Irrational use of anti-tubercular therapy
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《美国医学杂志》
3/12, Blenheim Street, Randwick, NSW 2031, Australia
The diagnosis of tuberculosis in children is extremely challenging. The most important reason for this is the inability to demonstrate AFB, which is the gold standard for diagnosis. Clinical symptoms and signs of tuberculosis are non-specific and common symptoms of poor appetite, cough, fever, malaise, fatigability and failure to gain weight can lead to overdiagnosis.[1] Many children with such non-specific symptoms are started empirically on anti-tubercular therapy (ATT) by quacks or unfortunately even by some pediatricians without even investigating the likely etiology. We report our observations on 38 children presenting to Pediatric OPD of a Community level trust hospital (catering mostly to poor and rural population) with vague non-specific symptoms and either taken ATT in last six months or on ATT therapy. A detailed history and physical examination and review of old records and investigations, wherever available were done for each case. Inappropriate therapy was defined when (i) an alternative clinical diagnosis can be attributed to the symptoms, (ii) no clinical response to anti-tubercular therapy taken for at least 2 months could be documented. These children were divided into two groups.
Group I: This consisted of 14 (36.8%) children (range 4-8 yrs) who have an obvious behavioural problem as these children were gaining weight normally and their anthropometric data was within normal centiles. They had complaints of seasonal cough and fever, growing pains and fatigue and malaise. 10 children were partially investigated but Mountoux test was not done in a single child. Parents were interviewed with the pediatric symptom checklist.[2] Most parents could be reassured about the problem with their children.
Group II: This group consisting of 24 (63.2%)children (range 2- 10 yrs) was a cause of major worry. 10 children with pathologic short stature (2 possible celiac diseases (raised tissue transglutaminase levels and symptomatic improvement to gluten free diet), 3 rheumatic heart diseases with congestive heart failure, 1 chronic liver disease and 4 children with Grade III-IV protein-energy malnutrition were taking anti-tubercular treatment for more than 6 months with no improvement. 14(36.8%) were taking ATT for recurrent running nose, breathlessness and wheezing
Above-cited observations clearly highlight the irrational use of these life saving drugs. Misuse of anti-tubercular therapy by private practitioners in India has been reported more than a decade ago but the scenario has not improved.[3] The situation deserves a serious note with the emergence of multi-drug resistant tubercular strains. As clinicians we are bound to remember the pitfalls in the diagnosis of tuberculosis.[4] Running nose, seasonal attacks and rapid improvement over few days do not point towards primary complex. Also vague symptoms of poor appetite, growing pains, and fatigability are common in growing children as part of their behavioural need for attention and love. Poor appetite due to other systemic diseases must be kept in mind and ATT must be started only after finding some definite indicators of Tuberculosis. The guidelines given by the WHO should be used for the diagnosis of tuberculosis.[5] Children with rheumatic heart disease, chronic liver disease and celiac disease been given ATT for more than 6 months with no improvement is unacceptable under all circumstances. We as childcare providers have this responsibility to sharpen our clinical skills and be more rational and scientific with use of anti-tubercular drugs.
Acknowledgements
Author wants to thank Dr A K Singh, Administrator, Shanti-Mangalick hospital for giving permission to publish the findings.
Contributions: PG collected the data and drafted the manuscript
Funding: none Competing interests: none
References
1. Sethi GR, Batra V. Diagnosis of tuberculosis in children. Pediatr Today 1999; 2(1): 60-70.
2. Little M, Murphy JM, Jellinek MS et al. Screening 4- and 5- year-old children for psychosocial dysfunction: A preminary study with the paediatric symptom checklist. J Dev Behav Pediatr 1994; 15: 191.
3. Uplekar MW, Shepard DS. Treatment of tuberculosis by private general practioners in India. Tubercle 1991; 72: 284-290.
4. Seth V, Srinivasan S. Pitfalls in diagnosis of Tuberculosis. In Seth V, Kabra SK, eds. Essentials of tuberculosis in children. Jaypee Brothers Med Publishers Pvt Ltd, Delhi; 2001; 286-294.
5. World Health Organisation. WHO tuberculosis programme framework for effective tuberculosis control. WHO/TB/94 Geneva WHO 1994.(Garg Pankaj)
The diagnosis of tuberculosis in children is extremely challenging. The most important reason for this is the inability to demonstrate AFB, which is the gold standard for diagnosis. Clinical symptoms and signs of tuberculosis are non-specific and common symptoms of poor appetite, cough, fever, malaise, fatigability and failure to gain weight can lead to overdiagnosis.[1] Many children with such non-specific symptoms are started empirically on anti-tubercular therapy (ATT) by quacks or unfortunately even by some pediatricians without even investigating the likely etiology. We report our observations on 38 children presenting to Pediatric OPD of a Community level trust hospital (catering mostly to poor and rural population) with vague non-specific symptoms and either taken ATT in last six months or on ATT therapy. A detailed history and physical examination and review of old records and investigations, wherever available were done for each case. Inappropriate therapy was defined when (i) an alternative clinical diagnosis can be attributed to the symptoms, (ii) no clinical response to anti-tubercular therapy taken for at least 2 months could be documented. These children were divided into two groups.
Group I: This consisted of 14 (36.8%) children (range 4-8 yrs) who have an obvious behavioural problem as these children were gaining weight normally and their anthropometric data was within normal centiles. They had complaints of seasonal cough and fever, growing pains and fatigue and malaise. 10 children were partially investigated but Mountoux test was not done in a single child. Parents were interviewed with the pediatric symptom checklist.[2] Most parents could be reassured about the problem with their children.
Group II: This group consisting of 24 (63.2%)children (range 2- 10 yrs) was a cause of major worry. 10 children with pathologic short stature (2 possible celiac diseases (raised tissue transglutaminase levels and symptomatic improvement to gluten free diet), 3 rheumatic heart diseases with congestive heart failure, 1 chronic liver disease and 4 children with Grade III-IV protein-energy malnutrition were taking anti-tubercular treatment for more than 6 months with no improvement. 14(36.8%) were taking ATT for recurrent running nose, breathlessness and wheezing
Above-cited observations clearly highlight the irrational use of these life saving drugs. Misuse of anti-tubercular therapy by private practitioners in India has been reported more than a decade ago but the scenario has not improved.[3] The situation deserves a serious note with the emergence of multi-drug resistant tubercular strains. As clinicians we are bound to remember the pitfalls in the diagnosis of tuberculosis.[4] Running nose, seasonal attacks and rapid improvement over few days do not point towards primary complex. Also vague symptoms of poor appetite, growing pains, and fatigability are common in growing children as part of their behavioural need for attention and love. Poor appetite due to other systemic diseases must be kept in mind and ATT must be started only after finding some definite indicators of Tuberculosis. The guidelines given by the WHO should be used for the diagnosis of tuberculosis.[5] Children with rheumatic heart disease, chronic liver disease and celiac disease been given ATT for more than 6 months with no improvement is unacceptable under all circumstances. We as childcare providers have this responsibility to sharpen our clinical skills and be more rational and scientific with use of anti-tubercular drugs.
Acknowledgements
Author wants to thank Dr A K Singh, Administrator, Shanti-Mangalick hospital for giving permission to publish the findings.
Contributions: PG collected the data and drafted the manuscript
Funding: none Competing interests: none
References
1. Sethi GR, Batra V. Diagnosis of tuberculosis in children. Pediatr Today 1999; 2(1): 60-70.
2. Little M, Murphy JM, Jellinek MS et al. Screening 4- and 5- year-old children for psychosocial dysfunction: A preminary study with the paediatric symptom checklist. J Dev Behav Pediatr 1994; 15: 191.
3. Uplekar MW, Shepard DS. Treatment of tuberculosis by private general practioners in India. Tubercle 1991; 72: 284-290.
4. Seth V, Srinivasan S. Pitfalls in diagnosis of Tuberculosis. In Seth V, Kabra SK, eds. Essentials of tuberculosis in children. Jaypee Brothers Med Publishers Pvt Ltd, Delhi; 2001; 286-294.
5. World Health Organisation. WHO tuberculosis programme framework for effective tuberculosis control. WHO/TB/94 Geneva WHO 1994.(Garg Pankaj)