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PENDAHULUAN123DIAGNOSIS4PATOGENESISPENATALAKSANAAN5PENUTUP*
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PENDAHULUANWHO:1,3 juta anak menderita TB/tahun 11% seluruh
kasus TB
Indonesia:Peringkat ke-3 tertinggi di dunia
TB pada anak kurang diperhitungkan:Anak mendapat infeksi
M.tuberkulosis dari dewasaTidak berperan dalam penyebaran
penyakit
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PENDAHULUANKegagalan dlm mengidentifikasi dan terapi TB pada
anak meningkatkan angka kematian pada anak usia < 3 tahun.
Infeksi TB pada anak:Asimptomatis >>Konfirmasi
bakteriologis jarang sulitnya pengumpulan spesimenDiagnosis
kombinasi dari px klinis, X-thorax foto, tes tuberkulin yg ,
riwayat kontak dng penderita TB aktif dewasa, computed tomografi
& bronkoskopi (>> negara-negara industri).*
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PENDAHULUANInterpretasi tes Tuberkulin pada anak dipengaruhi
:Vaksinasi BCGMalnutrisiSupresi imunPemeriksaan radiologis pd anak
bervariasi
Pemeriksaan serodiagnostik infeksi M.tuberkulosis:Sensitivitas
& spesivisitas rendah terutama pd anakData seroreaktivitas TB
pd anak juga rendahPenelitian terbaru evaluasi multiple antigen
menggunakan ELISA, multiantigen print immunoassay pd manusia
(-)*
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PENDAHULUAN123DIAGNOSIS4PATOGENESISPENATALAKSANAAN5PENUTUP*
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Figure. Pathogenesis of primary tuberculosisdroplet nuclei
inhalationalveoliingestion by PAMSintracellular replicationof
bacillidestruction of bacillidestruction of PAMSTubercle
formationHilar lymph nodeshematogenic spreadmultiple organs remote
foci Lymphogenic spreaddisseminated primary TBacute hematogenic
spread occult hematogenic spread primary
focuslymphangitislymphadenitisprimary complexCMIPATOGENESIS
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PATOGENESISM tuberculosis inoculationphagocytocis by PAMM tb
destroyedM tb survive, replicate primary focus formationlymphogenic
spreadhematogenous spread primary complexCMI (+) complication of:
(1)primary complex, (2)lymphogenic and (3)hematogenous
spreadoptimal immunityTB diseaseTB infectiondeathcuredTB
diseasetuberculin test (+)primary TBpost primary TBreactivation /
reinfectionincubation period 2-12weeks
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Miller FJW. Tuberculosis in children, 1982A minority of
childrenexperience :1. Febrile illness2. Erythema Nodosum3.
Phlyctenular ConjunctivitisComplications of focus1. Effusion2.
Cavitation3. Coin shadowComplications of nodes1. Extension to
bronchus2. Consolidation3. HyperinflationMENINGITIS OR MILIARYin 4%
of children infectedunder 5 years of ageLATE COMPLICATIONSRenal
& SkinMost after 5 years123456BONE LESIONMost within3 years24
monthsResistance reduced :1. Early infection (esp. in first year)2.
Malnutrition3. Repeated infections :measles, whooping
coughstreptococcal infections4. Steroid therapyinfectionBRONCHIAL
EROSIONMost childrenbecome tuberculinsensitive12 monthsDIMINISHING
RISKBut still possible90% in first 2 yearsGREATEST RISK OF LOCAL
& DISEMINATED LESIONSDevelopment Of Complex4-8 weeks3-4 weeks
fever of onsetPRIMARY COMPLEXProgressive HealingMost casesUncommon
under 5 years of age25% of cases within 3 months75% of cases within
6 months3-9 monthsIncidence decreasesAs age increased
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TB Extra Paru Pada Anak*
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PENDAHULUAN123DIAGNOSIS4PATOGENESISPENATALAKSANAAN5PENUTUP*
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*
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DIAGNOSIS*
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Langkah Diagnosis TB Pada Anak*
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Sugestif TB ?*
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Faktor Resiko*
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Sumber penularan:SulitPenting : Untuk dxBerhasil/tidaknya txAx :
Febris lama Batuk lama Bb Lesu Aktifitas
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Tbc primer : sering asymptomatikGx. Paru/r : ~ INFEKSI
LAINConjunctivitis phlyctenularisTbc
extrathoracalScrofulodermaPembesaran kelenjarMen-serCold abscesTbc
tulang/SendiCariPEMERIKSAAN FISIK
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Mantoux TestSangat penting untuk diagnostikDipakai : Ot 0,9 mg
Ppd 5 tuR :Tidak spesifikFoto bersih : tidak menyangkal ada
prosesDx. TBC TIDAK DAPAT DIBUAT ATAS DASAR rPersangkaan kuat tbc :
Gbr miliair Pembesaran kelenjar paratracheal
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INTERPRETASI MANTOUX 0-4 mm NEGATIF5-9 ragu> 10 mm
POSITIFKlinis : infeksi Klinis : sedang/pernah terinfeksiTidak
perlu diulang, kecuali ada dugaan keras tbcKlinis :Teknik salahAda
infeksiCross reaksiPsot bcg/crpAktif, bila :< 6 thTx Bcg
Konverse : Dlm 1 thTx Bcg InfeksiCross reaksi post bcgMUNGKIN 5x
TBCKet : konversi :I. 0 2 mm II. BERTAMBAH > 10 mm> 10 mm
TetapTetap tanda-tanda lainDiulang dgn dosis sama
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*
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*
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Interpretasi Tes Mantoux*
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DIAGNOSISNegara-negara berkembang:Diagnosis TB pd anak sistem
skoring
*
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*A score of 7 or more indicates a high likelihood of TB,
treatmentis justified
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Skor Keith Edwards*A score of 7 or more is indicative of
tuberculosis
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*According to this scoring system, 7 or more points
indicateunquestionable TB; 5-6 points indicate probable TB,
therapymay be justified; 3-4 points indicate that further
investigationsare needed
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DIAGNOSIS*
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DIAGNOSIS*
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DIAGNOSIS*
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DIAGNOSIS*
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Catatan Sistem Skoring TB IDAI 2008 Diagnosis dengan sistem
skoring ditegakkan oleh dokterJika dijumpai skrofuloderma, langsung
didiagnosis tuberkulosisBerat badan dinilai saat pasien datang
(moment opname)Demam dan batuk tidak ada respons terhadap terapi
sesuai baku puskesmas.Foto rontgen toraks bukan alat diagnostik
utama pada Tb anakSemua anak dengan reaksi cepat BCG harus
dievaluasi dengan sistem skoring Tb anakDidiagnosis Tb jika skor 6
(skor maksimal 13). Pasien usia balita yang mendapat skor 5,
dirujuk ke RS untuk evaluasi lebih lanjut.Gambaran sugestif TB :
pembesaran kelenjar hilus atau paratrakeal dengan/tanpa
infiltrat;konsolidasi segmental/lobar;milier;kalsifikasi dengan
infiltrat;atelektasis;tuberkuloma.
*
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DIAGNOSIS*
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Batuk akut dengan kesembuhan yang lamaBatuk akut
berulangPersisten, non- remitting cough
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Objectives of TB therapyRapid reduction of the bacilli number,
to cure the patientSterilization to prevent relapsesto achieve two
phases:Initial phase (2 months) intensive, bacilli
eradicationMaintenance phase (4 months / more) sterilizing effect,
prevent relaps
Prevention of acquired drug resistance,to achieve: principles of
therapy
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Ped TB therapy principles Multi drug, NOT single drug
(monotherapy)to prevent drug resistancerisk of fall and rise
phenomenoneach TB drug has specific action to certain TB bacilli
populationLong term, continue, uninterrupted problem of adherence
(compliance)The drug is taken daily and regularly
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DrugsDaily dose(mg/Kg/day)Adverse reactions2
Time/weekdose(mg/Kg/dose))Isoniazid(INH)5-15(300 mg))Hepatitis,
peripheral neuritis,hypersensitivity15-40(900
mg))Rifampicin(RIF)10-15(600 mg))Gastrointestinal upset,skin
reaction, hepatitis, thrombocytopenia,hepatic enzymes, including
orangediscolouraution of secretions10-20(600 mg)Pyrazinamide(PZA)15
- 40(2 g)Hepatotoxicity, hyperuricamia,arthralgia, gastrointestinal
upset50-70(4 g)Ethambutol(EMB)15-25(2,5 g)Optic neuritis, decreased
visualacuity, decreased red-green colourdiscrimination,
hypersensitivity,gastrointestinal upset50(2,5 g)Streptomycin(SM)15
- 40(1 g)Ototoxicity nephrotoxicity25-40(1,5 g)When INH and RIF are
used concurrently, the daily doses of the drugs are reducedNational
consensus of tuberculosis in children, 2001Dosage of
antituberculosis drug
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TB therapy regimen 2 mo 6 mo 9 mo 12mo
INHRIFPZA
ETBSM
PREDDOT.S !
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KORTIKOSTEROIDAnti inflamasiPrednison : oral, 1-2mg/kgBW/day,
tid 2-4 weeks, tap offIndikasi :TB MiliarMeningitis TBPleuritis TB
dengan efusi
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TB drugs & pharmaceutical formulationIsoniazid (H)Rifampicin
(R)Pyrazinamide (Z)Ethambutol (E)monosubstancecombi-packsfixed dose
comb
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KOMBIPAK 2 macam obat terpisah dalam satu kemasan
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FDC with IDAI formulation
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FDC tablet formulationWHOH: 30 mgR: 60 mgZ: 150 mgIDAIH: 50 mgR:
75 mgZ: 150 mg
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Anti-tuberculosis Lini Kedua*
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PENUTUP*