150 AJTCCM VOL. 30 NO. 4 2024
EDITORIAL
Non-cystic brosis (CF) bronchiectasis remains a common condition
in many paediatric pulmonology clinics in low- to middle-income
country (LMIC) settings. Most of these children only present to
a hospital when they have severe disease, usually because of an
acute exacerbation. Given the severity of the disease at this stage,
it is dicult, and oen nearly impossible, to identify its cause and
timeline.
In children living with HIV (CLWH), it is easier to understand
the pathogenesis, as these children are prone to recurrent infections,
have a slow response to antibiotic treatment and have reduced
immunity, and certain decisive diseases, such as lymphoid interstitial
pneumonia, are well known to cause bronchiectasis.
[1]
In the developing world, respiratory tract infections and tuberculosis
(TB) have always been speculated to cause bronchiectasis, but this
remains mostly unproven. In very few aected children, the original
infection is known, or they had a previous normal chest radiograph
(CXR) to base this assumption on.
TB has long been identied and made a scapegoat as the cause of
bronchiectasis. In adolescent children, this may be the case, as they
can present with cavities and structural parenchymal lung disease
similar to adults, especially if bilateral. In younger children, this is
not clear, as most young children with TB have lymph node disease
and not severe destructive disease. Goussard et al.
[2]
have reported a
small percentage (2.4%) of children with bronchiectasis in a cohort
of 250 children with severe airway obstruction. e children who did
develop bronchiectasis were either HIV positive or had a broncho-
oesophageal stula to the le main bronchus, leading to chronic
aspiration. Children with expansile pneumonia may be considered
high-risk candidates for bronchiectasis, but even among these,
very few will develop bronchiectasis. Expansile pneumonia mostly
aects the upper lobes with better drainage and heals with brosis.
[3]
So which TB children are then at high risk for bronchiectasis?
Juggernath et al.
[4]
reported that 86% of children were presumed
to have a post-infectious cause of bronchiectasis, which was based
on a previous history of a severe lower respiratory tract infection.
Other causes included inborn errors of immunity (4%), secondary
immune deciencies (4%) or primary ciliary dyskinesia (PCD) (6%).
ey reported that 67 children (74%) had previously been treated for
pulmonary TB (PTB), with only 5 (7%) of these having conrmed
PTB. In this study, 42% of the children were CLWH, which highlights
the diculty in diagnosing TB in children, but also suggests that not
all chronic lung diseases are due to TB.
In a high-incidence area for TB and HIV, TB is underdiagnosed
but also overdiagnosed, which makes it extremely dicult to nd
the correct cause of bronchiectasis. Except for CF, PCD, HIV and
immunodeficiency, the rest of the causes of bronchiectasis are
very dicult to identify, and bronchiectasis is typically blamed on
infectious diseases. Post-adenovirus bronchiolitis obliterans is a
disease with a high incidence in LMICs. It can only be diagnosed on a
chest computed tomography (CT) scan. Depending on the severity of
the insult, there may be mosaic diusion and areas of bronchiectasis
visible on the CT scan.
[5]
is cause of bronchiectasis is relatively
easy to diagnose based on the history of severe adenovirus infection
and the CT scan changes. e same applies to hydatid disease, which
very infrequently is reported as a cause of bronchiectasis, especially
in children with complicated, ruptured and infected cysts.
[6]
Children from LMICs live in a dierent environment to those in
the developed world; they have higher biofuel and cigarette smoke
exposure, are more prone to recurrent infections, and receive fewer
vaccinations. So, the simple question is, is it the chicken or the egg
situation? Van der Zalm et al.
[7]
have recently reported on adolescents
with and without TB; evaluating their lung function, they found a
significant number who had not had TB having abnormal lung
function.
Prospective long-term cohort studies are necessary to determine
the long-term growth, lung function and structural outcome of
these children with more sophisticated biomarkers, looking at the
underlying reason why children in LMICs develop bronchiectasis
without a clear cause.
Treatment of bronchiectasis in children remains mostly
conservative, such as infection prevention, vaccination and
physiotherapy. Physiotherapy services are lacking in South Africa
(SA), and the number of patients who can be treated remains
limited. Parents must be trained, as physiotherapy devices are far
too expensive. Azithromycin is used in most of these children with
bronchiectasis, but evidence as to its value remains lacking.
[8]
Surgery remains an option if children full the criteria of lobar, non-
bilateral disease, but except for HIV-positive children, the numbers
of children having a lobectomy performed for bronchiectasis have
signicantly decreased. In the Tygerberg Hospital system, there has
been a signicant decline in recent years, which could be due to the
more conservative, supportive treatment these children now receive.
So, before we blame TB as an important cause of bronchiectasis,
more information is needed. Without microbiological conrmation,
TB remains unproven and cannot be blamed as the cause of the child’s
bronchiectasis owing to many overlapping radiological presentations
of other conditions. It is also important to make clear notes on what
appeared on the CXR that suggested TB, as this will be useful when
the child is seen in a later stage. SA lacks a universal picture archiving
and communication system for the whole country, leading to the loss
of some of these children’s original CXRs.
Currently, the jury is still out on whether TB can be blamed as
the cause of many children’s bronchiectasis, and more research is
needed before TB can be given a life sentence. What is clear from
the Juggernath et al.
[4]
study is that preventing HIV will reduce the
incidence of bronchiectasis in the developing world.
What is the main cause of childhood non-cystic brosis
bronchiectasis in the developing world – should pulmonary
tuberculosis be the number one accused?
AJTCCM VOL. 30 NO. 4 2024 151
EDITORIAL
Pierre Goussard, FC Paed (SA), PhD
Head of Clinical Unit: Paediatric Pulmonology and Paediatric Intensive Care,
Department of Paediatrics and Child Health, Faculty of Medicine and Health Sci-
ences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
pgouss@sun.ac.za
Ernst Eber, MD, ATSF, FERS
Head of Division of Paediatric Pulmonology and Allergology and Chair of
Department of Paediatrics and Adolescent Medicine, Medical University of
Graz, Austria
1. eron S, Andronikou S, George R, et al. Non-infective pulmonary disease in HIV-
positive children. Pediatr Radiol 2009;39(6):555-564. https://doi.org/10.1007/s00247-
009-1156-2
2. Goussard P, Gie RP, Janson JT, et al. Decompression of enlarged mediastinal lymph
nodes due to Mycobacterium tuberculosis causing severe airway obstruction
in children. Ann Thorac Surg 2015;99(4):1157-1163. https://doi.org/10.1016/j.
athoracsur.2014.12.042
3. Goussard P, Gie RP, Kling S, Beyers N. Expansile pneumonia in children caused by
Mycobacterium tuberculosis: Clinical, radiological, and bronchoscopic appearances.
Pediatr Pulmonol 2004;38(6):451-455. https://doi.org/10.1002/ppul.20119
4. Juggernath P, Mopeli K, Masekela R, et al. Bronchiectasis in children in a high HIV
and tuberculosis prevalence setting. Afr J oracic Crit Care Med 2024;30(4):e1899.
https://doi.org/10.7196/AJTCCM.2024.v30i4.1899
5. Flanagan F, Casey A, Reyes-Múgica M, Kurland G. Post-infectious bronchiolitis
obliterans in children. Paediatr Respir Rev 2022;42:69-78. https://doi.org/10.1016/j.
prrv.2022.01.007
6. Goussard P, Eber E, Mngwana L, et al. Paediatric pulmonary echinococcosis: A
neglected disease. Paediatr Respir Rev 2022;43:11-23. https://doi.org/10.1016/j.
prrv.2021.11.001
7. Van der Zalm MM, Jongen VW, Swanepoel R, et al. Impaired lung function
in adolescents with pulmonary tuberculosis during treatment and following
treatment completion. EClinicalMedicine 2024;67:102406. https://doi.org/10.1016/j.
eclinm.2023.102406
8. Valery PC, Morris PS, Byrnes CA, et al. Long-term azithromycin for indigenous
children with non-cystic-brosis bronchiectasis or chronic suppurative lung disease
(Bronchiectasis Intervention Study): A multicentre, double-blind, randomised
controlled trial. Lancet Respir Med 2013;1(8):610-620. https://doi.org/10.1016/
S2213-2600(13)70185-1 (Erratum in: Lancet Respir Med 2015;3(8):e29. https://doi.
org/10.1016/S2213-2600(15)00277-5)
Afr J Thoracic Crit Care Med 2024;30(4):e2884. https://doi.
org/10.7196/AJTCCM.2024.v30i4.2884
