Miliary Tuberculosis

Supervisor
Dr. Ulynar Marpaung, SpA

Presented by:
Siti Amanda Seanuria
1102012277
 Patient Identity
Name Child BMR
Gender Male
Age 5 years
Religion Islam
Adress Cengkareng, West Jakarta
Date of admission May 27, 2017
Date of examination May 28, 2017
 Parent’s Identity
Father Mother

Name Mr. FM Mrs. M

Age 34 years old 32 years old

Job Buisness Man Housewife

Nationality Indonesian Indonesian

Religion Islam Islam

Education Bachelor Degree High school

Address Kampung Kebon Jahe street RT 15/03, Cengkareng, West Jakarta

 Anamnesis
The anamnesis was taken on May 28, 2017 by
alloanamnesis from patient’s mother
• Chief complain:
Fever since 18 days before admission to hospital
• Additional complain:
Cough, cold
 History of illness
Didn’t felt suddenly
Persist during the day through the
18 days before admission night (The temperature between
Fever + cough 38-39 C at home)
to the hospital
Consumed paracetamol but there
is no change

Been hospitalized at Grand Family

4 days before admission Hospital with miliary tuberculosis
Fever + cough but referred to Polri hospital
to the hospital
because they haven’t isolated room

3 days before the Cough with sputum

Cough
admission to the hospital The sputum can’t be excreted
 Birth History
Mother’s Pregnancy History
• Antenatal Care:
Mother checkups her pregnancy to doctor
monthly
• Pregnancy Illness:
No history of problems and diseases during
pregnancy
• Drug Consumed:
Mother get vitamins every antenatal care
 Birth History
• Labor : Hospital
• Birth attendants : Midwife
• Mode of delivery : Pervaginam
• Gestation : 38 weeks
• Infant state : Health
• Birth weight : 2900 grams
• Body length : 49 cm

According to the mother, the baby cried, spontaneus breathing.

 Development History
• First dentition : 7 months
Conclusion:
• Psychomotor development
Growth and
– Smile : 4 months
developmental is still in
– Slant : 4 months
the normal limits and was
– Speech initiation : 6 months
appropriate according to
– Prone position : 6 months the patient’s age.
– Sitting : 6 months
– Crawling : 7 months
– Standing : 12 months
– Walking : 17 months
– Jumping : 29 months
 History of Eating
• Breast milk : Exclusively 4 months
• Formula milk : SGM
• Baby biscuit : Milna
• Fruit and vegetables: Banana
 Immunization History
• He get complete immunization (BCG, DPT,
Hep, Polio, Measless)
 Family illness history
 Patient’s both parents were married when they were 28 years old and 26 years
old, and this is their first marriage.
 There are not any significant illnesses or chronic illnesses in the family declared.
 The patient is the second child of the family.
 The patient has a brother
 Born died: (-)
 Child dies: (-)
 Miscarriage: (-)
 Physical examination (May 28, 2017)
General Status
• General condition : Mild illness
• Consciousness : Compos Mentis
• Pulse : 108 x/min, regular
• Breathing rate : 26 x/min
• Temperature : 37,2°C per axilla

Anthropometry Status
• Weight : 16 kg
• Height : 106 cm
Head :Head circumference 40cm, hair Neck : Lymph node enlargement (-),
(black, normal distribution, not easily scrofuloderma (-)
removed), no sign of trauma Thorax
Eyes : Scleral icterus -/-, pale conjunctiva - • Inspection: Symmetric when breathing,
/-, lacrimation +/+, pupil 3mm/3mm, retraction (-), ictus cordis is not visible
isocor, direct light response +/+, • Palpation: Fremitus tactile +/+ symmetric,
indirect light response +/+ mass (-)
Ears : Normal shape, no wound, no • Percussion: Sonor on both lungs
bleeding, no secretion, no cerumen.
• Auscultation:
Nose : Normal shape, midline septum,
secretion -/- Cor : S1S2 reguler, murmur (+), gallop (-)
Mouth Pulmo: vesicular +/+, rhonchi +/+,
wheezing -/-
Lips : dry
Mucous : dry
Tongue : no dirty
Pharynx : no hyperemia
• Abdomen
o Inspection : Relax, spider nevi (-)
o Palpation : Abdominal mass (-),
hepatomegaly (-) and splenomegaly (-)
o Percussion : tympanic, shifting dullness (-)
o Auscultation : Increased bowel sound, bruit (-)
• Extremity : Warm, capillary refill time <2
second, edema -/-
• Skin : Skin pinch goes back slowly
 Neurological examination
Meningeal Sign
• Nuchal rigidity (-)
• Kernig sign (-)
• Lasegue sign (-)
• Brudzinski I (-)
• Brudzinski II (-)
 Motoric examination
Power
Hand 5555/5555
Feet 5555/5555
Tonus
Hand Normotonus
Feet Normotonus
Physiological Reflex
Upper extremity (Biceps/Triceps) +2 / +2
Lower extremity (Patella/Achilles) +2 / +2
Patological Reflex
Upper extremitas (Hoffman & Tromner) -/-
Lower extremitas (Babinsky, chaddock, oppenheim, -/-
gordon, schaeffer)
Clonus (Patella & Achilles) -/-
 Nutritional Status
based CDC
• WFA (Weight for Age): 16/18 x 100 %
= 88,8% (good nutrition)
• LFA (Length for Age): 106/110 x 100 %
= 96,36% (good stature)

Conclusion: the
patient has a good
nutritional status
 Autonom examination
• Defecation : Normal
• Urination : Normal
• Sweating : Normal
 Laboratory Investigation
May 29, 2017
Value Normal Value
Haemoglobin 8,4 g/dl 13 – 16 mg/dl
White blood cells 13.500 u/l 5.000 – 10.000 u/l
Hematocryte 26 % 40 – 48 %
Platelet count 489.000 /ul 150.000 – 400.000 /ul
 Value Normal Value
Haemoglobin 9,1 g/dl 10,7 – 14,7 mg/dl
White blood cells 31.400 u/l 5.000 – 14.500 u/l
Hematocryte 29 % 31 – 43 %
Platelet count 707.000 /ul 217.000 – 497.000 /ul
Blood sedimen:
Basofil 0 0–1
Eosinofil
Stem
0
2,0
1–5
3–6
Laboratory Investigation
Segment
Limfosit
72,0
24,0
25 – 60
25 – 50
(Grand Family Hospital)
Monosit
Eritrosit count
2,0
4,1
1–6
3,7 – 5,7
May 23, 2017
MCV 70,0 72 – 88 fl
MCH 22,0 23 – 31 pg
MCHC 31,0 32 – 36 g/dl
Kidney Function
Creatinin 0,9 < 1,0 mg/dl
Serology
CRP +48 < 6,0 mg/L
Immunoserology
TB IGRA Negatif Negatif
 Value Normal Value
Haemoglobin 10,0 g/dl 10,7 – 14,7 g/dl
White blood cells 12.600 u/l 5.000 – 14.500 u/l
Hematocryte 33 % 31 – 43 %
Platelet count 685.000 /ul 217.000 – 497.000 /ul
Blood sedimen:
Basofil
Eosinofil
0
0
0–1
1–5
Laboratory Investigation
Stem
Segment
2,0
62,0
3–6
25 – 60
(Grand Family Hospital)
Limfosit
Monosit
35,0
1,0
25 – 50
1–6 May 26, 2017
Eritrosit count 4,5 3,7 – 5,7
MCV 72,0 72 – 88 fl
MCH 21,0 23 – 31 pg
MCHC 30,0 32 – 36 g/dl
Kidney Function
Creatinin 0,9 < 1,0 mg/dl
Serology
CRP +48 < 6,0 mg/L
 Value Normal Value
Urine
Color Clear Yellow Clear Yellow
pH 7,0 4,8 – 7,4
Density 1010 1015 - 1025
Protein - -
Glucose - -
Keton - -
Urobilinogen 0,1 0,1 – 1,0
Laboratory Investigation
Bilirubin - - (Grand Family Hospital)
Blood - -
Nitrit - -
May 26, 2017
Leukosit - -
Sedimen:
•Eritrosit 0–1 0–1
•Leukosit 2–3 0–4
•Silinder - -
•Epitel +
•Kristal - -
•Jamur - -
•Bakteri - -
 Value Normal Value
Hepar function
SGOT 23,4 < 36 U/L Laboratory Investigation
SGPT
Renal Function
16,2 < 29 U/L
(Grand Family Hospital)
Ureum 37,0 < 48 mg/dl May 27, 2017
Creatinin 0,8 < 1,0 mg/dl
 Chest X-Ray
(Grand Family Hospital)
• Cor is not enlarged, configuration normal
• Aorta normal
• Mediastinum is not widened
• Hili normal
• Pulmo rough bronchovaskular pattern ,
rough infiltrat diffuse spreading in both of
pulmo
• Sinus and diapraghma normal
• Thorax bone intake

Impression:
Cor : not enlarged
Pulmo : suspect miliary tuberculosis
Working Diagnosis

Miliary tuberculosis on OAT

Anemia
 Management
• IVFD KAEN3B 1000cc/24 jam
• Paracetamol syr 3 x 1 cth
• Rifampisin 150 mg
• Isoniazide 150 mg
• Pirazinamide 450 mg
• Etambutol 2 x 20 mg
• Prednisolon 2 x 100 mg
 Mild febris (+)
S Cough with sputum (+)
Cold (+)
Consciousness: Compos Mentis
General condition: Midly ill
Temperature: 37,2 °C
Pulse:120 x/min
Respiratory rate: 26 x/min
Head: Normocephal
O Eyes: Pale conjungtiva (-), icteric sklera (-), sunken eyes (-)
Mouth: Dry lips, dry mucous, tonsils T1/T1, hyperemia pharynx (-)
Pulmonary: Vesicular +/+, rhonchi +/+, wheezing -/-
Cardio: S1S2 reguler, murmur (+), gallop (-)
Abdomen: Distention (-), bowel sound (+) normal, shifting dullness (-)
Follow up
Extremity: Warm, CRT <2 seconds
Laboratory Investigation
(May 28, 2017)
Results Normal Value
Hemoglobin 8,4 13 – 16 g/dl
White blood cells 13.500 5.000 – 10.000 u/l 2nd day of
Hematocrit 26 40 – 48 % hospitalization,
Platelet count 489.000 150.000 –400.000 /ul
Miliary Tuberculosis 18th day of illness
A
Anemia
 IVFD KAEN3B 1000cc/24 jam
 Paracetamol syr 3 x 1 cth
 Rifampisin 150 mg
P  Isoniazide 150 mg
 Pirazinamide 450 mg
 Etambutol 2 x 200 mg
 Cough with sputum (+)
S
Cold (+)

Consciousness: Compos Mentis

General condition: Midly ill
Temperature: 36,8 °C
Pulse:122 x/min
Respiratory rate: 24 x/min
Head: Normocephal
O Eyes: Pale conjungtiva (-), icteric sklera (-), sunken eyes (-)
Mouth: Dry lips, dry mucous, tonsils T1/T1, hyperemia pharynx (-)
Pulmonary: Vesicular +/+, rhonchi +/+, wheezing -/- Follow up
Cardio: S1S2 regular, murmur (+), gallop (-)
Abdomen: Distention (-), bowel sound (+) normal, shifting dullness (-)
(May 29, 2017)
Extremity: Warm, CRT <2 seconds
3rd day of
Milliary Tuberculosis
A
Anemia
hospitalization,
 IVFD KAEN3B 1000cc/24 jam 19th day of illness
 Paracetamol syr 3 x 1 cth
 Rifampisin 150 mg
P  Isoniazide 150 mg
 Pirazinamide 450 mg
 Etambutol 2 x 20 mg
 Prednisolon 2 x 100 mg
S Cough with sputum (+)
Consciousness: Compos Mentis
General condition: Midly ill
Temperature: 37,3 °C
Pulse:122 x/min
Respiratory rate: 24 x/min
Head: Normocephal
O Eyes: Pale conjungtiva (-), icteric sklera (-), sunken eyes (-)
Mouth: Dry lips, dry mucous, tonsils T1/T1, hyperemia pharynx (-)
Pulmonary: Vesicular +/+, rhonchi +/+, wheezing -/- Follow up
Cardio: S1S2 regular, murmur (+), gallop (-)
Abdomen: Distention (-), bowel sound (+) normal, shifting dullness (-)
(May 30, 2017)
Extremity: Warm, CRT <2 seconds
Milliary Tuberculosis
4th day of
A
Anemia hospitalization,
 IVFD KAEN3B 1000cc/24 jam 20th day of illness
 Paracetamol syr 3 x 1 cth
 Rifampisin 150 mg
P  Isoniazide 150 mg
 Pirazinamide 450 mg
 Etambutol 2 x 20 mg
 Prednisolon 2 x 100 mg
 Prognosis
• Quo ad vitam : Bonam
• Quo ad functionam : Dubia ad malam
• Quo ad sanationam : Dubia ad malam
Literature review
and discussion
 Definition
Tuberculosis (TB) is an infectious disease caused
by Mycobacterium tuberculosis.

Miliary TB is a systemic lympho hematogen-induced

disease The spread of M. tuberculosis from the primary
complex that usually occurs within the first 2-6 months after
the initial infection.
 Etiology

Rod-shaped bacteria
Mycobacterium with a length of 1-4 /
Aerobic bacteria Acid-resistant rod
Tubeculosis μm and thickness of
0.3 to 0.6 / lm
• 95% are from developing
countries in Asia (5.2
million), Africa (2.8
million), the Middle East
(0.7 million), and Latin
America (0.3 million).
• From Alabama, USA,
estimated that the number
of child TB cases per year is
5-6% of the total TB cases.
• In developing countries, TB
in children aged <15 years
is 15% of all TB cases.
 Clinical Manifestation
• Common symptoms are unusual chronic complaints, such as
anorexia and weight loss or failure to thrive (with mild or no fever),
old fever with unclear causes, and coughing and shortness of
breath.
• Acute attacks of high fever that is often intermittent (remittent),
the patient is severely ill within a few days, but the signs and
symptoms of respiratory disease has not been there. In
approximately 50% of patients, superficial lymphadenopathy and
hepatomegaly will happen in a few weeks.
• Other symptoms that can be found are skin disorders such as
tuberculoid, necrotic papules, nodules or purpura.
 Diagnosis
Non-specific manifestation Specific manifestation

• Weight loss or malnutrition for no • Tb skin / skrofuloderma

• History of apparent reason or no rise in 1
month.
• Tb bones and joints
• Spine (spondylitis): gibbus
contact with • No appetite (anorexia) with growth • Pelvic bone (koksitis): limp
failure and failure to thrive
adult TB patients • Long / repeated fever for no apparent
• Knee bone: limp and / or swelling
• Foot and hand bones
reason, may be accompanied by night
are infectious sweats. • Tb Brain and Neuro
• Meningitis with irritable symptoms,
(smear positive) • Enlarged superficial lymph nodes
• Respiratory symptoms:
stiff neck, vomiting and decreased
consciousness
• An older cough for more than 3
• Eye symptoms: Conjunctivitis
weeks
phlyctenularis, Choroidal tubercle
• Signs of fluid in the chest, chest pain (seen only with funduscopy)
• Gastrointestinal symptoms:
• Persistent diarrhea that does not
heal with diarrhea treatment
• Lump / mass in the abdomen
• Signs of fluid in the abdomen
 Supporting investigation
Test tuberculin (Mantoux)

• Used tuberkulin PPD RT 23 strength 2 TU or PPD-S power 5 TU

• The reading is 48-72 hours after the injection.
• Measured the tranversal diameter of the induration occurs. The size is expressed in millimeters.
• Positive if induration > 10 mm.

BCG quick reaction

• Injection of BCG rapid reaction

• Redness and induration> 5 mm (within 3-7 days) it is suspected to have infected with
Mycobacterium tuberculosis.

X-Ray

• Found infiltrates with enlarged hilar glands or paratracheal glands.

• Miliary pattern
 Supporting investigation
Microbiological examination

• BTA direct examination (microscopic)

• Culture of sputum (in children gastric washings because sputum is hard to come by)

Serology

• ELISA
• PAP
• Mycodot
• etc

Anatomic pathology examination

 Management
Nama Obat Dosis harian Dosis maksimal Efek Samping
While the treatment of
(mg/kgBB/hari) (mg/hari)
miliary TB is the
Isoniazid 5-15* 300 Hepatitis, neuritis perifer,
provision of 4-5 kinds of
hipersensitivitas
combination isoniazid
Rifampisin** 10-20 600 Gastrointestinal, reaksi kulit, hepatitis,
OAT drugs, rifampicin,
trombositopenia, peningkatan enzim hati,
and streptomycin or
cairan tubuh berwarna oranye kemerahan
ethambutol during the
Pirazinamid 15-30 2000 Toksisitas hati, atralgia, gastrointestinal
first 2 months, followed
Etambutol 15-20 1250 Neuritis optik, ketajaman penglihatan
by isoniazid and
berkurang, buta warna merah-hijau,
rifampicin to 9-12
penyempitan lapang pandang,
months according to
hipersensitivitas, gastrointestinal
clinical development.
Streptomisin 15-40 1000 Ototoksis, nefrotoksik
 Dosis kombinasi pada TB anak
Berat badan (kg) 2 bulan RHZ (75/50/150) 4 bulan RH (75/50)
5-9 1 tab 1 tab
10-14 2 tab 2 tab
15-19 3 tab 3 tab
20-32 4 tab 4 tab
 Prognosis
If left untreated, the mortality associated with miliary tuberculosis is assumed to be close to
100%.

With early and appropriate treatment, however, mortality is reduced to less than 10%.

The relapse rate is 0-4% with adequate therapy and directly observed therapy, although results
from studies vary. Most relapses occur during the first 24 months after completion of therapy.