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Respirology Division DCH FMUI-CMH

Department of Child Health


Faculty of Medicine, University of Indonesia
Respirologi IKA FKUI - RSCM Transmission
Usually from adult TB patient with AFB (+)
Modes of transmission :
airborne : >90%, droplet nuclei 1-5 m
orally : drink infected cow milk
direct contact: skin wound
congenital : during pregnancy, very rare
Respirologi IKA FKUI - RSCM Etiology
Mycobacterium tuberculosis
Mycobacterium bovis
Characteristics :
1. acid fast
2. grows slowly
3. live in weeks in dry condition
4. sensitive to sunlight, ultraviolet light,
temp > 600 C
Location of primary focus
Respirologi IKA FKUI - RSCM
in 2,114 cases, 1909-1928
Location %
Lung 95.93
Intestine 1.14
Skin 0.14
Nose 0.09
Tonsil 0.09
Middle ear (Eustachian tube) 0.09
Parotid 0.05
Conjungtiva 0.05
Undetermined 2.41

Source: Adapted from Ghon and Kudlich, in Engel and Pirquet (eds.),
Handbuch de Kindertuberkulose, Georg Thieme Verlag, Stuttgart, 1930, Vol 1
Inhalation Alveoli Ingestion by PAMS

Respirologi IKA FKUI - RSCM

Intracellular multiplication Destruction


of bacilli of bacilli

Destruction of PAMS

Resolution Tubercle formation Hilar lymph nodes

Calcification

Caseation Hematogenous spread


Ghon Complex

Liquefaction

Lesions in liver, spleen,


Secondary lung lesions kidneys, bone, brain,
other organs
Figure 1. Pathogenesis of tuberculosis. PAMS, pulmonary alveolar macrophages

Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20


Respirologi IKA FKUI - RSCM
Respirologi IKA FKUI - RSCM
Prognostic factors
A. TB bacilli :
virulence
infection dose
B. Patient :
General condition
age
Nutritional state
Dosis infeksi lain misalnya morbili
Genetik
Tekanan fisik dan psikis, misalnya trauma,
tindakan bedah
Respirologi IKA FKUI - RSCM Klasifikasi dasar
0. Tidak ada kontak, tidak ada infeksi (uji
tuberkulin negatif)
I. Ada kontak, tidak ada infeksi (uji
tuberkulin negatif)
II. Ada infeksi, tidak ada penyakit TB
(uji tuberkulin positif)
III.Penyakit tuberkulosis
TB classification (ATS/CDC modified)
Respirologi IKA FKUI - RSCM

Manage
Class Contact Infetion Disease
ment

0 - - - -
I + - - proph I?

II + + - proph II?

III + + + therapy
Respirologi IKA FKUI - RSCM
Diagnosis
1. Tuberculin skin test
2. Chest X ray
3. Clinical manifestation
4. Microbiologic
5. Pathology
6. Hematological
7. Known infection source
8. others : serologic, lung function,
bronchoscopy
Respirologi IKA FKUI - RSCM
Tuberculin test
TB infection

cellular immunity

delayed type hypersensitivity

tuberculin reaction
Respirologi IKA FKUI - RSCM

TUBERCULIN
Tuberkulin PPD-S Tuberkulin OT
Strength
mg/dosis TU PPD RT 23 2 TU mg/dosis Pengenceran
1
First 0,00002 1 - 0,01
10,000
1
0,00001 5 2 -
2,000
Intermediate
1
- 10 5 0,1
1,000
1
Second 0,005 250 100 1,0
100
Respirologi IKA FKUI - RSCM Tuberculin
PPD S
Strength PPD RT23
Seibert

first 1 TU 1 TU

intermediate
5-10 TU 2-5 TU
(standard dose)

second 250 TU 100 TU


Tuberculin delivery
Respirologi IKA FKUI - RSCM

1. Mantoux : intradermal injection


2. Multiple puncture :
Heaf, special apparatus with 6 needles
Tine, disposable, 4 needles
3. Patch test
Tuberculin
Respirologi IKA FKUI - RSCM

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 diameter :
0 - 5 mm : negative
5 - 9 mm : doubt
> 10 mm : positive
Respirologi IKA FKUI - RSCM
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
Respirologi IKA FKUI - RSCM Anergi
Uji tuberkulin dapat negatif untuk sementara karena :
TB berat misalnya TB milier
PEM berat
Mendapat kortikosteroid lama
Penyakit virus : morbili, varicella
Penyakit bakteri : typhus abdominalis, difteri, pertusis
Vaksinasi virus : morbili, polio
Penyakit keganasan : penyakit Hodgkin
Respirologi IKA FKUI - RSCM
Imaging diagnostic

routine : chest X ray


on indication : bone, joint, abdomen
majority of CXR non suggestive TB
pitfall in TB diagnostic
Respirologi IKA FKUI - RSCM
Gambaran radiologi paru
Pembesaran kelenjar
Fokus primer
Atelektasis
Kavitas
Tuberkuloma
Pneumonia
Air trapping
Trakeobronkitis
Bronkiektasis
Efusi pleura
Gambaran milier
Respirologi IKA FKUI - RSCM Clinical manifestation
None
General manifestation
Organ specific manifestation
Respirologi IKA FKUI - RSCM
General manifestation
Chronic fever
Anorexia dan BB / tidak naik
Malnutrition
Malaise
Chronic cough
Chronic / recurrent diarrhea
Others
Gejala spesifik
sesuai organ yang terkena
Respirologi IKA FKUI - RSCM

Respiratorik : batuk, sesak, mengi


Nerologik : kejang, kaku kuduk
Ortopedik : gibbus, pincang
Kelenjar : membesar, skrofuloderma
Gastrointestinal : diare berlanjut
Lain-lain
Respirologi IKA FKUI - RSCM
Pemeriksaan mikrobiologis
Memastikan D/ TB
Hasil negatif tidak menyingkirkan D/ TB
Hasil positif : 10 - 62 % (cara lama)
Cara :
cara lama
PCR
Respirologi IKA FKUI - RSCM
Hematological
Not specific
BSR could elevate
Limphocyte could increase

Pathology
Lymph node, hepar, pleura
On indication
Respirologi IKA FKUI - RSCM
Other examinations
Uji faal paru
Bronkoskopi
Bronkografi
Serologi
Complications of nodes
Complications of focus 1. Extension into bronchus
1. Effusion 2. Consolidation
Respirologi IKA FKUI - RSCM
2. Cavitation 3. Hyperinflation
3. Coin shadow

EVOLUTION AND TIMETABLE OF


UNTREATED PRIMARY TUBERCULOSIS
IN CHILDREN
MENINGITIS OR MILIARY
in 4% of children infected
under 5 years of age
LATE COMPLICATIONS
Renal & Skin
Most children Most after 5 years
become tuberculin BRONCHIAL EROSION
sensitive
3-9 months
Uncommon under 5 years of age Incidence decreases
PRIMARY COMPLEX 25% of cases within 3 months As age increased
A minority of children 75% of cases within 6 months
Progressive Healing
experience :
Most cases
1. Febrile illness
BONE LESION
2. Erythema Nodosum Most within
3. Phlyctenular Conjunctivitis
1 2 3 4 3 years
5 6

Resistance reduced :
infection 1. Early infection
(esp. in first year)
2. Malnutrition
3. Repeated infections :
measles, whooping cough 24 months
4-8 weeks 3-4 weeks fever of onset 12 months streptococcal infections
4. Steroid therapy
Development
Of Complex DIMINISHING RISK

But still possible


GREATEST RISK OF LOCAL & DISEMINATED LESIONS 90% in first 2 years Miller FJW. Tuberculosis in children, 1982
Respirologi IKA FKUI - RSCM
Pengobatan TB
Permulaan intensif
Kombinasi 3 atau lebih OAT
Teratur dan lama
Pemberian gizi yang baik
Pengobatan dan pencegahan penyakit lain
Respirologi IKA FKUI - RSCM
Obat Anti Tuberkulosis (OAT)
1. Isoniazid (INH) : 5 - 15 mg/Kg BB/hari, max. 300 mg/hari
oral 1 - 2 x / hari
2. Rifampisin : 10 - 20 mg/Kg BB/hari, max. 600 mg/hari
oral 1 - 2 x / hari, perut kosong
3. Pirazinamid : 15 - 30 mg/Kg BB/hari, max. 2 gram/hari
oral 1 - 2 x / hari (20 - 40 mg/Kg BB/hari)
4. Streptomisin : 20 - 40 mg /Kg BB/hari, max. 1gram/hari
intramuskulus
5. Etambutol : 15 - 20 mg/Kg BB/hari, max. 1,5 gram/hari
oral 1 x /hari, perut kosong
6. Lain-lain : Ethionamide, Kanamycin, Cycloserin,
Ciprofloxacin
Respirologi IKA FKUI - RSCM Populasi basil TB pada pasien

Kavitas, Dalam makrofag


Massa kiju
ekstrasel (intrasel)

Jumlah populasi 107 - 109 104 - 105 104 - 105


Metabolisme dan Lambat atau
Aktif Lambat
perkembang biak intermiten
pH Netral/basa Netral Asam
Obat paling efektif INH, RIF,
RIF, INH PZA, RIF, INH
(berturut-turut) STREP
Respirologi IKA FKUI - RSCM
Corticosteroid
Anti inflammation
prednison : 1 - 3 mg/kg BB/hari, 3x/hari
oral 2 - 4 minggu, tapering off
Indications :
TB milier
Meningitis TB
Pleuritis TB with effusion
Respirologi IKA FKUI - RSCM
Pencegahan
Perbaikan sosio ekonomi
Kemoprofilaksis
Imunisasi BCG
Respirologi IKA FKUI - RSCM
Kemoprofilaksis primer
Mencegah infeksi
Anak kontak dengan pasien TB aktif, tetapi belum
terinfeksi (uji tuberkulin negatif)
Obat : INH 5 - 10 mg/kg BB/hari
Respirologi IKA FKUI - RSCM
Kemoprofilaksis sekunder
Mencegah penyakit TB pada anak yang terinfeksi :
1. Mantoux (+), R (-), klinis (-) :
Umur < 5 th
Kortikosteroid lama
Limfoma, Hodgkin, lekemi
Morbili, pertusis
Akil baliq
2. Konversi Mt (-) menjadi (+) dalam 12 bl, R (-), klinis (-)
Obat INH 5 - 10 mg/kg BB/hari
Respirologi IKA FKUI - RSCM
Imunisasi BCG
Imunitas spesifik
Uji tuberkulin menjadi (+)
Mt (-) baru BCG
Masal : langsung BCG tanpa Mt
Reaksi lokal : membantu screening
Komplikasi tuberkulosis primer
Respirologi IKA FKUI - RSCM

1. Komplikasi komplex primer


Fokus primer : kavitas, efusi pleura, dll
Kelenjar : menekan bronkus, dll
2. Penyebaran hematogen
Tuberkulosis milier
Meningitis TB
TB tulang dan sendi
TB ginjal
Lain-lain
3. Penyebaran limfogen
4. Per kontinuitatum

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