Case ReportPulmonary Tuberculosis

Putri Laura

Patient Identity

• Name: S• Age: 3 years 8 months• Sex : Famale• Parent’s name: Mr. A• Religion : Islam• Address : Waled

History Taking

• Chief ComplaintThe patient complained of cough.

• History of Present IllnessA three year old girl admitted to RSUD Waled with three

week history of cough. His mother said that his presistent cough ,no phlegm with blood and intermittent fever, the fever is raised slowly. That was not associated with shortness of breath, wheezing. Headache (-), nausea (-), vomiting (-). • Past Medical History

Referring to the statements made by his mother the patient, Pulmonary TB history denied and History of asthma denied.

• Familial HistoryHistory of asthma denied, his grandmother suffered from

pulmonary tuberculosis since 6 month ago.• Pregnancy history:

• regular ANC midwife• History of disease during pregnancy (-)• Consumption of drugs during pregnancy (+) à drugs given midwife (vitamins)

• History of birth:• Spontaneous Birth attended by midwives, quite a month and started to cry.• BBL: 3300 g• PBL: 49 cm

• History of food: breast milk since the age of 0-18 months formulas since the age of 18 months - 36 months Additional food (porridge team) is given from the age of 4 monthsImpression: The food according to age

• Immunization history:• Hepatitis 3x• BCG 1x• Polio 4x• DPT 3x• Measles 1x impression of complete primary immunization

• History Growth:• Stomach age of 3 months• Crawling age of 5 months• Sit the age of 7 months• Walk the age of 12 months

• Allergy History:• Allergy Air (-)• Milk Allergy (-)• Food allergies (-)• Allergy medications (-)• Allergy to dust (-)

• General : looks ill being• Awareness : Compos Mentis• Vital sign

T :38 cP :120x/mB :26 x/m

General

• Head: NormochepalEyes: Conjunctival pallor - / -, sclera jaundice - / -, eyelid edema (-), sunken eyes (-/-)Nose: Nostril Breathing (-), septal deviation (-), discharge (- / -), blood (- / -)Ears: Normotia, secretions (- / -)Mouth: Dry Lips (-), dirty tongue (-), bleeding gums (-), Tonsil T1 / T1, pharyngeal hyperemia (-)Neck: Enlarged lymph nodes (-), enlargement of the thyroid gland (-)

• ChestPulmoInspection: symmetrical chest, there is no retraction of the chest wallPalpation: vocal fremitus symmetrical right and left, nothing left part of the chest wallPercussion: resonant throughout the lung fieldsAuscultation: vesicular, Wheezing - / -, Crackles - / -

• The HeartInspection: ICTUS cordis not seemPalpation: ICTUS cordis palpable in the left midclavicula ICS 5 lineaPercussion: right and left heart border within normal limitsAuscultation: BJ I and II pure, murmur (-), gallops (-)

• AbdomenInspection: Abdominal distension (-), ascites (-)Auscultation: bowel (+) normalPalpation: Hepatosplenomegaly (-), epigastric tenderness (-)Percussion: Timpani throughout the quadrant of the abdomen

• Extremityup and downCyanosis: - / - - / -Akral cold: - / - - / -Edema: - / - - / -RCT: <2 “ <2"Petechiae: - / - - / -

• Inguinal: inguinal gland enlargement (-)

• Genitalia: No abnormalities

• PPD skin test had 16mm of induration at 48 hours.

• Radiologychest radiography

DIFFERENTIAL DIAGNOSTIC• Pulmonary Tuberculosis• Bronkopneumonia

WORKING DIAGNOSTIC• Pulmonary Tuberculosis

Theraphy

• Isoniazid syr 1 dd 1 cth• Rifampicin 150mg mf dtdpulvdd 1 pulv• Pirazinamid 250mg mf dtdpulvdd 1 pulv

Pulmonary Tuberculosis

Overview of Tuberculosis

• Tuberculosis (TB) is the most common cause of infection-related death worldwide. In 1993, the World Health Organization (WHO) declared TB to be a global public health emergency.

• Tubercle bacilli belong to the order Actinomycetales and family Mycobacteriaceae.

TB Risk Factors

• Risk factors for the acquisition of tuberculosis (TB) are usually exogenous to the patient. Thus, likelihood of being infected depends on the environment and the features of the index case. However, the development of TB disease depends on inherent immunologic status of the host.

• Tuberculosis has been reported in patients treated for arthritis, inflammatory bowel disease, and other conditions with tumor necrosis factor (TNF)-alpha blockers/antagonists

Mechanism of TB Infection

• Tuberculosis (TB) occurs when individuals inhale bacteria aerosolized by infected persons. The organism is slow growing and tolerates the intracellular environment, where it may remain metabolically inert for years before reactivation and disease. The main determinant of the pathogenicity of TB is its ability to escape host defense mechanisms, including macrophages and delayed hypersensitivity responses.

TB Incidence and Prevalence

• Globally, the World Health Organization (WHO) reports more than 9 million new cases of tuberculosis (TB) occur each year,and an estimated, 19-43.5% of the world's population is infected with M tuberculosis.This disease occurs disproportionately among disadvantaged populations, such as homeless individuals, malnourished individuals, and those living in crowded areas. Most cases of TB occur in the South-East Asia (35%), African (30%), and Western Pacific (20%) regions

Asymptomatic infection

• Patients with asymptomatic infection have a positive tuberculin skin test (TST) result, but they do not have any clinical or radiographic manifestations. Children with asymptomatic infection may be identified on a routine well-child physical examination, or they may be identified subsequent to TB diagnosis in household or other contacts (eg, children who recently have immigrated, adopted children).

• Primary TB is characterized by the absence of any signs on clinical evaluation. As discussed above, these patients are identified by a positive TST result. Tuberculin hypersensitivity may be associated with erythema nodosum and phlyctenular conjunctivitis.

Parameter 0 1 2 3Contact Not clear BTA - - BTA +

Tuberculine test

- - - positif

Body weight - Below red line or stunting

Poor nutritional status

-

Fever of unknown origin

- + - -

cough <3 weeks >3 weeks - -

lymphadenopathy

- ≥1cm, >1cm pain (-)

- -

arthritis - + - -

Thoraks radiography

normal suspicious - -

Theraphy

• INH : 5-15mg/kg/day, max. 300mg/day• Rifampicin: 10-20 mg/kg/day, max. 600mg/day• Pirazinamid: 15-30 mg/kg/day. Max

2000mg/day• Etambutol: 15-20 mg/kg/day. Max 1250mg/day• Streptomicin: 15-40 mg/kg/day. Max 1000

mg/day

FDC ( Fixed Dose Combination) Body weight 2 month/day

RHZ (75/50/150)4 month/day RH (75/50)

5-9 1 tab 1 tab

10-14 2 tab 2 tab

15-19 3 tab 3 tab

20-32 4 tab 4 tab

• Thanks…..