• a. Investigation: Flow volume loop (FVL) and pulmonary function test (PFT) / spirometry reading.
  • Parameters to look for: Shape of the flow-volume loop (inspiratory and expiratory limbs), FEV1, FVC, FEV1/FVC ratio, FEF 25–75%, and PEFR.
• b. Indications: Chronic cough, recurrent/persistent wheeze, bronchial asthma, cystic fibrosis, and interstitial lung disease (ILD).
• c. Conditions requiring PFT monitoring: Transfusion-dependent thalassemia major, sickle cell anemia, connective tissue diseases/autoimmune lung disease, ataxia telangiectasia, and chest wall deformities (e.g., pectus excavatum, scoliosis).
• d. Contraindications: Massive hemoptysis of unknown origin, recent pneumothorax, recent eye/abdominal/thoracic surgery, thoracic/cerebral aneurysms, pulmonary embolism, and acute severe respiratory distress.

• a. Possible diagnosis: Bronchial asthma (cough-variant / exercise-induced).
  • Parameters to assess: FEV1, FVC, FEV1/FVC ratio, FEF 25–75%, and PEFR.
• b.
  • FEV1 (Forced Expiratory Volume in 1 second): The volume of air exhaled in the first second during a forced vital capacity maneuver. Normal is >80–90% of predicted. Decreased in obstructive and restrictive defects.
  • FEF 25–75% (Maximal Mid-Expiratory Flow Rate): The average forced expiratory flow rate during the middle 50% of the FVC maneuver. It is a sensitive indicator of small airway obstruction.

• a. Interpretation: Flow-volume loop shows a "scooped-out" (concave upward) appearance in the expiratory limb with decreased FEV1, FEV1/FVC ratio, FEF 25–75%, and PEFR.
• b. Diagnosis: Obstructive airway disease (likely bronchial asthma).
• c. Next step: Post-bronchodilator reversibility testing (spirometry repeated 15 minutes after administering 400 µg inhaled salbutamol; reversibility defined as ≥12% and ≥200 mL increase in FEV1).

• a. Interpretation: Expiratory limb shows concavity ("scooped-out" pattern). Pre- and post-bronchodilator values show significant improvement (FEV1 34% vs. 51%, FEF 25–75% 15% vs. 24%, PEF 41% vs. 70%) confirming significant bronchodilator reversibility (>12%). Diagnosis: Bronchial asthma.
• b. The arrow points to a sudden flow transient / dip caused by a cough artifact during the forced expiration maneuver.

• a. Peak Expiratory Flow Meter (Wright's peak flow meter).
• b. Asthma action plan zones:
  • Green zone (80–100% of personal best): Good asthma control; maintain regular controller therapy.
  • Yellow zone (50–80% of personal best): Caution / worsening airway narrowing; initiate short-acting beta-2 agonist (SABA) rescue and adjust controller medication as per action plan.
  • Red zone (<50% of personal best): Medical alert / severe obstruction; take inhaled rescue bronchodilator immediately and seek emergency medical care.
• c. Take rescue medication (SABA) right away and seek emergency medical attention.

• a.
  • GINA: Global Initiative for Asthma
  • ICS: Inhaled Corticosteroid
  • MART: Maintenance and Reliever Therapy
  • AIR: Anti-inflammatory Reliever
• b. GINA recommends that children 6–11 years with mild/intermittent asthma should receive an inhaled corticosteroid (ICS) whenever a short-acting beta-2 agonist (SABA) is taken for symptom relief (concomitant SABA + low-dose ICS), rather than SABA alone.

• a. Combination of an Inhaled Corticosteroid (Budesonide or Beclomethasone) plus a rapid-onset Long-Acting Beta-2 Agonist (Formoterol) in a single inhaler device.
• b. Formoterol has both a rapid onset of action (within 1–3 minutes, comparable to salbutamol) and a long duration of action (12 hours). Using it as a reliever simultaneously delivers an anti-inflammatory dose of ICS, preventing severe exacerbations.
• c. Inhalation devices by age group:
  • <3 years: Pressurized metered-dose inhaler (pMDI) + Valved holding chamber (spacer) + tight-fitting Face Mask (or nebulizer with mask).
  • 4–6 years: pMDI + Spacer with Mouthpiece (± face mask if uncooperative).
  • >6 years: pMDI + Spacer / Dry Powder Inhaler (DPI) / Breath-actuated pMDI.

• a.
  • Very low-dose ICS-formoterol: Formoterol 6 µg + Budesonide 100 µg (or Beclomethasone 100 µg).
  • Low-dose ICS-formoterol: Formoterol 6 µg + Budesonide 200 µg (or Beclomethasone 200 µg).
• b. Maximum daily reliever doses (total puffs/day including maintenance):
  • Adolescents (≥12 years): Maximum 12 puffs per day (total 72 µg formoterol).
  • Children (6–11 years): Maximum 8 puffs per day (total 48 µg formoterol).

• a. Modified Centor Score (McIsaac Score) for Streptococcal Pharyngitis:
  • Fever >38°C (+1)
  • Absence of cough (+1)
  • Tonsillar exudates or swelling (+1)
  • Tender anterior cervical lymphadenopathy (+1)
  • Age: 3–14 years (+1), 15–44 years (0), ≥45 years (-1)
• b. Westley Croup Score:
  • Inspiratory stridor (none=0, with agitation=1, at rest=2)
  • Intercostal/chest retractions (none=0, mild=1, moderate=2, severe=3)
  • Air entry (normal=0, decreased=1, severely decreased=2)
  • Cyanosis (none=0, with agitation=4, at rest=5)
  • Level of consciousness (normal=0, disoriented/depressed=5)

• CT: Computed Tomography
• HRCT: High-Resolution Computed Tomography
• MDCT: Multi-Detector Computed Tomography
• CECT: Contrast-Enhanced Computed Tomography

• a. Bilateral upper lobe: Cystic fibrosis, Allergic Bronchopulmonary Aspergillosis (ABPA), Sarcoidosis, Histiocytosis.
• b. Unilateral upper lobe: Pulmonary tuberculosis (post-primary TB).
• c. Lower lobe: Post-infectious bronchiectasis, aspiration pneumonia, congenital pulmonary airway malformation (CPAM), sequestration.

• a. CT findings in bronchiectasis:
  • Increased bronchoarterial ratio >0.8–1.0 ("signet ring" sign)
  • Lack of bronchial tapering towards periphery ("tram-track" sign)
  • Visualization of airways within 1 cm of pleural surface
  • Bronchial wall thickening
  • Mucoid impaction / "tree-in-bud" appearance
  • Mosaic attenuation / air trapping
• b. Syndromes associated with bronchiectasis:
  • Young syndrome (sinusitis, bronchiectasis, obstructive azoospermia)
  • Mounier-Kuhn syndrome (tracheobronchomegaly)
  • Williams-Campbell syndrome (congenital deficiency of bronchial cartilage)
  • Kartagener syndrome / Primary Ciliary Dyskinesia
  • Yellow nail syndrome

• Right eye finding: Ocular conjunctival telangiectasia (characteristic of Ataxia-Telangiectasia).
• CT Chest findings: Bronchiectasis with bronchial wall thickening, mucus impaction, and areas of air trapping in the left lung.

• a. Magnetic Resonance Imaging (MRI) of the chest.
• b. Well-defined, hyperintense fluid-filled cystic lesion in the right superior-middle mediastinum with no communication with the esophageal lumen—Bronchogenic duplication cyst.

• a. Contrast-enhanced CT Chest / CT Pulmonary Angiography.
• b. Hypoplastic / decreased right lung volume with mediastinal shift to the right.
• c. Anomalous right pulmonary vein draining into the inferior vena cava (IVC) below the diaphragm.
• d. Systemic arterial supply arising from the abdominal aorta / celiac axis.
• e. Diagnosis: Scimitar syndrome (Congenital venolobar syndrome / hypogenetic lung syndrome).

• a. Hyperinflated, hyperlucent right middle lobe with attenuated vascularity, causing compression atelectasis of adjacent right upper and lower lobes and contralateral mediastinal shift.
• b. Diagnosis: Congenital Lobar Emphysema (CLE) / Congenital Lobar Overinflation of the right middle lobe.

• a. CT findings:
  • Large thick-walled cavity with air-fluid level
  • Extensive consolidation and parenchymal necrosis
  • Surrounding ground-glass opacities
  • Absence of significant mediastinal shift
• b. Diagnosis: Necrotizing pneumonia (right upper lobe) with lung abscess.

• a. Multiple enlarged mediastinal, paratracheal, subcarinal, and hilar lymph nodes showing central low attenuation (caseous necrosis) with peripheral rim enhancement.
• b. Diagnosis: Mediastinal tuberculous lymphadenitis (Tuberculosis).

• a. Barium swallow / Esophagogram.
• b. Marked proximal esophageal dilatation with smooth, tapered distal narrowing ("bird-beak" appearance) at the gastroesophageal junction.
• c. Regurgitation of undigested food ingested hours earlier, nocturnal cough, aspiration pneumonia, dysphagia, and failure to thrive.
• d. Treatment: Laparoscopic Heller's cardiomyotomy with partial fundoplication (or pneumatic dilatation / POEM).

• a. Overnight Polysomnography (Sleep Study).
• b. Parameters monitored:
  • Electroencephalography (EEG)
  • Electrooculography (EOG)
  • Electromyography (EMG - chin and leg)
  • Electrocardiography (ECG)
  • Pulse oximetry (SpO2) and End-tidal CO2 (EtCO2)
  • Nasal/oral airflow (thermistor/pressure transducer)
  • Respiratory effort bands (chest and abdominal plethysmography)
• c. Obstructive apnea/hypopnea events with recurrent oxygen desaturation and sleep fragmentation.
• d. Indications: Suspected obstructive sleep apnea syndrome (OSAS), habitual snoring with daytime sleepiness, evaluation before/after craniofacial or upper airway surgery.
• e. Treatment: Adenotonsillectomy (first-line in children with adenotonsillar hypertrophy); CPAP/BiPAP for residual or non-surgical cases.

• a. Device: ProSeal Laryngeal Mask Airway (ProSeal LMA).
  • Parts: Airway tube, drain tube (for gastric decompression/NG tube insertion), inflatable silicone cuff, pilot balloon with one-way check valve, and integral bite block.
• b. Used for establishing and maintaining a secure supraglottic airway during general anesthesia, elective procedures (e.g., flexible bronchoscopy/BAL), and difficult airway rescue.
• c. Can be used in all age groups from neonates/infants (Size 1: <5 kg) to adults.

• a. Parapneumonic effusion classification:

Parameter	Uncomplicated PPE (UPPE)	Complicated PPE / Empyema
Pleural fluid pH	>7.2	<7.2
Pleural fluid Glucose	>2.2 mmol/L (>40 mg/dL)	<2.2 mmol/L (<40 mg/dL)
Pleural fluid LDH	<1,000 IU/L	>1,000 IU/L
Gram stain & Culture	Negative	Often Positive
Appearance	Clear / serous	Turbid / Purulent (frank pus in empyema)

• b. Common organisms: Streptococcus pneumoniae, Staphylococcus aureus (including MRSA), Streptococcus pyogenes (Group A Strep), Haemophilus influenzae, and Mycoplasma pneumoniae.
• c. Stages and management:
  • Stage 1 (Exudative stage): IV Antibiotics alone ± simple thoracocentesis.
  • Stage 2 (Fibrinopurulent stage): IV Antibiotics + Intercostal tube drainage with intrapleural fibrinolytics (Urokinase/Alteplase) OR early VATS (Video-Assisted Thoracoscopic Surgery).
  • Stage 3 (Organizing stage): VATS debridement / Thoracotomy and formal decortication.

• a. Classification by duration:
  • Acute: <30 days
  • Subacute: 30–90 days (1–3 months)
  • Chronic: >90 days (>3 months)
  • Recurrent acute: ≥4 episodes per year with complete resolution between episodes
• b. Standard-dose Amoxicillin (45 mg/kg/day in 2 divided doses); for non-severe penicillin allergy: Cefdinir, Cefuroxime axetil, or Cefpodoxime.
• c. Conditions predisposing to recurrent/chronic sinusitis:
  • Allergic rhinitis
  • Cystic fibrosis
  • Primary ciliary dyskinesia (Kartagener syndrome)
  • Immunodeficiencies (IgA deficiency, IgG subclass deficiency, CVID)
  • Anatomical abnormalities (adenoid hypertrophy, deviated nasal septum, choanal atresia, cleft palate)
  • Gastroesophageal reflux disease (GERD)
• d. Indications for high-dose Amoxicillin-Clavulanate:
  • Daycare attendance
  • Age <2 years
  • Prior antibiotic exposure in preceding 1–3 months
  • Moderate-to-severe symptoms (fever ≥39°C with purulent discharge)
  • Lack of response to initial amoxicillin within 72 hours
  • Immunocompromised state

• a. Clinical presentation patterns of acute bacterial sinusitis:
  • 1. Persistent illness: Nasal discharge (any quality) or daytime cough lasting ≥10 days without clinical improvement.
  • 2. Severe onset: High fever (≥39°C / 102°F) with purulent nasal discharge for ≥3 consecutive days.
  • 3. Worsening course ("Double sickening"): Typical viral URI symptoms that improve and then acutely worsen with new fever, increased discharge, or headache.
• b. Mucorales (Rhizopus, Mucor) causing invasive mucormycosis, and Aspergillus species.
• c. Predisposing factors: Severe neutropenia (hematologic malignancy, chemotherapy), hematopoietic stem cell transplant, poorly controlled diabetes mellitus / DKA, prolonged systemic corticosteroid therapy, and severe COVID-19 infection.

• a. Pseudo-Bartter syndrome (hypochloremic, hypokalemic metabolic alkalosis with hyponatremia).
• b. Cystic Fibrosis (due to massive salt loss in sweat).
• c. Sweat test (pilocarpine iontophoresis); sweat chloride ≥60 mEq/L is diagnostic of cystic fibrosis (30–59 mEq/L is intermediate).
• d. Immunoreactive Trypsinogen (IRT) on dried blood spot newborn screening.

• a. Presumptive pediatric TB criteria (NTEP):
  • Persistent fever for >2 weeks without a known cause
  • Unremitting cough for >2 weeks
  • Weight loss (>5% in past 3 months) or failure to gain weight over the past 3 months despite nutritional advice
  • History of close contact with a known pulmonary TB patient in the past 2 years
• b. Chest X-ray (CXR PA/AP view) and upfront rapid molecular testing (CBNAAT / Truenat on gastric aspirate or induced sputum).

• a. CXR findings:
  • i. Highly suggestive: Intrathoracic / hilar / paratracheal lymphadenopathy with or without parenchymal lesion, miliary shadows, chronic fibrocavitary lesions.
  • ii. Non-specific: Segmental/lobar consolidation, patchy bronchopneumonic opacities, atelectasis.
• b. CT findings highly suggestive: Mediastinal lymphadenopathy with central low attenuation (caseous necrosis) and rim enhancement, centrilobular nodules with "tree-in-bud" pattern, cavities with surrounding satellite nodules.
• c. Management based on CXR:
  • Highly suggestive: Perform rapid molecular testing (CBNAAT/Truenat on induced sputum/gastric aspirate) and initiate ATT.
  • Non-specific: Treat with a course of broad-spectrum antibiotics (avoiding fluoroquinolones/linezolid/aminoglycosides) and reassess after 10–14 days.
  • Normal: Look for extrapulmonary TB or alternative diagnoses; follow up clinically.

• a.
  • i. Sterile screw-capped 50 mL Falcon tube.
  • ii. Refrigerator (at 2–8°C).
  • iii. Up to 7 days.
• b. Diagnostic test limits and turnaround times:

Diagnostic Method	Detection Limit (Bacillary Load)	Turnaround Time
Direct Smear (ZN / Auramine)	5,000–10,000 bacilli/mL	1–2 hours
MGIT Liquid Culture	10–100 bacilli/mL	Up to 42 days
CBNAAT (GeneXpert MTB/RIF)	~130 bacilli/mL	~2 hours
CBNAAT Ultra (Xpert MTB/RIF Ultra)	~16 bacilli/mL	~2 hours

• c. Pleural fluid, ascitic fluid, and pericardial fluid (pauci-bacillary nature leads to lower sensitivity compared to tissue biopsies or pus).

• a. Intradermal injection (Mantoux method) of Purified Protein Derivative (PPD) to assess cell-mediated delayed-type hypersensitivity (Type IV) to Mycobacterium tuberculosis antigens.
• b. 2 TU of PPD RT 23 with Tween 80 injected intradermally on the volar aspect of the forearm.
• c. Induration of ≥10 mm transverse diameter at 48–72 hours.
• d. Induration of ≥5 mm transverse diameter in HIV-infected or severely immunocompromised children.
• e. Indicates infection with M. tuberculosis (present or past); it does not differentiate between latent TB infection (LTBI) and active TB disease.

• a. Novel specific skin test (Cy-Tb / C-Tb) for detecting M. tuberculosis infection, combining the operational simplicity of TST with the high specificity of IGRA.
• b. ≥5 mm induration at 48–72 hours is the universal cutoff.
• c. Recombinant ESAT-6 (Early Secretory Antigenic Target-6) and CFP-10 (Culture Filtrate Protein-10) antigens.
• d. No, it is not affected by prior BCG vaccination or infection with non-tuberculous mycobacteria (NTM).

• a. CECT Brain findings in CNS TB:
  • Basal meningeal enhancement
  • Hydrocephalus (communicating > non-communicating)
  • Periventricular / basal ganglia infarcts (due to tuberculous vasculitis)
  • Ring-enhancing granulomatous lesions (tuberculomas)
• b. Differential diagnoses: Cryptococcal meningitis, toxoplasmosis, viral/bacterial meningitis, fungal granuloma, CNS lymphoma, neurosarcoidosis.
• c. CSF findings in TBM:
  • Appearance: Clear or slightly turbid; cobweb/pellicle formation on standing
  • Pleocytosis: 10–500 cells/mm³ (predominantly lymphocytes; neutrophils early)
  • Protein: Markedly elevated (often 100–500 mg/dL or higher)
  • Glucose: Low (<40 mg/dL or CSF/blood glucose ratio <0.5)
  • Rapid NAAT (CBNAAT): Positive for M. tuberculosis
• d. Tuberculoma vs. Neurocysticercosis (NCC):
  • Tuberculoma: Usually >2 cm, irregular thick rim enhancement, marked surrounding edema with midline shift, hypointense core on T2, MR spectroscopy shows high lipid peak.
  • NCC: Usually <2 cm, thin smooth regular ring enhancement, mild perilesional edema, scolex seen as eccentric hyperdense nodule ("hole-with-dot" sign).

• a. TPT Regimens for DS-TB contacts:
  • 3HP: Once-weekly Isoniazid + Rifapentine for 12 weeks (3 months) in children ≥2 years.
  • 6H: Daily Isoniazid monotherapy for 6 months (10 mg/kg/day for <10 years; 5 mg/kg/day for ≥10 years; max 300 mg/day).
  • 3HR: Daily Isoniazid + Rifampicin for 3 months.
• b. FDC of INH + Rifapentine: Available as fixed-dose combination tablets containing 150 mg Isoniazid + 150 mg Rifapentine (or 300 mg/300 mg).

• 1. Ileocecal region involvement with concentric circumferential bowel wall thickening.
• 2. Contracted, pulled-up cecum with obtuse, distorted ileocecal angle.
• 3. Multiple short strictures (<3 cm) in the ileum/jejunum.
• 4. Necrotic mesenteric lymphadenopathy with peripheral rim enhancement and central hypodensity.
• 5. High-attenuation loculated ascites with fine fibrinous septations.
• 6. "Caked" or thickened omentum and peritoneal nodularity.

• a.
  • Tuberculous dactylitis: Spina ventosa
  • Spinal tuberculosis: Pott's spine (tuberculous spondylodiscitis)
• b.
  • Dactylitis: Short tubular bones of hands and feet (metacarpals, metatarsals, proximal/middle phalanges).
  • Spinal TB: Lower thoracic and upper lumbar vertebrae.
• c. 30–50% bone mineral loss is required before visible on plain radiograph.
• d. Magnetic Resonance Imaging (MRI) of spine.
• e. MRI findings in Pott's spine:
  • Vertebral body bone marrow edema (hypointense on T1, hyperintense on T2)
  • Destruction and erosion of adjacent opposing vertebral endplates
  • Loss of intervening intervertebral disc height with discitis
  • Prevertebral, paravertebral, and epidural abscesses ("cold abscess") with subligamentous spread
  • Cord compression / canal stenosis

• a. Four distinct bacillary subpopulations:
  • 1. Actively multiplying extracellular bacilli in cavity walls (rapid growers)
  • 2. Slowly multiplying intracellular bacilli within macrophages (acidic environment)
  • 3. Slowly multiplying extracellular bacilli in caseous necrotic tissue (neutral pH)
  • 4. Dormant / persister bacilli
• b. Drug actions on subpopulations:
  • INH: Potent bactericidal action against rapidly multiplying extracellular bacilli.
  • Rifampicin: Bactericidal against both rapidly multiplying and semi-dormant / spurting bacilli (sterilizing action).
  • Pyrazinamide: Bactericidal against slowly multiplying intracellular bacilli in acidic environment within macrophages.
• c. Standard DS-TB regimen: 2 HRZE (Intensive Phase) + 4 HRE (Continuation Phase).
• d. Duration of CP: 10 months for CNS TB and Spinal TB (Total 12 months therapy: 2 HRZE + 10 HRE).

• a. To rapidly kill the large initial bacillary population, rapidly render the patient non-infectious, and prevent the selection and emergence of drug-resistant mutant bacilli.
• b. Ethambutol protects against the emergence of drug resistance if initial isoniazid (INH) resistance is present (baseline primary INH resistance ~10–13%).
• c. Aim of Intensive Phase (IP): Rapid bactericidal reduction of bacillary load, clinical improvement, and prevention of acquired drug resistance.
• d. Aim of Continuation Phase (CP): Elimination of slow-growing and persisting bacilli to achieve cure and prevent relapse.

• a. First-line ATT drug dosages:

Drug	Daily Dose (mg/kg/day)	Recommended Range (mg/kg)	Maximum Daily Dose (mg)
Isoniazid (H)	10	7–15	300
Rifampicin (R)	15	10–20	600
Pyrazinamide (Z)	35	30–40	2,000
Ethambutol (E)	20	15–25	1,500

• b. Pediatric Dispersible FDC formulations:
  • Intensive Phase (3-drug FDC): H 50 mg + R 75 mg + Z 150 mg (+ Ethambutol 100 mg separate dispersible tablet).
  • Continuation Phase (2-drug FDC): H 50 mg + R 75 mg (+ Ethambutol 100 mg separate tablet).
• c. Adult Non-dispersible FDC formulations:
  • Intensive Phase (4-drug FDC): H 75 mg + R 150 mg + Z 400 mg + E 275 mg.
  • Continuation Phase (3-drug FDC): H 75 mg + R 150 mg + E 275 mg.

• a. Weight band dosing for pediatric DS-TB (P = Pediatric FDC [H50/R75/Z150], E = Ethambutol 100mg, A = Adult FDC [H75/R150/Z400/E275]):

Weight Band (kg)	Intensive Phase Daily Dose	Continuation Phase Daily Dose
4–7 kg	1 P tablet + 1 E tablet	1 (H+R) tablet + 1 E tablet
8–11 kg	2 P tablets + 2 E tablets	2 (H+R) tablets + 2 E tablets
12–15 kg	3 P tablets + 3 E tablets	3 (H+R) tablets + 3 E tablets
16–24 kg	4 P tablets + 4 E tablets	4 (H+R) tablets + 4 E tablets
25–29 kg	3 P + 3 E + 1 Adult FDC	3 (H+R) + 3 E + 1 Adult CP FDC
30–39 kg	2 P + 2 E + 2 Adult FDC	2 (H+R) + 2 E + 2 Adult CP FDC
≥40 kg	Adult dosing regimen	Adult dosing regimen

• b. Pyridoxine (Vitamin B6): Added to prevent Isoniazid-induced peripheral neuropathy (INH interferes with pyridoxine metabolism); recommended dose is 10 mg/day (especially in malnourished children, exclusively breastfed infants, and HIV coinfection).

• a. Indications of Corticosteroids in TB:
  • Tuberculous meningitis (TBM)
  • Tuberculous pericarditis with constriction/effusion
  • Adrenal tuberculosis (Addison's disease)
  • Miliary TB with acute respiratory failure / ARDS / alveolar-capillary block
  • TB uveitis / choroiditis
• b. Other indications:
  • Endobronchial TB with airway obstruction / atelectasis
  • Mediastinal compression syndrome
  • Severe massive tuberculous pleural effusion with dyspnea
  • Paradoxical TB-IRIS
• c. Dosage and duration: Oral Prednisolone 1–2 mg/kg/day (or IV Dexamethasone 0.6 mg/kg/day) for 2–4 weeks, followed by gradual tapering over the subsequent 2–4 weeks (total duration 4–8 weeks).

• 1. Presence of cavities or extensive bilateral disease on chest radiography.
• 2. Severe forms of extrapulmonary TB (CNS TB / tuberculous meningitis, spinal TB / Pott's spine, miliary/disseminated TB, pericardial TB).
• 3. TB in the presence of severe acute malnutrition (SAM) / advanced wasting.
• 4. TB with advanced immunosuppression (severe HIV infection / CD4 <15%).
• 5. Massive pleural effusion or acute airway obstruction.

• a. Management of Treatment Interruption:
  • Interruption <4 weeks: Resume previous regimen and extend duration to complete the full planned doses.
  • Interruption ≥4 weeks: Send sample for repeat microbiological testing and rapid DST (CBNAAT / LPA) to check for drug resistance (DR-TB).
    • If Rifampicin-sensitive: Restart full DS-TB regimen from the beginning (test for INH mono-resistance).
    • If Rifampicin-resistant: Initiate MDR-TB regimen.

• a. Paradoxical Upgrading Reaction (PUR): Clinical or radiological worsening of pre-existing tuberculous lesions or the appearance of new lesions during appropriate and effective anti-TB treatment, after initial improvement.
• b. Typically occurs 3–12 weeks after initiating ATT (due to restored host cell-mediated immune response against released mycobacterial antigens).
• c. Manifestations:
  • Enlargement of existing lymph nodes or appearance of fresh peripheral/mediastinal nodes
  • Development of new pleural/pericardial effusion
  • Appearance or worsening of pulmonary infiltrates
  • Enlargement of tuberculomas or new hydrocephalus in CNS TB
  • High spiking fever
• d. Treatment: Continue the ongoing ATT regimen without alteration. Reassure the family; add a short course of oral corticosteroids (prednisolone 1–2 mg/kg/day) for severe compression symptoms or CNS involvement. Aspirate fluctuant nodes if needed.

• a. In children <10 years, weight-for-age < -2 Z-scores (underweight) or weight-for-height < -3 Z-scores (severe wasting). In adolescents/adults, BMI <18.5 kg/m².
• b. Tuberculosis Infection (TBI): A state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens without clinical, microbiological, or radiological evidence of active TB disease.
• c. Tuberculosis Preventive Treatment (TPT): A course of one or more anti-TB drugs given to individuals with TB infection (or contacts at high risk) to prevent the development of active TB disease.

• a. Anti-TB medications reserved specifically for the management of drug-resistant tuberculosis (DR-TB).
• b. Streptomycin is now classified as a second-line injectable anti-TB drug (Group C).
• c. Used only when amikacin is unavailable or when there is documented resistance to amikacin with proven susceptibility to streptomycin.
• d. Dose: 15–20 mg/kg/day IM (max 1,000 mg). Side effects: Ototoxicity (vestibular/cochlear damage) and nephrotoxicity.

• a. Isoniazid-resistant TB (HR-TB): Resistance to Isoniazid with documented susceptibility to Rifampicin.
• b. Mono-resistant TB (MR-TB): Resistance to only one first-line anti-TB drug.
• c. Multidrug-resistant TB (MDR-TB): Resistance to at least both Isoniazid and Rifampicin simultaneously.
• d. Extensively drug-resistant TB (XDR-TB): MDR/RR-TB that is additionally resistant to any fluoroquinolone (Levofloxacin or Moxifloxacin) AND at least one Group A drug (Bedaquiline or Linezolid).
• e. Rifampicin-resistant TB (RR-TB): Resistance to Rifampicin detected by phenotypic or genotypic methods, with or without resistance to other drugs.

• a. Line Probe Assay (LPA) (GenoType MTBDRplus and MTBDRsl).
• b. Smear-positive sputum specimen or culture isolate of Mycobacterium tuberculosis.
• c. Approximately 48–72 hours.
• d.
  • First-line LPA (MTBDRplus): Isoniazid (inhA, katG) and Rifampicin (rpoB).
  • Second-line LPA (MTBDRsl): Fluoroquinolones (gyrA, gyrB) and Second-line injectables (rrs, eis).

• Group A (Include all three):
  • Levofloxacin or Moxifloxacin
  • Bedaquiline
  • Linezolid
• Group B (Add one or both):
  • Clofazimine
  • Cycloserine or Terizidone
• Group C (Add to complete regimen when Group A & B cannot be used):
  • Ethambutol, Delamanid, Pyrazinamide, Imipenem-cilastatin/Meropenem, Amikacin/Streptomycin, Ethionamide/Prothionamide, p-aminosalicylic acid (PAS).

• Levofloxacin (Lfx):
  • <5 years: 15–20 mg/kg/day divided twice daily
  • ≥5 years: 10–15 mg/kg/day once daily (max 1,000 mg)
• Moxifloxacin (Mfx): 7.5–10 mg/kg/day once daily (high dose: 10–15 mg/kg/day).
• Linezolid (Lzd):
  • <6 years: 10–12 mg/kg/day (once or divided bid)
  • ≥6 years: 15 mg/kg once daily (max 600 mg)
• Bedaquiline (Bdq):
  • For ≥5 years: 200 mg daily for 2 weeks, followed by 100 mg thrice weekly for 22 weeks (weight-adjusted in younger children).

• Regimen: 6 (Lfx - R - Z - E) (6 months of Levofloxacin, Rifampicin, Pyrazinamide, and Ethambutol; may extend up to 9 months in extensive disease).
• Dosages:
  • Levofloxacin: 15–20 mg/kg/day (<5 yr) or 10–15 mg/kg/day (≥5 yr)
  • Rifampicin: 15 mg/kg/day (10–20 mg/kg)
  • Pyrazinamide: 35 mg/kg/day (30–40 mg/kg)
  • Ethambutol: 20 mg/kg/day (15–25 mg/kg)

• Duration: 9–11 months (4–6 months Intensive Phase + 5 months Continuation Phase).
• Regimen formula:
  • Initial Phase (4–6 months): 4–6 Bdq - Lfx - Cfz - Z - E - High-dose H - Eto
  • Continuation Phase (5 months): 5 Lfx - Cfz - Z - E
    (Bedaquiline given for total 6 months)

• Duration: 18–20 months (all-oral regimen, without separate IP/CP).
• Regimen formula:
  • 18–20 (Lfx/Mfx - Lzd - Cfz - Cs) + 6 Bdq
  • Linezolid dose may be tapered to 10 mg/kg after 4–6 months / smear conversion to avoid myelosuppression/neuropathy.

• a. QT Prolongation: Bedaquiline, Fluoroquinolones (Moxifloxacin > Levofloxacin), Clofazimine, Delamanid.
• b. Hepatotoxicity: Pyrazinamide > Isoniazid > Rifampicin, Ethionamide, PAS, Bedaquiline.
• c. Ototoxicity: Amikacin, Kanamycin, Streptomycin.

• MDR-TB Contacts (FQ-susceptible source): Daily Levofloxacin for 6 months (6 Lfx).
• Isoniazid Mono-resistant Contacts (R-susceptible source): Daily Rifampicin for 4 months (4 R).

• a. Yes, administer BCG at birth to all HIV-exposed infants regardless of maternal status unless the infant has symptoms suggestive of HIV disease.
• b. No, contraindicated in confirmed HIV-infected children with significant immunodeficiency due to the risk of disseminated BCG infection (BCG-osis).

• a. Transplacental transmission primary focus:
  • i. Liver (primary hepatic complex / caseating granuloma)
  • ii. Lungs
  • iii. Gastrointestinal tract (GIT) / mesenteric lymph nodes
• b. Modified Cantwell Criteria for Congenital TB:
  • Proven tuberculous lesion in the infant PLUS at least one of the following:
    • 1. Lesions occurring within the first week of life
    • 2. Primary hepatic complex or caseating hepatic granuloma on biopsy/autopsy
    • 3. Tuberculous infection of placenta or maternal genital tract
    • 4. Thorough contact investigation excluding postnatal transmission
• c. Treatment: 2 HRZE + 4 HRE for 6 months (extended to 12 months in CNS involvement).

• a. Yes, mother can safely breastfeed while wearing a surgical mask and practicing cough hygiene (anti-TB drugs excreted in breast milk are safe for the baby).
• b. BCG vaccine should be deferred while the infant is on TB Preventive Therapy (Isoniazid kills the live BCG strain). Administer BCG after completion of the TPT course.

• 1. Cured: Smear/culture-negative in the last month of treatment and on at least one previous occasion.
• 2. Treatment Completed: Completed treatment without evidence of failure but without documented negative smear/culture in the last month.
• 3. Treatment Success: Sum of 'Cured' and 'Treatment Completed'.
• 4. Treatment Failed: Smear or culture positive at month 5 or later during treatment.
• 5. Died: Patient died from any cause during treatment.
• 6. Lost to Follow-up (Defaulter): Treatment interrupted for 1 consecutive month or more.
• 7. Not Evaluated: Transferred out or outcome unknown.

• Findings: Incorrectly placed high BCG scar and ipsilateral non-suppurative axillary lymphadenopathy (BCG lymphadenitis).
• Management:
  • Reassurance; most cases resolve spontaneously over months.
  • Do NOT perform incision and drainage or routine FNAC.
  • No indication for anti-tubercular therapy (ATT) or antibiotics.
  • If the node becomes large, fluctuant, and on the verge of spontaneous rupture, perform needle aspiration with a wide-bore needle (or surgical excision).

Ni-kshay (Web-based portal by NTEP: Ni = End, Kshay = Tuberculosis).

• CT finding: High-resolution CT shows widespread, randomly distributed 1–3 mm micronodules throughout both lungs (Miliary pattern).
• Causes:
  • Infections: Miliary tuberculosis, fungal infections (histoplasmosis, blastomycosis, coccidioidomycosis), Mycoplasma, Nocardia.
  • Immune/Inflammatory: Sarcoidosis, Langerhans cell histiocytosis (LCH), Hypersensitivity pneumonitis, Tropical pulmonary eosinophilia.
  • Malignancy: Hematogenous pulmonary metastases (papillary thyroid carcinoma, renal cell carcinoma, melanoma), bronchioloalveolar carcinoma.
  • Inhalational/Occupational: Silicosis, siderosis.
  • Miscellaneous: Pulmonary alveolar microlithiasis.