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 Emergency

Department. 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

� 2012 Elsevier Ltd. All rights reserved.

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

� 2012 Elsevier Ltd. All rights reserved.

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 22:10

indu

reac

nega

(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

� 2012 Elsevier Ltd. All rights reserved.

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

� 2012 Elsevier Ltd. All rights reserved.

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.