Unmasking childhood tuberculosis – A case series with review of literature

Childhood tuberculosis (TB) remains a major global health issue, particularly in high-burden countries like India, which accounts for 26% of global TB cases. The national TB elimination programme has adopted a focused approach to meet the World Health Organization (WHO’s) end TB targets through active case finding and standardised treatment protocols based on updated WHO guidelines. This report presents three paediatric TB cases from a tertiary care hospital, illustrating the diagnostic and therapeutic challenges across varying disease spectrums and age groups. The first case involves a 14-year-old girl with advanced pulmonary TB (PTB), managed successfully with appropriate anti-tubercular treatment (ATT) for non-severe drug-susceptible TB. The second case describes a 5-year-old girl who developed TB during immunosuppressive treatment for nephrotic syndrome. Her condition progressed to severe extra-PTB as grade 3 tubercular meningitis with brainstem tuberculomas, which later got complicated by paradoxical reactions. Management required immunosuppressants, including thalidomide and steroids. Despite intensive care, she remained neurologically impaired and ventilator-dependent, eventually succumbing to ventilator-associated pneumonia. The third case involves another 15-year-old girl, with advanced PTB, diagnosed with isoniazid (INH)-resistant TB through WHO-recommended rapid diagnostic tools (Xpert- Mycobacterium TB/rifampicin [RIF] and Line Probe Assay). She was classified as RIF-susceptible, INH-resistant TB and treated appropriately with the WHO drug-resistant TB regimen. All three children underwent contact tracing and received nutritional support, reinforcing the importance of a comprehensive care approach. Two children recovered, whereas the child with TB meningitis succumbed during a prolonged hospital stay. These cases underscore the complexities in managing paediatric TB and the need for adherence to evolving WHO guidelines for effective diagnosis and treatment.