simposium online idai - tuberkolosis anak
DESCRIPTION
Presentasi Simposium IDAI, 6 April 2011.Judul presentasi : Tuberkolosis pada Anak.TRANSCRIPT
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dr. Nastiti Kaswandani, SpA
UKK Respirologi – PP IDAI
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Masalah utama TB anakDiagnosis
gejala klinis umum tidak khas over diagnosis & over treatment
spesimen diagnostik sulit didapatmembedakan infeksi / sakit ? belum ada
perangkat diagnostiknyaTata Laksana
Keteraturan (adherence/compliance)Jenis, dosis dan cara pemberian
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kelaskelas kontakontakk
infeksiinfeksi sakitsakit tindakatindakann
00 -- -- -- --
II ++ -- -- prof I prof I
IIII ++ ++ -- prof II prof II
IIIIII ++ ++ ++ terapiterapi
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Infeksi TB dan Sakit TB
Infeksi TB: CMI dapat mengendalikan infeksi TBkompleks primer (+)cell mediated immunity (+)tuberculin sensitivity (DTH) (+)jumlah kuman TB sedikittidak ada manifestasi klinis dan radiologis
Sakit TB: CMI gagal mengendalikan infeksi TB
infeksi + manifestasi klinis dan/atau radiologis
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TB infection
TB CMI
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TB disease
TB
CMI
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Risk factors for developing TBRisk factors:
Close, prolonged exposureExposure to a smear positive caseAge; the younger the greaterDecreased immunity
HIV Severe malnutrition
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Age specific risk for disease after recent Age specific risk for disease after recent primary infectionprimary infection
0
10
20
30
40
50
%
<1 1to2 2to5 5to10 10to15
Age in Years
PTB
Disseminated
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Bagaimana menegakkan diagnosis TB Anak?
Diperlukan 3 elemen menegakkan diagnosis:1. Bukti adanya infeksi
– Sumber penularan – Uji tuberkulin positif
2. Kumpulan gejala– Demam > 2 minggu– Penurunan BB / BB tidak naik – Batuk persisten– Multi- L
3. Foto Rontgen menyokong ke arah TB4. Bakteriologis
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Bagaimana menegakkan diagnosis TB Anak?
Diperlukan 3 elemen untuk menegakkan diagnosis:1. Bukti adanya infeksi
– Sumber penularan – Uji tuberkulin positif
2. Kumpulan gejala– Demam > 2 minggu– Penurunan BB / BB tidak naik – Batuk persisten– Multi- L
3. Foto Rontgen menyokong ke arah TB4. Bakteriologis
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TB infection riskHome
Environment
Adapted from Etkind S., Veen J., In Reichman-Hershfield: Tuberculosis: A Comprehensive International Approach, 2000
IndexCase
Close
Casual
LeisureEnvironment
Work/SchoolEnvironment
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Shaw JB, Am Rev Tuberc 1954;69:724-32Grzybowski S, et al. Bull Int Union Tuberc 1975;50:90-106
Van Geuns HA, Bull Int Union Tuberc 1975;50:107-21
S+/C+
S+/C+S+/C+
S-/C+
S-/C+S-/C+
S-/C-
S-/C- S-/C-
0
10
20
30
40
50
60
70
Bedfordshire 1948-1952
Rotterdam 1967-1969
Saskatchewan1966-1971
Pe
rce
nt
infe
cte
dRisk of M.tb transmission
MTB Infection Among Children by Type of Contact and bacteriological Status of Index case
Close
CloseCasual
Casual
05
10152025303540
Smear + Smear -
Per
cen
t in
fect
ed
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Uji tuberkulin, dasarhipersensitivitas thp tuberkuloprotein sistem imun TB utama : seluleruji tuberkulin, dasar : imunitas selulerPurified Protein Derivative sel Tmemory
tipe 4 (delayed type) hypersensitivity sebukan sel inflamasi indurasi
sensitivitas 100%, spesifisitas 99%
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Uji tuberkulin, pembacaandilakukan 48-72 jam pasca
injeksi
dituliskan dalam mm (misalkan ‘0’ mm, bukan hanya disebut ‘negatif’)< 5 mm : negatif5 – 9 mm : meragukan> 10 mm : positif
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Uji tuberkulin positif
infeksi TB alamiahBCG (infeksi TB
buatan)infeksi M. atipikpositif palsu
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Uji tuberkulin negatif
tidak ada infeksi TBdalam masa inkubasi (2-12 minggu)anergi :
infeksi virus : morbili, variselagizi buruk (bukan gizi kurang)sakit TB berat : TB milier, meningitis TBinfeksi bakteri berat : tifoid, pertusis, difteriamalignansiimunokompromais : terapi steroid, sitostatik,
HIV
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Berapa lama PPD dapat digunakan setelah dibuka ?
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Bagaimana menegakkan diagnosis TB Anak?Diperlukan 3 elemen untuk menegakkan
diagnosis:1. Bukti adanya infeksi
– Sumber penularan – Uji tuberkulin positif
2. Kumpulan gejala– Demam > 2 minggu– Penurunan BB / BB tidak naik – Batuk persisten– Multi- L
3. Foto Rontgen menyokong ke arah TB4. Bakteriologis
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Gejala dan tanda klinis umum : BB turun / sulit naik, tanpa sebab jelas nafsu makan kurang demam kronik dan berulang batuk kronik berulang malaise diare persisten keringat malam ?
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Gejala dan tanda klinis lokal (sesuai organ yang terkena) : p> kgb superfisialis (servikal, aksila,
inguinal) konjuntivitis fliktenularis kaku kuduk skrofuloderma : servikal, inguinal gibbus, kifosis paraparesis, paraplegia pincang, nyeri pangkal paha / lutut PARU : umumnya dijumpai dlm batas
normal
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TB kelenjar TB kulit
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TB tulang
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Bagaimana menegakkan diagnosis TB Anak?Diperlukan 3 elemen untuk menegakkan
diagnosis:1. Bukti adanya infeksi
– Sumber penularan – Uji tuberkulin positif
2. Kumpulan gejala– Demam > 2 minggu– Penurunan BB / BB tidak naik – Batuk persisten– Multi- L
3. Foto Rontgen menyokong ke arah TB4. Bakteriologis
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Foto Rontgen toraks
tidak khas !baku : AP dan lateralterbanyak : infiltrat minimal (tidak
sugestif)Rontgen toraks sugestif TB : lebih
jarang
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Rontgen toraks sugestif TB p> kgb hilus & mediastinum atelektasis lobus medius gambaran milier pneumonia efusi pleura kavitas pleuropneumoni
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100
32
0
20
40
60
80
100
Diagnosed by X-ray alone
Actual cases
Over diagnosis TB by CXR
Over-diagnosis
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Ghon focus
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Complicated Ghon focus
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Lymph node disease AP
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Cardiac Catheterization
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Lymph node disease Lat
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Pleural effusion
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Disseminated (miliary) disease
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MikrobiologikGold standard diagnostiksulit memperoleh spesimenpemeriksaan langsung : BTAbiakan :
konvensional : hasilnya lamaBactec : fluoresensi radioaktif, mahal
PCR (Polymerase chain reaction) :sens: 92%; spes: 99%belum klinis praktis
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Serologi (diagnostik humoral)pitfall diagnostik TB pada anakPAP Tb, ICT, Mycodot, ELISA, A60,
anti IFN, 38kD sensitivitas & spesifisitas ?
sens & spes tinggi pada pasien confirmed
TB, rendah pada populasi umum hanya menunjukkan ada infeksi : tidak
lebih unggul dibanding uji tuberkulin
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QuantiFERON-TB
QuantiFERON-TB Gold
QuantiFERON-TB Gold in tube
T-SPOT.TB
www.cellestis.com
www.oxfordimmunotec.com
New Kits on the block…..
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IDAI Pediatric TB scoring systemFeature Feature 00 11 22 33 Score Score
Contact Contact not clearnot clear -- reported, reported, AFB(-)AFB(-)
AFB(+)AFB(+)
TSTTST -- -- -- positive positive
BW BW (KMS)(KMS) -- <red line, BW<red line, BW severesevere malnutritionmalnutrition
--
Fever Fever -- unexplainedunexplained -- --
Cough Cough <3weeks<3weeks >>3weeks3weeks -- --
Node Node enlargemnt enlargemnt
-- >>1 node, 1 node, >>1cm,1cm, painlesspainless
-- --
Bone,jointBone,joint -- swellingswelling -- --
CXRCXR normalnormal sugestivesugestive -- --
Total scoreTotal score
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IDAI scoring systemDiagnosis TB: total score ≥6 (by doctor)BW at presentFever & cough no respons to standard txCXR is NOT a main diagnostic tool Accelerated BCG reaction: evaluated <5 y.o: Score 5 or strong suspicion referINH prophylaxis: score <6 with contact (+)
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04/14/23 53
TB treatment many years ago …
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04/14/23 54
Sun bathing …..
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04/14/23 55
TB treatment now …
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FDC with IDAI formulation
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Pengobatan kombinasi OAT, jangan tunggal awal (2 bulan) - intensif lama, ketaatan aspek lain :
perbaikan gizi cegah / obati penyakit lain
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2 mo 6 mo 9 mo 12mo
INHRIFPZA
EMBSM
PREDDOT.S !
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60
IDAI FDC (H/R/Z:50/75/150 & H/R:50/75)
Note: BW < 5kg should be referred and need tailored dosing
BW (kg)
Intensive, 2 mo(tablet)
Continuation, 4 mo(tablet)
05 - 09 1 1
10 - 14 2 2
15 - 19 3 3
20 - 33 4 4
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Evaluasi pengobatanperubahan nyata (klinis / penunjang) :
dalam 2 bulan awalutama : klinis, penunjang hanya tambahanperbaikan klinis :
peningkatan berat badan hilang / berkurangnya gejala (demam, batuk dll)
penunjang : foto Rontgen toraks : 2 / 6 bulan (atas indikasi)pemeriksaan darah: LED uji tuberkulin : jangan diulang !
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3/4
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From Epidemiology. Katzenellenbogen et al. OUP
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*If TB is suspected, investigate as per guidelines‡ unless the child is HIV-infected (in which case INH 6/12)
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pasienTB anak
Pasien TB dws
sentri-petal
sentri-fugal
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KesimpulanUntuk menegakkan diagnosis TB Anak diperlukan
anamnesis dan pemeriksaan fisis yang cermat, terutama tentang riwayat kontak dengan pasien TB dewasa, gambaran demam, batuk, letargi serta gangguan pertumbuhan
Uji tuberkulin harus dikerjakan untuk membuktikan adanya infeksi
Sistem skoring dapat membantu penegakan TB Anak
Anti tuberkulosis pada anak jarang menimbulkan hepatotoksisitas, dosis yang diberikan harus sesuai panduan WHO
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Dr. Nastiti Kaswandani, SpADr. Nastiti Kaswandani, SpALahir: Surabaya, 12 November 1970Pendidikan:
Dokter, FKUI, 1995Dr Spesialis Anak, FKUI, 2004
Pekerjaan/jabatan:- Staf Pengajar Dept. Anak FKUI / RSCM- Sekretaris UKK Respirologi – PP IDAI - Anggota Pokja TB Anak DepKes
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M. tuberculosis inhalation
phagocytosis by PAM
live bacilli
multiplies
primary focus formationlymphogenic spread
hematogenic spread1)
Primary complex2)
Cell mediated immunity (+)TST (+)
incubation period(2-12 weeks)
Pri
mary
TB
3)primary complex complication
hematogenic spread complicationlymphogenic complication
TB disease
Dead
Optimal immunity
TB infection
Cured TB disease4)
immunity reactivation/reinfecktion
bacilli dead
TB TB pathogenesispathogenesis
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69
WHO FDC (H/R/Z:30/60/150 & H/R:30/60)
BW(kg)
Intensive, 2 mo(tablet)
Continuation, 4 mo(tablet)
<7 1 1
8-9 1,5 1,5
10-14 2 2
15-19 3 3
20-24 4 4
25-29 5 5