Long-term consequences of tuberculosis in children and adolescents

In April 2023, a systematic literature review on the possible long-term consequences of tuberculosis (TB) disease in childhood and adolescence was published in the Lancet Infectious Diseases. The authors (Vanessa Igbokwe, student assistant at the DZK, et al.) describe a broad spectrum of somatic and psychosocial residual effects and their impact on the quality of life of those affected.

Despite good chances of cure with adequate TB treatment, recent data from adult TB patients point to possible long-term consequences for years after the disease (1). These long-term effects (13 to 87% of the population studied, depending on the study) may include structural changes in lung tissue, clinically measurable limitations such as ventilatory dysfunction and persistent symptom burden (2-4). The totality of possible pulmonary residuals in adults is summarized under the term post-tuberculosis lung disease (PTLD) and is associated with increased mortality (5). Little is known about the long-term status of pediatric TB patients (6).

Auch bei Kindern stellt die pulmonale TB die häufigste Manifestation dar. Je jünger die Kinder, desto höher ist jedoch die Vulnerabilität für disseminierte und extrapulmonale TB-Manifestationen. Daher zielte die Übersichtsarbeit darauf ab, das Spektrum der Residuen bei Kindern möglichst umfassend aufzuzeigen. Die systematische Literaturanalyse umfasste Daten aus den Jahren 1947 bis 2022 von insgesamt 71 Studien, die 3529 pädiatrische Patient*innen (zum Diagnosezeitpunkt <18 Jahre alt) aktiv nachuntersucht haben. Die radiologischen und klinischen Untersuchungen fanden bis zu 36 Jahre nach abgeschlossener Behandlung statt. Die Mehrheit der Patient*innen hatte extrapulmonale TB-Manifestationen, angeführt von spinaler TB (n=32 Studien, n=1249 Kinder).

Almost all studies described organ-specific residual effects, the most serious for tuberculous meningitis (n=17 studies, n=872 children examined). Up to 100% of those examined suffered from permanent motor impairments, headaches and seizures, including global developmental delays, even long after treatment. Possible consequences of musculoskeletal and cutaneous TB were permanent deformities, scars and growth disorders, which led to lasting stigmatization of the children. Abdominal and urogenital TB manifestations led to adhesions that required repeated hospitalizations and surgical interventions far beyond drug therapy - a long process of suffering at a young age. The few studies (n=6) on pulmonary TB identified residuals consistent with PTLD, with almost one in five children showing radiological abnormalities. Clinical late sequelae after pulmonary TB were described in individual cases, a possible connection to the structural residuals remained open. Frequently mentioned risk factors for the development of late sequelae are the young age of the children (especially infancy and early childhood) and the severity of the disease.

The picture of the long-term status of TB disease in childhood can be frightening at first glance. Despite adequate treatment, sometimes massive restrictions in quality of life and social participation remain, which is all the more significant in young children who still have a long life expectancy and are in the middle of crucial developmental phases. However, clinical pictures such as tuberculous meningitis and its serious late effects are fortunately rare in all cases. Moreover, the included studies are extremely heterogeneous and no study could be identified that examined an average pediatric TB population for late effects of the disease in a sufficient number of cases. Nevertheless, this study underlines the importance of systematic follow-up after TB, particularly in children, in order to identify any residual effects as early as possible and to improve quality of life in the long term, even after the acute phase of the disease.

Link to article: https://pubmed.ncbi.nlm.nih.gov/36963920/

Literature:

1. Allwood BW, Byrne A, Meghji J, Rachow A, van der Zalm MM, Schoch OD. Post-Tuberculosis Lung Disease: Clinical Review of an Under-Recognized Global Challenge. Respiration. 2021; 100(8): 751-63.
2. Ravimohan S, Kornfeld H, Weissman D, Bisson GP. Tuberculosis and lung damage: from epidemiology to pathophysiology. Eur Respir Rev. 2018; 27(147).
3. Allwood BW, Myer L, Bateman ED. A systematic review of the association between pulmonary tuberculosis and the development of chronic airflow obstruction in adults. Respiration. 2013; 86(1): 76-85.
4. Byrne AL, Marais BJ, Mitnick CD, Lecca L, Marks GB. Tuberculosis and chronic respiratory disease: a systematic review. Int J Infect Dis. 2015; 32: 138-46.
5. Migliori GB, Marx FM, Ambrosino N, et al. Clinical standards for the assessment, management and rehabilitation of post-TB lung disease. Int J Tuberc Lung Dis 2021; 25: 797-813.
6. Allwood BW, van der Zalm MM, Amaral AFS, et al. Post-tuberculosis lung health: perspectives from the First International Symposium. Int J Tuberc Lung Dis. 2020; 24(8): 820-8.