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SELF-ASSESSMENT
PAE
Self-assessment
Questions
Case 1
affecting all layers and extending from the centre to the
peripheries of the retina. Over the next 24 h the boy exhibited
episodes of unprovoked crying but was otherwise well.
A 10-month-old baby boy is brought to the EmergencyDepartment. His mother says that he fell from the sofa and
became unresponsive. She called 999 and at the scene he
was briefly apnoeic and GCS was initially recorded as 3/15.
On arrival in ED GCS is 15/15 and there are no visible
injuries. His observations are: pupils 3 mm and reactive,
heart rate 104/min, BP 88/60 mmHg, respiratory rate 28/
min, oxygen saturations 98% in air. The boy’s twin sister is
at home in the care of their aunt who also lives in their
multiple occupancy house.
A CT head is performed (Figure 1). No skull fractures are
apparent on the bone windows.
(i) What does this CT show?
a Bilateral subdural haemorrhage
b Extradural haemorrhage
c Intracerebral haemorrhage
d Left subdural haemorrhage
e Right subdural haemorrhage
(ii) Which is the most important action now? Choose ONE
a Contact the duty Social Worker as you think there is
a risk of non-accidental injury in this case
b Contact the police to ascertain and ensure the well-
being of the twin sister
c Contact your local Neurosurgical team to discuss
whether urgent intervention is needed
d Proceed with investigations to determine whether
there are any indicators of abuse
(iii) Which ONE of the following features from this
presentation is most associated with inflicted brain
injury?
a Absence of bruising to the head and neck
b Absence of skull fracture
c Age less than 1 year
d Apnoea
e Male infant
f Trivial reported mechanism, resulting in significant
injury (i.e. non-consistent)
The boy remained stable and his sister was brought to the
hospital by police, she did not have any evidence of injury.
Further investigations on the boy revealed no evidence of
coagulation disorder, metabolic disorder and no fractures on
skeletal survey. However, ophthalmological review on the
day of presentation revealed bilateral retinal haemorrhages
Meredith Robertson MBChB (Glas) MRCPCH PGCME is an ST8 in Paediatrics
at Addenbrooke’s Hospital, Cambridge, UK.
Donna McShane MBChB (Ed) MRCPCH is a Consultant Respiratory
Paediatrician at Addenbrooke’s Hospital, Cambridge, UK.
DIATRICS AND CHILD HEALTH 22:10 451
(iv) When writing your report for the police and social care
what will your summary state? Choose ONE
a The bilateral subdural haemorrhages are strongly
suggestive of physical abuse and are likely to have
been sustained shortly before the 999 call
b The bilateral subdural haemorrhages are strongly
suggestive of physical abuse and are likely to have
been sustained up to 3 days prior to presentation
c The bilateral subdural haemorrhages may have been
caused by physical abuse, but in the absence of other
evidence is not possible to ascertain the balance of risk
d The bilateral subdural haemorrhages in conjunction
with bilateral retinal haemorrhages are suggestive of
abnormal vasculature with bleeding provoked by
a relatively minor accidental fall
Case 2
A 7-month-old girl presents to the emergency department
with increased crying, particularly on movement or
touching her left knee. Her parents do not report any fever.
She has a runny nose and cough, but no other specific
symptoms. There is no history of trauma and no bruising or
swelling of the leg. Systemic examination is normal.
Observationsare:heart rate120/min, capillary refill time2s
centrally, BP 78/54 mmHg, respiratory rate 42/min, tempera-
ture 38.6 �C. She appears pale and although alert is quiet and
Figure 1
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SELF-ASSESSMENT
you cannot make her smile. Examination of the chest and
abdomen is normal. There are some small (less than 1 cm),
smooth cervical lymph nodes palpable, there are also palpable
nodes in the left groin, one of which is 2 cm.
(i) According to best evidence, which investigations are
indicated at this stage? Choose FOUR
a Alpha-fetoprotein
b Blood culture
c Blood gas
d Blood glucose
e Chest X-ray
f CRP
g ESR
h Full blood count
i Infectious mononucleosis screen
j Lactate dehydrogenase
k Liver function tests
l Lumbar puncture
m Meningococcal PCR
n Urea and electrolytes
o Urinalysis
p USS of groin
Initial results are as follows:
White blood count 16.9 � 10
ˇ
9/L (6e17.5)
Haemoglobin 11.6 g/dL (11.3e14.1)
Neutrophils 4.1 � 10
ˇ
9/L (1.5e8.5)
Lymphocytes 11.3 � 10
ˇ
9/L (4.0e10.5)
CRP <1 mg/L (0e10)
Fig
PAE
ure 2
DIATRICS AND CHILD HEALTH 22:10
Case
A 3-
with
Film e lymphocytosis, occasional reactive lymphocytes.
Over the next 6e12 h she improves with antipyretics and
her Mum notices that she is now only crying when her left
leg is touched or moved.
The following X-rays (see Figure 2) are obtained:
(ii) What do these images show? Choose ONE
a Normal bone
b Pathological fracture
c Poorly-defined lytic lesion with no periosteal reaction
or soft-tissue swelling
452
d Poorly-defined lytic lesion with significant periosteal
reaction and soft-tissue swelling
e Well-defined lytic lesion with no periosteal reaction
or soft-tissue swelling
f Well-defined lytic lesion with significant periosteal
reaction and soft-tissue swelling
(iii) What is now the most likely diagnosis? Choose ONE
a Ewing sarcoma
b Eosinophilic granuloma (Langerhan’s cell histiocytosis)
c Leukaemia
d Osteomyelitis
e Osteosarcoma
(iv) An MRI scan confirms the diagnosis and blood culture
comes back positive for Staphylococcus aureus, which is
fully sensitive to the panel of antibiotics You decide to
give a 6-week course of intravenous ceftriaxone. What
monitoring is most important during this period?
Choose ONE
a Repeat MRI
b Serial ESR
c Serial FBC
d Serial LFTs
e Serial U&Es
f Serial X-rays
g Trough antibiotic levels
3
month-old boy is coming to your rapid referral clinic
a possible diagnosis of mumps parotitis. He was seen 4
days ago in the Emergency Department with a 1-day history
of crying, fever and swelling at the left angle of the jaw. He
has been previously fit and well and his immunizations are
up-to-date, including BCG. His family is of Nepalese origin
and only moved to the UK 5 months ago. His 4-year-old
brother has been immunized according to the Nepalese
schedule, which does not include MMR. The HPA has been
informed by the ED doctor and have sent you a salivary
swab kit.
(i) Is this child at significant risk of having mumps?
Choose ONE
a No e mumps is rare at this age, whatever the
immunization status
b Perhaps e you need to check whether there have
been any confirmed cases locally in recent weeks
c Yes e any unimmunized child with a probable
parotid swelling should be considered to have
mumps until proven otherwise
d Yes e mumps is endemic to Nepal and the family
may be carrying the virus from their time there
Since being seen in A&E the baby has been apyrexial and
has been feeding well. You find he has a firm 3 � 4 cm mass
in the left anterior neck, there is no associated erythema but
the mass appears to be tender. There is no swelling anterior
to the left ear.
(ii) What two investigations would you do first? Choose
TWO
a CRP
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SELF-ASSESSMENT
b Full blood count
c Mumps serology
d PCR on saliva
e PCR on urine
f Ultrasound scan of the swollen area
An ultrasound scan confirms your clinical suspicion that
the swelling is not parotid in origin, but rather affects the
jugulo-digastric lymph node. You start him on oral clari-
thromycin and arrange to see him again in 5 days’ time.
When he returns he remains well. The swelling is no
smaller but is starting to become fluctuant.
Blood tests reveal the following:
CRP 20 mg/L (0e10)
ESR 74 mm/h (0e20)
WBC 17.9 � 109 /L (6e18)
Neutrophils 9.2 � 109 /L (1.2e7.5)
Lymphocytes 6.0 � 109 /L (3.0e13.5)
Platelets 738 � 109 /L (150e450)
Hb 9.4 g/dL (9.4e13.0)
PAE
DIATRICS AND CHILD HEALTH 22:10indu
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(ii)
(iii) What action should you take next? Choose ONE
a Change to a broader spectrum oral antibiotic
b Refer to the Paediatric Surgical team
c Repeat the ultrasound
d Start intravenous broad-spectrum antibiotics
The affected lymph node is removed and antibiotics are
stopped. One week later your surgical colleague informs
you that the culture has grown Mycobacterium abscessus.
(iv) What action should you take?
a Commence a 12-week course of clarithromycin by
mouth
b Contact the HPA to arrange contact screening
c None
d Perform a Mantoux test
e Re-admit the patient for IV antibiotics
f Request a chest X-ray
Figure 3
Case 4
A 12-year-old girl is referred to your out-patient clinic by the
UK Borders Agency and Health Protection Authority,
requesting screening for TB. She is an asylum seeker who
has travelled, alone, to the UK from Eritrea via Somalia. She
is accompanied to clinic by her new foster carer. She knows
that she had a ‘chest problem’ several years ago, for which
she was treated with a tablet every day for 8 months. She
thinks that her siblings and parents are all healthy. She has
a nocturnal cough, which sounds wet, but is not productive
of sputum. Height and weight are on the 75th centiles, there
are no night sweats reported. Examination is normal.
(i) Which three investigations are needed to make a diag-
nosis? Choose THREE.
a Aero-allergen skin prick testing
b Bronchoscopy and broncho-alveolar lavage
c Chest X-ray
d CT chest
e Exhaled nitric oxide
453
f Full blood count
g Gastric lavage for AAFBs and TB culture
h Heaf test
i HIV testing
j IgE
k Induced sputum for AAFBs and TB culture
l Interferon-gamma
m Mantoux test
n Spirometry
o Sputum culture
p Stool for ova and parasites
The Mantoux is read at 48 h and is strongly positive with
ration measuring 20 � 15 mm. Interferon-gamma is
tive. Screening for HIV, hepatitis and syphilis are all
tive. The following chest X-ray (Figure 3) is obtained.
What is the most important abnormality? Choose ONE
a Apical scarring of old TB
b Bronchial thickening
c Diffuse nodular changes suggestive of miliary TB
d Hyperinflation
e Left hilar lymphadenopathy
f Left upper lobe consolidation and volume loss
g Right middle lobe pulmonary infiltrate typical of TB
A sputum is induced in clinic by the administration of
a hypertonic saline nebulizer. Treatment is started imme-
diately, with a regimen recommended for multi-drug resis-
tant TB, which accounts for around 1% of new cases in
both Eritrea and Somalia.
A few days later she is admitted for bronchoscopy and
BAL. All of the samples are smear and culture negative. Her
foster parents tell you that she is settling into school and
gets on well with their other fostered child, who is 15 years
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SELF-ASSESSMENT
old. They want to know if they or her classmates are at risk
of contacting TB.
(iii) What do you tell them? Choose ONE.
a The risk is very low and no screening is needed
unless symptoms develop
b The risk is low, but the whole foster family should be
screened
c The risk is intermediate; household contacts and
classmates all need to be screened, the school will be
contacted directly
d The risk is high and screening will be comprehensive,
including those who were on the same plane to the UK
Answers
Case 1
(i) a. bilateral subdural haemorrhage (Figure 4)
Subdural haemorrhages are crescent shaped and the blood
is not limited by suture lines.
(ii) a. (duty SW)
The Social Care team, should contact the police to
ascertain the well-being of the twin sister, which is of
paramount importance. This allows you to focus primarily
on the child in your care. If, however, the Social Care
team are unavailable or do not seem to be prioritizing the
sister’s safety, then it would be appropriate to contact the
police directly. Once her safety has been established you
Question 1
R L
Bilateral Subdural haemorrhage with areas of differing density
A – Hyperdense (fresh bleeding)
B – Hypodense (old bleeding)
A
B
Figure 4
PAEDIATRICS AND CHILD HEALTH 22:10 454
can proceed with other safeguarding actions, such as
investigations. The boy is clinically stable and is being
closely observed, so discussion with the Neurosurgical
team can be postponed for the time being. If the clinical
status should deteriorate, this decision must be reviewed
urgently.
(iii) b. Absence of skull fracture
In data published by the Welsh Child Protection
Systematic Review Group in a child less than 3 years with
brain injury and apnoea, the positive predictive value for
inflicted brain injury is 93% (95% CI 73%e99%) and OR of
17.1 (95% CI 5e58, p < 0.001).
Whilst a history which is not apparently consistent with
the observed injury is often a trigger for instigating inves-
tigations and other safeguarding procedures there is no
published data allowing analysis of the likelihood of
abusive brain injury in this situation.
Bruising to the head and neck is not commonly reported
in the published data. For the data that are available,
neither the PPV or the OR is significant in distinguishing
abusive from non-abusive brain injuries.
Boys are more likely than girls to suffer from brain
injuries, but there is no reported difference in the incidence
of abusive brain injury compared to non-abusive brain
injury.
Infants of less than6months of age aremore likely to suffer
brain injury as a result of physical abuse than older children.
Skull fracture is the only feature which is positively
associated with non-abusive brain injury. In a child less
than 3 years with brain injury and skull fracture the positive
predictive value for inflicted brain injury is 44% (95% CI
22%e68%) and odds ratio 0.8 (95% CI 0.3e2.3).
(iv) b. Physical abuse likely to have been sustained up to 3
days prior to presentation
See image above. The differing densities seen within the
subdural haemorrhage suggest that the blood is not fresh, but
has undergone changes (clotting, CSF leak into the subdural
space, rebleeding) likely to have occurred over several days.
Retinal haemorrhages are found in 70e80% of children
with abusive head trauma, when they commonly affect all
layers of the retina and are more often bilateral than
unilateral. In contrast they are found in less than 10% of
children with non-abusive head trauma, when they are few
in number and are located primarily at the posterior pole or
around the optic disc. The pattern in this case increases the
likelihood of abusive head trauma.
FURTHER READING
Kemp AM. Abusive head trauma: recognition and essential inves-
tigation. Arch Dis Child Educ Pract Ed 2011; 96: 202e8.
Morad Y, Wygnansky-Jaffe T and Levin AV. Retinal haemorrhage in
abusive head trauma. Clin Exp Opthalmol July 2010; 38: 514e20.
The Welsh Child Protection Systematic Review Group e review of
the available evidence up to January 2008 at http://www.core-
info.cardiff.ac.uk/index.html.
� 2012 Elsevier Ltd. All rights reserved.
SELF-ASSESSMENT
Case 2
(i) b, f, h and o. Blood culture, CRP, FBC and urinalysis
These four investigations are recommended by NICE for chil-
dren less than5yearsoldwithno focus identified for their fever.
The same guidance recommends that LP, chest X-ray,
blood gas and serum electrolytes should be considered
depending on specific clinical features and are unlikely to
be helpful in the absence of these.
All the other tests may be considered at some point but
are not justified in the initial phase and the results of the
primary investigations should be awaited in order to narrow
down the differential diagnosis before proceeding further.
Investigations are costly and their use should be limited to
those which will directly influence immediate management.
For example, in our tertiary teaching hospital ‘electrolyes
and creatinine’ costs £0.96 with urea an additional £0.96.
ESR costs £2.39, routine CSF microscopy and culture £11.50
and a chest X-ray £25.00. Costs vary from hospital to hospital
and will also vary depending on whether the test is per-
formed outside of normal working hours. However, it can
easily be seen that costs soon add up and unnecessary
investigations should be avoided for this and other reasons.
(ii) d. Poorly-defined lytic lesion with significant periosteal
reaction and soft-tissue swelling (Figure 5)
Bone lesions with well-defined edges have a clear
demarcation between normal and abnormal bone, which
can also be described as a narrow transition zone. These
lesions are likely to be slow-growing and benign. This
lesion is diffuse but there is no cortical destruction (inter-
ruption of the surface of the bone) or soft-tissue mass
(extending out beyond the normal border of the bone).
Fibula
Tibia
Lesion
Soft tissueswelling
Question 2
Figure 5
PAEDIATRICS AND CHILD HEALTH 22:10 455
In benign lesions the periosteal reaction is either absent
or solid in appearance (as here). Periosteal reactions with
a ‘sun-burst’ or ‘onion skin’ pattern, suggest a more
malignant lesion.
The lesion in this case has mixed features and should be
assumed to be aggressive, pending further investigation and
definitive diagnosis.
(iii) d. Osteomyelitis
The radiological appearances of infection canmimicmany
of the other conditions causing lytic bone lesions. Typically
deep soft-tissue swelling appears on days 1e3, swelling of the
muscles adjacent to the infection on days 3e4 and bony
destruction with periosteal reaction on days 10e14.
Even though the full blood count and CRP are (almost
entirely) normal, these do not rule out osteomyelitis where
there is a strong clinical suspicion. ESR is more sensitive
than CRP in screening for osteomyelitis. FBC is of no
discriminative value as the white cell count can be normal
in up to 60% of cases of osteomyelitis.
However, FBC does aid in the exclusion of other
important differentials, for example, Ewing sarcoma,
leukaemia and lymphoma may all present with anaemia
and white blood cell abnormalities.
The incidence of osteomyelitis in children is around 13
per 100,000 in Europe, but higher than this in the under
threes. This is much higher than any of the other differen-
tials, which range from 0.2 per 100,000 (Ewing sarcoma,
osteosarcoma) to 2e8 per 100,000 (leukaemias).
Both Ewing sarcoma and osteosarcoma have peak inci-
dence in the second decade of life. EG usually present at 5e10
years of age and most commonly affects the skull.
Soft tissueswelling
Perostealreaction
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SELF-ASSESSMENT
Bonychanges in leukaemiaare likely to includegeneralized
demineralization and growth arrest lines in the metaphyses.
(iv) c. Serial FBC
In the UK most children with osteomyelitis are treated
with 4e6 weeks of intravenous antibiotics, often followed
by oral antibiotics to a total of 3 months.
Recently small studies have indicated that shorter
courses of antibiotics can be effective, although large multi-
centre trials are awaited.
Adverse drug events (ADEs) during prolonged courses of
intravenous antibiotics are common and can necessitate
withdrawal of the drug in up to a quarter of patients.
Rash is the most frequently occurring ADE, followed by
bone marrow toxicity (often leuckopenia) and then hepatic
toxicity. Cephalosporins are associated with lower rates of
ADEs when compared to other antibiotics. For this reason,
monitoring FBC regularly is essential. LFTs should also be
monitored, although less likely to identify a cause for concern.
Non-response to treatment is equally likely to be indi-
cated by a lack of clinical improvement (pain, fever) than
by a persistently raised ESR. Measuring ESR at the start and
(planned) end of treatment is probably adequate unless
there are clinical concerns which warrant additional
investigation. Treatment should not be discontinued until
the ESR has normalized.
Repeat MRI is unlikely to directly lead to a change in
management and is not routinely indicated. Its’ use should
be limited to those who fail to respond clinically or who
have persistently raised inflammatory markers. Serial
X-rays are not helpful. U&Es and drug levels need only be
monitored if nephrotoxic agents are used.
FURTHER READING
Faden D and Faden FS. The high rate of adverse drug events in chil-
dren receiving prolonged out-patient parenteral antibiotic therapy
for osteomyelitis. Pediatr Infect Dis J June 2009; 28: 539e41.
Feverish illness in children: Assessment and initial management in
children younger than five age years, NICE, 2007 at http://
publications.nice.org.uk/feverish-illness-in-children-cg47.
Harris JC et al. How useful are laboratory investigations in the
emergency department evaluation of possible osteomyelitis?
Emerg Med Aust 2011; 23: 317e30.
Jagodzinski NA et al. Prospective evaluation of a shortened regimen
of treatment for acute osteomyelitis and septic arthritis in chil-
dren. J Pediatr Orthop 29: 518e25.
Case 3
(i) a. No
Children under 1 year of age are very unlikely to get mumps
as they receive passive immunity from maternal antibodies
transferred across the placenta. The highly infective nature
of the mumps virus means that in the UK population 98% of
adults born before the introduction of MMR demonstrate
natural immunity from previous infection. We can therefore
assume that this boy’s mother is immune due to her
exposure in Nepal, where mumps is endemic.
PAEDIATRICS AND CHILD HEALTH 22:10 456
In unimmunized children over 1 year of age, parotid
swelling may be caused by mumps, but this is only likely if
there is a current, local outbreak or contact with
a confirmed case of mumps. Other infective causes of
parotitis include many of the common viral infections of
childhood (EpsteineBarr virus, adenovirus, parainfluenza,
coxsackie virus and parvovirus B19). Non-infective causes
are rare, especially in children, the commonest being sali-
vary stones and also including the use of diuretics, diabetes
mellitus and autoimmune connective tissue disorders.
(ii) d and PCR (saliva) and ultrasound
CRP may be raised in mumps orchitis, or in other
inflammatory conditions in the differential diagnosis, such
as lymphadenitis. However, neither a normal nor a raised
CRP will guide your management at this time.
In mumps there may be either a high or low total white
cell count. The difference from normal would be explained
by a lymphocytosis or lymphopenia.
Mumps specific IgG rises between the acute and conva-
lescent stages, but this information would not be available
soon enough to take the necessary public health precautions.
PCR for mumps can be performed on saliva, urine or
CSF (in cases of suspected meningitis or encephalitis). In
this case, as the HPA have been informed of a suspected
case, it is necessary to perform PCR analysis. Salivary
swabbing is the preferred method as the swab may be
transferred easily to the HPA’s lab by post. If clinical
findings are unclear then ultrasound can help at this stage
to differentiate between parotitis and other facial/neck
swellings. This will help to guide your further investiga-
tion and management.
(iii) b. Surgeons
Antibiotic penetration into abscesses is unreliable and this
is likely to be the reason for treatment failure, rather than an
organism not suited to treatment with clarithromycin. A
further course of oral antibiotics, or changing to an intrave-
nous agent are both unlikely to be effective or to alter
outcomes.
Repeated ultrasound scanning is unlikely to give addi-
tional information as we already know where the infection
is and that there are cystic areas within the affected node.
Removal of the infected node will not only allow the
pus to be cultured, confirming the causative organism
(commonly Staphylococcus or Streptococcus), but will also
be therapeutic. Once the pus is drained then antibiotics
could safely be stopped.
(iv) c. None
The correct management for non-tuberculous mycobac-
terium (NTM) lymphadenitis is surgical excision.
FURTHER READING
Griffith et al. Diagnosis, treatment and prevention of non-
tuberculous mycobacterial disease. Am J Respir Crit Care Med
2007; 175: 367e416.
HPA. Laboratory confirmed cases of measles, mumps and rubella,
England and Wales: July to September 2011. HPR 2011; 4:
� 2012 Elsevier Ltd. All rights reserved.
Aortic arch
Lymphadenopathy
Question 3
Figure 6
SELF-ASSESSMENT
immunization. Available at: http://www.hpa.org.uk/hpr/archives/
2011/hpr4711.pdf.
NHS Clinical Knowledge summaries; http://www.cks.nhs.uk/
mumps and http://www.cks.nhs.uk/knowledgeplus/in_your_area/
notifiable_infectious_diseases.
Case 4
(i) c, k and l. (CXR, Interferon and Mantoux)
NICE guidance recommends that children aged 5e15 years
from high-risk areas should have a Mantoux test in the first
instance, followed by an interferon-gamma test if the
Mantoux is positive (dual strategy). In patients who are HIV
positive, either interferon-gamma alone, or concurrently
with Mantoux is recommended.
Until this patient’s HIV status is known a negative
Mantoux must be interpreted with caution.
Chest X-ray is needed to diagnose active pulmonary TB,
but will miss infection in other locations and latent TB.
Three sputum samples should be obtained, either before
starting treatment or as soon as possible after treatment
commences, but this is to check for secretory status and
guide contact screening and is not best practice for diag-
nosis. If organisms are visible on microscopy then PCR can
determine multi-drug resistant strains of TB, which will
inform your treatment plan. The best method for obtaining
sputum will depend on the age of the patient. Initiation of
treatment should not be delayed whilst sputum is obtained.
(ii) e. Left hilar lymphadenopathy (Figure 6)
Active pulmonary TB can have many different appear-
ances. The commonest abnormalities include consolidation
and cystic changes (cavitations), most often in the upper
lobes, although abnormalities can occur in any location. Hilar
or mediastinal lymphadenopathy may or may not be present.
In HIV positive patients the chest X-ray can appear
normal even during active pulmonary TB infection.
(iii) b. The risk is low, but the whole foster family should be
screened
All cases of active TB should undergo contact tracing
and all household contacts should be screened. Symptoms
may not appear for many years after contact. The nature of
screening depends on the contact’s age and BCG status.
Wider screening, in this case of classmates, is only
needed if the index case is smear positive. There may be
PAEDIATRICS AND CHILD HEALTH 22:10 457
considerable unease within the wider community if wide-
spread screening is indicated and therefore this should be
handled by a Consultant in Communicable Disease
Prevention who has had specific media training.
Screening contacts from air travel is rarely needed, and
is dependent on the index case being smear positive and
also having either MDR TB or a frequent and productive
cough. Flights shorter than 8 h do not warrant contact
tracing.
FURTHER READING
Health Topics: Tuberculosis, World Health Organization at http://
www.who.int/topics/tuberculosis/en and http://www.who.int/tb/
country/data/profiles/en/index.html.
Tuberculosis: Clinical diagnosis and management of tuberculosis, and
measures for its prevention and control, NICE CG 117, 2011.
� 2012 Elsevier Ltd. All rights reserved.