From the Guidelines
For a child on long-term corticosteroids presenting with fever, weight loss, low appetite, and a superior cavity lesion on chest X-ray, the next step should be to initiate combination antituberculosis chemotherapy promptly, as the clinical presentation strongly suggests tuberculosis, particularly given the immunosuppression from corticosteroids, which increases TB risk, as recommended by 1. The clinical presentation of fever, weight loss, and anorexia, along with a superior cavity lesion on chest X-ray, is highly suggestive of tuberculosis, especially in an immunocompromised patient on long-term corticosteroids.
- The decision to initiate combination antituberculosis chemotherapy should be based on clinical, pathologic, and radiographic features of the patient, as well as epidemiologic information, as stated in 1 and 1.
- A purified protein derivative (PPD)-tuberculin skin test may be performed, but a negative result does not exclude the diagnosis of active tuberculosis, especially in immunocompromised patients, as noted in 1 and 1.
- Given the high suspicion of tuberculosis and the patient's serious illness, initiating combination chemotherapy using one of the recommended regimens is appropriate, often before AFB smear results are known and usually before mycobacterial culture results have been obtained, as recommended by 1.
- It is also important to consider the potential for opportunistic infections in patients under long-term exposure to immunosuppressive drugs, and antibiotic prophylaxis should be envisioned to prevent such infections, as suggested in 1.
- However, the most recent and highest quality study 1 prioritizes the initiation of combination antituberculosis chemotherapy based on clinical presentation and epidemiologic information, making it the guiding principle for the next step in management.
From the Research
Next Steps in Managing a Child on Long-term Corticosteroids
The child in question is presenting with fever, weight loss, and anorexia, along with a chest X-ray (CXR) showing a superior cavity lesion. Given these symptoms and the fact that no purified protein derivative (PPD) test has been performed, the next steps should focus on diagnosing and managing potential tuberculosis (TB), especially considering the child's immunocompromised state due to long-term corticosteroid use.
Diagnosing TB:
- The use of rapid diagnostic tools such as the Xpert® MTB/RIF assay 2 could be beneficial for quickly identifying TB and rifampicin resistance.
- Tissue-based laboratory-developed polymerase chain reaction (PCR) assays have shown increased detection of Mycobacterium tuberculosis disease compared to standard diagnostics 3.
- New diagnostic platforms like "Patho-tb" offer rapid detection of acid-fast bacilli (AFB) with high sensitivity and low dependence on human skills 4.
Importance of Rapid Diagnosis:
- Rapid detection of TB is critical, especially in immunocompromised patients, to initiate appropriate treatment promptly.
- The emergence of drug-resistant TB strains, such as those resistant to pyrazinamide, underscores the need for accurate and rapid detection of resistance patterns 5.
- Studies have shown that time to sputum culture conversion is an important indicator of treatment efficacy in multidrug-resistant TB, with predictors including previous treatment, initial sputum culture colony count, and extent of disease on chest radiography 6.
Considerations for Immunocompromised Patients:
- The child's immunocompromised state due to long-term corticosteroid use increases the risk of TB and other infections.
- It is essential to consider the potential for atypical presentations of TB in immunocompromised patients, which may require a broader range of diagnostic tests.
- The choice of diagnostic test should consider the patient's ability to produce sputum and the potential need for invasive procedures to obtain tissue samples for analysis.