Pediatric TB (Repaired)

TUBERCULOSIS

Presentators : Fildzah Yamami Rizal ; Regina Marhadisony

Day, Date :

Supervisor : dr. Hj. Tiangsa Sembiring, Sp.A(K)

Introduction

Tuberculosis remains one of the most important causes of death from an

infectious disease, and it poses formidable challenges to global health at the

public health, scientific, and political level.1 The urgency of the problem of TB in

children, whose full scope is still not fully known, cannot be underestimated.2 It is

estimated that one third of the world’s population is infected with Mycobacterium

tuberculosis (the bacterium that causes tuberculosis (TB)), and that each year,

about 9 million people develop TB, of whom about 2 million die. Of the 9 million

annual TB cases, about 1 million (11%) occur in children (under 15 years of age).

Of these childhood cases, 75% occur annually in 22 high-burden countries that

together account for 80% of the world’s estimated incident cases. In countries

worldwide, the reported percentage of all TB cases occurring in children varies

from 3% to more than 25%.3

Tuberculosis is a direct contagious disease caused by Mycobacterium

tuberculosis. The disease primarily involves the lungs, and at times distant blood-

borne spread results in the development of extrapulmonary TB.1,4 Pediatric

tuberculosis (TB) is different than that in adults in several ways. Children with TB

differ from adults in their immunological and pathophysiological response in

ways that may have important implications for the prevention, diagnosis and

treatment of TB in children.3 The diagnosis of TB is more difficult in children due

to non-specific or complete absence of symptoms and difficulty in confirming the

diagnosis microbiologically. So for making the diagnose for children, need other

criteria with using the scoring system.4,5 Coordination Work Division Unit of

3

Respirology PP IDAI has made National Guideline of Pediatric Tuberculosis with

using scoring system, which giving score for each signs or symptoms found.4

Table 1. TB Scoring System for Child based on Clinical and Supportive

Work-Up4

Parameter 0 1 2 3 Total

TB Contact Not

clear

Family

report, AFB

negative or

not sure,

Acid Fast

Bacilli not

clear

Acid Fast Bacilli

positive

Tuberculin Test negative Positive (≥ 10

mm, or ≥ 5

mm in immune

compromised state

Body

Weight/Nutritional

State

Under red

line on KMS

or BW for

age

< 80%

Poor

nutrition

state

(BW for age

< 60%)

Febrile without

cause

> 2 weeks

Cough ≥3 weeks

Enlargement of

Coli/Axilla/Inguina

l Lymph Node

>1 cm, >1,

No

tenderness

Swollen of hip

/knee/phalang joint

positive

Thorax X-Ray Normal TB

4

or not

clear

suggestive

Total

After taking careful history, physical examination and another work up

such us tuberculin test and chest x-ray, the scoring system can be done. If the

patient got score 6 or more, should be treat as TB patient and get ATT (Anti-

Tuberculosis Therapy). If the score is below 6 but the clinically support for TB,

another work up should be done in indication such us, gastric lavage, pathological

anatomy, lumbal punction, pleural punction, bone and joint x-ray, funduscopy,

CT-Scan and etc.4

In most cases of childhood tuberculosis, 6 months treatment is adequately

enough. After 6 months therapy, evaluation should be performed clinically and

based on laboratory or another supportive examination results. The clinical

evaluation is the best parameter for check the successfulness of the therapy given.4

. The aim of this paper is to report the case of 12

years 4 months old girl with tuberculosis with poor

nutrition and suspect of intra abdominal mass.

Case Report

5

VM, female, 12 years 4 months, came to RSHAM on 1st November 2013

with cough as the main complaint. This happened since 2 months ago and worsen

in the last 5 days. Sputum (+) but can’t be expelled, bloody cough (-). Contact

history with chronic coughing person directly were doubted. Dyspnea was not

found.

History of recurrent fever (+), felt by the patient for the past 5 months. The

fever come especially at night and relieved by anti pyretic drugs. History of

seizure (-), shivering (-)

Enlargement of the abdomen (+) was felt since 5 months ago and getting

bigger since then. At first, there was two mass at the umbilical regio about an egg

size for each. Then, the family brought her to the alternative treatment and get

some poison covered the abdomen. But there’s no improvement, the abdomen

getting bigger and the mass blended with the stomach. This complain

accompanied with intermitten pain, that resolved with analgetics.

Patient also complain for loss of appetite since 3 months ago. The patient

loss some weight since then. But from the start she always malnourished, the

maximum weight that she ever achieved was 30kg, but now she’s only weigh

20kg.

Another complain was swelling at both of the leg and foot. The patient

realized this since 2 weeks ago. At first, it just a fine swelling but get worsen in

these 2 days.

History of birth : normal, assisted by ‘dukun beranak’, cried as soon as

baby was born. Body weight and length was not recorded. History of feeding was

not remembered by patient’s mother. The patient did not receive any

immunization.

Physical Examination

BW : 20kg, BH: 130cm, Arm Circumference : 10cm

BW/Age : 47,6%

BH/Age : 86%

BW/BH : 74%

6

Presens status

Sens : Compos Mentis , Body temperature: 36,8oC, Pulse: 78 bpm, Respiratory

Rate: 24 bpm.

Localized status

1. Head : Flag sign (+) Eye : Light reflexes (+/+), isochoric pupil,

conjunctiva palpebra inferior normal, icteric was not found, ear :

normal appereance, mouth : no sianosis, nose: normal appereance

2. Neck : Lymph node enlargement (+), 1 piece about 5mm

3. Thorax : Symmetrical fusiformis. epigastrial retraction (+). easily seen ribs

HR: 94 bpm, reguler, no murmur. RR: 40 bpm, regular, no

crackles.

4. Abdomen : Symmetrical enlargement. Rigid. liver/spleen/renal : not

palpable. Peristaltic was normal. Tenderness (+) at left hypochondrial regio

5. Extremities : Pulse 94 bpm, regular, adequate pressure and volume, warm

acral, CRT<3”, hypotropy muscle (+) subcutan fat decreasing

(+) pretibial edema (+), pitting edema (+)

Differential Diagnosis

TB + Malnutrition + Susp. Intraabdominal Tumor

Bronchopneumonia + Malnutrition + Susp. Intraabdominal Tumor

Working Diagnosis

TB + Malnutrition + Susp. Intraabdominal Tumor

Treatment

- IVFD D5% NaCl 0,45% 50gtt/i

- Diet F75 80cc/3hours

- Ceftriaxone 200 mg/6 hours/IV

- Gentamycin 50 mg/24 hours/IV

7

Planning

- Complete Blood Count

- Blood glucose

- Electrolyte

- Chest X-Ray

- Mantoux Test

- CT-Scann Upper Lower Abdomen with IV Contrast

8

Follow up

1st November 2013 (First day)

S: Coughing, Shortness of breath

O: Sens: Compos Mentis , Temp: 37oC, Body weight: 20 kg

Head Eye : light reflexes (+/+), isochoric pupil, conjunctiva palpebra inferior

normal, icteric was not found , ear : normal appearance, mouth : no

sianosis, nose: normal appereance.

Thorax Symmetrical fusiform. easily seen ribs. Epigastrial retraction (+) HR: 110

bpm, reguler, no murmur. RR: 45 bpm, regular, no crackles.

Abdomen Enlargement (+) Rigid. peristaltic (+) normal. liver/spleen/renal: not

palpable. Pain on pressure at the left hypochondrium (+).

Extremitie

s

Pulse 100 bpm, regular, adequate pressure and volume, warm acral, CRT

< 3”, Pitting edema (+)

A: DD TB + Malnutrition + Suspect Intra abdominal Tumor

Bronchopneumonia + Malnutrition + Suspect Intra abdominal tumor

P: Management

- IVFD D5 NaCl 0.45% IV, 50 drops/minute micro

- Diet F 75 1500 kkal + 40 g protein

- Ampicilin 1000 mg/12hours/IV


Plan :

- Complete Blood Count, LFT, AFP, LDH, CRP, SI/TIBC/Ferritin, Blood Cultures,

Urinalysis, Urine Culture Mantoux Test, Sputum BTA test

- Abdominal USG

- Consult to Respirology division

- Consult to Nutrition and metabolic diseases division

- Consult to Hematooncology division

- Consult to Gastro-enterohepatology division

9

Laboratory Result:

November , 1st 2013

Complete Blood Count

Hemoglobin (HGB) g% 6.7 11.3 – 14.1

Eritrosit (RBC) 106/ mm3 2.61 4.40 – 4.48

Leukosit (WBC) 103/ mm3 15.56 4.5- 13.5

Hematokrit % 22.70 37 – 41

Trombosit (PLT) 103/ mm3 442 217 – 497

MCV fL 87.0 81 – 95

MCH Pg 25.7 25 – 29

MCHC g% 29.5 29 – 31

RDW % 19.9 11.6 – 14.8

MPV fL 9.8 7.2 - 10.0

PCT % 0.43

PDW fL 10.4

Diftel

Neutrofil % 91.3 37 – 80

Limfosit % 5.2 20 – 40

Monosit % 3.3 2 – 8

Eosinofil % 0.1 1 – 6

Basofil % 0.1 0 – 1

Neutrofil Absolut 103/µL 14.19 2.4 - 7.3

Limfosit Absolut 103/µL 0.81 1.7 - 5.1

Monosit Absolut 103/µL 0.52 0.2 - 0.6

Eosinofil Absolut 103/µL 0.02 0.10 - 0.30

Basofil Absolut 103/µL 0.02 0 - 0.1

Laboratory Result:

November, 1st 2013

Hemorrhagic Screening Test

10

PT + INR

Prothrombin Time

Control 13.00

Patient 16.6

INR

APTT

Control 33.0

Patient 38.0

Thrombin Time

Control 16.0

Patient 22.2

Clinical Chemistry

Blood Gas Analysis

pH 7.49 7.35-7.45

pCO2 mmHg 23.0 38-42

pO2 mmHg 160.4 85-100

Bikarbonat (HCO3) mmol/L 17.2 22-26

Total CO2 mmol/L 17.9 19-25

Base Excess mmol/L -3.9 (-2) – (+2)

O2 Saturation % 96.8 95-100

Liver Function

Albumin g/dL 1.9 3.8-5.4

Carbohydrate Metabolism

Blood Glucose mg/dL 111.10 <200

Kidney Function

Ureum mg/dL 21.0 <50

Creatinin mg/dL 0.99 0.53-0.79

11

Electrolyte

Natrium (Na) mEq/L 128 135-155

Kalium (K) mEq/L 3.3 3.6-5.5

Klorida (Cl) mEq/L 102 96-106

2nd November (Second Day)

S : Coughing (+), Shortness of breath (+)

O : Sens: Compos Mentis , Temp: 37,2oC, Body weight: 20 kg








Extremitie

s





P: Management





Plan :

- Hypoalbumin Correction

Laboratory Result, 2nd November 2013

Anemia Profile

Ferritin ng/mL 299.6 Adult : 15-300

Child : 15-240

12

Iron (Fe) Mg/dL 10 61-157

TIBC µg/dL 95 112-346

Liver Function

Alkali Posphatase

(AFP)

U/L 949 <300

AST/SGOT U/L 74 <32

ALT/SGPT U/L 44 <31

Total Protein g/dL 5.8 6.0-8.0


Globulin g/dL 4.3 2.6-3.6

LDH U/L 636 240-480

Immunoserolgy

Qualitative CRP Positive

Procalcitonin ng/mL 1.97 <0.05

IT Ratio 0.21 <0.2

13

3rd November (Third day)

S: No fever, cough (+), shortness of breath (+)

O: Sens: Compos Mentis , Temp: 37.1oC








Extremitie

s





P: Management:





- Albumin correction

Plan :

- Chest X-Ray PA/Lateral

- Blood Culture

- Mantoux Test

- Sputum Test for AFB

14

4th November (fourth day)

S : Fever was not found, Coughing (+)

O : Sens: Compos Mentis, temp: 36.8oC




Thorax Symmetrical fusiform. easily seen ribs. HR: 90 bpm, reguler, no murmur.

RR: 28 bpm, regular, no crackles.



Extremitie

s





P: Management:





Plan :

- Work Up for Abdominal Mass

- Urin Routine, Feces routine

- Tumor Marker

- Abdominal CT Scan with contrast IV

15

Laboratory Result, 4th November 2013

Tumor Marker

AFP ng/mL 0.61 0-15

Blood β-HCG U/mL 0 0-1

5th November (fifth day)

S : Coughing (+), Fever was not found

O: Sens: Compos Mentis, temp: 36.8oC


normal, icteric was not found , ear : normal appearance, mouth : erosion (+)

at the lip mucose, nose: normal appereance.





Extremitie

s





P: Management:


- Diet F 75 210cc/3hours + mineral mix 4.2cc



Plan :

- Respirology consult

- Gastric Lavage

- Urine culture

- Wait for the abdominal CT scan to be scheduled

- Wait for the answer from the nutrition division

16

6th November (sixth day)

S : Coughing (+), Shortness of breath (+)

O : Sens : Compos Mentis, Temp : 37.3 oC








Extremitie

s



A : DD TB + Malnutrition + Suspect Intra abdominal Tumor


P : Management:


- Diet F 100 210cc/3hours + mineral mix 4.2cc



Plan :

- Liver USG

Chest X Ray Result, 6th November 2013 :

Both of costophrenicus sinus are sharp, both of the diaphragm smooth. Infiltration

was seen in both lungs, some of it were consolidated. The heart was normal with

CTR less than 55%. Tarchea was in the middle. Bone and soft tissue were normal.

Radiologic Summary :

Suspect Active Lung TB + Suspect Bronchopneumonia

17

7th November (seventh day)

S: Fever was not found, Coughing (+), Abdominal pain (+)

O: Sens: Compos Mentis, temp: 37oC






Abdomen Enlargement (+) Rigid. peristaltic (+) normal. Venectation (+)

liver/spleen/renal: not palpable. Pain on pressure at the left hypochondrium

(+).

Extremitie

s





P: Management:


- Diet F 100 210cc/3hours + mineral mix 4.2 cc

- Multivitamin without Fe 1xcth 1



Plan :

- Repeat Renal Function Test examination

- Urinalysis

- Abdominal CT scan or USG

18

8th November (eighth day)

S: Fever was not found, Abdominal pain (-), pain on pressure (+), Coughing (+)







Abdomen Enlargement (+) Rigid. peristaltic (+) normal. Venectation (+)


(+).

Extremitie

s





P: Management:



- Multivitamin without Fe 1xcth 1



Plan :

- Gastric Lavage

- AP lateral Foto thorax

- Abdominal USG

Mantoux Test Result : Negative

19

9th November (Ninth day)

S: Abdominal pain (+) Heartburn is felt after patient is fed. Vomitting (-).

Coughing (+)







Abdomen Enlargement (+) Rigid. peristaltic (+) lessen. Venectation (+)


(+).

Extremitie

s





P: Management:



- Univit 1x1 Cth



Plan :

- Gastric Lavage

- Lateral foto thorax

Laboratory Result, 9th November 2013 :

Complete Blood Count

Hemoglobin (HGB) g% 6.7 11.3 – 14.1

Eritrosit (RBC) 106/ mm3 2.56 4.40 – 4.48

20

Leukosit (WBC) 103/ mm3 16.61 4.5- 13.5

Hematokrit % 22.6 37 – 41

Trombosit (PLT) 103/ mm3 357 217 – 497

MCV fL 89.1 81 – 95

MCH Pg 26.2 25 – 29

MCHC g% 29.4 29 – 31

RDW % 20.5 11.6 – 14.8

MPV fL 9.7 7.2 - 10.0

PCT % 0.35

PDW fL 10.4

Diftel

Neutrofil % 95.1 37 – 80

Limfosit % 3.2 20 – 40

Monosit % 1.5 2 – 8

Eosinofil % 0.1 1 – 6

Basofil % 0.1 0 – 1

Neutrofil Absolut 103/µL 15.99 2.4 - 7.3

Limfosit Absolut 103/µL 0.54 1.7 - 5.1

Monosit Absolut 103/µL 0.25 0.2 - 0.6

Eosinofil Absolut 103/µL 0.01 0.10 - 0.30

Basofil Absolut 103/µL 0.02 0 - 0.1

Clinical Chemistry

Liver Function

AST/SGOT U/L 58 <32

ALT/SGOT U/L 25 <31


Carbohydrate Metabolism

Blood Glucose mg/dL 86 <200

Renal Function

21

Ureum mg/dL 24.9 <50

Creatinin mg/dL 0.54 0.53-0.79

Uric Acid mg/dL 2.9 <5.7

USG Liver Result, 9th November 2013 :

Size and shape of the liver seems a little bigger, internal echostructural heterogen

elevated. Vena porta wall differentiation slightly dark. Intraabdominal free fluid

collection were seen with floating bowel pattern.

Radiologic Summary :

Mild hepatomegaly with ascites

Suggestion : Abdominal CT Scan with IV Contrast

10th November (Tenth day)

22

S: Abdominal pain (+), Coughing (+)









(+).

Extremitie

s



A: DD TB + Malnutrition + Suspect Intra abdominal Tumor + Mild

Hepatomegaly + Ascites

Bronchopneumonia + Malnutrition + Suspect Intra abdominal tumor +

Mild Hepatomegaly + Ascites

P: Management:



- Univit 1x1 Cth



- Ranitidine 20mg/8hours/IV

- Albumin Correction (2.5-1.6) x 20 x 0.8 = 16 ; Plasbumin 25% = 64cc

11th November (Eleventh day)

S: Cough (+), Shortness of breath (+), Abdominal Pain (+) less than before


23








(+).

Extremitie

s







P: Management:



- Univit 1x1 Cth



Plan :

- Waiting for Abdominal CT Scan

Gastric Lavage Result : Negative-Positive-Negative

Urinalysis Result, 11th November 2013 :

Complete Urine Examination

Colour Clear Yellow Yellow

Glucose Negative Negative

Bilirubin Negative Negative

24

Aff, change with Ceftriaxone 1gr/12 hours/IV

Keton Negative Negative

Berat Jenis 1.015 1.005-1.030

pH 6.0 5-8

Protein Negative Negative

Urobilinogen Negative

Nitrit Negative Negative

Blood Negative Negative

Urine Sedimentation

Erythrocyte LPB 0-1 <3

Leucocyte LPB 1-2 <5

Epithel LPB 0-1

Casts LPB Negative Negative

Crystal LPB Negative

12th November (Twelfth day)

S: Cough (+), Shortness of breath (+)


25








(+).

Extremitie

s







P: Management:



- Univit 1x1 Cth

- Ceftriaxone 1gr/12hours/IV

Plan :

- Repeat Electrolyte Test

13th November (Thirteenth day)

S: Cough (+), Shortness of breath (+)


26








(+).

Extremitie

s







P: Management:



- Univit 1x1 Cth


- Rifampisin 1x300mg

- INH 1x200mg

- Pyrazinamide 1x400mg

- Ethambutol 1x400mg

Gastric Lavage Culture Results, 13th November 2013 : Negative

14th November (Fourteenth day)

S: Cough (+), Shortness of breath (+) lessen


27








(+).

Extremitie

s







P: Management:



- Univit 1x1 Cth



- INH 1x200mg



- Vit B6 1x1

Plan :

- Check for Liver Function Test include Albumin

28

Laboratory Result, 14th November 2013 :

Liver Function

AST/SGOT U/L 80 <32

ALT/SGPT U/L 31 <31


Immunodeficiency Profile

Anti HIV (3 methode)

Anti HIV Non Reactive Non Reactive

Anti HIV (Rapid I) Non Reactive Non Reactive

Anti HIV (Rapid II) Non Reactive Non Reactive

CT Scan Whole Abdomen with IV Contrast , 14th November 2013 :

Shape and size of the liver seems enlarge. Regular side, parenchym homogen.

Billiary system and intrahepatic are not wider. Vascular structural are intact.

Ascites were found and there were infiltration on both of the lungs. Shape and

size of the spleen were seems bigger with hipodense multiple lesions.

Pancreas : shape and size are good. Parenchym homogeny.

Kidney : shape and size are good. Regular side. Cortico-meduler differentiation

are clear, no stone were seen. No dilatation of PCS and ureter.

No para-aortal, parailliaca, and bilateral inguinal lymph node enlargement.

Gall Bladder : size and shape are good. Wall is regular.

Vesica Urinaria : size and shape are good. Wall is regular.

The bowel seems distended with thickening of the wall, but the air of the bowell

still seen minimally, pelvic minor projection.

Bone and soft tissue around the wall look good.

Summary :

- Mild splenomegaly with hypodense multiple lesions and hepatomegaly.

- Ascites

- Pneumonia

- Partial Ileus Obstructive

29

- Any other intraabdominal organ are in good conditions

Suggestion : MRI Abdomen

15th November (Fifteenth day)










(+).

Extremitie

s







P: Management:



- Univit 1x1 Cth



- INH 1x200mg



- Vit B6 1x1

- Albumin correction : Plasbumin 25% = 100cc

30

16th November (Sixteenth day)










(+).

Extremitie

s







P: Management:



- Univit 1x1 Cth



- INH 1x200mg



- Vit B6 1x1

- Prednison 2-1-1

Patient PAPS on 16th November 2013 afternoon

31

Discussion

Tuberculosis is a direct contagious disease caused by Mycobacterium

tuberculosis. The disease primarily involves the lungs, most children with TB

have pulmonary TB, and at times distant blood-borne spread results in the

development of extrapulmonary TB.1,3,4 Pediatric tuberculosis (TB) is different

than that in adults in several ways. (1) The diagnosis of TB is more difficult in

children due to non-specific or complete absence of symptoms and difficulty in

confirming the diagnosis microbiologically. (2) Young children suffer more

extrapulmonary and disseminated TB than adults. (3) Treatment of TB in children

is challenging due to the lack of pediatric drug formulations and challenges in

monitoring for toxicity. Fortunately, children generally do very well with

treatment and tolerate the medications well. Treatment regimens are very similar

to those used in adults. Four drug treatment should be initiated for treatment of

presumed active TB if there are any risks of drug resistance in the child or adult

source case (including residence or travel to an area where there is > 4%

resistance to INH). (4) Children should be TB skin tested only if they have risks

for TB infection, are likely to progress to active TB, or are suspected of having

active TB. Unlike adults, all children should be treated for latent TB infection if

identified because the therapy is very safe in young people, they were likely to

have been infected relatively recently, and they have a long time to reactivate their

latent infection. (5) Young children are not contagious with active TB and

acquired their disease from shared airspace with adolescents or adults with

pulmonary TB or ingestion of unpasturized milk products (M. bovis).5

Making the TB diagnosis in children is hard, since it’s always

misdiagnosis for being overdiagnosis or underdiagnosis. In children, cough is not

the main complaint. Sputum collecting also really hard to obtain, so for making

the diagnosis we need a scoring system. Coordination Work Division of

Respirology Unit PP IDAI has made ‘Pedoman Nasional Tuberkulosis Anak’

using scoring system which giving score for each signs and symptoms found. This

guideline were officially use by national program for treating TB for making

diagnosis in children.4 For the criteria of the scoring, look Table 1.

32

After taking careful history, physical examination and another work up

such us tuberculin test and chest x-ray, the scoring system can be done. If the

patient got score 6 or more, should be treat as TB patient and get ATT (Anti-

Tuberculosis Therapy). If the score is below 6 but the clinically support for TB,

another work up should be done in indication such us, gastric lavage, pathological

anatomy, lumbal punction, pleural punction, bone and joint x-ray, funduscopy,

CT-Scan and etc.4 Although bacteriological confirmation of TB is not always

feasible, it should be sought whenever possible, e.g. by sputum microscopy for

children with suspected pulmonary TB who are old enough to produce a sputum

sample. A trial of treatment with anti-TB medications is not recommended as a

method to diagnose TB in children. 3

This patient was admitted to the hospital with coughing as the chief

complaint. Cough may include in the scoring after excluding other cause of

chronic cough as asthma, sinusitis etc.4 From history taking, there were no clear

evidence of the patient being ever contact with TB patient. Mantoux test that have

been done has negative result. Assessment of the nutritional state by using CDC-

NCHS 2000 shown severe malnutrition. The patient also complain about

intermittent fever that felt for about 5 months. There was an enlargement of lymph

node on the coli about 5mm in size on physical examination. And last, the chest x-

ray were suspecting pulmonary TB because of the infiltration shown. Total TB

Score for VM is 6, details are shown on Table 2.

Table 2. TB Scoring System for VM

Parameter 0 1 2 3 Total

TB Contact Not

clear

Family

report, AFB

negative or

not sure,

Acid Fast

Bacilli not

clear

Acid Fast Bacilli

positive

0

Tuberculin Test negative Positive (≥ 10 0

33

mm, or ≥ 5

mm in immune

compromised state

Body

Weight/Nutritional

State

Under red

line on KMS

or BW for

age

< 80%

Poor

nutrition

state

(BW for age

< 60%)

2

Febrile without

cause

> 2 weeks 1

Cough ≥3 weeks 1

Enlargement of

Coli/Axilla/Inguina

l Lymph Node

>1 cm, >1,

No

tenderness

0

Swollen of hip

/knee/phalang joint

positive 0

Thorax X-Ray Normal

or not

clear

TB

suggestive

2

Total 6

With total score of 6, following the reference that said children with score

more than or equal to 6 were diagnosed as TB4, this patient are considered to be

diagnosed by Tuberculosis.

Other than scoring system that been used in Indonesia to diagnose TB in

children, WHO recommend some approach to diagnose TB in children. First,

careful history taking. Contact, just like one point in the Indonesian TB Scoring

System. Close contact is defined as living in the same household as or in frequent

contact with a source case with sputum smear-positive pulmonary TB. Source

cases that are sputum smear-negative but culture-positive are also infectious, but

34

to a much lesser degree.3 This patient has no clear evidence of being contact with

sputum smear-positive pulmonary TB or else.

Then, the symptoms. In most cases, children with symptomatic TB

develop chronic symptoms. The commonest are Chronic cough, an unremitting

cough that is not improving and has been present for more than 21 days. Fever,

body temperature of >38 °C for 14 days, after common causes such as malaria or

pneumonia have been excluded. Weight loss or failure to thrive, in addition to

asking about weight loss or failure to thrive, it is necessary to look at the child's

growth chart.3 This patient has chronic cough that been felt for the past 5 months,

followed by intermittent fever. Since the nutritional state indicate severe

malnutrition and no signs of gaining weight for the past 5 months, may suggest

the third symptoms. Documented weight loss or failure to gain weight, especially

after being treated in a nutritional rehabilitation programme, is a good indicator of

chronic disease in children, of which TB may be the cause.3

Mantoux test or Tuberculin Skin Test (TST) is another recommended

approach for diagnose TB in children. A positive TST occurs when a person is

infected with M. tuberculosis, but does not necessarily indicate disease. However,

the TST can also be used as an adjunct in diagnosing TB in children with signs

and symptoms of TB and when used in conjunction with other diagnostic tests. A

TST should be regarded as positive as follows; in high-risk children (includes

HIV-infected children and severely malnourished children, i.e. those with clinical

evidence of marasmus or kwashiorkor): >5 mm diameter of induration; in all

other children (whether they have received a bacille Calmette–Guérin (BCG)

vaccination or not): >10 mm diameter of induration.3

There can be false-positive as well as false-negative TSTs. Possible causes

for these results are in table 3. Sometimes it is useful to repeat the TST in children

once their nutritional status has improved or their severe illness (including TB)

has resolved, as they may be initially TST negative, but positive after 2–3 months

on treatment. A negative TST never rules out a diagnosis of TB in a child. 3 In this

patient, the TST test shown negative result, this maybe happen because of her

nutritional state that were severe malnourished.3

35

Table 3. Causes of False-Negative and False Positive TST3

Like on adult TB diagnosis, in children, the gold standard for diagnose TB

still bacteriological confirmation, whenever possible. Appropriate specimens from

the suspected sites of involvement should be obtained for microscopy and, where

facilities and resources are available, for culture (and also histopathological

examination). Appropriate clinical samples include sputum, gastric aspirates and

certain other material (e.g. lymph node biopsy or any other material that is

biopsied).3 Because there’s no expectoration from this patient, gastric lavage were

arrange to get some specimens for examinations, but still, there’s no evidence of

acid fast-bacilli.

Chest radiography is useful in the diagnosis of TB in children. In the

majority of cases, children with pulmonary TB have CXR changes suggestive of

TB. In areas with a high prevalence of HIV infection in the general population,

where TB and HIV infection are likely to coexist, HIV counselling and testing is

indicated for all TB patients as part of their routine management.3 This patient

chest X-ray shown suggestive TB as said from consultation from Radiology

Department. And for HIV Testing, this patient had been test for 3-methodes

ELISA and the result are negative.

After the diagnose were obtained, the next step is to treat. The main

objectives of anti-TB treatment are to:

1. cure the patient of TB (by rapidly eliminating most of the bacilli)

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2. prevent death from active TB or its late effects;

3. prevent relapse of TB (by eliminating the dormant bacilli);

4. prevent the development of drug resistance (by using a combination of

drugs);

5. decrease TB transmission to others

Picture 1. TB Treatment Plot for Children at Basic Health Facility4

The decision to treat a child should be carefully considered and once such

a decision is made, the child should be treated with a full course of therapy.3 Basic

principle of TB treatment is at least 3 kind of drugs and given in 6 months term.

ATT in children were given everyday, on intensive phase and on continuation

phase and the dose were based on the weight of each child.4

Anti-TB treatment is divided into two phases: an intensive phase and a

continuation phase. The purpose of the intensive phase is to rapidly eliminate the

majority of organisms and to prevent the emergence of drug resistance. This phase

uses a greater number of drugs than the continuation phase. The purpose of the

continuation phase is to eradicate the dormant organisms. Fewer drugs are

generally used in this phase because the risk of acquiring drug resistance is low,

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Score ≥ 6

Give ATT for 2 months and evaluate

Response (+)Response (-)

Continue therapy Continue therapy while looking other cause

as most of the organisms have already been eliminated. In either phase, treatment

can be given daily or three times weekly.3

Table 4. Recommended doses of first-line anti TB drugs

This patient were treated with broad spectrum antibiotic as the working up

for diagnose TB were perform before she received any ATT. As it goes she

received F100 diet with mineral mix for correct her malnourished state. And then

she received RHZE for initial phase, each 300/200/400/400 in dose for initial

phase for 2 months.

In most cases of childhood tuberculosis, 6 months treatment is adequately

enough. After 6 months therapy, evaluation should be performed clinically and

based on laboratory or another supportive examination results. The clinical

evaluation is the best parameter for check the successfulness of the therapy given.

If there any clinical improvement even though radiologically not shown any

significant change, ATT still stopped.4

Prevention for TB was done in high prevalence country including

Indonesia, with BCG vaccination. BCG is a live attenuated vaccine derived from

M. bovis. The WHO Expanded Programme on Immunization recommends BCG

vaccination as soon as possible after birth in countries with a high TB prevalence.

Although BCG has been given to children since the 1920s, controversies about its

effectiveness in preventing TB disease among adults remain. Efficacy ranges from

0% to 80% in published studies from several areas of the world. The reasons for

this variability may be multiple, including different types of BCG used in

different areas, differences in the strains of M. tuberculosis in different regions,

38

different levels of exposure and immunity to environmental mycobacteria and

differences in immunization practices. However, it is generally accepted that after

effective BCG vaccination there is protection against the more severe types of TB

such as miliary TB and TB meningitis, which are most common in young

children.3 This patient never receive any kind of immunization since she were

born, including BCG vaccination.

In countries with a high TB prevalence, the benefits of BCG vaccination

outweigh the risks. In these countries, WHO recommends a policy of routine BCG

immunization for all neonates. A child who has not had routine neonatal BCG

immunization and has symptoms of HIV disease/acquired immunodeficiency

syndrome should not be given BCG because of the risk of disseminated BCG

disease. There is no evidence that revaccination with BCG affords any additional

protection and therefore revaccination is not recommended.3

39

Summary

VM, female, 12 years 4 months was admitted to RS Haji Adam Malik

with the main complaint of cough, fever and enlargement of the abdomen. On

physical examination the patient looks extreme wasting in appereance, easily seen

ribs (+), hypotropy muscle (+) subcutan fat decreasing (+), enlargement, rigidity

and tenderness of the abdomen (+), pitting edema of lower extremities (+).

Laboratory finding shows anemia, leucocytosis and hypoalbuminemia. Physical

examination shows tachipnea but no crackles in both lung, chest X-ray was

performed in the fourth day and the result was : suspect TB and pneumonia.

Mantoux test and gastric lavage were performed to provide diagnosis of

tuberculosis but the result was negative. The patient is treated as severly

malnourished patient with co-morbid of infection. As for the infection, the patient

were assess for TB diagnose using scoring system and the result are 6.

She was diagnosed with TB, malnutrition and susp. intra abdominal tumor

on first admission. While working up for diagnosing the Intraabdominal tumor,

the patient were treated as malnourished TB patient, managed with IVFD D5

NaCl 0.45% 50 drips per minute micro, diet F100 210cc/3hours with mineral mix

4.2cc, Univit 1x1 cth, Ceftriaxone 1gr/12hours/IV, Rifampisin 1x300mg, INH

1x200mg, Pyrazinamide 1x400mg, Ethambutol 1x400mg and Vit B6 1x1.

Unfortunately, the patient was back home as her family request and thought will

be missed her TB treatment and didn’t receive any other work up for her disease.

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References

1. Diagnosis and Management of Miliary Tuberculosis : Current State and Future

Perspectives. Ray, Sayantan, et al. West Bengal, India : Dove Press Journal,

2013, Therapeutics and Clinical Risk Management.

2. World Health Organization. [Online] 2013. [Cited: November 5, 2013.]

http://www.who.int/tb/challenges/children/en/.

3. —. Guidance for National Tuberculosis Programmes on the Management of

tuberculosis in Children. [Online] 2006. [Cited: November 5, 2013.] WHO/HTM/

TB/2006.371.

4. PEDOMAN NASIONAL PENANGGULANGAN TUBERKULOSIS .

DEPARTEMEN KESEHATAN REPUBLIK INDONESIA. 2006.

5. Pediatric Tuberculosis. Loeffler, Ann M. s.l. : Elsevier, 2003.

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Pediatric TB (Repaired)

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