Point-of-care ultrasound for EPTB – focused assessment with sonography for HIV/TB

181 March 2014, Vol. 104, No. 3 In South Africa (SA), childhood tuberculosis (TB) still accounts for considerable morbidity and mortality. The incidence of TB disease and risk of progression to severe or disseminated forms are especially high in young children or those with HIV infection. Childhood TB presents most commonly as primary TB, often with non specific signs and symptoms; TB may also present as acute pneumonia. The clinical diagnosis can therefore be challenging. [1] Furthermore, due to difficulty in obtaining goodquality specimens and the paucibacillary nature of childhood TB, microbiological confirmation is only achieved in a minority of children, especially in settings where there is limited capacity for microbiological confirmation. Imaging is a major part of the diagnostic work-up for childhood TB. Chest X-rays are relatively inexpensive and widely available. However, detection of mediastinal and hilar lymphadenopathy – cardinal signs of primary pulmonary TB – is often limited, there is wide inter-observer variability in detection of nodes and pulmonary findings may be non specific. Other imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) are capable of demonstrating comprehensively the lungs and the mediastinum, but the radiation dose in CT, the need for sedation in MRI, the costs and limited availability all currently prevent their use in routine management. The merit of ultrasound for detecting features of abdominal, pleural and pericardial TB has long been acknowledged and its application in paediatrics is especially attractive as it does not involve radiation nor require sedation. Furthermore, ultrasound of the mediastinum has been shown to detect lymphadenopathy in TB patients who have a normal chest X-ray. One strategy for improving the diagnosis of childhood TB is the refinement of currently available imaging tools and use of simplified protocols tailored to the detection of TB. Point-of-care ultrasound for extrapulmonary TB (EPTB), mediastinal ultrasound and limited chest MRI are all promising new imaging approaches presently being evaluated in paediatric studies. The increasing availability of digital imaging enables telemedicine, where radiological images can be transmitted anywhere in the world allowing for expert interpretation and opinion.