Child's silhouette filled with lung X-ray landscape showing TB bacteria.

Hidden Threat: Tuberculosis Masquerading as Pneumonia in Vulnerable Children

Elliot Brynn in Health & Wellness December 2025 • 4 min read.

"A review highlights the critical need to consider TB when treating pneumonia in malnourished and HIV-infected children, urging for increased vigilance and targeted research."

Pulmonary tuberculosis (PTB) presenting as acute pneumonia in children with severe malnutrition and HIV has been largely overlooked, but this is a critical concern, especially in areas where TB is widespread. Diagnosing and managing childhood pneumonia requires vigilance, particularly in these vulnerable populations.

Aims were to investigate instances of confirmed tuberculosis (TB) in children who presented with acute pneumonia, HIV infection, and/or severe acute malnutrition (SAM). Severe acute malnutrition was defined by a weight-for-length/height or weight-for-age z score of less than -3 based on the WHO median, or the presence of nutritional edema.

A literature search was conducted using PubMed and Web of Science in April 2013, covering the period from January 1974 through April 2013. The review focused on studies that reported confirmed TB, identified through smear microscopy for acid-fast bacilli (AFB) or culture-positive specimens, in children with acute pneumonia and SAM and/or HIV infection. Specimens were collected via induced sputum (IS), gastric lavage (GL), broncho-alveolar lavage (BAL), or percutaneous lung aspirates (LA). Pneumonia was defined based on radiological evidence of lobar or patchy consolidation and/or clinical signs of severe/very severe pneumonia, according to WHO criteria for acute respiratory infections.

Why TB Often Hides Behind Pneumonia: The Diagnostic Challenge

Child's silhouette filled with lung X-ray landscape showing TB bacteria.

The review identified six relevant studies, encompassing 747 children under five, which determined the tubercular etiology of acute pneumonia in children with SAM and/or positive HIV status. Studies were reported from South Africa, The Gambia, Ethiopia, and Thailand. The total of 93 (12%) children with active TB were identified.

Key findings from the studies include:

South Africa: Among 610 HIV-infected children, 64 (10%) were identified with active TB.
Other Studies: Among 137 children with SAM (from studies outside South Africa), 29 (21%) were found to have M. tuberculosis.
Study Focus: The South African studies primarily involved HIV-infected children without specifying their nutritional status, while studies from other countries focused on children with SAM but without indicating their HIV status.

The results indicate that pulmonary tuberculosis may be more prevalent than commonly recognized in children presenting with acute pneumonia, SAM, or HIV infection. Given the limited data, there’s an urgent need for larger, carefully-conducted studies, particularly outside of Africa, to investigate PTB as a potential cause of acute pneumonia in these vulnerable populations.

The Urgent Call: What Needs to Happen Now?

This review underscores the critical need for increased investigation into TB, especially in children outside Africa, to accurately define the tubercular etiology of acute pneumonia. By improving our understanding and diagnostic capabilities, clinicians can make more informed decisions regarding PTB in vulnerable children, and policymakers can update management guidelines for acute pneumonia in children with SAM, ultimately reducing morbidity and mortality.

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This article is based on research published under:

DOI-LINK: 10.3329/jhpn.v31i3.16516, Alternate LINK

Title: Pulmonary Tuberculosis In Severely-Malnourished Or Hiv-Infected Children With Pneumonia: A Review

Subject: Health, Toxicology and Mutagenesis

Journal: Journal of Health, Population and Nutrition

Publisher: Springer Science and Business Media LLC

Authors: Mohammod Jobayer Chisti, Tahmeed Ahmed, Mark Ac Pietroni, Abu Sg Faruque, Hasan Ashraf, Pradip K Bardhan, Md Iqbal Hossain, Sumon Kumar Das, Mohammed Abdus Salam

Published: 2013-10-05

Everything You Need To Know

Why is it difficult to diagnose Tuberculosis (TB) in children?

Pulmonary tuberculosis (TB) can often mimic the symptoms of pneumonia, especially in children. This overlapping presentation makes it difficult to diagnose TB accurately. In children with severe acute malnutrition (SAM) or HIV infection, the likelihood of TB being the underlying cause of pneumonia increases, making a correct diagnosis crucial. It highlights the diagnostic challenges faced by clinicians when dealing with these vulnerable populations.

Why is it so important to diagnose Tuberculosis (TB) in children with pneumonia, severe acute malnutrition (SAM), or HIV?

The review emphasizes the importance of diagnosing Pulmonary tuberculosis (PTB) in children with severe acute malnutrition (SAM) or HIV infection because the treatments for pneumonia and TB are different. Failure to identify and treat TB correctly could lead to the disease progressing, causing severe complications, increased illness and even potentially death. Effective management of acute pneumonia in these children must include consideration of PTB.

What is Severe Acute Malnutrition (SAM), and why is it relevant in this context?

Severe acute malnutrition (SAM) is defined by a weight-for-length/height or weight-for-age z-score of less than -3 based on the WHO median, or the presence of nutritional edema. SAM weakens a child's immune system. This makes them significantly more susceptible to infections like Pulmonary tuberculosis (TB). The co-occurrence of SAM and TB complicates the diagnosis and treatment of pneumonia.

How was Pulmonary tuberculosis (TB) diagnosed in the studies mentioned?

The review focused on studies that reported confirmed Pulmonary tuberculosis (TB) through smear microscopy for acid-fast bacilli (AFB) or culture-positive specimens in children with acute pneumonia, severe acute malnutrition (SAM), and/or HIV infection. The literature search used PubMed and Web of Science. Specimens were collected using induced sputum (IS), gastric lavage (GL), broncho-alveolar lavage (BAL), or percutaneous lung aspirates (LA). Pneumonia was defined based on radiological evidence of lobar or patchy consolidation and/or clinical signs of severe/very severe pneumonia, according to WHO criteria for acute respiratory infections.

What are the main conclusions drawn from the review, and what actions are recommended?

The review's key finding is that Pulmonary tuberculosis (TB) is often overlooked as a cause of pneumonia in children with severe acute malnutrition (SAM) or HIV infection. The results show that TB may be more prevalent than previously thought. This requires larger, more thorough studies, especially outside of Africa. Policymakers can update management guidelines for acute pneumonia in children with SAM. Clinicians can make more informed decisions regarding Pulmonary tuberculosis (PTB) in vulnerable children, ultimately reducing morbidity and mortality.