Journal of the Pediatric Infectious Diseases Society 218 • JPIDS 2020:9 (June) • Sartoris et al INVITED REVIEW Received 7 August 2019; editorial decision 27 November 2019; accepted 6 December 2019; Published online January 7, 2020. Correspondence: Giulia Sartoris, Department of Paediatrics and Child Health, Clinical Building, Room 2109, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg, South Africa (giulia.sartoris@hotmail.it). Journal of the Pediatric Infectious Diseases Society 2020;9(2):218–27 © The Author(s) 2020. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. DOI: 10.1093/jpids/piz093 Abdominal Tuberculosis in Children: Challenges, Uncertainty, and Confusion Giulia Sartoris, 1,2 James A. Seddon, 1,3 Helena Rabie, 1 Etienne D. Nel, 1 and H. Simon Schaaf 1 1 Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; 2 Department of Pediatric Sciences, Giannina Gaslini Institute, University of Genoa, Italy; and 3 Department of Paediatrics, Imperial College London, London, United Kingdom e diagnosis of abdominal tuberculosis (TB) is challenging, and the prevalence of abdominal TB in children is likely under- estimated. It may present with nonspecific abdominal symptoms and signs, but children who present with pulmonary TB may have additional abdominal subclinical involvement. Diagnosis is specifically challenging because none of the available diagnostic tools provide adequate sensitivity and specificity. In this review, we summarize the best available evidence on abdominal TB in children, covering the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment. We propose a diagnostic approach that could be followed for symptomatic children. We believe that a combination of investigations could be useful to both aid diagnosis and define the extent of the disease, and we propose that abdominal ultrasound should be used more frequently in children with possible TB and any abdominal symptoms. is neglected disease has received little attention to date, and further research is warranted. Keywords: abdominal; children; gastrointestinal; tuberculosis. Even in an age of advanced imaging and modern molecular tests, the diagnosis and treatment of abdominal tuberculosis (TB) in children remains challenging. is has implications for clinicians who have to manage symptomatic children and for epidemiologists and health program managers who need to un- derstand the burden of this disease. Here, we review recent evi- dence and summarize our current understanding of abdominal TB in children. SEARCH STRATEGY We searched PubMed using the keywords (“‘abdom*’” AND “‘tuberc*’ AND ‘child*’”) in English, Italian, Spanish, and French, without date restrictions. We also reviewed the refer- ence lists of all articles identified to search for additional arti- cles and included any article known to be relevant by any of the authors. We found 537 articles from 1907 to 2019. Of these, 30 were relevant to our review. DEFINITIONS At the outset, we defined which anatomical structures are in- cluded as abdominal TB. For this review, we included the gastrointestinal system from the distal esophagus to the rectum, the peritoneum, and the intraperitoneal organs (liver and spleen), as well as the associated lymphatic drainage system. We also included the retroperitoneal portions of duodenum and pancreas because, embryologically, these structures develop intraperitoneally. We excluded any lesions that affect the gen- itourinary tract, the reproductive organs, or the psoas muscles. EPIDEMIOLOGY e peak incidence of abdominal TB is reportedly between the second and fourth decades [1–5], with only 10%–20% of ab- dominal TB cases occurring in children [4, 6]. Abdominal TB is infrequently diagnosed in young children; it represents ap- proximately 1%–3% of all TB cases and 12% of extrapulmonary disease in children aged <15 years [6–9]. ese figures are probably underestimates due to nonspecific presentation that mimics other conditions or abdominal involvement that passes unnoticed in the presence of pulmonary TB. Furthermore, ul- trasound or other imaging, invasive sampling, and culture for microbiological confirmation are oſten not available in settings with high TB burden. In the prechemotherapy era, the majority of pediatric ab- dominal TB cases occurred in young children (<5 years) [10], which is similar to more recent South African studies [1, 11–13]. In contrast, other studies from India, Taiwan, Turkey, and Tunisia showed older mean ages that ranged from 9.5 to 14.7 years [14–18]. Many immunological changes occur with age and between the sexes, particularly around puberty [19]. However, differences in disease risk or disease phenotype have not been demonstrated between the sexes [7, 14–18]. Downloaded from https://academic.oup.com/jpids/article/9/2/218/5697911 by guest on 08 June 2022