Tuberculosis in children — OSCE assessment and communication station

OSCE \u2014 Assessment and communication station

Candidate instructions

You are the paediatric registrar. You have 8 minutes per station. [1]

Station A (classify, investigate and treat). A four-year-old boy is brought in thin, with a cough and intermittent fever for six weeks. His uncle was diagnosed with smear-positive pulmonary tuberculosis two weeks ago. His chest radiograph shows right paratracheal lymph-node enlargement without cavitation. Classify the child on the TB spectrum, outline the investigations, and explain the treatment plan to his mother through a trained interpreter. [1] [7]

Station B (TBM override and the contact). You are asked to review a two-year-old sibling of the same family who presents febrile, irritable and drowsy, and to counsel on an asymptomatic eight-month-old household contact. Recognise the emergency, outline immediate management, and explain contact screening and presumptive preventive therapy. [6] [1]

Examiner brief and marking domains

Domain 1 \u2014 Classification (Station A). Correctly places the child on the exposure-infection-disease spectrum as TB disease (symptoms plus a compatible radiograph), classifies the disease by site as intrathoracic and by severity as non-severe (lymph-node, non-cavitary, smear-negative pattern), and explains why the contact history is the most specific finding. [1] [3]

Domain 2 \u2014 Investigation (Station A). Outlines two to three early-morning gastric aspirates (or induced sputum) for Xpert MTB/RIF Ultra plus culture and susceptibility, a TST or IGRA to support infection, an HIV test, and a chest radiograph read for the lymph-node pattern. States clearly that a negative Xpert does not exclude disease and that treatment proceeds on a compatible picture. [5]

Domain 3 \u2014 Treatment and communication (Station A). Prescribes the weight-based 4-month regimen validated by the SHINE trial for non-severe disease using child-friendly fixed-dose combinations, with re-weighing at every visit and adherence support, and explains to the mother through a trained interpreter that TB is treatable, why the whole household is screened, and what to expect. Avoids inventing exact mg/kg doses and points to WHO/NICE guidance for the operational detail. [7]

Domain 4 \u2014 Tuberculous meningitis override (Station B). Recognises the febrile, drowsy contact with a TB exposure as presumed tuberculous meningitis and acts immediately: urgent brain imaging, lumbar puncture with CSF for cell count, protein, glucose, acid-fast bacilli, Xpert and culture, and empirical extended intensive therapy with corticosteroids without waiting for confirmation, with intracranial-pressure management and neurosurgical input. [6]

Domain 5 \u2014 Contact screening and public health (Station B). Outlines notification, household contact screening (symptom review, TST/IGRA, chest radiograph as indicated), presumptive tuberculosis preventive therapy for the asymptomatic eight-month-old contact (under-five, high risk of rapid progression), and finding and treating the infectious source adult. Names the principle that children are infected by an undiagnosed household adult and that closing the transmission loop protects the next child. [1]

Examiners' notes for full marks

A distinction candidate will lead with the spectrum (exposure, infection, disease), name severity as a treatment decision (4-month SHINE for non-severe, 6-month for severe), and treat tuberculous meningitis on suspicion with corticosteroids. The candidate will use a trained interpreter for the family, will not invent exact doses but will point to WHO/NICE weight-band guidance, and will make notification, contact tracing and source-case finding explicit as core responsibilities rather than afterthoughts. [7] [6]

Anticipated pitfalls

• Misclassifying the child (treating disease as mere infection, or withholding treatment for a negative Xpert in paucibacillary disease). [5]
• Missing tuberculous meningitis in its prodrome by waiting for confirmation before treating. [6]
• Prescribing a 6-month regimen when non-severe disease qualifies for the 4-month SHINE regimen, or under-dosing by not re-weighing. [7]
• Failing to notify, trace contacts and give presumptive preventive therapy to the under-five contact. [1]
• Using a child or untrained family member as interpreter, or inventing exact mg/kg doses rather than pointing to national guidance. [1]