TB may present in atypical ways, such as acute severe pneumonia (more common in children aged under 2 years and children living with HIV) or fixed airway wheezing (more common in young children aged under 5 years) (72).
Signs of severe pneumonia include:
- peripheral oxygen saturation below 90% or central cyanosis;
- severe respiratory distress (e.g. grunting, nasal flaring, very severe chest indrawing);
- signs of pneumonia, defined as cough or difficulty in breathing with fast breathing (tachypnoea) or chest indrawing, with any of the following danger signs:
- inability to breastfeed or drink;
- persistent vomiting;
- lethargy or reduced level of consciousness;
- stridor in a calm child;
- severe malnutrition.
PTB should be suspected if there is a poor response to antibiotics, and especially if there is a positive TB contact history. In children living with HIV, other HIV-related lung disease such as Pneumocystis jirovecii pneumonia (formerly known as Pneumocystis carinii pneumonia or PCP) should also be suspected.
Asymmetrical and persistent wheezing can be caused by airway compression due to enlarged intrathoracic TB lymph nodes. PTB should be suspected when a wheeze is asymmetrical, persistent and monophonic, not responsive to bronchodilator therapy, and associated with other typical features of TB (e.g. poor weight gain, persistent fever).