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8/3/2019 Case Pres. - Winning Over TB in Children,,,A Lost Cause[1]
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General Data:J.C.N., 12-year-old male,
Filipino, Catholic, presently residing
at Manatra Buli, Muntinlupa City,
was admitted at MCGH for the firsttime on May 6, 2010.
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Chief Complaint:cough and abdominal pain
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History of Present Illness:9 months PTA fever
cough
Consult: Health CenterMeds:Paracetamol
Salbutamol
Follow-up twice
Med: Paracetamol
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7 months PTA fever, cough, coldsvomiting, dizzinesshypogastric painbilateral flank paindysuria, nocturiadark yellow urinepolyuria, oliguria
feeling of bladdernot fully emptied
Consult: Health Center
Dx: TonsillitisMeds: ParacetamolSalbutamol?med. for vomiting
Amoxicillin
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5 months PTA persistence of symptoms
abdominal pain(epigastric, RUQ)
Consult: PGH
CXR: PneumoniaMed: AmoxicillinPTB consideredAdvised ff-up
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3 months PTA condition unimproved
urinary symptoms notedgradual abdominal enlargementweight lossnight sweats
Consult: PGHDx: UTIMed: Cotrimoxazole
Ff-up at PGH
Med: Cefaclor
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2 months PTA condition persisted
Consult: Ospital ng
MuntinlupaWhole Abdomen Ultrasound:
Hepatomegaly with liver parenchymal disease process notruled out
Bilateral renal parenchymal disease considered.
Pre-aortic possibly mesenteric lymphadenopathy.
Ultrasonically normal gallbladder, bile ducts, pancreas,spleen and aorta
Advised consult atHealth Center fortreatment of Tuberculosis
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Few hours PTA persistence of condition
Consult: PGHImpression: t/c Disseminated TB
(Pulmo, GI, lymph nodes)
Referred to SLH
CXR requested
Admitted
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Family History: (+) PTB Father, not compliant to medications
- paternal grandmother died of PTB
(+) Asthma paternal side
(+) Hypertension maternal grandfather
(-) Diabetes Mellitus
(-) Cancer
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Immunization History:No Vaccinations
Personal & Social History/Environment:Patients parents separated since he was 5 mos. old.
He presently lives along railways in a congested area withhis mother. There are 5 household members, including thepatient, who occupies a small room. He is the youngest
among 4 siblings. He is an incoming grade 4 student.
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Review of Systems:- no irritability, no changes in sensoriumno convulsion
- no head lesions; no eye, nasal nor auraldischarge; no throat pain
- with shortness of breath
- with easy fatigability
- no cyanosis
- no diarrhea nor constipation
- no hematuria
- no muscle nor joint pains
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Physical Examination : conscious, coherent, weak-looking, in mild cardio-
respiratory distress
CR = 122 RR = 25 T = 37.6oC
pink palpebral conjunctivae, anicteric sclerae, mattedcervical lymphadenopathy, pale skin
symmetrical chest expansion, tachypneic, no retractions,harsh breath sounds with occasional rales
adynamic precordium, tachycardic, no murmur
globular abdomen, normoactive bowel sounds, directtenderness on RUQ, hepatomegaly, visible abdominalveins, (+) Kidney Punch Test
full and equal pulses
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Admitting Diagnosis at the Ward:Disseminated TB (Hepatic, lymph nodes)
Pneumonia
UTI
Severe Malnutrition
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Admission:IVF : D5 0.3 NaCl
Labs: CBC w/ platelet count., urinalysis,serum Na, K, Cl, SGOT, SGPT,Alkaline Phosphatase, BUN,
Creatinine, sputum AFB smear x 3days
PPD
Chest x-ray- negative
UTZ of whole abdomen
Meds: Paracetamol (10 mg/kg/dose)
Penicillin G Na (200,000 u/kg/day)
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1st Hospital day:Subjective
Afebrile * Productive cough no dyspnea * hypogastric pain bilateral flank pain * dysuria, nocturia dark yellow urine * polyuria, oliguria * feeling of bladder not fully emptied
Objective
weak-looking * pallor matted CLAD * prominent rib cage liver edge 6cm below right subcostal margin
iManagement
Continue present management I and O strictly monitored
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2nd Hospital day:Subjective
Afebrile no dyspnea No abdominal pain
Objective
weak-looking * pallor matted CLAD * prominent rib cage liver edge 9cm below right subcostal margin * grade 3/6 systolic murmur at 2nd ICS MCL
Diagnostics
PT,PTT * Abdominal CT Scan w/ contrast Urine CS with ARD * 2D Echo
Blood CS with ARD * ECG
Management
Pen. G shifted to Cefuroxime (100mkd)
Referral to Gastro. & Cardio
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5/8/10
PT
Patient = 13.8
Control = 15.2
% Activity = 86.5%
INR = 1.08
5/8/10
APPT
Patient = 31.6
Control = 36.2
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5th Hospital day:Subjective
Afebrile pallor Good oral intake
Objective
weak-looking * pallor
matted CLAD * prominent rib cage liver edge 9cm below right subcostal margin * grade 3/6 systolic murmur at 2nd ICS MCL
Diagnostics
CBC with platelet * Blood typing Peripheral Blood smear * Serum Electrolytes
Scour film of the abdomen
Management
INH (9mkd) * Abdominal CT Scan deferred Rifampicin (15mkd) PZA (20mkd) Streptomycin (25mkd)
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5/11/1 CBC/ platelet
Hgb 9.53
Hct 29.82
WBC 8.4
Neu. 73.80
Lym 16.40
Plt. 288
Blood Type: O+
5/11/1 Peripheral Blood SmearThe smears show microcytic
hypochromic red blood cellswith anisocytosis andpoikilocytosis. The white bloodcells are adequate in numberwith predominance ofneutrophils. Likewise seen aremany lymphocytes, raremonocytes, and eosinophils,there are no immature bloodcells, or inclusions noted.Platelets are adequate with nomorphological abnormalitiesnoted.
5/11/1 Scout Film of theAbdomen There are normalbowel gas pattern.
The liver andsplenic shadows areenlarged. The psoasand flanks stripes
are intact. Irregularcalcifications areseen in the leftlumbar arealevel of L4 to S1.The osseousstructures areunremarkable.
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8th Hospital day:Subjective
Febrile
Objective Harsh Breath sounds, right
Diagnostics
Repeat CBC with platelet Chest Xray
Blood culture and sensitivity
Management
Cefuroxime shifted to Ceftriaxone (100mkd)
Pleural Effusion considered
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10th Hospital day:Subjective
febrile,
no oliguria
Management
Urine AFB for 3 days
Anti-Kochs meds. continued
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Whole Abdomen Ultrasound
Enlarged liver with parenchymal disease
TB of the liver not ruled out
Slightly enlarged spleen
Enlarged left kidney with parenchymal disease
Normal gallbladder, right kidney and urinary bladder
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12th HD
febrile night sweats
vomiting, 1 episode harsh BS
occasional rhonchi
13th HD
febrile, no dyspnea
repeat urinalysis
Medications continued
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5/18-20/10
Urine AFB
acid-fast bacilli present 1+
5/19/10 Urinalysis Dark red, turbid
sp. gr. 1.027 pH 5.5
Sugar negative
protein 50 mg/dL RBC >20/hpf WBC >50/hpf Bilirubin 1.0 mg/dL+++ Nitrite 0.1 mg/dL+ hyaline cast many (+4) RBC cast many (+4)
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15th Hospital day:Subjective
Afebrile * no dyspnea no cyanosis * urinary symptoms
Objective (+)murmur grade 1 -2
Diagnostics Urine AFB result
Management
Dibencozide * Multivitamins Vitamin B Complex * Quadruple anti-Kochs meds.
continued
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18th Hospital day:Subjective
Afebrile * no dyspnea no abdominal pain * no polyuria (+) complete bladder emptying
Objective pallor
Diagnostics
repeat CBC with platelet count
CXR result
Management
Meds. continued
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5/2/1
Chest x-ray
Normal ChestFindings
CBC w/ platelet Hgb 9.87
Hct 30.65
WBC 8.29
Neu. 80.3
Lym. 10.2
Plt. 386
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25th Hospital day:
afebrile,comfortable.
No urinarysymptoms
Home meds:
* INH (10mkd)
* Rifampicin (15mkd)
* PZA (20mkd)
* Streptomycin(21mkd)
* Vit. B Complex
* Dibencozide
* Discharged
improved
* Follow- up @OPD Pedia
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Final Diagnosis:
Disseminated TB (Hepatic, Renal, Lymph nodes)
Anemia secondary to Chronic Infection
Severe Malnutrition
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a common and often deadly infectious
disease caused by various strains ofmycobacteria, usually Mycobacteriumtuberculosis in humans
attacks the lungs but can also affect otherparts of the body
most infections in humans result in anasymptomatic, latent infection
one in ten latent infections eventuallyprogresses to active disease which, if leftuntreated, kills more than 50% of its victims
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EpidemiologyOne third of the worlds population is
infected with Mycobacterium tuberculosis
Each year, about 9 million people developTB, of whom about 2 million die.
Of the 9 million annual TB cases, about 1million (11%) occur in children (
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Causes
Mycobacterium tuberculosis
- a small aerobic non-motile bacillus
- high lipid content
- divides every 16 to 20 hours- classified as a Gram-positive bacterium
- can withstand weak disinfectants & survive in a drystate for weeks
- can grow only within the cells of a host organism, butcan be cultured in vitro
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Transmission
people suffering from active PTB
cough, sneeze, speak, or spit
infectious aerosol droplets (0.5 to 5 um)
transmit the disease
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Transmission
- people with prolonged, frequent, or intense contact: highrisk of becoming infected (22% infection rate)
- people with active but untreated TB can infect 10 15
other people per year
- can only occur from people with active not latent TB
- depends upon the number of infectious droplets expelled
by a carrier, effectiveness of ventilation, duration ofexposure, & virulence of M. TB strain
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Pathogenesis
- Mycobacteria reach the pulmonary alveoli, where theyinvade & replicate within the endosomes of alveolarmacrophages
- primary site of infection in the lungs: Ghon focus
- bacteria are picked up by dendritic cells (can transportthe bacilli to local/mediastinal lymph nodes)
- further spread through bloodstream to other tissues &organs where secondary TB lesions can develop in
other parts of the lung, peripheral lymph nodes,kidneys, brain, & bone
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Risk of TB infection in children
Depends on contact with an adult who has
active TB disease
- extent and duration of exposure
Susceptibility to infection -very young (
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Risk of progression from infection to active
disease: (often within 12 months of infection)
- more common among children
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Primary TB infection in children
Asymptomatic in 80-90%
- 5-10% may develop disease
Extra Pulmonary TB is common
Transmission of TB- source of infection
mostly adults
Children represent about 5-15% of all TBcases
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Young children with TB differ from Adult
Presentation
Infectiousness- generally not infectious
Progression to disease- faster, more often,
more extrapulmonary
Response to treatment Side effect profile
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o Often difficult!- Children rarely cough up sputum
- gastric aspiration not always possible
- Under 2 years of age- other infection/s may mask TB, e.g.,
pneumonia
R d d A h
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Recommended Approach
Careful history identify index case
Clinical examination
TB Skin Test
Bacteriology whenever possible
Investigations relevant to the suspected
type of TB
H t di g TB i hildr
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How to diagnose TB in children
Diagnosis depends on:
History of contact with a smear positive adult
Chronic symptoms
Clinical picture suggestive symptoms
Positive tuberculin skin test
Chest X-ray suggestive of TB
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Clinical signs and symptoms
General most common clues are:
Failure to gain weight/ failure to thrive
Loss of appetite without obvious cause
Chronic cough for 2 weeks or more, not
responding to a course of antibiotics
Painless swelling of the lymph nodes
An audible wheeze due to airway compression
Unexplained fever
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Tools to help with the diagnosis
Chest X Ray
Tuberculin Skin Test (TST) or
Mantoux Test/PurifiedProtein Derivative (PPD)
- intra-dermal injection- read 48-72 hours later
- It measures the bodys immuneresponse to TB
- Infected not necessarily activeTB disease
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Clinical Manifestations
25% of active cases occurs more commonly in immunosuppressed
persons & young children
sites:
- pleura in tuberculosis pleurisy
- CNS in meningitis
- lymphatic system in scrofula of the neck
- genitourinary system in urogenital TB
- bones & joints in Potts disease of the spine
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Tuberculosis of the Cervical Lymph Nodes (Scrofula)
the most common form of extrapulmonary TB in
children
through direct extension from a primary pulmonaryinfection
the cervical chain of nodes becomes the mostcommonly affected
often unilateral; bilateral involvement may occur
cervical nodes may also be involved from other
tuberculous foci: nasopharynx, middle ear ortonsils
diagnosis:(+) tuberculin test, excisional biopsy &culture & fine needle aspiration cytology
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Genitourinary Tuberculosis
2nd most common site for tuberculous infection afterthe lungs
almost always affects the kidneys during the primaryexposure to infection but does not present clinically
true incidence of renal TB may be underestimated:
- radiologic findings may be absent
- diagnosis made by urine culture
Genital TB- usually secondary to renal tuberculous
infection
Renal TB-an uncommon complication of primaryTB occurring very late, up to 15 20 years afterprimary infection
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Renal Tuberculosis
can be unilateral or bilateral
can spread caudad to involve the bladder
can be insidious in onset
75% of patients would present with symptomsrelated to urinary tract inflammation- dysuria,
hematuria, sterile pyuria, flank pain
suspected in the presence of destructive PTB with
persistent, painless, sterile pyuria with associated
albuminuria & hematuria
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Diagnosis of GUTB
GUTB: very uncommon in children
symptoms of renal TB do not appear for 3 to 10 ormore years after the primary infection
frequent painless micturition
urgency uncommon unless there is extensive bladderinvolvement
urine normally sterile, contains leukocytes in high
proportion of patients overt hematuria: 10% of patients; microscopic
hematuria: up to 50%
renal & suprapubic pain: rare presenting symptom
Diagnosis of GUTB
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secondary TB with vague symptoms; often long-
standing urinary symptoms with no obvious cause
latent period of 20 years or more between infection
with the tubercle bacillus & the expression of GUTB
characterized with pyuria, albuminuria, hematuria
75% of patients- abnormal chest X-ray on admission
88% (+) skin tests
63%: abnormal excretory urography
16%: renal calcification
Renal TB:accompanied by manifestations of the urinarysyndrome in 70.4% of cases & by thepresence of Mycobacteria TB in 100%
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Diagnosis of GUTB
most important step:patient history
- history of voiding problems & chronicurgency non-responding to antibacterialdrug regimens: indicative of GUTB
- other symptoms: back, flank, & suprapubicpain, hematuria, frequency, & nocturia
- renal colic: uncommon
- constitutional symptoms: unusual
- symptoms are intermittent & have beenpresent for some time before the patientseeks medical advice
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Diagnosis of GUTB
microbiologic diagnosis of TB- isolation of the
causative organism from urine or biopsymaterial on conventional solid media or byan automated system (radiometry)
positive culture or histological analysis of biopsyspecimens possibly combined with PCR- definitediagnosis
detection of AFB from urine samples by microscopy
(Ziehl-Neelsen acid fast stain)- not reliable
(bec. of the possible presence of M. smegmatis)
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Diagnosis of GUTB
- made based on culture studies
-at least 3, but preferably 5, consecutive early morningspecimens of urine should be cultured, each onto 2slants:
(1) a plain Lowenstein-Jensen culture medium toisolate M. TB, BCG, & the occasionalnontuberculous mycobacteria
(2) a pyruvic egg medium containing penicillin toidentify M. bovis
Diagnosis of GUTB
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Diagnosis of GUTB
Radiography:
Plain X-ray films of the urinary tract:
- may show calcification in the renal areas & in thelower GUT
Intravenous urography:
- distortion of a calyx (fibrosed & completelyoccluded, multiple small calyceal deformities, orsevere calyceal & parenchymal destruction)
Ultrasonography:- may reveal renal calyceal dilation & more overtevidence of obstruction
Computed tomography & nuclear magnetic imaging
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Treatment of GUTB
6-month regimens for the treatment of uncomplicatedGUTB
Intensive phase Continuation phase
3 months
INH, RMP, EMB (or SM)
daily
3 months
INH, RMP
Twice or thrice per week
2 months
INH, RMP, PZA, EMBdaily
4 months
INH, RMPTwice or thrice per week
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