Pleural Effusion Ec Pulmonary Tuberculosis

PLEURAL EFFUSION EC PULMONARY TUBERCULOSIS

Presenters: Erwin Siahaan (060100090) Yunny Safitri (060100158)

Supervisor: Dr.Tina Christina L.Tobing, SpA

TUBERCULOUS PLEURAL EFFUSION

Pleural effusion is the abnormal accumulation of fluid in the pleural space. A pleural effusion is always abnormal and indicates the presence of an underlying disease.

Pleural effusion that caused by tuberculosis infection is called tuberculosis pleural effusion.

ETIOLOGY

Mycobacterium tuberculosis causes tuberculosis and is a very important pathogen of humans

EPIDEMIOLOGY Infection occurs at an earlier age in urban than in

rural populations This risk is proportionate to the rate of active

infection in the population, crowding, socioeconomic disadvantage, and inadequacy of medical care

It is influenced by age (high risk in infancy and in the elderly), by undernutrition, and by immunologic status, coexisting diseases, and other individual host resistance factors.

PATHOGENESIS Pleural effusion occurs in 2-38% of all

cases of pulmonary tuberculosis in children Can be either primary or results of

reactivation disease Results from direct hematogenous invasion

of the pleural space The rupture of subpleural foci into the

pleural space 6 to 12 weeks after primary infection then promotes a delayed hypersensitivity response to the mycobacterial proteins, resulting in a pleural effusion

SIGN AND SYMPTOMS

Many children with tuberculosis do not have significant cough

pleuritic pain Night sweats low-grade fever weight loss easy fatigability

DIAGNOSIS detailed history and physical examination chest x-ray complete blood count and cell differential acid-fast stain and culture Adenosine deaminase Tuberculin test Thoracentesis Ultrasonography

DIAGNOSIS

Children were categorized as bacteriologically confirmed tuberculosis, radiologically certain tuberculosis, probable tuberculosis or not tuberculosis.

DIFFERENTIAL DIAGNOSIS

bacterial pneumonia

TREATMENT The same general principles that apply to the

treatment of tuberculosis in adults also apply to children

COMPLICATION

Possible complications include respiratory failure caused by massive fluid accumulation, septicemia, bronchopleural fistula, pneumothorax, or pleural thickening

PREVENTION

method available to prevent tuberculosis in children is administration of a bacille Calmett-Guérin (BCG) vaccine

interrupting transmission through a community-based contact investigation with appropriate chemotherapy, and the treatment of tuberculosis infection to prevent the development of disease.

PROGNOSIS

The prognosis of pleural diseases depends on the underlying cause

Most tuberculosis effusions completely resolve with the use of proper antituberculosis agents.

Residual pleural thickening can occur in 50% of patients

CASE REPORT

OBJECTIVE

The aim of doing this paper is to report a case of tuberculosis pleural effusion in a 7 years old boy that was admitted to Infection Unit of Pediatrics Departement in Haji Adam Malik General Hospital

CASE Y, 7 years old boy, body weight 21 kg, and

125 cm of height, was admitted to infection unit of pediatrics departement, Haji Adam Malik General Hospital on December 3rd 2010 at 10.45 am with chief complain breathlessness. Breathlessness occurs since 1 week ago and subsided when the patient lie down on right side. This complain was followed by cough. The cough occurs since 1 month ago with yellow phlegm and no bloody streak. These chief complain also followed by night hyperperspiration, decreased of body weight and lessen of appetite. Night hyperperspiration occurs since 1 week ago. Decreased of body weight and lessen of appetite occurs since 1 month ago.

The patient also complained having fever since 1 month ago, the fever is subfebrile, the temperature falls with the adminstration of paracetamol. Fever always occur at night and subsided in the morning. History of having contact to tuberculosis patient was not found. History of immunization is complete (according to his mother) and a BCG scar was found.

He had history to be inpatient in RB4 with diagnoses dengue fever 2 weeks later before his chief complain for his medical problem now.

PHYSICAL EXAMINATION

Presence StatusSens: Compos MentisTemp : 37,60CBW : 21 kg BL : 125 cm

Anemic (-) Cyanosis (-)Dypsnoe (-) Oedema (-) Icteric (-)

LOCALIZED STATUS

Head: - Eye: light reflexes (+/+), isochoric pupil, conjunctiva palpebra inferior pale (-/-). Ear/Mouth/Nose: within normal limit

Neck : lymph node enlargement (+) at sinistra and dextra colli regio, size + 1 cm, multiple, soft, mobile and without pain pressure

Thorax : asymmetric, seems like right dominant, retraction (+) epigastrial. HR 112 bpm, regular, without murmur. RR 32 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion

Abdomen: symmetric, soepel, peristaltic (+). With no palpable of liver and spleen

Extremities: pulse 122 bpm, regular,adequate pressure and volume, warm acral, BP 100/60 mmHg. Physiological reflexes: within normal limit, pathological reflexes (-) and meningeal reflexes (-)

DIFFERENTIAL DIAGNOSE:

Pneumonia Sinistra pleural effusion ec tuberculosis

Working Diagnose: Pneumonia

Management: IVFD D5% NaCl 0,225% 10 gtt/I micro

FUTHER EXAMINATION:

CBC Chest X-Ray LFT RFT 3 times Direct Smear Sputum Tuberculin Skin Test

FOLLOW UPFollow Up December 3 rd 2010 S: Breathless (+), fever (+), cough (+) O: Sens: CM, T: 39,2, BL= 125 cm, BW= 22 kg, BW/ BL=

89, 79% Head: Eye: pupil reflex (+/+), isochoric pupil (+), pale

palpebra inferior conjunctiva (+) E/N/T: within normal limit Neck: Lymph node enlargement (+) bilateral, size ± 1

cm, multiple, consistency soft, mobile (+), tenderness (+).

Chest: asymmetric, seems like right dominant, retraction (+) epigastrial. HR: 110 bpm, regular, without murmur. RR: 38 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.

Abdominal: Soepel, normal peristaltic, liver/ spleen: unpalpable.

Extremities: Pols: 120 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities. BP: 100/70 mmHg.

A: Left pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition

2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV - Inj. Chloramphenicol 600 mg/ 8 hours/ IV - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever) R: - Consult to respirology department Sputum analysis AFB direct smear Pleural tapping

LABORATORY FINDING (DECEMBER 3RD 2010) – EMERGENCY UNITTestTest ResultResult Normal ValueNormal Value

Complete Blood CountComplete Blood CountHemoglobin (Hb)Hemoglobin (Hb)Erytrocytes (RBC)Erytrocytes (RBC)Leucoytes (WBC)Leucoytes (WBC)Hematocrite (Ht)Hematocrite (Ht)Trombocytes (Plt)Trombocytes (Plt)MCVMCVMCHMCHMCHCMCHCRDWRDWMPVMPVPCTPCTPDWPDW

10,7010,704,37x104,37x10 6 6

9,75x109,75x1033,0033,00503x10³503x10³75,5075,5024,5024,5032,4032,4014,1014,107,907,900,400,407,87,8

11,3-14,111,3-14,14,40-4,484,40-4,484,5-13,54,5-13,537-4137-41150-450150-45081-9581-9525-2925-2929-3129-3111,6-14,811,6-14,87,0-10,27,0-10,2

Chest X-Ray finding: Massive pleura effusion on the left

hemithorax. CTR < 50%

Follow Up December 4 th 2010 S: Breathless (+), fever (-), cough(+) O: Sens: CM, T: 37,3, BL= 125 cm BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+), pale

palpebra inferior conjunctiva (+). E/N/T: within normal limit

Neck: Lymph node enlargement (+) bilateral, size ± 1 cm, multiple, consistency soft, mobile (+), tenderness (+).

Chest: asymmetric, seems like right dominant, retraction (+) epigastrial. HR : 98 bpm, regular, without murmur. RR: 30 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.




2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225%10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 1) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV (Day

1) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever) R: - Consult to respirology department Sputum analysis AFB direct smear Montoux Test Pleural tapping Pleural fluid analysis

Follow Up December 5 th 2010 S: Breathless (+), fever (-),cough(+) O: Sens: CM, T: 36,8, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+),

pale palpebra inferior conjunctiva (+). E/N/T: within normal limit




Extremities: Pols: 120 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities.

BP: 100/60 mmHg.


2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute

micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 2) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV

(Day 2) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)

Follow Up December 6 th 2010 S: Breathless (+), fever (-), cough (+) O: Sens: CM, T: 36,7, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+),



Chest: Asimetric, seems like right dominant with minimal epigastrial retraction (+) epigastrial. HR: 100 bpm, regular, without murmur. RR: 26 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.




2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 3) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV (Day

3) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg R: - Consult to respirology department Sputum analysis AFB direct smear Pleural tapping Pleural fluid analysis

Montoux Test Result: - Positive - Undulation (+) hyperemis, size 12 mm

Follow Up December 7 th 2010 S: Breathless (+), fever (-), cough (+) O: Sens: CM, T: 36,8, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+), pale






A: Pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition


micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV

(Day 4) - Inj. Chloramphenicol 600 mg/ 8 hours/

IV (Day 4) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)

Advice from Pediatric Pulmonology Departement:

- Pleural tapping- Pleural fluid analysis

Follow Up December 8 th 2010 S: Breathless (+), fever (+), cough (+) O: Sens: CM, T: 39,2, BL= 125 cm , BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+),






A: Let pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition

2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 5) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV (Day

5) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)

Until 22.00 WIB AFB direct smear result is negative

Follow Up December 9 th 2010 S: Breathless (+), fever (-), cough (+) O: Sens: CM, T: 36,2, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+), pale








micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day

6) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV

(Day 6) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)

Follow Up December 10 th 2010 S: Breathless (+), fever (-), cough (-) O: Sens: CM, T: 39,2, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+),



Chest: Asimetric with minimal epigastical retraction.

HR: 100 bpm, regular, mur-mur (-) RR: 48 rpm, regular Abdominal: Soepel, normal peristaltic, liver/

spleen: unpalpable. Extremities: Pols: 100 bpm, regular, pressure and

volume was adequate, cyanotic (-), with warm extremities. BP: 100/70 mmHg..

A: Left pleural effusion ec: DD: 1. Pulmonary TB + Mild malnutrition

2. Pneumonia P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 7) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV (Day

7) - Rifampicin 1 x 240 mg - INH 1 x 240 mg - Pirazinamid 2 x 40 mg - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)December, 11 th 2010 Patient discharge from

RSUP HAM

Discussion

Teory Case

Pleural effusion most common complication of bacterial pneumonia in child

Epidemiology of tuberculosis pleural effusion is influenced by age, undernutrition,immunologic status,coexisting disease and other individual host factors.

In this case report, the patient was firstly diagnosed as pneumonia pleural effusion based on epidemiologic study

This patient is young boy with undernutrition and immunodepressed status caused by dengue fever

Teory Case

In pleural effusion, the radiographic finding show a homogenous density that obscured the underlying lung.

Treatment decicion in children wih pleural effusionare dictated based on the likely etiology of he infectous organism from the pleural fluid analysis and and the clinical status of the patient.

In this case, the chest x ray show homogenous consolidation in left side thorax

In this case we give Inj. Cefotaxime 600 mg/ 8 hours

- Inj. Chloramphenicol 600 mg/ 8 hours

- Rifampicin 1 x 240 mg - INH 1 x 240 mg - Pirazinamid 2 x 40 mg because the pleural tapping didn’t do.

SUMMARY

It has been reported a case of an 7 years old boy with pleural effusion. Who was suspected as pleural effusion caused by M. tuberculosis infection. The diagnosis was established based on history taking, clinical manifestation, radiology finding and laboratory findings. Treatment for this patient was based on underlying disease, symptomatic and supportive treatment

Documents

Pleural Effusion Ec Pulmonary Tuberculosis