Differential diagnostic and treatment considerations in chronic lung diseases in children, including chronic and complicated pulmonary TB
| Diagnosis | Clinical and X-ray features, investigations in favour of diagnosis | Treatment* |
| Persistent or recurrent pneumonia | Rapid onset or worsening of tachypnoea, hypoxaemia, fever New changes on chest X-ray Consider recurrent viral infections as a cause, rather than chronic respiratory disease | Broad-spectrum antibiotics trimethoprim–sulfamethoxazole for PjP if HIV positive Oxygen if SpO2 <90% |
| Bronchiectasis | Purulent sputum Halitosis Clubbing Localised signs on chest X-ray | Chest physiotherapy Treatment of intercurrent infections (base antibiotics on sputum culture if possible) Erythromycin daily dose Oxygen if SpO2 <90% Oral hygiene |
| Chronic airways disease: may be reactive or non-reactive/asthma | Wheeze Chest X-ray may define focal (such as endobronchial lymph node obstruction) or diffuse nature of airflow obstruction Low PEFR or low FEV1(on spirometry) | Trial of salbutamol (measuring PEFR) Trial of prednisolone or inhaled corticosteroid/long acting beta-2 agonist |
| Bronchiolitis obliterans | Chest X-ray air-trapping and atelectasis | Oxygen |
| Pulmonary hypertension | Examine for signs of heart failure—tachycardia, raised jugular venous pressure, loud pulmonary second sound Cardiomegaly on chest X-ray | Frusemide Sildenafil Enalapril if systemic hypertension Oxygen if SpO2 <90% |
| Additional diagnoses to consider if HIV positive | ||
| Pneumocystis pneumonia | Rapid onset or worsening of tachypnoea, hypoxaemia, fever New changes on chest X-ray—fine reticular interstitial or perihilar pattern, no effusions | Broad-spectrum antibiotics, trimethoprim–sulfamethoxazole for PjP Oxygen |
| Lymphoid interstitial pneumonitis | Generalised lymphadenopathy Clubbing Chest X-ray: multiple nodular densities throughout the lung fields | Prednisolone Bronchodilators may be useful |
| IRIS | Paradoxical worsening in signs weeks—months after starting ART, lymphadenopathy, parotid gland swelling, X-ray consolidation, fever | TB treatment Prednisolone for severe IRIS |
| Aspergillus (can also occur in HIV-negative immune-suppressed children) | Exposure to building dust Immune suppression (eg, long-term steroids) Septated hyphae on sputum wet smear Chest X-ray nodular consolidation or cavitation | Amphotericin Voriconazole |
| Other complications to consider if there is poor response to TB treatment | ||
| TB non-adherence/relapse | History of likely non-adherence to TB treatment Changes consistent with TB on chest X-ray GeneXpert MTB/Rif positive on gastric aspirates or sputum Strongly positive Mantoux test | Recommence TB treatment and hospitalise or supervise closely |
| MDR TB | Deterioration or no improvement despite good adherence to TB treatment Changes consistent with TB on chest X-ray History of exposure to MDR contact GeneXpert MTB/Rif positive on gastric aspirates or sputum Strongly positive Mantoux test | MDR TB treatment, for example, Ciprofloxacin Amikacin or kanamycin Ethionamide Cycloserine |
If the initial diagnosis is uncertain, or no improvement after one of supervised TB treatment: Take a detailed history of treatment and adherence to TB and other medications, MDR contact, check for signs of HIV, check for effusion, wheeze, loud pulmonary second sound, signs of heart failure, clubbing, anaemia, lymphadenopathy, do an HIV test, cardiac Echo, sputum smear for GeneXpert, AFB stain, TB culture, sputum wet preparation for fungal elements and Mantoux test. Do spirometry or PEFR if the child is old enough, a standardised exercise tolerance test, and do a chest CT if you can.
*Treatment includes ART if HIV positive.
AFB, acid fast bacilli; ART, antiretroviral therapy; FEV1, forced expiratory volume in 1 s; IPT, isoniazid preventative therapy; IRIS, immune reconstitution inflammatory syndrome; MDR, multidrug resistant; PEFR, peak expiratory flow rate; PjP, Pneumocystis jirovecii pneumonia; SpO2, cutaneous oxygen saturation using pulse oximetry; TB, tuberculosis.