Paediatrica Indonesiana

VOLUME 52 NUMBER 2 March 2O12

Original Article
78 Paediatr Indones, Vol. 52, No. 2, March 2012
Tuberculosis score chart signs and symptoms in
children with positive tuberculin skin tests
Finny Fitry Yani
1
, Rizanda Machmoed
2
, Marhefdison
1
, Darfioes Basir
1
Abstract
Background 1he lndonesian Pediatrics Respirolo,v Workin,
Oroup (lPRWO) developed the tuberculosis (1B) score
chart to assist in dia,nosin, 1B in communitv health centers
(Puskesmas).
Objectives 1o document si,ns and svmptoms of the lPRWO 1B
score chart, to analvze various combinations of these si,ns and
svmptoms, and to compare these combinations in children with
1B to those without 1B, based on a 1B score chart.
Methods We performed a cross-sectional studv from Julv to
ctober 2OOo, in Padan,, Bukittin,,i and Pasaman. We recruited
children with known positive tuberculin skin tests (1S1) from a
2OO6 tuberculin survev. Questionnaires on si,ns and svmptoms
(lPRWO 1B score chart) were completed and chest radio,raphs
were obtained for all children. Subjects fulfillin, a total score of
six or more were considered to have a dia,nosis of 1B.
Results We dia,nosed 1B in 7o/2o5 (27.3') subjects. A score
value of 3 for the cate,orv of household contact (HHC) positive
smears was added in 21/7o subjects. However, the hi,hest risk for
1B disease was found in those dia,nosed with no clear historv of
HHC (5o.9', R 192, 95' Cl 22 to 1679). 1he hi,hest risk
factors for 1B were su,,estive chest X-rav (31.6', R 9.2, 95'
Cl 3.6 to 23.1) and fever lastin, > 2 weeks (17.9', R o, 95'
Cl 2.2 to 29.1), respectivelv. f 16 children with 1B dia,nosis
but without HHC, the combination of undernourishment, lvmph
node enlar,ement and su,,estive chest X-rav was hi,hest (2o.2').
lndividual or dual combination si,ns and svmptoms were also
found in children without 1B dia,nosis.
Conclusion Various combinations of si,ns and svmptoms could
lead to fulfillment of scorin, for 1B dia,nosis. [Paediatr Indones.
2012;52:78-85].
Keywords: tuberculosis score chart, children, signs,
symptoms
lrom the Departments of Child Health
1
and Public Health
2
, Andalas
Universitv Medical School, M.Djamil Hospital, Padan,, lndonesia.
Reprint requests to: linnv litrv Yani, Departments of Child Health,
Division of Respirolo,v, Andalas Universitv Medical School, M. Djamil
Hospital, Jl. Perintis Kemerdekaan, Padan,, lndonesia. 1el. 62-751-
37913. lax. 62-751-o11179. lmail: finny_fy@yahoo.com
C
hildhood 1B remains a major challen,e in
the twentieth centurv. Children comprise
a si,nificant proportion of the disease
population and experience considerable
morbiditv and mortalitv due to this ailment. ln the
vear 2OOO, children made up as manv as oo1,OOO out
of o.3 million new 1B cases (1O.7'),
1
with hi,her
estimates in endemic areas.
2
As disease transmission
continues, there are increasin, numbers of new
childhood 1B cases. lndonesia, one of the 22 most
hi,hlv burdened countries with 1B, has little data on
1B prevalence in children < 15 vears of a,e. However,
the WH estimated it to be 2.7', with a case rate
of 23 per 1OO,OOO.
1
A previous studv in Padan,, West
Sumatera, on children 6-7 vears of a,e, reported a
prevalence of 9.9'.
3
1B dia,nosis in children is challen,in,, as there
are limited specific si,ns and svmptoms, makin, it
difficult to differentiate from other diseases.
1-6
Chest
radio,raph is re,arded as a valuable dia,nostic tool,
but it is often difficult to interpret.
7,o
Bacteriological
confirmation is rarelv achieved, and often not even
Finny Fitry Yani et al: 1uberculosis score chart si,ns and svmptoms in children with positive tuberculin skin tests
Paediatr Indones, Vol. 52, No. 2, March 2012 79
attempted.
9
1uberculin skin test results frequentlv
show false positives and ne,atives. ln addition, the
distinction between latent 1B infection and active
disease is hi,hlv problematic.
1O,11
Dia,nostic al,orithms and 1B score charts were
developed especiallv for endemic areas. Most are
partlv based on si,ns and svmptoms, poorlv validated
and lack standardized svmptom definitions.
12-15
The
lPRWO developed a 1B score chart for primarv health
care services.
16
1raditional svmptoms associated with
1B, such as prolon,ed fever, and recurrent cou,h,
and si,ns, such as nutritional status and lvmph node
enlar,ement, have been used for the score chart. But,
there has been little data on the prevalence of 1B or
the various combinations of si,ns and svmptoms usin,
the 1B score chart.
Methods
A cross-sectional studv was carried out from Julv to
ctober 2OOo, as part of a lar,er studv to determine
risk factors and prevalence of 1B, two vears after a
tuberculin survev. lrom the tuberculin survev, 36o
children a,ed 6-7 vears had positive 1S1s. 1his
re,ion (Padan,, Bukittin,,i and Pasaman) is a hi,hlv
endemic adult 1B in West Sumatera. (1he avera,e
case notification rate of new, positive AlB sputum-
confirmed cases was reported to be 31/1OO,OOO
per vear).
17
1his studv was approved bv the lthics
Committee of the lacultv of Medicine, Andalas
Universitv.
We attempted to recruit all children with positive
1S1, based on the results of the 2OO6 tuberculin
survev in this area. 1rained field workers collected the
baseline data. Written informed consent was obtained
from parents. We administered questionnaires,
phvsical examinations and chest radio,raphs (CXR)
to all subjects. Data was completed accordin, to ei,ht
indicators in the lPRWO 1B score chart (Table 1).
Questionnaires were completed bv parents
under supervision of trained field workers and were
used to record svmptoms commonlv associated with
1B, includin, historv of household contact with
positive smears, fever lastin, >2 weeks, and cou,h
lasting >3 weeks. We assessed for nutritional status
Table 1. PRWG TB score chart, 2008
16
Feature 0 1 2 3 Score
TB contact not clear - By family report;
smear neg/ not
known/not clear
smear pos
Tuberculin skin test
(Mantoux test)
negative - - positive (> 10mm or
> 5mm if
immunosuppressed)
Nutritional status - BW/H <90% or
BW/A < 80%
Severe malnutrition
(BW/A <60%)
-
Fever of unknown origin
(FUO)
- 2 weeks - -
Chronic cough - 3 weeks - -
Lymphadenopathy
(cervical, axillary,
inguinal)
- 1 cm, amount
>1, pain (-)
- -
Joint swelling (hip, knee,
vertebral, phalangeal)
- Swelling - -
CXR Normal/
not clear
Suggestive TB -
Total Score
ATTENTION: Hospital referral should be made in presence of critical signs, such as seizure, decreased level of consciousness,
neck stiffness, spinal masses, limping, chessboard phenomenon.
Notes: Positive TB diagnosis if total score 6 (by doctor); BW based on present BW; fever and cough relevant if no response
to standard therapy; CXR is not considered to be a main diagnostic tool; evaluated for accelerated BCG reaction (< 7 days);
hospital referral to be made for children <5 y.o. if score > 5 or strong suspicion for TB; NH prophylaxis to be prescribed for
score < 6 if (+) household contact
Finny Fitry Yani et al: 1uberculosis score chart si,ns and svmptoms in children with positive tuberculin skin tests
80 Paediatr Indones, Vol. 52, No. 2, March 2012
(WH standard), lvmph node enlar,ement > 1 cm,
and joint-specific svmptoms (spondvlitis, coxitis) bv
phvsical examination.
Standard anteroposterior and lateral view CXRs
were taken. 1hree independent experts (2 pediatric
respirolo,ists and 1 radiolo,ist), blinded to all clinical
information, evaluated the CXRs and documented
their findin,s on a standard report form. Radiolo,ic
criteria scorin, depended on the presence of a
su,,estive CXR accordin, to lPRWO ,uidelines, and
a,reed upon bv two of three independent experts.
Subjects were considered to have 1B if thev had
a score total of > 6 usin, lPRWO 1B score chart
,uidelines. Because all subjects had positive 1S1s, a
minimum score total of 3 for the remainin, cate,ories
resulted in a 1B dia,nosis.
Data analvses were carried out with a statistical
analvsis pro,ram. lrequencies of si,ns and svmptoms
were compared amon, subjects' a,e ,roups, nutritional
status, as well as between positive 1S1 subjects
with and without a 1B dia,nosis. We performed
binarv lo,istic re,ression analvsis with backward lR
method to assess si,nificant si,ns and svmptoms in
1B dia,nosis.
Results
f the 36o children with positive 1S1 in the 2OO6
studv, 2o5 were included in our studv. Demo,raphic
data of 2O7 children without 1B and 7o children
with 1B, as dia,nosed bv 1B score chart, is shown
in Table 2. 1here were no si,nificant differences in
,ender and a,e distribution between the two ,roups.
1here was a hi,her proportion of ne,ative BCO scars
in children with 1B dia,noses (25.7') compared to
those without 1B. Binarv lo,istic re,ression analvsis
with backward lR method revealed that subjects
with 1B dia,noses had ,reater historv of household
contact bv familv report/ne,ative smears than those
with positive smears (R 13o, 95' Cl 1O.5 to 1oO7).
lnterestin,lv, subjects with 1B dia,noses but without
clear HHC had the hi,hest risk for 1B disease (R
192, 95' Cl 22 to 1679).
Table 2. Characteristics of subjects diagnosed with TB and without TB
No TB (%)
(n=207)
TB (%)
(n=78)
OR (95% C) P
value
Gender
Male
Age distribution in years
8-<10
10-12
BCG scar
positive
negative
TB contact (HHC)
Unclear
Family reported, but smear neg unknown/unclear
Smear positive
116 (56.0)
77 (37.2)
130 (62.8)
169(81.6)
38(18.4)
198 (95.7)
9 (4.3)
0
45 (57.7)
33 (42.3)
45 (57.7)
58(74.3)
20(25.7)
46(58.9)
11(14.1)
21(27.1)
1.1 (0.5 to 2.4)
1.2 (0.6 to 2.8)
0.8 (0.3 to 2)
192.5 ( 22 to 1679)
138 (10.5 to 1807)
0.80
0.59
0.67
0.00
0.00
Table 3. Comparison of signs and symptoms reported in children with and without TB
No TB (%)
(n=207)
TB (%)
(n=78)
OR (95% C)
P
value
ndividual symptoms
FUO > 2 weeks
Chronic cough > 3 weeks
Nutritional status
Well-nourished
Undernourished*
Lymph node enlargement
Joint swelling
Suggestive CXR
6(2.9)
18(8.7)
160(77.3)
47(22.7)
43(20.8)
0(0.0)
22(10.6)
14(17.9)
18(23.1)
44(56.4)
34(43.6)
35(44.9)
0(0.0)
27(34.6)
8 (2.2 to 29.1)
2.97 (1 to 9.13)
6 (2.6 to 14.1)
3.26 (1.4 to 7.5)
9.2 (3.6 to 23.4)
0.00
0.56
0.00
0.006
0.00
*One subject with TB was severely malnourished
Finny Fitry Yani et al: 1uberculosis score chart si,ns and svmptoms in children with positive tuberculin skin tests
Paediatr Indones, Vol. 52, No. 2, March 2012 81
Table 3 compares the si,ns and svmptoms
reported in children dia,nosed to have and not have
1B. All si,ns and svmptoms were si,nificantlv more
frequent in children with 1B, with P < O.O5 and R >
1, except for well-nourished nutritional status. Usin,
lo,istic re,ression, the presence of su,,estive CXR
showed the ,reatest odds for 1B (31.6' of patient
dia,nosed with 1B, R 9.2, 95' Cl 3.6 to 23.1),
followed bv fever of unknown ori,in (lU) lastin, >
2 weeks (17.9' of patients dia,nosed with 1B, R o,
95' Cl 2.2 to 29.1). nlv one subject was severelv
malnourished. Si,nificantlv, more children with 1B
had lvmph node enlar,ement than those without 1B
(11.9' vs 2O.o', respectivelv). ln addition, chronic
cou,h ~ 3 weeks showed the lowest odds for disease
(R 2.97, 95' Cl 1 to 9.1). None of our subjects
exhibited bone or joint swellin,.
Accordin, to the lPRWO 1B score chart, a
minimum total score of 3 for non-1S1 criteria was
needed to dia,nose 1B in our subjects since all had
positive 1S1 (score value 3). ln order to further
evaluate the contribution of other si,ns and svmptoms
to the fulfillment of score value 6 in subjects with 1B,
we separated subjects with HHC accordin, to the
lPWRO 1B score chart, into a positive smear ,roup
(additional score value of 3), and a ne,ative smear
,roup (additional score value of 2) (Figure 1).
Table 4 shows the frequencv of five clinical
si,ns and svmptoms in the 1B score chart in various
combinations (fever, cou,h, nutritional status, lvmph
node enlar,ement and su,,estive CXR) in 16 children
with 1B but without clear HHC. 1here were 6
Figure 1. Flowchart of subjects to diagnose TB using the TB score chart
Children with TST (+)
n = 285
(score = 3)
HHC smear neg/
unknown/unclear
n = 20 (score = 2)
HHC smear pos
n = 21
(score = 3)
Signs and symptoms
>1
n = 12
(score > 1)
No signs and
symptoms
n = 9
(score = 0)
No HHC
n = 244
(score = 0)
Signs and symptoms
1 or 2,
n = 198
(score < 3)
TB (-)
n = 207
(Total score < 6)
TB (+)
n = 78
(Total score > 6)
Signs and symptoms
>3
n = 46
(score > 3)
Signs and symptoms
>1
n = 11
(score > 1)
No signs and
symptoms
n = 9
(score = 0)
Finny Fitry Yani et al: 1uberculosis score chart si,ns and svmptoms in children with positive tuberculin skin tests
82 Paediatr Indones, Vol. 52, No. 2, March 2012
combinations (score value of 3) to obtain total score of
6, and 3 combinations (score value > 3) to obtain total
score of > 6. We found the hi,hest prevalence in the
combination of 3 indicators: lvmph node enlar,ement,
su,,estive CXR and undernourishment (2o.2').
1he lowest prevalence was the combination of severe
malnourishment and lvmph node enlar,ement (2.2').
1he presence of lvmph node enlar,ement and lU
lasting > 2 weeks were found in almost all combinations
(6 out of the 9 combinations), followed bv cou,h lastin,
> 3 weeks (5 out of the 9 combinations).
Table 5 shows the comparison of si,ns and
svmptoms prevalence reported in children without
1B (n~216) and with 1B (n~32) based on HH
contact. ln the sin,le si,n/ svmptom cate,orv,
undernourishment and lvmph node enlar,ement were
more frequent in children with 1B dia,nosis compared
to those without 1B, but su,,estive CXR was more
frequent in children without 1B dia,nosis. More
patients with 1B dia,nosis had > 2 si,n/ svmptom
combinations than those without 1B. lnterestin,lv,
there were 9 (1.3') children without 1B dia,nosis
reported to have HHC, but with ne,ative/unclear
smears (score value of 2). lurthermore, there were 9
(12.5') children with 1B dia,nosis who had positive
HHC smears (score value of 3) but no other si,ns/
svmptoms.
Discussion
We have documented 1B si,ns and svmptoms based
on the lPRWO 1B score chart in children with
positive 1S1. 1here were ei,ht si,ns and svmptoms
Table 4. Combinations of signs and symptoms in children diagnosed with TB but with no clear HHC
(n = 46)
Combinations of signs and symptoms TB (%)
Add score value of 3
Lymph node enlargement, severe malnourishment
Fever, cough, lymph node enlargement
Fever, cough , suggestive CXR
Fever, lymph node enlargement, suggestive CXR
Cough, lymph node enlargement, suggestive CXR
Lymph node enlargement, suggestive CXR, undernourishment
Add score value of > 4
Fever, cough, lymph node enlargement, suggestive CXR
Fever, cough, lymph node enlargement, undernourishment
Fever, lymph node enlargement, suggestive CXR and undernourishment
1 (2.2)
4 (8.7)
5 (10.9)
6 (13.1)
7 (15.2)
13 (28.2)
4 (8.7)
3 (6.5)
3 (6.5)
Table 5. Comparison of signs and symptoms prevalence reported in children without TB (n=216) and
with TB (n=32) based on HH contact
ndicator
No TB (%) TB (%)
No HHC
(n=207)
HHC smear
(-) (n=9)
HHC smear
(-) (n=11)
HHC smear
(+) (n=21)
1 signs/symptom (add 1 score value)
Undernourishment
Lymph node enlargement
Suggestive CXR
>2 signs/symptoms (add >2 score values)
Cough + lymph node enlargement
Fever + undernourishment
Fever + lymph node enlargement
Cough +undernourishment
Lymph node enlargement + suggestive CXR
Cough + suggestive CXR
Lymph node enlargement + undernourishment
Cough + lymphnode enlargement + undernourishment
No other signs/symptoms
30 (14.5)
24 (11.6)
15 (7.2)
4 (1.9)
2 (1)
2 (1)
2 (1)
3 (1.4)
1 (0.5)
10 (4.8)
0
114 (55)
0
0
0
0
0
0
0
0
0
0
0
0
9 (4.3)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
1 (9.09)
0
4 (19)
3 (14)
0
0
0
0
0
1 (5)
1 (5)
2 (9.5)
1 (5)
9 (42.5)
Finny Fitry Yani et al: 1uberculosis score chart si,ns and svmptoms in children with positive tuberculin skin tests
Paediatr Indones, Vol. 52, No. 2, March 2012 83
in the 1B score chart, includin, 1S1 and HHC.
All subjects in our studv had positive 1S1, but onlv
7.3' had HHC with positive smears. 1here was a
statisticallv si,nificant difference for HHC positive
smears in children with 1B compared to those
without 1B. All subjects without 1B dia,nosis had
no historv of HHC positive smears. 1he majoritv of
subjects with 1B dia,nosis were without clear historv
of HHC. Household contact was a major determinant
for 1B dia,nosis, but is difficult to identifv HHC
due to the social sti,ma of 1B. 1herefore, havin,
no historv of HHC does not exclude a 1B dia,nosis.
However, in a settin, of hi,h 1B prevalence, most
infections, particularlv in children older than 2 vears,
are contracted from outside the household but within
the communitv. Additional care,ivers outside the
household are also important sources of infection,
especiallv ,randparents or extended familv members
who care for children durin, the dav.
1o
ln addition,
there has been poor recordin, of positive sputum
smears at communitv health centers (Puskesmas),
makin, HHCs difficult to confirm.
Cou,h lastin, > 3 weeks, fever lastin, > 2
weeks and/or undernourishment often leads to the
investi,ation of 1B in children. lndeed, we found
these conditions to be more frequent in children with
1B. lndividual svmptoms in the lPRWO 1B score
chart contributed an additional score value of 1,
increasin, when combined with other svmptoms. 1he
combination of lvmph node enlar,ement, su,,estive
CXR and undernourishment was the most frequentlv
observed combination. Contribution of these three
si,ns and svmptoms should be further defined for more
objective use.
15
Althou,h si,nificant differences were
found, thev are of limited dia,nostic value and onlv
relevant for an epidemiolo,ical perspective. A studv
at Cape 1own randomlv selected children from a hi,h
burden communitv and reported specific definitions
of cou,h and wei,ht loss in the precedin, 3 months as
svmptoms associated with 1B. Well-defined svmptoms
such as acute cou,h with delaved recoverv, recurrent
acute cou,h, and persistent non-remittin, cou,h were
important for increased dia,nostic value.
13
lmproved
case definitions and svmptom characterization are
required when assessin, the dia,nostic value of
svmptoms.
12,15
1herefore, if a svmptom could not be
defined more specificallv, it could potentiallv increase
the score value, leadin, to overdia,nosis of 1B.
We found that children with positive 1S1s and
undernourishment had a 6 times hi,her likelihood
for 1B than those in a studv in lndia (3.9 times).
19
ln children without 1B dia,nosis, we observed that
undernourishment was the most frequent si,n, both
individuallv and in combination with other si,ns
and svmptoms. Nutritional status in the lPRWO
1B score chart was based on the WH standard.
However, we did not distin,uish between subjective
and objective wei,ht loss. Subjective wei,ht loss
showed poor correlation with 1B, differin, from that
of objective wei,ht loss. Marais et al. found objective
wei,ht loss to be more sensitive and si,nificant
when used for 1B contact tracin,.
12
ln endemic 1B
settin,s, the dia,nostic value of wei,ht loss mav be
enhanced bv first eliminatin, other common causes
of poor wei,ht ,ain, such as worm infestation and
food securitv. 1herefore, a more specific definition of
undernourishment in the 1B score chart mav prevent
1B overdia,nosis.
We found about one-third of subjects with 1B
had abnormal CXRs, based on three reports from
independent experts (2 pediatric respirolo,ists and a
radiolo,ist) blinded to all clinical information. ln dailv
practice, a CXR is evaluated bv onlv one radiolo,ist
who has the summarized clinical data, potentiallv
leadin, to overdia,nosis, too. lt is important for
pediatricians to competentlv evaluate CXRs, in order
to confirm the radiolo,ist's findin,s.
Since all subjects in our studv had positive
1S1, an initial score value of 3, a 1B dia,nosis could
be made if subjects had score values of > 3 from
other si,ns and svmptoms, for a total score value
of > 6. 1he additional si,ns and svmptoms in the
1B score chart included reports of HHC with (i)
positive smear (score value of 3), or (ii) ne,ative/
unclear smear (score value of 2). ther si,ns and
svmptoms contribute a score value of 1, except for
severe malnutrition which contributes 2 score values.
ln 9 children, 1B was dia,nosed bv addin, the score
from HHC positive smears (score value of 3) to the
positive 1S1 (score value of 3). 1hese 9 subjects
had no other contributin, si,ns and svmptoms. ln
fact, the internationallv accepted definition of 1B
infection is positive 1S1, without other si,ns and
svmptoms.
1O
Based on the looser definition, it is
possible that those 9 subjects were dia,nosed with 1B
when thev actuallv had no disease. Bv this standard,
Finny Fitry Yani et al: 1uberculosis score chart si,ns and svmptoms in children with positive tuberculin skin tests
84 Paediatr Indones, Vol. 52, No. 2, March 2012
oral antituberculosis treatment should be ,iven, as
prophvlaxis or therapv.
We found 3 si,ns and svmptoms presentin,
individuallv and o combinations of two si,ns and
svmptoms in both children with and without
dia,nosed 1B. lnterestin,lv, the majoritv of the 2
si,n and svmptom combinations had lvmph node
enlar,ement, followed bv cou,h lastin, > 3 weeks
and undernourishment. 1his observation su,,ests that
these three si,ns and svmptoms should be evaluated
bv phvsicians prior to makin, a 1B dia,nosis. lf
these three si,ns and svmptoms are poorlv validated
bv the phvsician at the communitv health center
(Puskesmas), additional score values mav be included,
leadin, to overdia,nosis of 1B.
1his studv had several limitations. 1he question-
naire was subject to recall bias and reporter subjectivitv.
We attempted to limit recall bias bv focusin, on current
si,ns and svmptoms to reduce reporter subjectivitv bv
standard characterization of svmptoms. lnvesti,ator
bias was limited, as svmptom characterization was done
before CXR results were known.
We describe the potential for overdia,nosis of 1B
in children when usin, the lPRWO 1B score chart.
All our subjects were 1S1 positive, and therefore, at
a hi,her risk to be dia,nosed with 1B. lt is essential
to know the prevalence of si,ns and svmptoms within
the ,eneral communitv bein, studied in order to assi,n
appropriate score values to particular svmptoms.
Most importantlv, our studv emphasizes the need for
improved svmptom characterization and accurate
outcome definitions to adequatelv dia,nose active
1B disease. A lar,e prospective, communitv-based
studv is required to validate the dia,nostic value of
this svmptom-based approach.
References
1. Nelson lJ, Wells CD. Olobal epidemiolo,v of childhood
tuberculosis. lnt J 1uberc lun, Dis. 2OO1,o:636-17.
2. Marais BJ, Oie RP, Schaaf HS, Hesselin, AC, bihara CC,
Nelson lJ, et al. 1he clinical epidemiolo,v of childhood
pulmonarv tuberculosis: a critical review of literature
from the pre-chemotherapv area. lnt J 1ubec lun, Dis.
2OO1,o:27o-2o5.
3. Yantri l, Yani ll, Basir D, Machmoed RM. Prevalensi
sakit tuberculosis pada anak usia 6-7 tahun di kota Padan,
|master's thesis]. |Padan,, lndonesia]: Andalas Universitv
Medical School, 2OOo.
1. sborne CM. 1he challen,e of dia,nosin, childhood
tuberculosis in a developin, countrv. Arch Dis Child.
1995,72:369-71.
5. Ri,outs l. Dia,nosis of childhood tuberculosis. lur J Pediatr.
2OO9,16o:12o5-9O.
6. lamranond P, Jaramillo l. 1uberculosis in children:
reassessin, the need for improved dia,nosis in ,lobal
strate,ies. lnt J 1uberc lun, Dis. 2OO1,5:591-6O3.
7. Swin,ler OH, 1oit O, Andronikou S, Merwe l, zar HJ.
Dia,nostic accuracv of chest radio,raphv in detectin,
mediastinal lvmphadenopathv in suspected pulmonarv
tuberculosis. Arch Dis Child. 2OO5,9O:1153-6.
o. lisenber, Rl, Romero J, litmanovich D, Boiselle PM,
Bankier AA. 1uberculosis: value of lateral chest radio,raphv
in pre-emplovment screenin, of patients with positive
purified protein derivative skin test results. Radiolo,v.
2OO9,252:oo2-7.
9. Schaaf HS, Marais BJ, Whitelaw A, Hesselin, A, llev B, Hussev
OD, et al. Culture-confirmed childhood tuberculosis in Cape
1own, South Africa: a review of 596 cases. BMC lnfectious
Diseases |serial online]. 2OO7 |cited 2O11 Jan o],7:11O. Available
from: http://www.biomedcentral.com/1471-2334/7/140
1O. Marais BJ, Oie RP, Schaaf S, Bevers N, Donald PR, Starke
JR. Childhood pulmonarv tuberculosis: old wisdom and new
challen,e. Am J Respir Crit Care Med. 2OO6,173:1O7o-9O.
11. Nicol MP, zar HJ. New specimens and laboratorv dia,nostics
for childhood pulmonarv 1B: pro,ress and prospects. Paediatr
Respir Rev. 2O11,12:16-21.
12. Marais BJ, Oie RP, Hesselin, AC, Schaaf HS, lombard C,
lnarson DA, et al. A refined svmptom-based approach to
dia,nose pulmonarv tuberculosis in children. Pediatrics.
2OO6,11o:e135O-9.
13. Marais BJ, bihara CC, Oie RP, Schaaf HS, Hesselin,
AC, lombard C, et al. 1he prevalence of svmptoms
associated with pulmonarv tuberculosis in randomlv selected
children from a hi,h burden communitv. Arch Dis Child.
2OO5,9O:1166-7O.
11. lourie PB, Becker PJ, lestenstein l, Mi,liori OB, Alcaide
J, Antunes M, et al. Procedures for developin, a simple
scorin, method based on unsophisticated criteria for
screenin, children for tuberculosis. lnt J 1uberc lun, Dis.
199o,2:116-23.
15. Marais BJ, Oie RP, bihara CC, Hesselin, AC, Schaaf
HS, Bevers N. Well-defined svmptoms are of value in the
dia,nosis of childhood pulmonarv tuberculosis. Arch Dis
Child. 2OO5,9O:1162-5.
Finny Fitry Yani et al: 1uberculosis score chart si,ns and svmptoms in children with positive tuberculin skin tests
Paediatr Indones, Vol. 52, No. 2, March 2012 85
16. Rahajoe NN, Basir D, Makmuri MS, Kartasasmita CB.
Pedoman Nasional 1uberkulosis Anak. Jakarta: Badan
Penerbit lDAl, 2OOo. p. 93-1OO.
17. Sie P21B Dinas Kesehatan Provinsi Sumatera Barat. Profil
Kesehatan Sumatera Barat tahun 2OOo. p. 2O. Draft report.
Padan,: lndonesian Oovernment Publishin, Service, 2OOo.
1o. Miller lJW, Seal RMl, 1avlor MD. 1uberculosis in children.
london: J and A Churchill ltd, 1963. p. 79-163.
19. Sin,h M, Mvnak Ml, Kumar l, Mathew Jl, Jindal SK.
Prevalence and risk factors for transmission of infection
amon, children in household contact with adults havin,
pulmonarv tuberculosis. Arch Dis Child. 2OO5,9O:621-o.