Mycobacterial Diseases
Open Access

Multidrug-Resistant Tuberculosis affecting Pediatric Populations

Carvhoai Trowiczoi^{* *}Correspondence: Carvhoai Trowiczoi, Department of Microbiology, Colorado State University, Fort Collins, USA, Email:

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Description

Despite advancements in medical research and global Tuberculosis (TB) control programs, the disease remains prevalent in many communities. One significant but often overlooked factor contributing to the spread of TB is exposure through social networks. Understanding how these networks facilitate transmission can provide insights into prevention strategies and enhance targeted intervention efforts. Social networks encompass the web of relationships and interactions individuals maintain with family, friends, co-workers, and community members. These connections, while essential for social and emotional well-being, can inadvertently become pathways for the spread of infectious diseases like TB. Close and prolonged contact with an infected individual, particularly in confined or poorly ventilated spaces, significantly increases the risk of transmission. Research indicates that the transmission of M. tuberculosis is not random but often clustered within social groups. These groups may include households, workplaces, schools, or community gatherings. The dynamics of social networks influence the patterns of exposure, with certain individuals, often termed super spreaders, playing a pivotal role in disseminating the infection to multiple contacts.

Factors of exposure in social networks

Overcrowded housing and shared living spaces are common in many low-income communities, creating an ideal environment for the spread of M. tuberculosis. Extended contact with household members increases the likelihood of exposure, especially if one member is an active TB case. Certain occupational settings, such as healthcare facilities, prisons, or factories, pose a higher risk due to prolonged close contact among individuals. Workers in these environments often have limited access to preventive measures like ventilation or respiratory masks. Cultural gatherings, festivals, or rituals involving large groups in confined spaces may facilitate the spread of TB. In some cultures, stigma surrounding TB discourages infected individuals from seeking timely medical care, increasing the risk of unknowingly transmitting the infection. Limited access to healthcare services in underserved areas leads to delayed detection and treatment of TB, prolonging the infectious period. Infected individuals may unknowingly expose their social networks before being diagnosed. To effectively curb TB transmission, it is crucial to identify high-risk social networks. Contact tracing, a well-established public health tool, plays a vital role in this effort. By mapping the interactions of TB patients, healthcare professionals can identify and screen individuals who are most at risk. Molecular epidemiology, which involves analysing the genetic material of M. tuberculosis strains, also helps determine links between cases within a network. Key populations to focus on include, household members of active TB patients. Individuals in frequent contact with vulnerable populations, such as the elderly or immunocompromised. Communities with high levels of poverty, overcrowding, or limited access to healthcare.

Prevention strategies targeting social networks

Educating communities about TB transmission, symptoms, and the importance of early diagnosis can reduce stigma and encourage individuals to seek timely care. Investing in better housing, ventilation, and sanitation can mitigate the risk of TB transmission in overcrowded settings. Conducting regular screenings in high-risk groups ensures early detection and treatment, minimizing exposure within social networks. Expanding access to healthcare services, particularly in rural and low-income areas, helps reduce delays in diagnosis and treatment. Providing prophylactic treatment to individuals exposed to active TB cases can prevent latent infections from progressing to active disease. Strengthening vaccination programs, such as the Bacillus Calmette-Guérin (BCG) vaccine, can provide protection against severe forms of tuberculosis in children. Ensuring adequate supply and accessibility of essential TB medications can improve treatment adherence and reduce drug resistance. Community-based support programs can aid patients in completing their treatment regimens, reducing the risk of relapse. Enhancing public health surveillance systems enables early identification of outbreaks and targeted interventions. Collaborative efforts between governments, NGOs, and local communities are crucial for sustained progress in TB prevention and control.

Multidrug-Resistant Tuberculosis (MDR-TB) poses a particularly serious threat. MDR-TB is defined as resistance to at least isoniazid and rifampin, the two most effective first-line anti-TB drugs. In pediatric populations, disseminated tuberculosis, which affects multiple organ systems, is a severe manifestation of the disease and can present atypically, complicating diagnosis and treatment. Disseminated tuberculosis occurs when Mycobacterium tuberculosis spreads from the primary site of infection to other parts of the body, typically through the bloodstream. In children, this condition often arises due to their immature immune systems, making them more susceptible to widespread infection compared to adults. Common sites affected include the lungs, liver, spleen, lymph nodes, and bones. The clinical presentation of disseminated TB in children can vary widely, ranging from fever, weight loss, and fatigue to more specific symptoms like lymphadenopathy, hepatosplenomegaly, or bone pain. The diversity of symptoms often leads to delayed diagnosis, underscoring the need for heightened clinical awareness and prompt investigation.

Multidrug resistance and presentations of disseminated TB

The emergence of multidrug-resistant tuberculosis complicates the management of pediatric TB. MDR-TB arises primarily due to incomplete or inappropriate treatment of TB, which selects for resistant bacterial strains. In children, transmission is usually from an adult source case with MDR-TB, although primary resistance can also occur. The global burden of MDR-TB among children is significant but often underreported due to diagnostic challenges. Children with MDR-TB have poorer outcomes compared to those with drug-sensitive TB, largely because of delays in initiating effective therapy and the limited availability of child-friendly formulations of second-line drugs. One of the challenges in diagnosing pediatric TB is its potential to present in unusual or atypical ways. While pulmonary TB is the most common form, disseminated TB can manifest in ways that mimic other diseases. Rarely, TB can involve the extremities, including the small bones of the fingers, known as tuberculous dactylitis. Tuberculous dactylitis, though uncommon, is a form of osteoarticular TB that affects the small bones of the hands and feet. It is more commonly seen in young children, possibly due to the rich vascular supply to the growing epiphyses, which facilitates bacterial spread. Initial symptoms may include swelling, pain, or deformity of the affected digit, often mistaken for trauma, infection, or other conditions such as juvenile idiopathic arthritis.

Treatment and preventive measures

Diagnosing disseminated MDR-TB in children is inherently challenging due to nonspecific symptoms, difficulty in obtaining sputum samples, and the limited sensitivity of conventional diagnostic tools. Key diagnostic approaches include, a high index of suspicion is crucial, particularly in children with a known TB contact or those not responding to first-line treatment. X-rays, ultrasound, and CT/MRI scans can help identify disseminated involvement of bones, organs, and lymph nodes. Molecular tests such as Xpert MTB/RIF are essential for detecting Mycobacterium tuberculosis and rifampin resistance. Culture and drug susceptibility testing remain the gold standard but are time-consuming. Biopsy of affected tissue may reveal granulomas, aiding in diagnosis. Managing pediatric MDR-TB requires a multidisciplinary approach, including infectious disease specialists, pediatricians, and public health professionals. Key principles include, prompt diagnosis and initiation of appropriate treatment are critical for improving outcomes. Treatment regimens are based on drug susceptibility testing and typically involve second-line drugs such as fluoroquinolones, aminoglycosides, and newer agents like bedaquiline and delamanid. Ensuring adherence to lengthy treatment regimens is essential. Strategies include Directly Observed Therapy (DOT), counseling, and social support. Regular monitoring for drug toxicity and treatment response is necessary, as is follow-up to ensure disease resolution and prevent relapse. Preventing MDR-TB in children involves multiple strategies, such as, identifying and screening contacts of MDR-TB patients is vital for early detection and prevention. Implementing infection control measures in healthcare and community settings can reduce transmission. While the Bacille Calmette-Guérin (BCG) vaccine offers limited protection against TB, it is particularly effective in preventing severe forms like disseminated and meningeal TB in children. Addressing the social determinants of health, such as malnutrition and overcrowding, can help reduce TB transmission.

Conclusion

Pediatric multidrug-resistant disseminated tuberculosis is a severe and complex condition that underscores the importance of early diagnosis, appropriate treatment, and robust public health measures. Atypical presentations, such as involvement of the small bones of the fingers, highlight the need for clinical vigilance and a multidisciplinary approach to care. By improving diagnostic capacity, ensuring access to effective therapies, and strengthening preventive strategies, we can improve outcomes for children affected by this challenging disease.