Tuberculosis in Children — MCQs
True regarding the presentation of primary tuberculosis is
According to DOTS-PLUS guidelines 2013, which of the following statements about the treatment of multidrug-resistant TB is incorrect?
From January 1st, 2007, to June 30th, 2007, 22 new cases of tuberculosis were reported per 165,000 population. However, during this period, 120 suspected cases of TB were registered. What is the incidence rate?
A 3 month old asymptomatic infant with H/o TB exposure has taken 3 months of chemoprophylaxis (isoniazid). What is to be done next?
In a 10-year-old school child under the school health program, which vaccine should be administered?
Radiological hallmark of primary tuberculosis in childhood is?
Case finding in RNTCP is based on –
A patient with cough was sputum AFB negative but chest X-ray was suggestive of TB. What should be the next step according to RNTCP?
A poverty-stricken mother suffering from active tuberculosis delivers a baby. Which one of the following would be the most appropriate advice in her case?
What is the most common presentation of tuberculosis (TB) in children?
Tuberculosis in Children Indian Medical PG Practice Questions and MCQs
Question 1: True regarding the presentation of primary tuberculosis is
- A. B/L pleural effusion with negative Tuberculin test
- B. U/L hilar lymphadenopathy (Correct Answer)
- C. Sustained chronic pyrexia
- D. B/L pleural effusion with positive tuberculin test
Explanation: ***U/L hilar lymphadenopathy*** - A **unilateral hilar lymphadenopathy** is a classic radiographic finding in **primary pulmonary tuberculosis** in children and often in adults, representing the enlargement of lymph nodes draining the primary lung lesion. - The disease typically begins with a primary lesion (Ghon focus) in the lung parenchyma and regional **lymph node involvement** constitutes the primary complex [1]. *B/L pleural effusion with negative Tuberculin test* - **Bilateral pleural effusion** is an uncommon presentation for primary tuberculosis; typically, effusions are unilateral. - A **negative Tuberculin test** (PPD) would make a diagnosis of tuberculosis less likely, although it can be negative in immunocompromised individuals or in the very early stages of infection. *Sustained chronic pyrexia* - While fever (pyrexia) is a common symptom of tuberculosis, **sustained chronic pyrexia** is more characteristic of secondary (post-primary) or disseminated tuberculosis, not necessarily primary infection which is often asymptomatic or mildly symptomatic [2]. - Fevers in primary TB, if present, can be low-grade and intermittent rather than sustained and chronic. *B/L pleural effusion with positive tuberculin test* - Although a **positive Tuberculin test** indicates prior exposure to M. tuberculosis, **bilateral pleural effusion** is an unusual initial presentation of primary tuberculosis. - Pleural effusions in TB are typically unilateral and usually result from a hypersensitivity reaction or direct spread from a primary lesion, but bilateral involvement is less common.
Question 2: According to DOTS-PLUS guidelines 2013, which of the following statements about the treatment of multidrug-resistant TB is incorrect?
- A. Total duration 24-27 months
- B. Intensive phase 6-9 months
- C. Continuation phase - 2 drugs (Correct Answer)
- D. Intensive phase - 6 drugs
Explanation: ***Continuation phase - 2 drugs*** - According to DOTS-PLUS guidelines (2013), the continuation phase for multidrug-resistant TB (MDR-TB) should include at least **three to four effective drugs**, not two. - Using only two drugs in the continuation phase would be grossly inadequate and would likely lead to treatment failure and the development of extensively drug-resistant TB (XDR-TB). - This statement is **clearly incorrect** and represents a major deviation from standard treatment protocols. *Total duration 24-27 months* - According to DOTS-PLUS 2013 guidelines, the total treatment duration for MDR-TB is typically **18-24 months** (at least 18 months after culture conversion). - In complex cases, treatment may be extended beyond 24 months, though 24-27 months falls within acceptable parameters for difficult cases. - This statement is essentially correct for the upper range of treatment duration. *Intensive phase 6-9 months* - The intensive phase for MDR-TB treatment is indeed typically **6-9 months** or until culture conversion is documented. - This phase includes daily injectable agents and multiple oral drugs to rapidly reduce bacterial load. - This statement is **correct**. *Intensive phase - 6 drugs* - The 2013 DOTS-PLUS guidelines recommend an intensive phase regimen comprising **at least 4 effective drugs including an injectable agent**. - A 5-6 drug regimen may be used in complex cases or when drug susceptibility is uncertain. - While not the minimum standard, using 6 drugs is within acceptable practice, making this statement **generally correct**.
Question 3: From January 1st, 2007, to June 30th, 2007, 22 new cases of tuberculosis were reported per 165,000 population. However, during this period, 120 suspected cases of TB were registered. What is the incidence rate?
- A. 90 Per 1,000,000 population
- B. 75 Per 1,000,000 population
- C. 270 Per 1,000,000 population
- D. 133 Per 1,000,000 population (Correct Answer)
Explanation: ***133 Per 1,000,000 population*** - The **incidence rate** is calculated by dividing the number of **new cases** by the population at risk and then scaling it to a standard population size. - Calculation: (22 new cases / 165,000 population) \* 1,000,000 = **133.33 per 1,000,000 population**. *90 Per 1,000,000 population* - This value is incorrect and does not result from the appropriate calculation for the incidence rate using the given new cases and population. - It might result from an incorrect denominator or numerator in the calculation. *75 Per 1,000,000 population* - This value is incorrect and does not correspond to the incidence rate based on the provided data. - It potentially arises from using an incorrect number of new cases or an erroneous population figure in the calculation. *270 Per 1,000,000 population* - This value is likely obtained by incorrectly using the **120 suspected cases** in the numerator instead of the 22 confirmed new cases. - The **incidence rate** specifically refers to new, confirmed cases, not suspected ones.
Question 4: A 3 month old asymptomatic infant with H/o TB exposure has taken 3 months of chemoprophylaxis (isoniazid). What is to be done next?
- A. Test sputum and then decide
- B. Immunise with BCG & stop prophylaxis
- C. Continue for 3 more months
- D. Tuberculin test then decide (Correct Answer)
Explanation: ***Tuberculin test then decide*** - According to **IAP guidelines** for management of TB exposure in infants, after completing **3 months of isoniazid prophylaxis**, the next step is to perform a **tuberculin skin test (Mantoux test)**. - By 3 months, the infant's immune system has had adequate time to mount a response if TB infection occurred. - **If TST is negative**: The infant can be given **BCG vaccination** and INH prophylaxis can be **stopped**. - **If TST is positive**: INH prophylaxis should be **continued for 3 more months** to complete a total duration of 6 months. - This approach prevents unnecessary prolonged chemoprophylaxis in uninfected infants while ensuring adequate treatment for those with latent TB infection. *Continue for 3 more months* - Simply continuing for 3 more months without testing would mean **unnecessary chemoprophylaxis** for infants who did not develop infection. - The standard protocol requires **TST assessment at 3 months** to guide further management, not automatic continuation. *Test sputum and then decide* - Sputum testing is impractical in a **3-month-old infant** as they cannot produce sputum voluntarily. - This test is used for diagnosing **active pulmonary TB** in symptomatic older children and adults, not for asymptomatic exposed infants. *Immunise with BCG & stop prophylaxis* - BCG should only be given after confirming the infant is **TST negative** at 3 months. - Giving BCG to a TST-positive infant (with latent TB infection) without completing full prophylaxis could lead to **progression to active TB disease**.
Question 5: In a 10-year-old school child under the school health program, which vaccine should be administered?
- A. DPT
- B. BCG
- C. Td (Correct Answer)
- D. MMR
Explanation: ***Td (Tetanus-Diphtheria)*** - For a 10-year-old child under the school health program in India, the recommended vaccination is a booster dose of **Td (tetanus-diphtheria)**. - This ensures continued **protection against tetanus and diphtheria**, as immunity from the primary series may wane over time. - **Td is preferred over TT** (tetanus toxoid alone) as it provides protection against both tetanus and diphtheria. - This is administered at **10 years and 16 years** as per the Indian Academy of Pediatrics immunization schedule. *DPT* - **DPT (diphtheria, pertussis, tetanus)** is administered in infancy and early childhood (at 6, 10, and 14 weeks, with boosters at 16-24 months and 4-6 years). - The **pertussis component is not given** in later childhood or adolescence due to increased reactogenicity in older children. *BCG* - **BCG (Bacille Calmette-Guérin)** vaccine protects against tuberculosis and is given **at birth** in endemic areas like India. - It is **not routinely administered** to a 10-year-old unless there are specific risk factors or documented non-vaccination status. *MMR* - **MMR (measles, mumps, rubella)** vaccine is given as **two doses**: first at 9-12 months and second at 16-24 months (or 4-6 years). - A 10-year-old child would have **already completed** their MMR vaccination schedule.
Question 6: Radiological hallmark of primary tuberculosis in childhood is?
- A. Ghon's focus
- B. Normal chest Xray
- C. Pleural effusion
- D. Lymphadenopathy (Correct Answer)
Explanation: ***Lymphadenopathy*** - Primary tuberculosis in children distinctively presents with **enlarged hilar and mediastinal lymph nodes** as a hallmark radiological finding. - This is often a result of the immune response to the primary infection in the lungs, leading to inflammation and swelling of regional lymph nodes. *Ghon's focus* - A **Ghon's focus** refers to the initial lung parenchymal lesion formed during primary tuberculosis, but it is typically small and often not the most prominent or defining radiological feature in childhood. - While it is a part of the primary complex, **lymphadenopathy** is generally considered the more striking and consistent radiological hallmark. *Normal chest Xray* - A **normal chest X-ray** is unlikely in a child with active primary tuberculosis, as the infection almost always produces detectable changes. - While some cases might be very mild, the presence of disease usually leads to visible radiological abnormalities. *Pleural effusion* - **Pleural effusion** can occur in primary tuberculosis, but it is a complication or a manifestation that typically develops later, rather than being the defining initial hallmark. - It indicates the spread of infection to the pleural space, often seen in more advanced or symptomatic cases.
Question 7: Case finding in RNTCP is based on –
- A. X-ray chest
- B. Sputum culture
- C. Antibody detection
- D. Sputum microscopy (Correct Answer)
Explanation: ***Sputum microscopy*** - The Revised National Tuberculosis Control Programme (RNTCP) in India primarily relies on **sputum smear microscopy** for **case finding** of pulmonary tuberculosis due to its cost-effectiveness, simplicity, and ability to identify individuals who are most infectious. - Patients presenting with **presumptive tuberculosis symptoms** (e.g., cough for 2 weeks or more) are asked to submit sputum samples for microscopic examination for **acid-fast bacilli (AFB)**. *X-ray chest* - While chest X-ray can detect pulmonary lesions suggestive of tuberculosis, it is used as a **screening tool** and not the primary method for confirming active, infectious cases in RNTCP's initial case-finding algorithm. - A chest X-ray is often used to facilitate diagnosis in cases of **sputum-negative presumptive TB** or in specific populations. *Sputum culture* - **Sputum culture** is a more sensitive method than microscopy and is essential for **drug susceptibility testing (DST)**, but it is more expensive, takes longer (weeks), and requires specialized laboratory infrastructure, making it a secondary diagnostic tool for initial broad case finding in RNTCP. - It is often reserved for presumptive TB cases that are **sputum smear-negative** or for follow-up and monitoring. *Antibody detection* - **Antibody detection tests** (serological tests) are generally **not recommended** by WHO for diagnosing active tuberculosis due to **poor sensitivity and specificity** and inconsistent performance. - While **molecular tests** like **Xpert MTB/RIF** (which use PCR technology to detect *Mycobacterium tuberculosis* DNA and rifampicin resistance) are increasingly being implemented for rapid diagnosis, they complement rather than replace sputum microscopy as the primary, widespread initial case-finding method in RNTCP.
Question 8: A patient with cough was sputum AFB negative but chest X-ray was suggestive of TB. What should be the next step according to RNTCP?
- A. Nucleic acid amplification test (Correct Answer)
- B. Tuberculin test
- C. Line probe assay
- D. Culture
Explanation: Nucleic acid amplification test - According to the and Revised National Tuberculosis Control Program (RNTCP) guidelines, if sputum AFB microscopy is negative but clinical suspicion and chest X-ray point towards TB, NAAT (Nucleic Acid Amplification Test) is recommended as the next confirmatory step [1]. - NAATs like CBNAAT (Cartridge-Based Nucleic Acid Amplification Test) or TrueNat provide rapid detection of Mycobacterium tuberculosis and resistance to Rifampicin, aiding in early diagnosis and appropriate treatment initiation. Tuberculin test - The Tuberculin Skin Test (TST), also known as the Mantoux test, indicates past exposure to TB or latent infection, but it cannot differentiate between active disease, latent infection, or past treated infection [2]. - A positive TST in an adult with a suggestive chest X-ray still requires further investigation for active disease, as it does not confirm active pulmonary TB [2]. Line probe assay - Line Probe Assay (LPA) is a molecular test used for rapid detection of MDR-TB (multi-drug resistant TB) by identifying mutations associated with resistance to Rifampicin and Isoniazid. - While useful for resistance testing, it typically requires a positive culture or direct sputum sample with a higher bacterial load and is not the primary diagnostic test for initial confirmation of TB when sputum AFB is negative. Culture - Mycobacterial culture is the gold standard for TB diagnosis, providing definitive confirmation and enabling drug susceptibility testing (DST) [1]. - However, culture results can take several weeks (typically 3-6 weeks), which delays treatment initiation, making it a less immediate next step compared to rapid molecular tests like NAAT in cases of strong clinical suspicion.
Question 9: A poverty-stricken mother suffering from active tuberculosis delivers a baby. Which one of the following would be the most appropriate advice in her case?
- A. Breast feeding and BCG immunization
- B. Breast feeding and isoniazid administration (Correct Answer)
- C. Expressed breast milk and BCG immunization
- D. Stop feeds and isoniazid administration
Explanation: ***Breast feeding and isoniazid administration*** - **Breastfeeding** is safe and encouraged for infants of mothers with active tuberculosis, as the benefits of breast milk (nutrition, antibodies) outweigh the minimal risk of TB transmission through milk. - **Isoniazid (INH) chemoprophylaxis** for the infant provides additional protection in high-risk exposure settings, particularly when the mother has active pulmonary TB and close contact is inevitable. - This approach represents a conservative strategy prioritizing immediate chemoprophylaxis in a poverty-stricken setting where follow-up may be challenging. *Breast feeding and BCG immunization* - **Breastfeeding** is beneficial and appropriate. - **BCG immunization** at birth is the current standard recommendation per WHO and IAP guidelines for infants born to TB-positive mothers. - However, in settings with very high exposure risk and uncertain follow-up, some protocols additionally recommend INH prophylaxis, making the first option more comprehensive for this specific scenario. *Expressed breast milk and BCG immunization* - Expressing breast milk offers no significant additional protection against TB transmission compared to direct breastfeeding. - Direct breastfeeding has additional benefits for mother-infant bonding and is not contraindicated in maternal TB. - While **BCG immunization** is appropriate, this option unnecessarily complicates feeding. *Stop feeds and isoniazid administration* - **Stopping breastfeeding** is not indicated and would deprive the infant of essential nutrition and passive immunity. - Breastfeeding is not contraindicated in maternal tuberculosis. - While **isoniazid administration** may be appropriate, cessation of feeding is an incorrect recommendation.
Question 10: What is the most common presentation of tuberculosis (TB) in children?
- A. Abscess
- B. Consolidation
- C. Hilar adenopathy (Correct Answer)
- D. CNS tuberculosis
Explanation: ***Hilar adenopathy*** - **Hilar adenopathy** is the most common radiographic finding in children with **primary tuberculosis**, reflecting lymph node involvement. - This is often accompanied by a small parenchymal lesion, forming the **Ghon complex**. *Abscess* - While TB can cause abscesses (e.g., cold abscesses in bone or soft tissue), it's not the **most common initial presentation** of primary childhood TB. - Abscess formation suggests a more **advanced or extrapulmonary** manifestation. *Consolidation* - **Consolidation** can be seen in adult-type or progressive primary TB, but it is less frequent than hilar adenopathy as the **initial presentation** in children. - It indicates **pneumonia-like changes** due to parenchymal inflammation. *CNS tuberculosis* - **Central Nervous System (CNS) tuberculosis** (e.g., tuberculous meningitis or tuberculoma) is a severe, extrapulmonary form of TB. - It is a **serious complication** rather than the most common initial presentation in children.
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