Bronchial erosion

(incidence decreases with increasing age)

4-8 weeks

Primary complex

(majority of cases heal)

Fever of onset

4-8 weeks

Decreasing risk 90% within first 2 years

Tuberculin- p¡¡sk 0f |oca| anc| disseminated lesions sensitive/

Fig. 13.1. The evolution of untreated primary tuberculosis (modified). (Reproduced by permission from Miller, F.J.W. (1982) Tuberculosis in Children, Churchill Livingstone, Edinburgh.)

Late complications renal and skin (most after 5 years)

Bone and joint (most within 3 years)-

(D early infection, especially in first year of life Resistance (reduced by-i © malnutrition

~ intercurrent infections, e.g. measles, pertussis

24 months

Tuberculin- p¡¡sk 0f |oca| anc| disseminated lesions sensitive/

Decreasing risk 90% within first 2 years

Fig. 13.1. The evolution of untreated primary tuberculosis (modified). (Reproduced by permission from Miller, F.J.W. (1982) Tuberculosis in Children, Churchill Livingstone, Edinburgh.)

resources, but sputum microbiology is still necessary to confirm the diagnosis and provide cultures for drug susceptibility testing.

A simpler form of search is made in the village of a newly diagnosed case. The contacts are examined to see if there is anybody with a productive cough or clinical signs, and a smear made. Contacts should be given BCG. Chemoprophylaxis is given to children under 6 years and to contacts positive for HIV, and followed up at regular intervals. This can all be included in the national registration system.

Transmission is by the airborne route, with coughing and spitting being the main modes of disseminating the organism. Many people meet the tubercle bacillus in early life, acquire resistance and are quite unaware of ever having come into contact with it. A proportion, approximately 5%, will manifest the disease in varying levels of severity. It might be nothing more than an enlargement of the primary focus with a few systemic effects, only to resolve spontaneously, while others may have respiratory symptoms or progress rapidly to blood stream spread presenting as a case of miliary or tuberculous meningitis. The type and severity of the disease is determined by the host response, but why one person should develop tuberculosis, and another should not, cannot generally be determined. There is some evidence that susceptibility may be genetically determined as people who have suffered from tuberculosis, even if adequately cured, are more likely to develop a new infection a second time. Some families are particularly susceptible, as with the famous literary family the Bronte sisters, where first the mother died from tuberculosis, followed by nearly all the children, yet the father never succumbed to the disease. The dose of bacilli might also be important because young children in close contact with an active case more commonly develop severe tuberculosis (miliary or meningitis). Factors that are known to reduce resistance are:

• young age, especially the first year of life;

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