Dr. H. Syihab Fayumi, Spa

Dr. H.
SYIHAB FAYUMI, SpA

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
Mycobacterium atipic
(unclassified, anonymous, non tuberculous)
Respirologi IKA FKUI - RSCM
Runyon (1974) :
Photochromogen : M kansasi, M marinum,
M siniae
Scotochromogen : M scrofuloceum, M.szulgai,
M. xenopi
Nonphotochromogen: M avium, M intracellulare
Rapid growers : M fortuitum, M chelonei
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
Inhalation Alveoli Ingestion by PAM’S
Intracellular multiplication Destruction

of bacilli of bacilli
Destruction of PAM’S
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. PAM’S, pulmonary alveolar macrophages
Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20

Risk/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
Diagnosis
1. Clinical manifestation
2. Tuberculin skin test
3. Chest X ray
4. Microbiologic
5. Hematological
6. Pathology
7. Known infection source
8. others : serologic, lung function,
bronchoscopy
Respirologi IKA FKUI - RSCM Clinical manifestation
None
General manifestation
Organ specific manifestation
General manifestation
Chronic fever
Anorexia dan BB / tidak naik
Malnutrition
Malaise
Chronic cough
Chronic / recurrent diarrhea
Others
Gejala spesifik
sesuai organ yang terkena
Respiratorik : batuk, sesak, mengi

Nerologik : kejang, kaku kuduk
Ortopedik : gibbus, pincang
Kelenjar : membesar, skrofuloderma
Gastrointestinal : diare berlanjut
Lain-lain
2.Tuberculin test
TB infection
cellular immunity
delayed type hypersensitivity
tuberculin reaction
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
1. Mantoux : intradermal injection
2. Multiple puncture :
• Heaf, special apparatus with 6 needles
• Tine, disposable, 4 needles
3. Patch test
Tuberculin
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
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
3.Imaging diagnostic
routine : chest X ray

on indication : bone, joint, abdomen
majority of CXR non suggestive TB
pitfall in TB diagnostic
Gambaran radiologi paru
Pembesaran kelenjar
Fokus primer
Atelektasis
Kavitas
Tuberkuloma
Pneumonia
“Air trapping”
Trakeobronkitis
Bronkiektasis
Efusi pleura
Gambaran milier
4.Pemeriksaan Mikrobiologis
Memastikan D/ TB
Hasil negatif tidak menyingkirkan D/ TB
Hasil positif : 10 - 62 % (cara lama)
Cara :
Cara lama,
Radiometrik,
PCR
Gen Expert
5.Hematological
Not specific
BSR could elevate
Limphocyte could increase
6.Pathology
Lymph node, hepar, pleura
On indication
Respirologi IKA FKUI - RSCM 7.Infection source
Known source of infection, has diagnostic
value
Shaw (1954), level of infectiousness :
AFB (+) : 62.5 %
AFB (-), M tb (+) : 26.8 %
AFB (-), M tb (-) : 17.6 %
8.Other examinations
Uji faal paru
Bronkoskopi
Bronkografi
Serologi
MPB64
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
Respirologi IKA FKUI - RSCM TB classification (ATS/CDC modified)
Manage
Class Contact Infetion Disease
ment
0 - - - -
I + - - proph I?
II + + - proph II?
III + + + therapy
Sistem Skoring
0 1 2 3
Kontak Tidak jelas - Laporan BTA (+)
ortu, BTA
(-)
PPD negatif - - positif
Berat badan - BB/U < 80% BB/U < -
60%
Demam - > 2 minggu - -
Batuk >3minggu >3 minggu - -
Pembesaran - multipel , >1cm, nyeri (-) - -
KGB
Sendi - bengkak - -
Rontgen dada normal sugestive - -
Total score: ________

Skor > 6
Beri OAT
2 bulan terapi, evaluasi
Respons (+) Respons (-)
Terapi diteruskan
Terapi teruskan
Rujuk ke RS pro evaluasi
Pengobatan TB
Permulaan intensif
Kombinasi 3 atau lebih OAT
Teratur dan lama
Pemberian gizi yang baik
Pengobatan dan pencegahan penyakit lain
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
Regimen of Antituberculosis drugs
2 mo 6 mo 9 mo 12 mo
INH
RIF
PZA
EMB
STREP
PRED
Directly Observed Treatment Short course (DOT’S)

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
Pencegahan
Perbaikan sosio ekonomi
Kemoprofilaksis
Imunisasi BCG
Kemoprofilaksis primer
Mencegah infeksi
Anak kontak dengan pasien TB aktif, tetapi belum
terinfeksi (uji tuberkulin negatif)
Obat : INH 5 - 10 mg/kg BB/hari
Kemoprofilaksis sekunder
Mencegah penyakit TB pada anak yang terinfeksi :
1. Mantoux (+), Rö (-), klinis (-) :
Umur < 5 th
Kortikosteroid lama
Limfoma, Hodgkin, lekemi
Morbili, pertusis
Akil baliq
2. Konversi Mt (-) menjadi (+) dalam 12 bl, Rö (-), klinis (-)
Obat INH 5 - 10 mg/kg BB/hari
Imunisasi BCG
Imunitas spesifik
Uji tuberkulin (-) menjadi (+)
Mt (-) baru BCG
Masal : langsung BCG tanpa Mt
Reaksi lokal : membantu screening
Komplikasi tuberkulosis primer
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
Complications of nodes
Complications of focus 1. Extension into bronchus
1. Effusion 2. Consolidation
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
Tuberkulosis milier
Penyebaran hematogen akut dan menyeluruh
Dapat menjadi kronik
Tanpa obat bisa fatal
Lesi-lesi ke seluruh tubuh
Demam, hepatomegali, splenomegali, tuberkel koroid
mata
Pungsi lumbal
Pleuritis TB dengan efusi
Pleuritis TB biasanya dengan efusi
Terjadi karena :
Perluasan fokus TB dekat pleura
Penyebaran hematogen
Hipersensitivitas terhadap tuberkulin efusi
pleura
Pungsi pleura
Dapat berupa empyema
Akibat pembesaran kelenjar
Menekan bronkus :
Atelektasis
Emfisema
Menembus bronkus :
Penyebaran bronkogen
Fistula
TB Tulang dan Sendi
Spondilitis
Koksitis
Gonitis
Daktilitis (Spina ventosa)
TB kelenjar superfisial
Akibat penyebaran limfogen dan hematogen
Dapat sembuh sendiri, dapat progresif
Dapat merupakan bagian dari TB milier
Biasanya multipel
Lokasi : leher, axilla, inguinal, supraklavikuler,
submandibula
Abses
TB Mata
TB primer konjungtiva pembesaran
kelenjar preaurikuler
TB koroid funduskopi
Conjunctivitis phluctenularis :
Fenomena hipersensitivitas
Sakit, sangat mengganggu
Rekuren
Terjadi dalam 5-15 tahun
Respirologi IKA FKUI - RSCM DOTS with a SMILE
S : Supervised
M : Medication
I : In
L : a Loving
E : Environment
(Grange JM, Int J Tuberc Lung Dis 1999; 3:360-362)
Terima Kasih

Dr. H. Syihab Fayumi, Spa

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Dr. H. Syihab Fayumi, Spa

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Dr. H.

SYIHAB FAYUMI, SpA

Respirologi IKA FKUI - RSCM

Intracellular multiplication Destruction

Resolution Tubercle formation Hilar lymph nodes

Caseation Hematogenous spread

Lesions in liver, spleen,

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

Respiratorik : batuk, sesak, mengi

delayed type hypersensitivity

second 250 TU 100 TU

Mantoux 0.1 ml PPD intermediate strength

routine : chest X ray

Total score: ________

Respons (+) Respons (-)

Kavitas, Dalam makrofag

Jumlah populasi 107 - 109 104 - 105 104 - 105

Directly Observed Treatment Short course (DOT’S)

1. Komplikasi komplex primer

EVOLUTION AND TIMETABLE OF

But still possible

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