]; cutoff, 351 µL; sensitivity, 61.1% and specificity, 97.1%).

So we can take either sample according to feasibility and during the stable period ,we can diffferentiate between asthma,COPD and asthma COPD overlap

REFERENCES:

Tamura K, Shirai T, Hirai K, et al. Differentiation of asthma, COPD, and asthma-COPD overlap via a simplified sputum cell count method. Presented at: CHEST Annual Meeting 2019; October 19-23, 2019; New Orleans, LA. Abstract 464.

UPDATED RECOMMENDATIONS IN PEDIATRIC TUBERCULOSIS,2019, DR. D. K. JHA, M. D

DR DEV KUMAR JHA - 05 Apr, 2019 - INFECTIOUS DISEASES,Respiratory, - 0 Comment

Pediatric tuberculosis is a burden to society and nation .

It is prevalent in every society and every nation.

It spreads by aerosols which comes in air after coughing by a diseased person and then inhaled by healthy person .

In children ,it is mostly contracted by a diseased adult suffering from pulmonary tuberculosis .

Lifetime risk for an infected child to become diseased is 10%.

CBNAAT-cartridge based nucleic acid amplification test, also known as GeneXpert test is now investigation of choice to detect Mycobacterium tuberculosis in children suspected to be suffering from tuberculosis .

The sensitivity of this test in sputum smear positive case is 98% and specificity is 99% but in smear negative and culture positive cases its sensitivity is only 72% but specificity is 99%

In GA(gastric aspirate sample ) the sensitivity is only 68% in culture positive sample and specificity is 99%.

Presently it is done on sputum, gastric aspirate ,CSF ,pleural fluid ,lymph done aspirate ,ascitic fluid,synovial fluid but not on blood .

In lymph node aspirate,the positivity is 35%.

In some children,in which induced sputum and gastric aspirate are negative ,BALf,bronchoalveolar lavage fluid obtained by bronchoscopy has been found to be positive.

The sensitivity is low in Synovial fluid,pericardial fluid,ascitic fluid and very low in pleural fluid.

SO ,NEGATIVE TEST RESULT OF CBNAAT/GeneXpert TEST DOES NOT RULE OUT TUBERCULOSIS

Only one sample is needed and if unable to send the sample to lab immediately, it can be stored safely in refrigerator for 7 days but should not be freezed .

It is a real time PCR test and gives result in 2 hours.

It detects Mycobacterium tuberculosis as well as its resistance to Rifampicin.

If resistance to Rifampicin is detected and there is no suspicion of resistant tuberculosis clinically,then a fresh second sample is sent.

In second sample, if there is sensitivity to Rifampicin, it is labelled as Drug sensitive TB.

In GeneXpert Ultra test,second sample is not required.

The yeild is high in this test if there is chest X-ray findings suggestive of tuberculosis.

In case of only clinical suspicion with no radiological findings,the sensitivity is approximately 10%

SO,FOR THE HIGH YIELD,THIS TEST SHOULD BE SENT WHEN THERE IS SUSPICIOUS LESION ON CHEST X-RAY

In case of pleural effusion,the highest yield is from the examination of pleural biopsy which is positive in 80% cases.

The culture of pleural fluid is positive in only 10% of cases.

Other recommended tests are LPA-Line probe assay and LAMP-Loop mediated isothermal amplification.

These tests (CBNAAT,LPA annd LAMP)are called WRDT-WHO recommended rapid detection test.

The Gold standard diagnostic test is now, liquid culture in the form of MGIT-Mycobacterium growth indicator tube culture which gives result in 3 weeks.Previously it was solid culture.

Culture is positive in 1/3 to 1/2 cases of Tuberculosis.

FUTURE PROSPECT: CBNAAT has been used to detect Mycobacterium tuberculosis in stool sample in children.Its sensitivity in one study in children and persons with HIV has been found to be over 80% and specificity over 95% when compared to respiratory sample.

After multicentre study,it may become the preferred sample for children in which respiratory sample is difficult to obtain.

TREATMENT:

Category II (CAT II) Treatment comprising of 2HRZES+1HRZE+5HRE has been completely withdrawn now.

There is only one category now, for all patiens ,comprising of 2HRZE+4HRE,FIRST LINE ATT

For newly diagnosed cases,whether smear positive or smear negative this treatment should be completed for 6 months.

All patients,who have not taken ATT previously or have taken it for less than 4 weeks are labelled as New Case

In cases of neurotuberculosis or spinal tuberculosis,the continuation phase comprising of HRE should be extended for 8 months.

In cases of relapse,defaulters, retreatment,treatment after failure, and any contact with resistance tuberculosis,the sample should be sent for DST-Drug sensitivity test, while the treatment started as 2HRZE+4HRE.

If the result comes as sensitive to first line medications,the treatment should be completed with this regimen only

If resistance comes to any drug, then the second line drugs should be started according to the sensitivity pattern.

Second line drugs are less potent and should be given for prolonged time.

Two highly potent drugs Dalaminid and Bedaquilline are now recommended for treatment of children with resistant tuberculosis.

Bedaquilline is recommended for children 6 years and above.

Dalaminid is recommended for children 3 years and above.

These two drugs are available at selected centres in India

In cases of LTBI -Latent tuberculosis bacillus infections,in which only Tuberculin sensitivity test or IGRA is positive but there is no clinical symptom and sign or any lesion in any organ suggestive of tuberculosis,no treatment is given in India.

In Western countries,the current recommendation is to treat LTBI with 12 Doses of HP-3HP-(3 months of HP)

Previously it was recommended for adults,but now it is recommended in children also

In such cases(LTBI),weekly doses of Rifapentine and isoniazid is given for 12 weeks.

Currently,it is not recommended for children below 2 years of age.

All children receiving isoniazid should be given daily dose of 10 mg of pyridoxine.

Definite indications of steroid along with ATT are TBM,Pericarditis,Addisons disease,Miliary TB with alveolocapillary block and TB uveitis.

Steroid can be given in endobronchial tuberculosis,pleurisy with severe distress,bronchial compression,mediatinal compression syndrome,laryngeal TB,and TB-IRIS(Immune reconstitution inflammatory sundrome).

Evidence is not sufficient for tuberculoma.

Prednisolone 1-2 mg/kg/day or dexamethasone 0.6mg/kg/day or any steroid in equivalent doses ,should be given for 4 weeks then tapered over next 4 weeks.

REFERENCES:

RNTCP Updated Pediatric TB Guidelines 2019 developed by Revised National TuberculosisControl Programme and Indian Academy of Pediatrics.

Guidance document draft as on 04.02.2019,Central TB division,Ministry of Health and Family Welfare,New Delhi India

CDC:Treatment Regimen for Latent TB infection

CDC:The 12 dose Regimen forLatent Tb infecvtion Treatment:Fact Sheet for clinicians

Eur Respir J 2019 53:1801832; published ahead of print 2018,
doi:10.1183/13993003.01832-2018

;

STEROID RESISTANT ASTHMA CAN BE PREDICTED NOW,DR.D.K.JHA,MD

DR DEV KUMAR JHA - 24 Mar, 2019 - Respiratory, - 0 Comment

Asthma is the most common chronic disorder in children all over the world.

Its incidence and prevalence has increased in last decades even in the presence of more advance diagnostic modalities and more sophisticated treatments available now a days.

The cornerstone of controller medication for asthma is inhalational steroid.

Injectable and or oral steroid is the principal agent for the treatment,and becomes life saving, when a child lends up in emergency department with acute severe exacerbation of asthma.

Few children with asthma do not respond to steroid therapy and the physicians lend up in problem when they give steroid, spend time and then do not see any improvement in the child.

In such situations,if we know which child will not respond to steroids,will be very helpful.

In a research study,192 asthmatic children who were on inhalation steroid treatment and 130 healthy were included.

Serum level of OX40L was estimated in all children.Its level was correlated with clinical characteristics of asthma and the response of steroid treatment.Serum levels of eosinophils,Nutrophils,IgE,Interleukin 6 and TSLP(Thymic stromal lymphopoietin) were estimated in all children.

There was a positive correlation between serum levels OX40L and serum levels of Eosinophils,Nutrophils,IgE,Interleukin 6 and TSLP which are known serum markers of asthma and its severity.

There was a significant high level of serum OX40L in asthmatic children in comparision to healthy children and the level of serum 0X40L was much higher in steroid resistant asthma(SRA) in comparision to Steroid sensitive asthma(SSA)

There was a negative correlation between serum level of 0X40L and Asthma score test(AST) and FEV1 which are measured to assess the severity of asthma at regular intervals.

So,the high level of serum 0X40L has 2 meanings,firstly, it indicates more severe asthma and secondly very high level may suggest the asthma is unresponsive to steroid treatment.

In future , the agent targetting this 0XL40 is required to customise the treatment of asthma.

REFERENCES:Elevated serum OX40L is a biomarker for identifying corticosteroid resistance in pediatric asthmatic patients
BMC Pulmonary Medicine — Ma SL, et al. | March 21, 2019