Table 2

Differential diagnostic and treatment considerations in chronic lung diseases in children, including chronic and complicated pulmonary TB

DiagnosisClinical and X-ray features, investigations in favour of diagnosisTreatment*
Persistent or recurrent pneumoniaRapid 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%
BronchiectasisPurulent sputum
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/asthmaWheeze
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 obliteransChest X-ray air-trapping and atelectasisOxygen
Pulmonary hypertensionExamine for signs of heart failure—tachycardia, raised jugular venous pressure, loud pulmonary second sound
Cardiomegaly on chest X-ray
Enalapril if systemic hypertension
Oxygen if SpO2 <90%
Additional diagnoses to consider if HIV positive
Pneumocystis pneumoniaRapid 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
 Lymphoid interstitial pneumonitisGeneralised lymphadenopathy
Chest X-ray: multiple nodular densities throughout the lung fields
Bronchodilators may be useful
 IRISParadoxical worsening in signs weeks—months after starting ART, lymphadenopathy, parotid gland swelling, X-ray consolidation, feverTB 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
Other complications to consider if there is poor response to TB treatment
 TB non-adherence/relapseHistory 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 TBDeterioration 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,
Amikacin or kanamycin
  • 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.