Download - Tuberculosis in Children (E)
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Transmission Usually from adult TB patient with AFB (+)
Modes of transmission :• airborne : >90%, droplet nuclei 1-5 • orally : drink infected cow milk• direct contact: skin wound• congenital : during pregnancy, very rare
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Etiology
• Mycobacterium tuberculosis
• Mycobacterium bovis
Characteristics :
1. acid fast
2. grows slowly
3. live in weeks in dry condition
4. sensitive to sunlight, ultraviolet light, temp > 600 C
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Location of primary focus in 2,114 cases, 1909-1928
Location %Lung 95.93
Intestine 1.14
Skin 0.14
Nose 0.09
Tonsil 0.09
Middle ear (Eustachian tube) 0.09
Parotid 0.05
Conjungtiva 0.05
Undetermined 2.41
04/08/23 5Figure 1. Pathogenesis of tuberculosis. PAM’S, pulmonary alveolar macrophages
Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20
Inhalation Alveoli Ingestion by PAM’S
Intracellular multiplicationof bacilli
Destruction of bacilli
Destruction of PAM’S
Tubercle formationResolution Hilar lymph nodes
Calcification
Secondary lung lesions
Ghon Complex Caseation Hematogenous spread
Liquefaction
Lesions in liver, spleen,kidneys, bone, brain,
other organs
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Prognostic factors
A. TB bacilli :– virulence – infection dose
B. Patient :– General condition– age– Nutritional state – Dosis infeksi lain misalnya morbili– Genetik– Tekanan fisik dan psikis, misalnya trauma,
tindakan bedah
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Klasifikasi dasar0. Tidak ada kontak, tidak ada infeksi
(uji tuberkulin negatif)
I. Ada kontak, tidak ada infeksi (uji tuberkulin negatif)
II. Ada infeksi, tidak ada penyakit TB
(uji tuberkulin positif)
III. Penyakit tuberkulosis
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TB classification (ATS/CDC modified)
Class Contact Infetion Diseas
e Manage
ment
0 - - - -
I + - - proph I?
II + + - proph II?
III + + + therapy
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Diagnosis
1. Tuberculin skin test2. Chest X ray3. Clinical manifestation4. Microbiologic5. Pathology6. Hematological 7. Known infection source8. others : serologic, lung function,
bronchoscopy
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Tuberculin test
TB infection
cellular immunity
delayed type hypersensitivity
tuberculin reaction
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TUBERCULIN
StrengthTuberkulin PPD-S
mg/dosis TUTuberkulin
PPD RT 23 2 TUOT
mg/dosis Pengenceran
First 0,00002 1 - 0,011
10,000
Intermediate0,00001
- 10
5 2
5 0,1
-
11,000
12,000
Second 0,005 250 100 1,01
100
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Tuberculin
StrengthPPD S
SeibertPPD RT23
first 1 TU 1 TU
intermediate(standard dose)
5-10 TU 2-5 TU
second 250 TU 100 TU
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Tuberculin delivery
1. Mantoux : intradermal injection
2. Multiple puncture: • Heaf, special apparatus with 6 needles
• Tine, disposable, 4 needles
3. Patch test
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Tuberculin
Mantoux 0.1 ml PPD intermediate strength
location : volar lower arm
reading time : 48-72 h post injection
measurement : palpation, marked, measure
report : in millimeter, even ‘0 mm’
Induration diameter : 0 - 5 mm : negative 5 - 9 mm : doubt > 10 mm : positive
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Tuberculin positive
1. TB infection : infection without disease / latent TB infection infection and disease disease, post therapy
2. BCG immunization
3. Infection of Mycobacterium atypic
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AnergiUji tuberkulin dapat negatif untuk sementara karena :• TB berat misalnya TB milier• PEM berat• Mendapat kortikosteroid lama• Penyakit virus : morbili, varicella• Penyakit bakteri : typhus abdominalis, difteri,
pertusis• Vaksinasi virus : morbili, polio• Penyakit keganasan : penyakit Hodgkin
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Imaging diagnostic
• routine : chest X ray
• on indication : bone, joint, abdomen
• majority of CXR non suggestive TB
• pitfall in TB diagnostic
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Gambaran radiologi paru• Pembesaran kelenjar• Fokus primer• Atelektasis• Kavitas• Tuberkuloma• Pneumonia• “Air trapping”• Trakeobronkitis• Bronkiektasis• Efusi pleura• Gambara milier
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Clinical manifestation
• None
• General manifestation
• Organ specific manifestation
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General manifestation
• Chronic fever
• Anorexia dan BB / tidak naik
• Malnutrition
• Malaise
• Chronic cough
• Chronic / recurrent diarrhea
• Others
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Gejala spesifiksesuai organ yang terkena
• Respiratorik : batuk, sesak, mengi• Nerologik : kejang, kaku kuduk• Ortopedik : gibbus, pincang• Kelenjar : membesar, skrofuloderma• Gastrointestinal : diare berlanjut• Lain-lain
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Pemeriksaan mikrobiologis
• Memastikan D/ TB
• Hasil negatif tidak menyingkirkan D/ TB
• Hasil positif : 10 - 62 % (cara lama)
• Cara : – cara lama,– radiometrik, – PCR
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Hematological
• Not specific
• BSR could elevate
• Limphocyte could increase
Pathology• Lymph node, hepar, pleura
• On indication
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Infection source
• Known source of infection, has diagnostic value
• Shaw (1954), level of infectiousness :– AFB (+) : 62.5 % – AFB (-), M tb (+) : 26.8 % – AFB (-), M tb (-) : 17.6 %
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Other examinations
• Uji faal paru
• Bronkoskopi
• Bronkografi
• Serologi
• MPB64
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Miller FJW. Tuberculosis in children, 1982
A minority of childrenexperience :1. Febrile illness2. Erythema Nodosum3. Phlyctenular Conjunctivitis
EVOLUTION AND TIMETABLE OF UNTREATED PRIMARY TUBERCULOSISIN CHILDREN
Complications of focus1. Effusion2. Cavitation3. Coin shadow
Complications of nodes1. Extension into bronchus2. Consolidation3. Hyperinflation
MENINGITIS OR MILIARYin 4% of children infected
under 5 years of ageLATE COMPLICATIONS
Renal & SkinMost after 5 years
1 2 3 4 5 6
BONE LESIONMost within
3 years
24 months
Resistance reduced :1. Early infection (esp. in first year)2. Malnutrition3. Repeated infections :measles, whooping coughstreptococcal infections4. Steroid therapy
infection
BRONCHIAL EROSION
Most childrenbecome tuberculin
sensitive
12 months
DIMINISHING RISK
But still possible90% in first 2 yearsGREATEST RISK OF LOCAL & DISEMINATED LESIONS
Development Of Complex
4-8 weeks 3-4 weeks fever of onset
PRIMARY COMPLEXProgressive HealingMost cases
Uncommon under 5 years of age25% of cases within 3 months75% of cases within 6 months
3-9 monthsIncidence decreasesAs age increased
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Pengobatan TB
• Permulaan intensif
• Kombinasi 3 atau lebih OAT
• Teratur dan lama
• Pemberian gizi yang baik
• Pengobatan dan pencegahan penyakit lain
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Obat Anti Tuberkulosis (OAT)
1. Isoniazid (INH) : 5 - 15 mg/Kg BB/hari, max. 300 mg/hari
oral 1 - 2 x / hari
2. Rifampisin : 10 - 20 mg/Kg BB/hari, max. 600 mg/hari
oral 1 - 2 x / hari, perut kosong
3. Pirazinamid : 15 - 30 mg/Kg BB/hari, max. 2 gram/hari
oral 1 - 2 x / hari (20 - 40 mg/Kg BB/hari)
4. Streptomisin : 20 - 40 mg /Kg BB/hari, max. 1gram/hari
intramuskulus
5. Etambutol : 15 - 20 mg/Kg BB/hari, max. 1,5 gram/hari
oral 1 x /hari, perut kosong
6. Lain-lain : Ethionamide, Kanamycin, Cycloserin, Ciprofloxacin
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RIF, INH
Netral
Populasi basil TB pada pasien
Kavitas,ekstrasel
Massa kijuDalam makrofag
(intrasel)
Jumlah populasi 107 - 109 104 - 105 104 - 105
Metabolisme danperkembang biak
AktifLambat atauintermiten
Lambat
pH Netral/basa Asam
Obat paling efektif(berturut-turut)
INH, RIF,STREP
PZA, RIF, INH
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Smear +Culture +
Smear -Culture +
Smear -Culture -
108
107
106
105
104
103
102
101
100
Start of treatment(isoniazid alone)
Weeks of treatment0 3 6 9 12 15 18 WHO 78351
Sensitive organisms Resistant organisms
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Toman K. Tuberculosis. WHO, 1979
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Regimen of Antituberculosis drugs
2 mo 6 mo 9 mo 12 mo
INHRIFPZA
EMBSTREP
PRED
Directly Observed Treatment Short course (DOT’S)
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Corticosteroid
• Anti inflammation
• prednison : 1 - 3 mg/kg BB/hari, 3x/hari oral 2 - 4 minggu, tapering off
• Indications :– TB milier– Meningitis TB– Pleuritis TB with effusion
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Pencegahan
• Perbaikan sosio ekonomi
• Kemoprofilaksis
• Imunisasi BCG
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Kemoprofilaksis primer
• Mencegah infeksi• Anak kontak dengan pasien TB aktif, tetapi
belum terinfeksi (uji tuberkulin negatif)• Obat : INH 5 - 10 mg/kg BB/hari
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Kemoprofilaksis sekunder
Mencegah penyakit TB pada anak yang terinfeksi :
1. Mantoux (+), Rö (-), klinis (-) :• Umur < 5 th• Kortikosteroid lama• Limfoma, Hodgkin, lekemi• Morbili, pertusis• Akil baliq
2. Konversi Mt (-) menjadi (+) dalam 12 bl, Rö (-), klinis (-)
Obat INH 5 - 10 mg/kg BB/hari
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Imunisasi BCG
• Imunitas spesifik
• Uji tuberkulin menjadi (+)
• Mt (-) baru BCG
• Masal : langsung BCG tanpa Mt
• Reaksi lokal : membantu screening
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Komplikasi tuberkulosis primer
1. Komplikasi komplex primer– Fokus primer : kavitas, efusi pleura, dll– Kelenjar : menekan bronkus, dll
2. Penyebaran hematogen– Tuberkulosis milier– Meningitis TB– TB tulang dan sendi– TB ginjal– Lain-lain
3. Penyebaran limfogen4. Per kontinuitatum
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Tuberkulosis milier
• Penyebaran hematogen akut dan menyeluruh• Dapat menjadi kronik• Tanpa obat bisa fatal• Lesi-lesi ke seluruh tubuh• Demam, hepatomegali, splenomegali, tuberkel
koroid mata• Pungsi lumbal
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Pleuritis TB dengan efusi
• Pleuritis TB biasanya dengan efusi• Terjadi karena :
– Perluasan fokus TB dekat pleura– Penyebaran hematogen
• Hipersensitivitas terhadap tuberkulin efusi pleura
• Pungsi pleura• Dapat berupa empyema
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Akibat pembesaran kelenjar
• Menekan bronkus :– Atelektasis– Emfisema
• Menembus bronkus :– Penyebaran bronkogen– Fistula
TB Tulang dan Sendi
Spondilitis
Koksilitis
Gonitis
Daktilitis (spina ventosa)
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TB kelenjar superfisial
• Akibat penyebaran limfogen dan hematogen • Dapat sembuh sendiri, dapat progresif• Dapat merupakan bagian dari TB milier• Biasanya multipel• Lokasi : leher, axilla, inguinal, supraklavikuler,
submandibula• Abses
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TB Mata
• TB primer konjungtivapembesaran kelenjar preaurikuler
• TB koroid funduskopi• Conjunctivitis phluctenularis :
– Fenomena hipersensitivitas– Sakit, sangat mengganggu– Rekuren– Terjadi dalam 5-15 tahun
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Mycobacterium atipic(unclassified, anonymous, non tuberculous)
Runyon (1974) :• Photochromogen : M kansasi, M marinum,
M siniae• Scotochromogen : M scrofuloceum,
M.szulgai, M. xenopi• Nonphotochromogen: M avium, M
intracellulare• Rapid growers : M fortuitum, M chelonei
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DOTS with a SMILE
S : SupervisedM : MedicationI : InL : a LovingE : Environment
(Grange JM, Int J Tuberc Lung Dis 1999; 3:360-362)
S : SupervisedM : MedicationI : InL : a LovingE : Environment
(Grange JM, Int J Tuberc Lung Dis 1999; 3:360-362)