Beruflich Dokumente
Kultur Dokumente
of Pediatric TB
Tjatur Kuat Sagoro
Persahabatan hospital
01/17/16
Definition
Tuberculosis is a disease due to
Mycobacterium tuberculosis
infection with systemic spread
thus can affect almost all
organs, and the most frequent
site is in the lung, which usually
as the site of primary infection
Faktor risiko
Risiko infeksi :
Terpajan orang dewasa TB aktif
Endemis,kemiskinan,lingkungan tidak sehat
Tempat penampungan umum
Risiko sakit :
Usia < 5 tahun
Konversi uji tuberkulin
Malnutrisi,imunokompromais
Risiko Sakit
Tidak Sakit
TB Paru
TB Diseminata
(milier,
meningitis
<1
50%
30-40%
10-20%
1-2
75-80%
10-20%
2-5%
2-5
95%
5%
0.5%
5-10
98%
2%
<0.5%
>10
80-90%
10-20%
<0.5%
M. tuberculosis inhalation
TB
pathogenesis
phagocytosis by PAM
live bacilli
multiplies
bacilli dead
incubation period
(2-12 weeks)
TST (+)
P
r
i
m
a
r
y
TB disease
TB infection
T
B
Optimal immunity
3)
Dead
immunity
reactivation/reinfecktion
Cured
TB disease4)
Pathogenesis
droplet nuclei
inhalation
alveoli
ingestion by PAMS
intracellular replication
of bacilli
destruction
of bacilli
destruction of PAMS
Tubercle formation
Lymphogenic spread
primary focus
lymphangitis
lymphadenitis
hematogenic spread
acute hematogenic
spread
occult hematogenic
spread
disseminated primary TB
multiple organs
remote foci
primary
complex
CMI
Diagnosis
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13
Diagnostic tools
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Clinical manifestation
Tuberculin skin test
Chest X ray
Microbiology
Pathology
Hematology
Others : serologic, lung
function, bronchoscopy
15
Suspect TB clinical
manifestation
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Diagnostic tools
gold standard
capture the trouble maker
microbiologic examination
adult TB
pediatric TB
sputu
m
scarce
specimen
TB culture
direct AFB
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NTP: D/ &
evaluation
Mantoux
TST
17
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Mantoux TST
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 of transversal diameter :
0 - 5 mm : negative
5 - 9 mm : doubt
> 10 mm : positive
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Mantoux
tuberculi
n skin
test
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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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Tuberculin negative
1. No TB infection
2. Incubation period
3. Anergy
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Anergy
Patient with primary complex do not give
reaction to TST due to supression of CMI :
Severe TB: miliary TB, TB meningitis
Severe malnutrition
Steroid, long term use
Certain viral infection: morbili, varicella
Severe bacterial infection: typhus
abdominalis, diphteria, pertussis
Viral vaccination: morbili, polio
Malignancy: Hodgkin, leukemia, ...
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If > 3 positive
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Next page
26
Considered TB
Give anti-TB therapy
Observation in 2 months
Clinical response (+)
TB
Continue anti-TB therapy
No clinical
response/worsening
Not TB
MDR TB
Refer to hospital
ATTENTION
Presence of any dangerous signs: Reevaluation in Referral Hospital:
Clinical signs
Seizure
Decreased level of consciousnessTuberculin test
Radiological findings
Neck stiffness
Microbiology and serology
Or signs such as:
examination
Spinal tumor/lump
Histopatology examination
Limping
Diagnostic procedure and therapy
Dam board phenomenon
according to each hospitals protocol
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27
Send
Encountered problem
Increasing demands of TB drugs
for Pediatric TB
Increasing diagnosis of Pediatric
TB using the IDAI algorhitm
Over diagnosis !?
Need improvement IDAI scoring
system
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28
not
clear
reported,
AFB(-)
AFB(+
)
TST
positiv
e
BW (KMS)
<red line,
BW
severe
malnutritio
n
Fever
unexplained
Cough
<3week
s
>3weeks
Node
enlargemn
t
>1 node,
>1cm,painle
ss
Bone,joint
swelling
normal
sugestive
CXR
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Score
29
BW assessement at present
Fever & cough no respons to standard tx
CXR is NOT a main diagnostic tool in children
All accelerated BCG reaction should be
evaluated with scoring system
TB diagnosis total score >6
Score 4 in under5 child or strong suspicion,
refer to hospital
INH prophylaxis for AFB(+) contact with score
<5
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TERLALU
diterima
Depkes
setengah hati
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SDM OK
Analisis OK
TB anak
diagnosis tepat
Sistem Skoring
TB anak
Fasilitas
kesehata
n
terbatas
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Sarana
terbatas,
SDM terbatas
TB anak
overdiagnosis
32
Sistem Skoring TB di RS
entry point
YES
end point
NO
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Skrofuloderma
TB tulang belakang, TB
lutut
Gonitis TB
Treatment
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Treatment
Adherence / compliance
Drug discontinuation treatment failure
Multi drug resistance (MDR)
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Pediatric TB therapy
2 mo
6 mo
9 mo
regimen
12mo
INH
RMP
PZA
ETB
SM
PREDNISON
DOTS !
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Drugs
Daily dose
(mg/Kg/day)
Isoniazide *
(INH)
5-15
(300 mg)
2 Time/week 3 Time/week
dose
dose
(mg/Kg/dose) (mg/Kg/dose)
15-40
(900 mg)
Adverse reactions
15-40
(900 mg)
Rifampicin
(RIF)
10-15
(600 mg)
10-20
(600 mg)
10-20
(600 mg)
Pyrazinamide
(PZA)
15 - 40
(2 g)
50-70
(4 g)
50-70
(3 g)
Hepatotoxicity, hyperuricaemia,
arthralgia, gastrointestinal upset
Ethambutol
(EMB)
15-25
(2,5 g)
50
(2,5 g)
50
(2,5 g)
Streptomycin
(SM)
15 - 40
(1 g)
25-40
(1,5 g)
25-40
(1,5 g)
Ototoxicity nephrotoxicity
Ped TB treatment
principles
Multi drug, NOT single drug
(monotherapy)
to prevent drug resistance
risk of fall and rise phenomenon
each TB drug has specific action to certain
TB bacilli population
42
Treatment problem
solutions
DOTS : Directly Observe
Treatment Short-course
FDC : Fixed dose combination i.e.
>2 drugs in one tablet / capsule
in a fixed dose formulation
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Program
Nasional
Penanggulangan
Tuberkulosis
dots
International Standards
for TB Care, ISTC
TB
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DOTS
Pediatric TB
National TB Program
(NTP)
Adult patient focus
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monosubstanc
e
combi-packs
Pyrazinamide
(Z)
Ethambutol (E)
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fixed dose
comb
47
Combipack drugs
two or more separate drugs put in one
pack
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IDAI
H : 50 mg
R : 75 mg
Z : 150 mg
49
&
H/R:30/60)
BW
(kg)
<7
8-9
10-14
15-19
20-24
25-29
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Intensive, 2 mo Continuation, 4 mo
(tablet)
(tablet)
1
1
1,5
1,5
2
2
3
3
4
4
5
5
50
IDAI FDC
(H/R/Z:50/75/150 &
H/R:50/75)
BW
(kg)
Intensive, 2 mo
(tablet)
Continuation, 4
mo
(tablet)
05 - 09
10 - 14
15 - 19
20 - 33
51
IDAI
INH: 5-10 mg/kgBW
simple BW grouping
more friendly both for doctor and patient
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TB tracking
Adult TB
patient
centrifugal
centripetal
Child TB
patient
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centrifugal
trace other
victims
children
close contact
by tuberculin
55
TB classification
(ATS/CDC
modified)
Class
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proph II?
therapy
proph I
56
Primary prophylaxis
to prevent TB infection in TB Class 1 person
exposure (+), infection (-) tuberculin
negative
drug: INH 5 - 10 mg/kgBW/day
as long as contact take place, the source
should be treated
at least for 3 months
repeat TST:
negative: success, stop INH
positive: fail, become TB Class 2 continue as 2 nd
proph
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Secondary prophylaxis
to prevent TB disease in TB Class 2 person
(exposure (+), infection (+), disease (-)
and person with tuberculin conversion
certain high risk population
58
Evaluasi
Awal
Dosis OAT
(mg/kg BB/hari)
Profilaksis
INH : 5-10 mg/kgbb
Terapi TB
INH
Rifampisin
Pirazinamid
Partus
Neonatus
Evaluasi klinis
Foto R
Pemeriksaan klinis &
Pemeriksaan penunjang Normal
DK/Kontak TB (+)
Profilaksis primer
Klinis TB (+)
DK/TB perinatal
Terapi TB
Evaluasi
Tuberkulin (+)
1 bulan
DK/TB
Terapi TB 9 bl
Tuberkulin (-)
DK/Kontak TB (+)
Uji Tuberkulin
(+) bila Indurasi > 5 mm Profilaksis primer
(-) bila Indurasi <5 mm
Evaluasi
3 bulan
Tuberkulin (+)
Tuberkulin (-)
Kontak (-)
Lengkapi :
Foto R
Bilas lambung
Tuberkulin (-)
DK/TB
Terapi TB diteruskan
Tuberkulin (-)
DK/Bukan TB
Stop terapi TB
Imunisasi BCG
Tuberkulin (+)
DK/ TB
Terapi TB
9 bl
Buktikan D/ TB pada ibu secara klinis, radiologis, & mikrobiologis. Bila D/ TB ibu tegak, obati dengan OAT
Bayi dipisahkan sampai minimal 2 minggu pemberian OAT pada ibu, namun ASI dapat diberikan
2)
Pemeriksaan penunjang: plasenta (PA: makroskopik, mikroskopik) dan darah vena umbilikalis (mikrobiologi: BTA,
biakan TB)
3)
Klinis: prematuritas, berat lahir rendah, distress pernapasan, hepato-splenomegali, demam, letargi, toleransi
minum buruk, gagal tumbuh, distensi abdomen
4)
Imunisasi BCG sebaiknya tidak diberikan sebelum usia 3 bulan
1)
Thank
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presented at
Pelatihan BP4 di RSP
7 Juli 2009
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