CASE CONFERENCEAng, Kevin

Aningalan, ArvinAntonio, Aby

Aramburo, JanCruel, Anna

General Data

• J.R.• 1 yr and 11 mos, Female• Santa Cruz, Manila• Filipino, Roman Catholic• Informant: Mother• Reliability: good

History of Present Illness• Mother palpated multiple movable, firm,

non-tender masses over lateral aspects of neck

• No other symptoms noted• No consult was done

6 weeks PTC

History of Present Illness• Patient experienced intermittent low-

grade fever (37.8°C), occurring at night time, not relieved by intake of Paracetamol

• No accompanying symptoms– no anorexia– no weight loss– no cough– no colds– no medications given

no consult done

2 weeks PTC

History of Present Illness• Patient experienced cough and colds

with clear discharge • (-) anorexia• (-) weight loss• (-) difficulty of breathing

8 days PTC

History of Present Illness• Patient sought consult at OPD

– (+) boggy turbinates– (+) multiple cervical lymphadenopathy,

movable, firm, non-tender over lateral aspects of neck

• Assessment: to r/o PTB• Plans: PPD, CXR, to follow-up with

results

5 days PTC

History of Present Illness• PPD test: 10mm• Chest X-Ray PA and Lateral: suggestive of

Primary Koch’s

Consult

Review of Systems(-) weight loss, (-)anorexia(-) itchiness, pigmentation, rash, active dermatoses(-) blurring of vision, redness, itchiness, Iacrimation(-) deafness, tinnitus, aural discharge(-) anosmia, epistaxis, sinusitis, nasal discharge(-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion(-) chest pain, nocturnal dyspnea, palpitation, syncope, edema(-) phlebitis, varicosities, claudication(-) dysphagia, nausea, vomiting, retching, hematemesis, melena,

hematochezia, belching, indigestion, diarrhea, constipation(-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia (-) joint stiffness, joint pain, muscle pain, cramps(-) heat-cold intolerance, polydipsia, polyphagia, polyuria(-) headache, depression, seizures

Past Medical HistoryNo Previous SurgeriesPast Medical Illnesses– Acute pyelonephritis (January 2009)– Acute rhinitis (February 2009)– Acute nasopharyngitis, probably viral (September 2009)

Immunizations: complete Hepa B1,2,3 Hib 1,2,3 MMR DPT 1,2,3 booster BCG OPV 1,2,3 booster Measles Allergies: none

Family History

(+) Hypertension – mother(+) DM – grandfather(+) PTB – uncle who stays at home with patient(-) Cardiovascular diseases, stroke

Family Profile

Family Age Occupation Health Status

Father: V.R. 34 Seaman Healthy

Mother: M.R. 31 Housewife Healthy

Sister: L.R. 4 N/A Healthy

Gestational and Birth History

• Patient born to a 31 y/o G2P1 unemployed housewife married to a 34 y/o seaman

• With regular prenatal check-up since 7 weeks AOG.

• Denied illnesses during the entire pregnancy• Outcome was live term singleton female

delivered via NSD AS 8,9 MT 38-39 wks AGA BW 3.01 BL 47 HC 33.5 CC 31.5 AC 30.

• No complications

Socioeconomic and Environmental History

Physical ExaminationGeneral Survey: Awake, alert, not in cardiorespiratory distress, well-nourished, well-hydratedVital Signs: HR 90bpm RR 20cpm T 36.7oC Anthropometric Data: 82.5cm (Z score above 0) Weight: 15kg (Z score above 0) HC: 48 cm WFL: above zero Skin: Warm moist skin, no rashes, no jaundice, no active dermatosisHead: Normocephalic, pink palpebral conjunctiva, anicteric sclera, isochoric pupils, midline septum, no alar flaring, (+) nasoaural discharge, turbinates congested, no oral ulcers, moist buccal mucosa, non-hyperemic pharyngeal wall, tonsils not enlarged, no aural pits or tags, no tragal tenderness, nonhyperemic EAC, intact TM, AU

Physical Examination

Adynamic precordium, apex beat at 4th LICS, MCL, no lifts, no heaves, no thrills, S1>S2 at the apex, S2>S1 at the base, (-) S3, (-) murmurs

Supple neck, (+) multiple cervical lymphadenopathies, trachea at midline

Symmetrical chest expansion, no barrel chest, no supraclavicular retractions, clear breath sounds, (-) wheezes, (-) crackles

Abdomen flabby, no scars, normoactive bowel sounds, tympanitic all over, no direct or rebound tenderness, no masses

Salient FeaturesSUBJECTIVE OBJECTIVE

1 year and 11 mos, FemaleExposure to PTB disease at home(+) 2 week duration of intermittent low-grade fever (37.8°C), occurring at night time(+) 8 day duration of cough, colds, clear discharge

(+) multiple cervical lymphadenopathies in lateral aspects of neckPPD: 10mmCXR suggestive of Primary Koch’s infection

Approach to Diagnosis

Presenting Manifestation• 2 week history of intermittent low grade fever (37.8 C),

occurring at night time• 8 day history of cough and colds• (+) multiple cervical lymphadenopathies• Exposure to PTB• PPD test: 10mm• Chest X-Ray PA and Lateral: suggestive of Koch’s infection

Approach to Diagnosis

• A presenting manifestation pointing to the least number of diseases

• Fever + Cervical Lymphadenopathy– PTB– Group A Strep Pharyngitis– Lymphoma– Kawasaki disease

Patient Lymphoma Group A Sreptococcal infections

Kawasaki Disease

Mycobacterial

2 weeks FeverColds

Fever, night sweats, weight loss

Fever, sorethroat

At least 5 days of feverChanges in extremitiesChanges in lips and oral cavity

Fever/ cough > 2 weeksPoor weight gain

•movable, firm, non-tender R lateral aspect of neck•Congested nasal turbinates•Tonsils not enlarged

•Very firm, rubbery nodes

•Cervical nodes warm, erythematous, and tender•Pharyngeal exudates

Unilateral cervical lympadeonopathy

•Painless, firm/matted cervical nodes

Primary Tuberculosis Infection

• Epidemiology: TB is endemic in the Philippines• The majority of children with tuberculosis

infection develop no signs or symptoms at any time.

• Non-specific signs & symptoms

Signs and Symptoms

• Cough of more than 2 weeks duration• Fever of more than 2 weeks duration • Painless cervical and/or other

lymphadenopathies• Poor weight gain• Failure to make a quick return to normal

health after infection• Failure to respond to appropriate antibiotics

Tuberculin Skin test

• Screening test of high risk individuals• Used to determine– Latent TB infection– Infected persons

• Measure of a person’s cellular immune responsiveness

Interpretation

• ≥ 5mm – Non BCG vaccinated– < 5 years old

• ≥ 10mm – BCG vaccinated– < 5 years old with positive exposure

• ≥ 15mm – > 5 years old with or without BCG

Tuberculosis Disease

At least 3 of the following:• (+) exposure to PTB• (+) TST• Clinical signs and symptoms of PTB• Radiographic Findings of PTB

Assessment

• Pulmonary Tuberculosis Disease

Tuberculin Skin TestInduration of 10 mm or more is considered a positive

TST result in the following children: • Children who are at a higher risk of dissemination of

tuberculous disease, including those younger than 5 years or those who are immunosuppressed because of conditions such as lymphoma, Hodgkin disease, diabetes mellitus, and malnutrition

• Children with increased exposure to the disease, including those who are exposed to adults in high-risk categories (eg, homeless, HIV infected, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized persons); those who were born in or whose parents were born in high-prevalence areas of the world; and those with travel histories to high-prevalence areas of the world

Treatment Plans

Curative:– Isoniazid 200mg/5ml, 1.5 ml (5mg/kg/d) OD– Rifampicin 200mg/5ml, 3 ml (10mg/kg/d) OD– Pyrazinamide 250mg/5ml, 3.5 ml (15mg/kg/d) OD– Streptomycin 1g/2ml, 0.5 ml IM (22mg/kg/d) OD

– Refer to DOTS– Refer to ENT

Treatment Plans

• Supportive– Multivitamins– Dietary advice given

Preventive– Advise the patient to strictly comply and complete the

regimen – Anticipatory guidelines– Follow-up on vaccination– Avoid overcrowded and unsanitary areas

• Follow up after 2 weeks

First Line Anti-TB drugs

• Isoniazid(H)• Rifampicin(R)• Pyrazinamide(Z)• Streptomycin(S)• Ethambutol(E)

Treatment

• a 6-month course of isoniazid (INH) and rifampin, supplemented during the first 2 months with pyrazinamide.

• Because poor adherence to these regimens is a common cause of treatment failure, directly observed therapy (DOT) is recommended for treatment of tuberculosis.

Treatment

Treatment

BRIEF DISCUSSION OF THE DIAGNOSIS

Tuberculosis

• Mycobacterium tuberculosis is the most important cause of tuberculosis disease in humans.

• Other causes include: M. bovis, M. africanum, M. microti, M. Canetti.

Latent Tuberculosis infection

• Occurs after inhalation of infective droplet nuclei containing Mycobacterium tuberculosis.

• Reactive tuberculin skin test (TST) and absence of clinical and radiographic manifestation are the hallmark of this stage

• Disease occurs when signs and symptoms and radiographic changes become apparent

• Untreated LTB have up to 40% likelihood of developing TB in children.

Transmission• Person to person• By airborne mucus droplet 4-5um in diameter• Increased when patient has positive AFB smear, extensive

upper lobe infection/cavity, copious production of thin sputum and severe and forceful cough

• Young children rarely infect others because tubercle bacilli are sparse in the endobronchial secretions of children with PTB and cough is often absent or lack tussive force required to suspend infectious particles for transmission.

Pathogenesis

• Primary complex includes local infection at the portal of entry and the regional lymph nodes that drain the area

• Tubercle bacilli multiply initially within the alveoli and alveolar ducts, most of the bacilli are killed, but some survive within nonactivated macrophages, which carry them through lymphatic vessels to the regional lymph nodes.

• Tissue reaction in the lung parenchyma and lymph nodes intensifies over the next 2-12 weeks.

• The parenchymal portion of the primary complex often heals completely by fibrosis or calcification after undergoing caseous necrosis and encapsulation.

Tuberculin Skin Testing (TST)• The development of delayed type hypersensitivity

reaction in most individuals infected with tubercle bacillus makes the TST a useful diagnostic tool.

• The Mantoux Tuberculin Skin Test is the intradermal injection of 0.1mL containing 5 tuberculin units of purified protein derivative (PPD.

• T cells sensitized by prior infection are recruited to the skin where they release lymphokines that induce induration through local vasodilatation, edema, fibrin depositon and recruitment of other inflammatory cells to the area.

• TST should be read by a trained person 48-72 hours after administration.

• Occasional patients will have the induration >72 hours after placement, this is also a positive result.

• Immediate hypersensitivity reaction are shortlived (<24 hours) and are not considered a positive result.

• Tuberculin sensitivity develops 3 weeks to 3 months after inhalation of organism

• Factors that can depress skin test reaction:– Very young age– Malnutrition– Immunosuppresion– Viral infection– Vaccines with live virus– Overwhelming tuberculosis

• False positive reaction to TST can be caused by cross sensitization to antigens on non tuberculous mycobacteria

• Previous BCG (Especially if 2 doses of BCG are already given)

• In general, a > or equal to 10mm in a BCG vaccinated child indicates infection

Tuberculin Skin Test

• Induration of 5 mm or more is considered a positive TST result in the following children:

• Children having close contact with known or suspected contagious cases of the disease, including those with household contacts with active tuberculosis whose treatment cannot be verified before exposure • Children with immunosuppressive conditions (eg, HIV)

or children who are on immunosuppressive medications • Children who have an abnormal chest radiography

finding consistent with active tuberculosis, previously active tuberculosis, or clinical evidence of the disease

Tuberculin Skin TestInduration of 10 mm or more is considered a positive

TST result in the following children: • Children who are at a higher risk of dissemination of

tuberculous disease, including those younger than 5 years or those who are immunosuppressed because of conditions such as lymphoma, Hodgkin disease, diabetes mellitus, and malnutrition

• Children with increased exposure to the disease, including those who are exposed to adults in high-risk categories (eg, homeless, HIV infected, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized persons); those who were born in or whose parents were born in high-prevalence areas of the world; and those with travel histories to high-prevalence areas of the world

Tuberculin Skin Test

• Induration of 15 mm or more is considered a positive TST result in children aged 5 years or older without any risk factors for the disease

Clinical Manifestations

• Majority develop no signs or symptoms• Occasionaly, with low grade fever and mild

cough• Rarely with high fever, cough, malaise and flu

like symptoms.

Primary Pulmonary Disease

• Primary complex includes parenchymal pulmonary focus and regional lymph nodes

• Initial parenchymal inflammation is usually not visible on chest radiograph

• Hallmark of primary tuberculosis in the lungs is the relatively large size of regional lymphadenitis compared with the relatively small size of the intial lung focus

• Usual sequence is hilar lymphadenopathy, focal hyperinflation, and then atelectasis– The resulting radiographic shadows has been

called collapse-consolidation• The symptoms and physical signs of primary

pulmonary tuberculosis in children are meager considering the degree of radiographic changes seen

• Non-productive cough and mild dyspnea are the most common symptoms

• Systemic complaints such as fever, and night sweats are seen less often

• Pulmonary signs are even less common.

Diagnosis

• Most specific confirmation of pulmonary TB is isolation of Mycobacterium tuberculosis

• For infants who can’t expectorate sputum, a jet nebulizer, chest percussion followed by nasopharngeal suctioning can be done.

• The traditional culture specimen is the early morning gastric acid obtained just before the child has arisen

• However, 3 consecutive morning gastric aspirate yield organism in only less than 50% of cases

• Negative culture should never exclude the diagnosis in children

• Diagnosis can be made if:– Positive TST– Abnormal chest radiograph findings suggestive of TB– History of exposure

Treatment

• Insert table from NElsons