crparu

No Registration : 1871015.00.125655

Entering RSAM : 1 – March -2011 Time 15:30 p.m

PATIENT’S IDENTITY

Name : Mrs. M

Age : 48 years old

Status : Married

Occupation : Housewife

Address : Negeri Sakti, Bandar Lampung

Tribe : Lampungnesse

Religion : Moeslem

Education : Elementary school

Anamnese :

Taken from autoanamnese in 2 March 2011 on 14.00 a.m

Disease History

Chief complaint : bloody cough

Addition complaint : breathless, decrease appetite, loss weight, night sweat

Patient Disease History :

Patient came because she was coughing up blood since 1 day before she went to

the hospital. The fresh blood was mixed with sputum. As the patient prediction,

the total ammount of blood is a half of glass (150cc). She was coughing so hard

before she expetorating the blood. She also feel so breathless since that. She feel

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breathless since 7 days ago, and become more severe, even she was resting in

previous 2 day.

Since 7 months ago, the patient has cough, usually are’nt productive and happen

all the day. She often sweating at night and had low grade fever (subfebris).

Patient appetite also decrease and she lost 13 kg of bodyweight in two months

(from 53 to 40 kg).

She was never smoking or inhale excessive polution. She had no alergic history.

There was no one of her family had similar symtoms like her. She never got

tuberculosis treatment before.

Physical Examination

Present Status

- Generality : Moderate ill appearence

- Awareness : Compos Mentis

- Blood Pressure : 130/80 mmHg

- Pulse : 80 x/minute, regular

- Respiration rate : 28 x/minute,

- Temperature : 36,7 º C

- Weight : 40 kg

- High : 150 cm

- Nutrition status : under weight

- Cyanosis : none

- Edema : none

- Habitus : Asthenikus

- Mobility : active

Mental Status

2

- Behaviour : Fair

- Feeling : Fair

- Thought process : Fair

Generalist Status

Skin

- Colour : dark

Head

- Face expression : moderate ill appearance

- Form : Symetric, normocephali

- Eye : Conjunctiva ananemic, sclera anikterik,

isochors pupil, reflex light (+/+),

- Ear : Spacious cave, cerumen (-)

- Nose : There’s no respiration of nose lobe, septum deviation (-), secret

(-/-), mucosa hyperemic (-)

- Mouth : pursed lips breathing (-), lips cyanosis (-), dirty tongue (-),

- Faring hyperemic (-), Tonsil T1-T1

Neck

- Form : Symetrical

- Lymph node : There’s no enlargement

- JVP : Not increased (5 cmH2O)

-

THORAX

Lungs

- Inspection

3

Static : symetrical

Dynamic : Thoraco abdominal breath movement, right slower

than left

Rib enlargement : Left right (-/-)

Rib retraction : Left right (-/-)

- Palpation : left fremitus tactile stronger than right

- Percussion : dulness from 3rd ICS to basal area of the right lung,

and Sonor on the other area of lung.

- Auscultation : vesiculer sound of the right lung weaker than left

lung, wet soft ronchi -/+, wheezing -/-

Heart

- Inspection : Ictus cordis invisible

- Palpation : Ictus cordis is touched in fifth ICS left linea

midclavicula

- Percussion : Up Boundary the inter costae space III left

parasternal

Right Boundary the inter costae space V left

parasternal

Left Boundary the inter costae space V left

midclavicula

- Auscultation : Sound of Heart I-II regular, murmur (-), gallop (-)

Abdomen

- Inspection : Stomach look flat and symmetric

4

- Palpation : Distence of Stomach (-), No depress pain of

stomach, liver and lien are not touched

- Percussion : Tympani in entire field of abdomen

- Auscultation : Bowel sound (+)

Externa Genitalia

- Sex : didn’t inspected

Extremity

- Superior

Muscle : Right Left

Tonus : eutoni eutoni

Mass : eutrophi eutrophi

Joint : pain (-) pain (-)

Movement : active active

Strenght : 5 5

- Inferior

Right Left

Injury : none none

Varicess : none none

Muscle (tonus and mass): normal, no mass normal, no mass

Joint : pain (-) pain (-)

Movement : passive passive

Refleks :

5

Right Left

Bisep + +

Trisep + +

Patella + +

Archilles + +

Skin Reflex + +

Patology Reflex - -

Supportive Examination

1. Thorax photograph has been taken on march,1st 2011

- opaq homogen appereance in right lung, suggesting right pleural effusion

- infiltrate and cavity like appearance in apex area of both lung

2. Laboratory :

1. Blood routine taken on march 2nd 2011

- Hb : 10 g/dl (13,5-18 g/dl)

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- Leucocytes : 6800/ µl (4500-10700/µl)

- Differential count: 0/0/0/58/30/12

- LED : 46 mm/hour

- SGOT : 19 U/L ( 6-30 U/L )

- SGPT : 8 U/L ( 6-45 U/L )

- Ureum : 30 mg/dl (10-40 mg/dl)

- Creatinin : 0,7 mg/dl (0,9-1,5 mg/dl)

- GDS : 83 mg/dl ( < 200 mg/dl)

2. Sputum Analysis (AFB) = -/-/-

3. Pleural fluid analysis = rivalta test (+) (March 4th )

Working Diagnose and Base of Working Diagnose

1. Working Diagnosis

New Case,Wide lesion ,AFB (acid fast bacilli) -/-/- lung tuberculosis with

right pleural effusion and hemoptoe

2. Base of Working Diagnose

From Anamnese :

Patient with chief complaint Patient came to hospital and complained of

coughing up blood with breathlessness. the symptom she feel since 6 to 7

month ago and followed by history of chronical cough, decrease of

appetite, lost 13 kg of weight, sweat at night and febris. The patient never

take tuberculosis medication

From Physical Examination :

Lungs

- Inspection

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Dynamic : Thoraco abdominal breath movement, right slower

than left

- Palpation : fremitus tactile of left stronger than right

- Percussion : dulness on the left apex and basal lung,

and Sonor on the medial right lung

- Auscultation : vesikuler +/+ , soft wet ronchi+/+, wheezing -/-

Supportive Examination :

Radiology

- opaque homogen appereance in right lung, pleural effusion sugestif in

right.

-infiltrate and cavity like appearance on left apex

Laboratory :

Blood routine taken on march 2nd 2011

LED : 46 mm/hour

Differential Diagnose and Base of Differential Diagnose

1. Differential Diagnose

Lung Malignancy or metastasis

2. Base of Differential Diagnose

The patient was hemoptisis ( Sputum and fresh blood)

The patient is an elder (48 years old)

sitology analysis of pleural fluid is needed to remove the differential diagnose.

Adviced Examination :

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Anatomy Patological Analysis of pleural fluid

Thorax CT scan

Management Plan :

Medicamentosa

- D5%: RL 20 gtt/hours

- Initial therapy for 1st category tuberculosis (2RHZE/4RH)

- Rifampicin 450 mg/day

- Isoniazid 300 mg/ day

- Pyrazinamide 1000 mg/day

- Ethambutol 1000 mg/day

- codein 3x 4mg/day

- Curcuma, Folic acid and Fe tablet for suplementation

- Therapeutic thoracocentesis

- Prepare for WSD if the pleural effusion become more massive

- Prepare O2 if the breathlessness worse

Non Medicamentosa

- Use Trandalenberg position (if the hemoptisis is become worse)

- Bed rest and advice the patient to not speak loudly

Prevention :

- Consumption of OAT regularly and according the doctor prescribe

- Advice the patient to use mask

- Take care the hygiene and sanitation to avoid transmition

- Screening and Education for her family to prevent Tuberculosis transmission

Prognosis : Dubia ad bonam

Follow up

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Date 02-03-2011 03-03-2011 04-03-2011 07-03-2011

Symptoms

- Breathless

- Expectorated cough

- Fever

- Eating

(+)

(+)

(-)

(-)

(-)

(+)

(-)

(-)

(-)

(+)

(-)

(+)

(-)

(+)

(-)

(+)

Generality Moderate ill appearance

Moderate ill appearance

Mild ill appearance

Mild ill appearance

Awareness Compos mentis

Vital Sign

- Blood Pressure

- Temperature

- Respiration

- Pulse

130/90 mmHg

36,5º C

34 x/minute

96 x/minute

130/80 mmHg

36,3º C

24 x/minute

76 x/minute

130/80 mmHg

36,5º C

20 x/minute

80 x/minute

130/70 mmHg

36,3º C

22 x/minute

76 x/minute

Physical Examination

Lung

- Inspection

- Palpation

- Percussion

- Auscultation

Hemithorax symmetrical breath of right – left

Symetrical fremitus tactile of left stronger than right

dulness on the left apex and basal lung, and Sonor on the medial right lung

vesikuler +/+ , soft wet ronchi+/+, wheezing -/-


Symetrical fremitus tactile of left stronger than right


vesikuler +/+ , soft wet ronchi+/+, wheezing -/-


Symetrical Fremitus tactil on the right – left lung


vesikuler +/+ , ronchi -/-, wheezing -/-


Symetrical Fremitus tactil on the right – left lung


vesikuler +/+ , ronchi -/-, wheezing -/-

Therapy

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1. Bed rest

2. Medication

O2 2-3 L/minute IVFD RL Codein Rifampicin450 mg Isoniazid 300 mg Pyrazinamide 500

mg Ethambuthol 500

mg

(+)

(-)

20 gtt/minute

3 x 1

-

-

-

-

-

+

(+)

(-)

20 gtt/minute

3 x 1

-

-

-

-

-

+

(+)

(-)

20 gtt/minute

-

-

-

-

-

-

+

(+)

(-)

Up

-

1 x 1

1 x 1

1 x 2

1 x 2

-

+

Supportive Examination

Complete Blood Examination, Liver Function Test, GDS, U/C, AFB

CASE ANALYSIS

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Is working diagnosis is right?

Base on anamnese that patient came with chief complaint coughing up blood and breathless.The complaints was followed by history of chronical cough, decrease of appetite, loss 13 kg of weights, sweat at night and low grade fever since 7 months ago. The blood routine found elevated LED about 46 mm/hour. All of these symptoms tend to tuberculosis with hemaptoe complication.

Base on physical examination which founded that right breathing movement is slower than left, left fremitus tactile is stronger than right, dullness percussion right chest area, right vesikuler sound is weaker than left lung, and soft wet ronchi on left lung.

Base on thorax photo which showed infiltrate and cavity apperance in apex area in both of lung. We can make conclution that lession is wide and active. Then, from homogen appereance in right lung, tend to pleural effusion in right lung. The patient never get tuberculosis medication and the sputum AFB test is negatif

What the supportives examination do you suggest?

Cytology analysis used to remove or establish the differential diagnosis (Malignancy)

Thorax CT scan used to look position of fluid and lung.

Are the management of therapy is right?

We give 1st category tuberculosis treatment for the patient. Body mass of the patient is 40 kg, so we use Rifampicin 450 mg/day, Isoniazid 300 mg/ day, Pyrazinamide 1000 mg/day, Ethambutol 1000 mg/day as intial therapy for 2 months. And than continue with Rifampisin 450 mg/day and Isoniazid 300mg/day for 4 month.

We give codein low dose to decrease the cough to preventing exccessive intrathoracal pressure increase. Therapeutic thoracocentesis is needed to remove the fluid immadiately. It will relieve the symptoms and avoid pleural thickening.

We recommend patient to positioning her head lower than the body to avoiding obstruction caused by blood when she sleeping. Oxygen canul can be used to relieve the breathless. D5% ,curcuma, folic acid and Fe suplementation used as supportive because the patient appetite is decrease during sick.

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PULMONARY TUBERCULOSIS

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DEFINISI A. Definitions

Tuberkulosis paru adalah infeksi paru yang menyerang jaringan parenkim paru,

disebabkan bakteri Mycobacterium tuberculosis . 1Pulmonary tuberculosis is a

lung infection that attacks the lung parenchymal tissue caused by the bacterium

Mycobacterium tuberculosis. 1

ETIOLOGI B. Etiology

TB paru disebabkan oleh basil TB (Mycobacterium tuberculosis humanis ). 2

Pulmonary tuberculosis is caused by the TB bacillus (Mycobacterium tuberculosis

humanist). 2

M.tuberculosis termasuk familie Mycobacteriacea yang mempunyai

berbagai genus, satu diantaranya adalah Mycobacterium, yang salah satu

spesiesnya adalah M.tuberculosis . 2 M.tuberculosis including Familie

Mycobacteriacea which have a range of the genus, one of which is a

Mycobacterium, in which one species is M.tuberculosis. 2

M.tuberculosis yang paling berbahaya bagi manusia adalah tipe humanis

(kemungkinan infeksi type bovinus saat ini dapat diabaikan, sehingga

hiegiene peternakan makin ditingkatkan). 2 M.tuberculosis the most

dangerous for humans is the humanist type (type bovinus possibility of

infection can now be ignored, so that more farm hiegien enhanced). 2

Basil TB mempunyai dinding sel lipoid sehingga tahan asam, sifat ini

dimanfaatkan oleh Robert Koch untuk mewarnainya secara khusus. TB

bacilli have lipoid cell wall so that acid resistant, this trait used by Robert

Koch to color in particular. Oleh karena itu, kuman ini disebut pula Basil

Tahan Asam (BTA). 2 Therefore, this germ is also called acid-fast bacteria

(AFB). 2

Karena sebetulnya Mycobacterium pada umumnya tahan asam, secara

teoritis BTA belum tentu identik dengan basil TB. Because in fact in

general acid-resistant Mycobacterium, theoretically smear is not

necessarily identical with the TB bacillus. Tetapi karena dalam keadaan

normal penyakit paru yang disebabkan oleh Mycobacterium (M.atipik) lain

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jarang sekali ditemukan dalam praktek BTA dianggap identik dengan basil

TB. 2 But because under normal circumstances lung disease caused by

Mycobacterium (M.atipik) other rarely found in the practice of smear is

considered synonymous with the TB bacillus. 2

Kalau untuk bakteri-bakteri lain hanya diperlukan beberapa menit sampai

20 menit untuk mitosis, basil TB memerlukan 12-24 jam. 2 If for other

bacteria only take a few minutes to 20 minutes for mitosis, the TB bacilli

requires 12-24 hours. 2

Basil TB sangat rentan terhadap sinar matahari, sehingga dalam beberapa

menit saja akan mati. TB bacilli are very vulnerable to sunlight, so that

within a few minutes to die. Ternyata ketahanan ini terutama terhadap

gelombang cahaya ultraviolet. It turned out that this resistance mainly

against ultraviolet light waves. Basil TB juga rentan terhadap panas-basa,

sehingga dalam 2 menit saja basil TB yang berada dalam lingkungan basa

akan mati bila terkena air bersuhu 100°C. TB bacilli are also prone to

heat-base, so in 2 minutes TB bacilli residing in an alkaline environment

will die when exposed to water temperature of 100 ° C. Basil TB juga

akan terbunuh dalam beberapa menit bila terkena alkohol 70% atau lisol

5%. 2 TB bacilli will also be killed within minutes when exposed to

alcohol lisol 70% or 5%. 2

C. EPIDEMIOLOGIEpidemiology

TB ditemukan disemua negara diseluruh dunia.TB was found in all countries

around the world. Dahulu sewaktu perhubungan antarnegara masih sulit, masih

ada beberapa rumpun suku bangsa yang bebas TB (misalnya suku Eskimo

sebelum kedatangan orang-orang Denmark dan beberapa suku penghuni pulau-

pulau terpencil di Samudera Pasifik). Previously, when communications between

countries is still difficult, there are still some tribes clump-free TB (eg Eskimo

tribes before the arrival of the Danish and some tribal inhabitants of remote

islands in the Pacific Ocean.) Tetapi dengan makin mudahnya perhubungan

antarnegara sejak abad XVI, sekarang TB sudah merupakan penyaki

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mancanegara. 2 But with the growing ease of communication between states since

the sixteenth century, now TB is already a foreign penyaki. 2

Dalam keadaan normal (yaitu kalau infeksi HIV/AIDS tidak merajalela), semakin

maju kemakmuran suatu negara, semakin sedikitlah rakyat yang terkena

TB.Under normal circumstances (ie, HIV infection / AIDS is not rampant),

advancing the prosperity of a country, the Little people affected by TB. Hal ini

disebabkan oleh pola hidup yang memenuhi syarat kesehatan (gizi tinggi dan

perumahan sehat) dan kemampuan ekonomis untuk mendapatkan pemeriksaan

medis serta pengobatan hingga sembuh bila masih juga terserang TB. This is

caused by a lifestyle that meets the health requirements (high nutrition and healthy

housing) and economic ability to obtain medical examinations and treatment to

recover if still too stricken with tuberculosis. Sebagai contoh dapat dikemukakan

keadaan di Amerika Serikat, prevalensi TB pada tahun 1994 adalah 95/100.000.

As an example could be offered a state in the United States, the prevalence of TB

in 1994 was 95/100.000. Secara terus menerus prevalensi ini turun samapai

dengan tahun1986, untuk kemudian meningkat lagi karena pengaruh AIDS

sehingga pada tahun 1990 prevalensi ini menjadi 10/10.000 (US PHS,1991). 2 The

prevalence has declined continuously samapai by 1986, to then increase again

because of the influence of AIDS so that in 1990 this prevalence became

10/10.000 (U.S. PHS, 1991). 2

Sebaliknya bila AIDS telah mewabah, kemakmuran tidaklah relevan

lagi.Conversely, if AIDS has been rampant, prosperity is not relevant anymore.

Dengan menurunnya sistem imunitas penderita AIDS, semua penyakit infeksi

mudah sekali menyerang, termasuk TB. With the decline in AIDS patient's

immune system, all easy to attack infectious diseases, including TB. Hal ini

tamapak sekali negara-nagera yang sudah maju (USA, Belanda, Denmark, dsb).

This was once state-nagera tamapak advanced (USA, Holland, Denmark, etc.). TB

yang diperkirakan bakal habis, ternyata dengan munculnya wabah AIDS, justru

mordibitas dan mortalitasnya makin meningkat, yaitu meningkat 20% dalam

kurun waktu 1985/1986-1992. 2 TB is expected to run out, apparently with the

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advent of the AIDS epidemic, it mordibitas and increased mortality, which

increased by 20% in the period 1985/1986-1992. 2

Di Indonesia saat ini diperkirakan terdapat 450.000 penderita TB menular setiap

tahunnya (atau suatu prevalensi sebesar 300/100.000) dengan angka insiden

225.000 kasus pertahunnya, sebagian besar penduduk dalam kelompok usia

produktif, yaitu antara 20-49 tahun. 2In Indonesia, currently estimated there are

450,000 people with infectious TB each year (or a prevalence of 300/100.000)

with the number 225 000 incident cases yearly, most of the population in

productive age group, between 20-49 years. 2

Keadaan di negara-negara yang sedang berkembang lainnya tidak berbeda

banyak, bahkan di negara-negara Afrika yang tertimpa wabah AIDS, keadaannya

jauh lebih buruk.The situation in countries emerging others do not differ much,

even in countries affected African AIDS epidemic, the situation is far worse.

Semua ini adalah yang mendorong WHO untuk menyatakan kegawatan TB secara

global (TB-A Global Emergency ). 2 All of this is that encourages WHO to declare

TB a global crisis (TB-A Global Emergency). 2 CARA PENULARAN

D. HOW Transmission

Penularan penyakit ini sebagian besar melalui inhalasi basil yang mengandung

droplet nuclei , khususnya yang didapat pada pasien TB paru dengan batuk

berdahak atau berdarah yang mengandung basil tahan asam (BTA).Transmission

of the disease is mainly through inhalation of bacillus-containing droplet nuclei,

particularly those obtained in patients with pulmonary TB cough or bloody

sputum containing acid-fast bacilli (AFB). Pada TB kuit atau jaringan lunak

penularan ini melalui inokulasi langsung. In TB biscuits or soft tissue infection is

through direct inoculation. Infeksi yang disebabkan M.Bovis dapat disebabkan

oleh susu yang kurang disterilkan dengan baik atau terkontaminasi. 3 Infections

caused by M. bovis can be caused by a lack of sterilized milk or contaminated

well. 3

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Sebagian besar dinding kuman terdiri atas asam lemak (lipid) kemudian

peptidoglikan dan arabinomannan.Most of the germ wall composed of fatty acids

(lipids) and peptidoglycan and arabinomannan. Lipid inilah yang membuat kuman

lebih tahan asam (asam alkohol). Lipid is what makes bacteria more resistant to

acid (acid alcohol). Kuman berada dalam sifat dormant . Germs are in a dormant

nature. Di dalam jaringan kuman hidup sebagai parasit intraseluler yakni dalam

sitoplasma makrofag. In the network of intracellular bacteria that live as parasites

in the cytoplasm of macrophages. Makrofag yang semula memfagositosis malah

kemudian disenanginya karena mengandung lipid. 3 Macrophages which was

originally memfagositosis even then his favorite because it contains lipids. 3

Sifat lain kuman adalah aerob.Other properties are aerobic bacteria. Kuman lebih

menyukai jaringan yang tinggi kadar oksigennya. Germs more like a network of

high levels of oxygen. Dalam hal ini tekanan oksigen pada bagian apikal paru-

paru lebih tinggi dari bagian lain, sehingga bagian apikal ini merupakan tempat

predileksi penyakit. 3 In this case the pressure of oxygen in the apical lung is

higher than other parts, so that the apical part of this is the place of predilection of

disease. 3 PATOGENESIS

E. Pathogenesis

TB PrimerPrimary TB

Bila orang mengalami infeksi basil TB, walaupun segera difagositosis oleh

makrofag , basil TB tidak akan mati, bahkan makrofagnya dapat mati.When

people become infected TB bacilli, although immediately difagositosis by

macrophages, the TB bacilli will not die, even makrofagnya to die. Dengan

demikian basil TB dapat berkembangbiak secara leluasa dalam 2 minggu pertama

di alveolus paru, dengan kecepatan 1 basil menjadi 2 basil setiap 20 jam, sehingga

pada infeksi oleh 1 basil saja, setelah 2 minggu akan bertambah menjadi 100.000

basil. Thus the TB bacilli can multiply freely within the first 2 weeks in the

pulmonary alveoli, with a speed of 1 to 2 basil basil every 20 hours, so that in the

course of infection by a bacillus, after 2 weeks will increase to 100,000 bacilli.

Kuman yang bersarang di jaringan paru akan berbentuk sarang tuberkulosis

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pneumonia kecil dan disebut sarang primer atau afek primer atau sarang fokus

(Ghon ). Germs are lodged in lung tissue will form a small nest of tuberculosis

and pneumonia called primary nest or nest or primary affective focus (Ghon). Bila

menjalar sampai pleura, maka terjadilah efusi pleura. When spread to the pleura,

the pleural effusion occurred. Bila masuk ke arteri pulmonalis maka terjadi

penjalaran ke seluruh bagian paru menjadi TB milier. 2.3 When you go into the

pulmonary artery occurred propagation to all parts of the lungs become out

military tuberculosis. 2.3

Dari sarang primer akan timbul peradangan saluran getah bening menuju hilus

(limfangitis lokal) dan juga diikuti pembesaran kelenjar getah bening hilus

(limfadenitis regional). From the primary nest will arise inflammatory lymph

channels toward the hilum (local lymphangitis) and also followed by an enlarged

hilar lymph nodes (regional lymphadenitis). Sarang limfangitis lokal +

limfadenitis regional = kompleks primer (Ranke). Nest Local lymphangitis + =

complex regional lymphadenitis primary (Ranke). Semua proses ini memakan

waktu 3-8 minggu. All this process takes 3-8 weeks. Kompleks primer selanjutnya

akan menjadi : Complex next primary will be:

o Sembuh sama sekali tanpa meninggalkan cacat. Heal completely

without leaving a defect.

o Sembuh dengan sedikit meninggalkan sedikit bekas berupa garis-

garis fibrotik, kalsifikasi di hilus, keadaan ini terdapat pada lesi

pneumonia yang luasnya >5mm dan ± 10 % diantaranya dapat

terjadi reaktivasi lagi karena kuman dormant . Cured with a little

left slight traces of fibrotic lines, calcifications in the hilum, there

are circumstances in which the extent of pneumonia lesions> 5 mm

and ± 10% of them may occur again due to reactivation of dormant

bacteria.

o Berkomplikasi dan menyebar secara perkontinuitatum, yakni

menyebar ke sekitarnya. Complicated and spread perkontinuitatum,

which spread to surrounding areas. Bronkogen : pada paru yang

bersangkutan maupun paru disebelahnya. Bronkogenic: in lung and

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lung adjacent concerned. Kuman dapat juga tertelan bersama

sputum dan ludah sehingga menyebar ke usus. Germs can also be

ingested with sputum and saliva that spreads to the intestines.

Secara limfogen : ke organ tubuh lain-lainnya. In limfogen: to

others organs. Secara hematogen ke organ tubuh lainnya. 3 In

haematogenous to other organs. 3

TB Sekunder Secondary TB

Penyakit TB yang baru timbul setelah lewat 5 tahun sejak terjadinya infeksi

primer. TB disease emerging after the 5 years after primary infection. Dengan

demikian, mulai sekarang apa yang disebut dengan TB-post primer, secara

internasional diberi nama TB sekunder. 2 Thus, from now on so-called post-

primary TB, the internationally given the name of secondary tuberculosis. 2

Bila karena sebab-sebab tertentu sistem pertahanan tubuh melemah, basil-basil Tb

yang dormant akan aktif kembali. If for certain reasons the body's defense system

is weakened, TB bacilli are dormant will be active again. Proses ini disebut

reinfeksi endogen . This process is called endogenous reinfection. Tb paska

primer juga dapat berasal dari infeksi eksogen dari usia muda menjadi TB usia tua

( ederly tuberculosis ). Post-primary TB can also be derived from exogenous

infection from a young age into old age TB (tuberculosis ederly). Tergantung dari

jumlah kuman, virulensinya dan imunitas pasien, sarang dini ini dapat menjadi :

Depending on the number of bacteria, virulence and immunity of patients, this

early nests can be:

o Direabsorbsi kembali dan timbul dan sembuh tanpa meninggalkan

cacat. Direabsorbsi back and come and heal without leaving a

defect.

o Sarang yang mula-mula meluas, tetapi segera menyembuh dengan

serbukan jaringan fibrosis. Nest which extends initially, but soon

healed with granulary tissue fibrosis. Ada yang membungkus diri

menjadi keras, menimbulkan perkapuran. Some wrapped

themselves become hard, causing calsification. Sarang dini yang

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meluas sebagai granuloma berkembang menghancurkan jaringan

ikat sekitarnya dan bagian tengahnya mangalami nekrosis, menjadi

lembek dan membentuk jaringan keju.. Early nest widespread as

granulomas develop destroy surrounding tissue and the middle

promising necrosis, become flabby and form a network of cheese ..

Terjadi perkijauan dan kavitas adalah karena hidrolisis protein lipid

dan asam nukleat oleh enzim yang diproduksi oleh makrofag dan

proses yang berlebihan dari sitokin dengan TNF nya. 2.3 Occur

perkijauan and cavity is due to hydrolysis of proteins lipids and

nucleic acids by the enzyme produced by macrophages and

excessive process of its cytokine with TNF. 2.3

KLASIFIKASIF. Classfication

Berdasarkan hasil pemeriksaan BTA, TB dibagi dalam : 1 Based on the results of

smear examination, TB is divided into: 1

1. TB dengan BTA (+) TB with AFB (+)

a. Sekurang-kurangnya 2 dari 3 spesimen dahak menunjukan hasil

BTA (+) At least 2 of 3 specimens of sputum smear results showed

(+)

b. Hasil pemeriksaan satu spesimen dahak menunjukan BTA (+) dan

kelainan radiologis menunjukan gambaran tuberculosis paru aktif.

The result of examination of sputum specimens showed AFB (+)

and radiologic abnormalities showed active pulmonary tuberculosis

picture.

c. Hasil pemeriksaan satu specimen dahak menunjukan BTA (+) dan

biakan (+). The result of examination of sputum specimens showed

AFB (+) and culture (+).

2. TB dengan BTA (-) TB with AFB (-)

a. Hasil pemeriksaan dahak 3 kali menunjukan BTA (-), gambaran

klinis dan kelainan radiologis menunjukan tuberculosis paru aktif.

The result of sputum examination 3 times showed AFB (-), clinical

21

and radiologic abnormalities showed active pulmonary

tuberculosis.

b. Hasil pemeriksaan dahak 3 kali menunjukan BTA (-) dan biakan

M.Tuberculosis (+). 1 The result of sputum examination 3 times

showed AFB (-) and cultured M. tuberculosis (+). 1

Berdasarkan tingkat keparahan yang ditunjukan oleh foto toraks TB paru dibagi

dalam: 1Based on the severity of which is shown by a chest radiograph of

pulmonary tuberculosis were divided into: 1

1. TB paru dengan kelainan paru luas Pulmonary TB with extensive lung

disorders

2. TB paru dengan kelainan paru sedikit Pulmonary TB with lung

abnormalities little

Berdasarkan organ selain paru yang terserang, TB paru dibagi dalam : Based on

the affected organs other than lung, pulmonary TB is divided into:

1. TB ekstra paru ringan : TB kelenjar limfe, TB tulang non vertebra, TB

sendi, TB adrenal Mild extra-pulmonary TB: TB lymph nodes,

tuberculosis non-vertebral bone, joint tuberculosis, adrenal tuberculosis

2. TB ektra paru berat : meningitis, TB milier, TB diseminata, TB usus, TB

genitourinarius. Severe extra pulmonary tuberculosis: meningitis, TB out

military, disseminated TB, intestinal TB, TB genitourinarius.

Berdasarkan riwayat pengobatan, TB paru dibagi dalam : 1Based on medical

history, pulmonary tuberculosis were divided into: 1

1. Kasus baru New cases

2. Kambuh (relaps) Relapse (relapse)

3. Drop out Drop out

4. Gagal terapi Failed therapy

5. Kronis Chronic

22

Tahun 1974 American Thoracic Society memberikan klasifikasi yang diambil

beradasarkan kesehatan masyarakat : 3American Thoracic Society in 1974

provides for the classification of public health taken based on: 3

Kategori 0 : tidak pernah terpajan, dan tidak terinfeksi, riwayat kontak

negatif, tes tuberkulin negatif Category 0: no prior exposure, and is not

infected, negative contact history, tuberculin test negative

Kategori I : terpajan tuberkulosis, tapi tidak tebukti ada infeksi, disini

riwayat kontak positif, tes tuberkulin negatif, Category I: exposure to

tuberculosis, but not tebukti no infection, a positive contact history here, a

negative tuberculin test,

Kategori II : terinfeksi tuberkulosis, tetapi tidak sakit, tes tuberkulin

positif, radiologis dan sputum negatif. Category II: infected with

tuberculosis, but no pain, positive tuberculin test, radiological and sputum

negative.

Kategori III : terinfeksi tuberkulosis dan sakit. Category III: tuberculosis

infection and illness.

G. MANIFESTASI KLINISClinical manifestations

Gejala utama TB paru adalah batuk lebih dari 4 minggu dengan atau tanpa

sputum, malaise, gejala flu, demam derajat rendah, nyeri dada, dan batuk

berdarah.The main symptoms of pulmonary TB is coughing for more than 4

weeks with or without sputum, malaise, flu-like symptoms, low grade fever, chest

pain, and coughing up blood. Gejala klinis tuberculosis dapat dibagi menjadi 2

golongan, yaitu gejala lokal dan gejala sitemik, bila organ yang terkena adalah

paru maka gejala lokal ialah gejala respiratori (gejala sesuai dengan organ yang

terlibat). 3.4 Clinical symptoms of tuberculosis can be divided into 2 groups,

namely the local symptoms and signs sitemik, when the organ affected is the lung,

the local symptoms are respiratory symptoms (symptoms according to the organ

involved). 3.4

23

1. Gejala respiratori : batuk ≥ 2 minggu, batuk darah, sesak nafas, nyeri dada.

Respiratory symptoms: cough ≥ 2 weeks, coughing up blood, shortness of

breath, chest pain.

2. Gejala sistemik dapat berupa Systemic symptoms may include

demam fever

keringat malam night sweats

anoreksia anorexia

malaise malaise

berat badan menurun weight loss

Pada pemeriksaan fisik ditemukan : 4 On physical examination found: 4

1. Tanda-tanda infiltrat (redup, bronkial, ronki basah dan lain-lain) The signs

of infiltrates (dim, bronchial, rhonchi wet and others)

2. Tanda-tanda penarikan paru, diafragma dan mediastnum Signs of

withdrawal of the lung, diaphragm and mediastnum

3. Sekret di saluran nafas dan ronki Secretions in the respiratory tract and

rhonchi

4. Suara nafas amforik karena adanya kavitas yang berhubungan langsung

dengan bronkus Amforik breath sounds due to the cavity is directly related

to the bronchial DIAGNOSIS 4

H. Diagnosis4

1. Anamnesis dan pemeriksaan fisikHistory and physical examination

2. Laboratorium darah rutin (LED normal atau meningkat,

limfositosis)Routine blood laboratory (ESR normal or increased,

lymphocytosis)

3. Foto toraks PA dan lateral.PA and lateral chest radiograph. Gamabaran

foto toraks yng menunjang diagnosis TB, yaitu : Gamabaran yng chest

radiograph support the diagnosis of TB, namely:

24

o Bayangan lesi terletak di lapangan atas paru atau segmen apikal

lobus bawah. The image of the lesion is located in the field of

pulmonary lower lobes or apical segments.

o Bayangan berawan (patchy ) atau bercak nodular Cloudy shadow

(Patchy) or spotting nodular

o Adanya kavitas tunggal atau ganda The existence of single or

double cavity

o Kelainan bilateral, terutama dilapangan paru atas Bilateral

abnormalities, especially the upper lung field

o Adanya kalsifikasi The presence calcification

o Bayangan menetap pada foto ulang beberapa minggu kemudian

Shadow re-settled on the photo a few weeks later

o Bayangan milier Shadow out military

4. Pemeriksaan sputum BTASputum smear examination

Pemeriksaan sputum BTA memastikan diagnosis TB paru, namun

pemeriksaan ini tidak sensitif karena hanya 30-70% pasien Tb yang dapat

didiagnosis berdasarkan pemeriksaan ini.Sputum smear examination

confirm the diagnosis of pulmonary tuberculosis, but this examination is

not sensitive because only 30-70% of patients can be diagnosed on the

basis of Tb which this examination.

5. Tes PAP (Peroksidase Anti Peroksidase)Test PAP (peroxidase anti-

peroxidase)

Merupakan uji serologi imunoperoksidase memakai alat histogen

imunoperoksidase staining untuk menentukan adanya IgG spesifik

terhadap basil TB.Is a serologic test using the tool histogen

imunoperoksidase imunoperoksidase staining to determine the presence of

specific IgG antibodies against TB bacilli.

6. Tes Mantoux/TuberkulinMantoux test / Tuberculin

7. Tehnik Poymerase chain Reaction Poymerase chain reaction technique

25

Deteksi DNA kuman secara spesifik melalui amplifikasi dalam baerbagai

tahap sehingga dapat mendeteksi meskipun hanya 1 mikroorganisme

dalam spesimen.Detection of specific bacterial DNA through amplification

in baerbagai stage so that it can detect even if only 1 microorganism in the

specimen. Juga mendeteksi adanya resistensi. Also detect any resistance.

8. Becton Dickinson Diagnostic Instrument System (BACTEC)Becton

Dickinson Diagnostic Instrument System (BACTEC)

Deteksi growth index berdasarkan CO 2 yang dihasilkan dari metabolisme

asam lemak oleh M.tuberculosis.Detection of growth index based on the

CO 2 produced from metabolism of fatty acids by M.tuberculosis.

9. Enzyme Linked Immunosorbent AssayEnzyme Linked Immunosorbent

Assay

Deteksi respon humoral, berupa proses antigen-antibodi yang

terjadi.Detection of humoral response, a process that occurs antigen-

antibody.

10. MYCODOT MYCODOT

Deteksi antibodi memakai antigen lipoarabinomannan yang direkat pada

suatu alat berbentuk seperti sisir plastik, kemudian dicelupkan ke dalam

serum pasien.Detection of lipoarabinomannan antibodies using antigens

that are glued on a tool shaped like a plastic comb, then dipped into the

serum of patients. Bila terdapat antibodi spesifik dalam jumlah memadai

maka warna sisir akan berubah. When specific antibodies were found in

adequate number will change the color comb.

Standard untuk diagnosis :Standard for diagnosis:

Standard 1 Standard 1

26

Setiap orang dengan batuk produktif selama 2-3 minggu atau lebih, yang tidak

jelas penyebabnya, harus dievaluasi untuk tuberkulosis.(Untuk pasien anak, selain

gejala batuk, entry untuk evaluasi adalah berat badan yang sulit naik dalam waktu

kurang lebih 2 bulan terakhir atau gizi buruk. 5Any person with a productive

cough for 2-3 weeks or more, which is not clear why, should be evaluated for

tuberculosis. (For pediatric patients, in addition to symptoms of cough, entry

weight for evaluation is a difficult ride in less than 2 months or nutrition bad. 5


Semua pasien (dewasa, remaja, dan anak) yang diduga menderita tuberkulosis

paru harus menjalani pemeriksaan dahak mikroskopik minimal 2 kali yang

diperiksa di laboratorium yang kualitasnya terjamin.All patients (adults,

adolescents, and children) suspected of having pulmonary tuberculosis should

undergo microscopic examination of sputum for at least 2 times the examination

in a laboratory whose quality is guaranteed. Jika mungkin paling tidak satu dahak

berasal dari dahak pagi hari. 5 If possible at least one sputum originated from the

morning sputum. 5


Pada semua pasien (dewasa, remaja dan anak) yang diduga menderita tuberkulosis

ekstra paru, spesimen dari bagian tubuh yang sakit seharusnya diambil

pemeriksaan mikroskopik, biakan, dan histopatologi.In all patients (adults,

adolescents and children) suspected of having extra-pulmonary tuberculosis, the

specimens from the body of the sick should be taken microscopic examination,

culture, and histopathology. (Sebaiknya dilakukan pemerikssaan foto thoraks

untuk mengetahui ada tidaknya TB paru dan TB milier. Pemeriksaan dahak juga

dilakukan bila mungkin pada anak). 5 (Should be done pemerikssaan thoracic

images to determine the presence or absence of pulmonary TB and TB out

military. Sputum examination was also performed when possible in children). 5


27

Semua orang dengan temuan oto toraks diduga tuberkulosis seharusnya menjalani

pemeriksaan dahak secara mikrobiologi. 5All people with suspected tuberculosis

chest bibs findings should undergo sputum examination in microbiology. 5


Diagnosis tuberkulosis paru sedian apus dahak negatif harus didasarkan kriteria

berikut : minimal 2x pemeriksaan dahak mikroskopik negatif (termasuk minimal

1x dahak pagi hari); temuan foto toraks sesuai tuberkulosis; dan tidak ada respon

terhadap antibiotik spektrum luas (fluorokuinolon harus dihindari karena aktif

terhadap M.tuberculosis complex sehingga dapat menyebabkan perbaikan sesaat

pada penderita tuberculosis).Diagnosis of pulmonary tuberculosis negative

sputum smear should be based on the following criteria: at least 2x a negative

microscopic examination of sputum (phlegm 1x including at least the morning);

according tuberculosis chest radiograph findings, and no response to broad

spectrum antibiotics (fluoroquinolone should be avoided because it is active

against M. tuberculosis complex which can cause momentary improvement in

patients with tuberculosis). Untuk pasien ini biakan dahak harus dilakukan. For

these patients sputum culture should be performed. Pada pasien yang sakit berat

atau diketahui atau diduga terinfeksi HIV, evaluasi klinis harus disegerakan dan

jika bukti klinis sangat mendukung ke arah tuberkulosis, pengobatan tuberkulosis

harus dimulai. 5 In patients with severe pain or known or suspected of being

infected with HIV, clinical evaluation should be hastened and if clinical evidence

strongly supports the direction of tuberculosis, tuberculosis treatment should be

started. 5


Pada semua anak yang menderita tuberkulosis intratoraks (yakni paru, pleura, dan

kelenjar getah bening mediastinum atau hilus), konfirmasi bakteriologis harus

dilakukan dengan pemeriksaan dahak ( dengan cara batuk, kumbah lambung, atau

induksi dahak) untuk pemeriksaan mikroskopik atau biakan.In all children who

suffer from tuberculosis intratoraks (ie, lung, pleura, and mediastinal lymph nodes

or hilum), bacteriological confirmation must be made by sputum examination (by

28

coughing, kumbah stomach, or induced sputum) for microscopic examination or

culture. Jika hasil bakteriologis negatif, diagnostik tuberkulosis harus didasarkan

pada kelainan radiografi toraks sesuai tuberkulosis, riwayat terpajan kasus

tuberkulosis yang menular, bukti infeksi tuberkulosis (uji tuberkulin positif atau

interferon gamma release assay) dan temuan klinis yang mendukug ke arah

tuberkulosis. If the negative bacteriological results, diagnostic of tuberculosis

should be based on radiographic abnormalities of the thorax according to

tuberculosis, a history of exposure to an infectious case of tuberculosis, evidence

of tuberculosis infection (positive tuberculin test or interferon gamma release

assay) and clinical findings support toward tuberculosis. Untuk anak yang diduga

tuberkulosis ekstra paru, spesimen dari lokasi yang dicurigai harus diambil untuk

dilakukan pemeriksaan mikroskopik, biakan, dan histopatologis. For a child

suspected extra-pulmonary tuberculosis, the specimens from the suspected site

should be taken for microscopic examination, culture, and histopathology. (Untuk

penatalaksanaan di Indonesia, diagnosis didasarkan atas pajanan terhadap kasus

tuberkulosis yang menular atau bukti infeksi tuberkulosis : uji kulit tuberkulin

positif atau interferon gammna release assay) dan kelainan radiografi toraks sesuai

TB. 5 (For management in Indonesia, the diagnosis was based on exposure to an

infectious case of tuberculosis or evidence of tuberculosis infection: a positive

tuberculin skin test or interferon gamma release assay) and thoracic radiographic

abnormalities as TB. 5

PENATALAKSANAAN

I. Management

Terapi yang dapat diberikan pada penderita TB paru antara lain: 1.3Therapy can be

given to people with pulmonary tuberculosis, among others: 1.3

Terapi umum : istirahat, stop merokok, hindari polusi, tatalaksana komorbit,

nutrisi, vitamin.General therapy: rest, stop smoking, avoid pollution, managing

komorbit, nutrition, vitamins.

29

Medikamentosa obat anti TB (OAT) :Medical anti-TB drugs (OAT):

30

Kategori 1 Category 1

Penderita baru TB paru, sputum BTA (+) New cases of pulmonary

tuberculosis, sputum smear (+)

Penderita TB paru, sputum BTA (-), rontgent toraks (+) dengan kelainan

paru yang luas. Patients with pulmonary tuberculosis, sputum smear (-),

rontgent thoracic (+) with extensive lung disorders.

Penderita Tb ekstra paru berat Patients with severe extra-pulmonary Tb

2RHZE/4RH-2RHZE/4R3H3-2RHZE/6HE 2RHZE/4RH-2RHZE/4R3H3-

2RHZE/6HE


Penderita kambuh Patients relapsed

Penderita gagal pengobatan Patients with treatment failure

Penderita after default/drop out Patients after-default / drop out

31

Terapi dengan Therapy with

o 2HRZE/1HRZE/5RHE 2HRZE/1HRZE/5RHE

o 2HRZES/1HRZE/5H3R3E3 2HRZES/1HRZE/5H3R3E3


Penderita baru TB paru, sputum BTA (-), rontgent toraks (+) dengan

kelainan paru tidak luas. New cases of pulmonary tuberculosis, sputum

smear (-), rontgent thoracic (+) with lung abnormalities are not

widespread.

Terapi dengan : Therapy with:

o 2RHZ/4RH 2RHZ/4RH

o 2RHZ/4H3R3 2RHZ/4H3R3

o 2RHZ/6HE 2RHZ/6HE


32

Penderita TB kronik Patients with chronic tuberculosis

Terapi dengan H seumur hidup dan bila mampu dengan OAT lini kedua.

Treatment with H for life and if able to second-line TB drugs. Secondline

Pengobatan TB juga dilakukan pada keadaan-keadaan khusus misalnya pada

penderita TB milier.TB treatment is also done in special circumstances such as in

patients with TB out military. Dan pasien ini termasuk penderita TB milier,

sehingga memerlukan penanganan khusus, seperti : 3 And this includes people

with TB patients out military, so it requires special handling, such as: 3

Rawat inap Inpatient

Panduan obat : 2RHZE/4RH Drug guide: 2RHZE/4RH

Pada keadaan berat khusus (sakit berat), tergantung keadaan klinis,

radiologi dan evaluasi pengobatan, maka kelanjutan pengobatan dapat

diperpanjang. In severe circumstances the special (severe pain), depending

on the state of clinical, radiological and treatment evaluation, the

continuation of treatment can be extended.

Pemberian kortikosteroid tidak rutin, dan hanya diberikan pada keadaan

tanda/gejala meningitis, sesak nafas, tanda/gejala toksik, demam tinggi.

Corticosteroids is not routine, and only given to the state signs / symptoms

of meningitis, shortness of breath, signs / symptoms of toxicity, high fever.

Komplikasi yang dapat terjadi akibat penyakit TB paru antara lain :

Complications that can occur due to pulmonary TB disease include:

Komplikasi paru : atelektasis, hemoptisis, fibrosis, bronkiektasis,

pneumotoraks, dan gagal nafas. Pulmonary Complications: atelectasis,

haemoptysis, fibrosis, bronchiectasis, pneumothorax, and respiratory

failure.

TB ektra paru : pleuritis, efusi pleura, perikarditis, peritonitis, TB kelenjar

limfe, dan kor pulmonal. Extra pulmonary TB: pleuritis, pleural effusion,

pericarditis, peritonitis, TB lymph nodes, and pulmonary choir.

33

Lama perawatan pada pasien TB paru : 3 Old treatment in patients with pulmonary

tuberculosis: 3

o Umumnya 2-3 mingguGenerally 2-3 weeks

o Lama pengobatan sebaiknya 6-8 bulanDuration of treatment should

be 6-8 months

o Perbaikan pada rontgent toraks terlihat setelah terapi 4

mingguImprovements in thoracic rontgent seen after 4 weeks of

therapy

o Konversi sputum setelah 2-3 bulan terapiSputum conversion after

2-3 months of therapy

o Terapi teratur selama 2 minggu dapat membuat pasien tidak

berbahaya terhadap masyarakat sekitarnya. 6Regular therapy for 2

weeks to make the patient is not dangerous to the surrounding

community. 6

Lama pemulihan bervariasi, umumnya 12 bulan setelah terapi. 3 Long recovery

varies, generally 12 months after therapy. 3

Standard untuk pengobatan : 5 Standards for treatment: 5


Memanfaat pelayanan kesehatan masyarakat lokal dan sarana lain untuk menilai

kepatuhan pasien.Utilize local public health services and other means to assess

patient compliance.


Dosis obat anti tuberkulosis harus sesuai dengan rekomendasi internasional.Doses

of anti-tuberculosis drugs should be in accordance with international

recommendations. Kombinasi tetap terdiri atas kombinasi 2 obat (isoniazid dan

rifampisin), 3 obat (isoniazid, rifampisin dan pirazinamid) dan 4 obat (isoniazid,

rifampisin, pirazinamid, dan etambutol). Fixed combination consisting of a

34

combination of two drugs (isoniazid and rifampicin), 3 drugs (isoniazid,

rifampicin and pyrazinamide) and 4 drugs (isoniazid, rifampin, pyrazinamide, and

ethambutol).


Directly Observed Treatment Shortcours (DOTS) 4J. Directly Observed

Treatment Shortcours (DOTS) 4

Adalah nama untuk suatu stategi yang dilaksanakan di pelayanan kesehatan dasar

dunia untuk mendeteksi dan menyembuhkan pasien TB. Is the name for a strategy

implemented in the world of basic health services to detect and cure TB patients.

Strategi ini terdiri atas 5 komponen : This strategy consists of 5 components:

1. Dukungan politik para pemimpin wilayah disetiap jenjang sehingga

program ini menjadi salah satu prioritas dan pendanaan pun

tersedia.Political support every level of municipal leaders that this

program become one of the priorities and funding was available.

2. Mikroskop sebagai komponen utama untuk mendiagnosis TB melalui

pemeriksaan sputum langsung pasien tersangka dengan penemuan secara

pasif.Microscope as a main component to diagnose tuberculosis by direct

sputum examination of patients suspected with the invention passively.

3. Pengawas minum obat (PMO) yaitu orang yang dikenal dan dipercaya

baik oleh pasien maupun petugas kesehatan yang akan ikut mengawasi

pasien minum obat.Supervisors take the medicine (PMO) that the person

known and trusted by both patients and health workers who will

participate in supervising the patient taking medication.

4. Pencatatan dan pelaporan dengan baik dan benar sebagai bagian dari

sistem surveilance penyakit ini sehingga pemantauan pasien dapat

berjalan.Recording and reporting properly as part of the disease

surveillance system so that monitoring of the patient can walk.

5. Panduan obat TB jangka pendek yang benar, termasuk dosis dan jangka

waktu yang tepat, sangat penting untuk keberhasilan pengobatan.Guide

35

short-term TB drugs correctly, including the dose and duration of the right,

it is crucial to the success of treatment.


Respon terhadap terapi pada pasien tuberkulosis paru harus dimonitor dengan

pemeriksaan dahak mikroskop berkala. 5Response to therapy in patients with

pulmonary tuberculosis should be monitored with periodic examination of sputum

microscopy. 5


Uji sensisitivitas obat seharusnya dilakukan pada awal pengobatan untuk semua

pasien yang sebelumnya pernah diobati, pasien yang apus dahak tetap positif

setelah pengobatan 3 bulan selesai, pasien gagal pengobatan, pasien putus obat

dan kasus kambuh. 5Sensitivity drug test should be done at the beginning of

treatment for all patients previously treated, patients who remain sputum smear

positive after 3 months treatment completed, patients fail treatment, the patient off

the drug and relapse cases. 5


Psien yang menderita atau kemungkinan besar menderita tuberkulosis yang

disebakan kuman resistensi obat (khususnya MDRI/XDR) seharusnya diobati

dengan panduan obat khusus yang mengandung obat tuberkulosis lini kedua. 5Patient who are suffering or likely to suffer from tuberculosis germs disebakan

drug resistance (especially MDRI / XDR) should be treated with special

medication guides that contain the second-line tuberculosis drugs. 5


Rekaman tertulis tentang pengobatan yang diberikan, respon bakteriologis dan

efek sampingnya seharusnya disimpan untuk semua pasien. 5Written records of

medications given, bacteriologic response and side effects should be kept for all

patients. 5

36

KOMPLIKASI 1K. Compliations 1

Komplikasi paru :Pulmonary Complications:

Atelektasis Atelectasis

Hemoptisis Hemoptysis

Fibrosis Fibrosis

Brokiektasis Brokiektasis

Pneumothoraks Pneumothorax

Gagal napas Respiratory failure

TB ekstra paru :Extra-pulmonary TB:

Pleuritis Pleuritis

Efusi pleura Pleural effusion

Perikarditis Pericarditis

Peritonitis Peritonitis

Tb kelenjar limfe Tb lymph nodes

Cor pulmonal Cor pulmonary

PROGNOSISL. Prognosis

Prognosis TB paru umunya adalah dubia.Prognosis of pulmonary tuberculosis is

generally dubia. Tergantung derajat berat, kepatuhan pasien, sensitivitas bakteri,

gizi, dan status imun. 1 Depending on the degree of weight, patient compliance,

bacterial sensitivity, nutrient, and immune status. 1

TUBERCULOSIS PLEURAL EFFUSION

Tuberculous pleural effusions occur in up to 30% of patients with tuberculosis. It

appears that the percentage of patients with pleural effusion is comparable in

human immunodeficiency virus (HIV)-positive and HIV-negative individuals,

although there is some evidence that HIV-positive patients with CD4+ counts

<200 cells·mL-1 are less likely to have a tuberculous pleural effusion.

37

The inner surface of the chest wall and the surface of the lungs are covered by the

parietaland visceral pleural, respectively, with a potential space of 10-24 μm

between the 2 pleural surfaces. This space is normally filled with approximately 1

ml of fluid, representing the balance between (1) hydrostatic and oncotic forces in

the visceral and parietal pleural vessels and (2) extensive lymphatic drainage.

Pleural effusions result from disruption of this balance. Large amounts of fluid

can accumulate in the pleural space under pathologic conditions. The parietal

pleura have sensory innervation and small apertures that aid in the absorption of

particles and fluid.

The current hypothesis for the pathogenesis of primary tuberculous pleural

effusion is that a subpleural caseous focus in the lung ruptures into the pleural

space 6–12 weeks after a primary infection [7]. Mycobacterial antigens enter the

pleural space and interact with T-cells previously sensitized to mycobacteria,

resulting in a delayed hypersensitivity reaction and the accumulation of fluid. It

seems that this reaction of the pleura augments the entry of fluid into the pleural

space by increasing the permeability of pleural capillaries to serum proteins , and

thereby increasing the oncotic pressure in the pleural fluid. Involvement of the

lymphatic system probably also contributes to the accumulation of pleural fluid.

An impaired clearance of proteins from the pleural space has been reported in

human tuberculous effusions. It is known that the clearance of proteins and fluid

from the pleural space is carried out by lymphatics in the parietal pleura. Fluid

gains access to the lymphatics through openings in the parietal pleura called

stomata. Since the parietal pleural is diffusely affected with pleural tuberculosis,

damage to or obstruction of the stomata could be an important mechanism

leading to accumulation of pleural fluid.

38

REFERENCES.

(1). Perhimpunan dokter spesialis penyakit dalam indonesia. Panduan Pelayanan

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Association of Indonesian medical specialist in internal medicine. Manual of

Medical Services. New York: Publishing Center Department of Medicine Faculty

of medicine. 2006. 2006. Hal : 109 Page: 109

(2).(2). Danusantoso, H. Ilmu Penyakit Paru. Jakarta : Hipokrates. Danusantoso,

H. Lung Pathology. London: Hippocrates. 2000. 2000. Hal : 97 Page: 97

(3).(3). Bahar, A. Buku Ajar Ilmu Penyakit Dalam, Jilid II . Bahar, A. Textbook of

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lung vesikuler

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