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Tjatur Kuat Sagoro Persahabatan hospital

Diagnosis & Treatment

of Pediatric TB

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Dr.Tjatur Kuat Sagoro SpA Tempat dan tanggal lahir :Semarang !" #$tober !% ! Pendidi$an : ' (K )*+ : !%",

' -KA (K ) D-P : !%%" ' (ello/ship 0espirologi -KA (K )- #rganisasi : ' Se$retaris )KK 0espirologi 1ab.DK- 2a$arta ' Anggota )KK 0espirologi -DA-

' Anggota -D- -DA- ' Anggota Po$ja Practical Approach to 3ung 4ealth 5PA36Dep$es Tempat be$erja : 0S Persahabatan 2a$arta

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Indonesia peringkat ke 3 penduduk terbanyakpenderita TB

Global TB : Insidens BTA + : 105/100.000penduduk

Tatalaksana TB : pada penderita sakit TB

infeksi TB !endekatan pen"ega#an infeksi dan sakit TB

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De7nition Tuberculosis is a disease due toMycobacterium tuberculosis

infection /ith s8stemic spreadthus can a9ect almost allorgans and the most fre uent

site is in the lung /hich usuall8as the site of primar8 infection

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(a$tor risi$o

Risiko infeksi :Terpajan orang dewasa TB aktif

Endemis,kemiskinan,lingkungan tidak sehatTempat penampungan umum

Risiko sakit :

Usia < 5 tahunKonversi uji tu erkulin!alnutrisi,imunokompromais

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Risiko sakit anak yangRisiko sakit anak yang

terinfeksi TBterinfeksi TB

+arais et.al.-nt 2 Tuberc 3ung Dis ;

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M. tuberculosis in#alation

p#ago"ytosis by !A$

li%e ba"illi

multiplies

pri&ary fo"us for&ationly&p#ogeni" spread#e&atogeni" spread 1'

!ri&ary "o&ple( )'*ell &ediated i&&unity +'T,T +'

in"ubation period)-1) eeks'

Pr i

mar

y

TB3)

pri&ary "o&ple( "o&pli"ation#e&atogeni" spread "o&pli"ation

ly&p#ogeni" "o&pli"ation

TB disease

ead

pti&al i&&unity

TB infe"tion

*ured

TB disease'

i&&unityrea"ti%ation/reinfe"ktion

ba"illi dead

TB TBpathogenesispathogenesis

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8/59"igure# $athogenesis of primar% tu er&ulosis

droplet nu"lei

in#alation

al%eoli ingestion by !A$2,

intra"ellular repli"ationof ba"illi

destru"tion of ba"illidestru"tion of !A$2,

Tu er&le formation 'ilar l%mph nodes

hematogeni& spread

&ultiple organsre&ote fo"i

(%mphogeni& spread

disse&inated pri&ary TB

a"ute #e&atogeni" spread

o""ult #e&atogeni" spread

pri&ary fo"us ly&p#angitis ly&p#adenitis

primar8

comple@

1+-

Pathogenesis

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TB infection & TB disease

TB infe.tion/ 01I .an .ontrolinfe.tion

primar8 comple@ 5 6cell mediated immunit8 5 6tuberculin sensitiCit8 5DT46 5 6limited amount of TB bacilli

no clinical or radiological manifestation TB disease/ 1+- failed to control TBinfection TB infection clinical and orradiological manifestation

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Diagnosis

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Ana$ E orang de/asa$ecil aspe$ tumbuh $embang

neonatus dapat AS- FmencretG

Famandel besarG pada AB* hal normal aspe$ pen8a$it: pen8a$it sama gejala

beda gejala sama pen8a$it bedaasma : sesa$ mengi> pada ana$ jarang

TB : batu$ $eringat malam> pada ana$ td$ TB de/asa menular> pada ana$ td$

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Diagnostic tools

1linical manifestation Tuberculin s$in test1hest H ra8+icrobiolog8Patholog8

4ematolog8#thers : serologic lungfunction bronchoscop8

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Suspect TB clinical

manifestationbod8 /eight problemappetite problem

recurrent A0-multiple l8mph nodesenlargement

multi 3

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Diagnostic toolsgold standard

capture the Ftrouble ma$erGmicrobiologic e@amination

adult TB

direct 'A(B

TB culture

sputum

pediatric TB

scarcespecimen

TP: D &eCaluation

1antou2TST

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Tuberculin s$in test

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+antou@ TSTMantoux 0.1 ml PPD intermediate strengthlocation : volar lower armreading time : 48-72 h ost in!ection

measurement : al ation" mar#ed" measurere ort : in millimeter" even $0 mm%&nduration o' transversal diameter :

0 - ( mm : negative( - ) mm : dou*t+ 10 mm : ositive

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+antou@tuberculi

n s$intest

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Tuberculin positiCe

1. TB infection : infection /ithout disease latent TB

infection infection A D diseasedisease post therap8

;. B1* immuniIation?. -nfection of Mycobacterium atypic

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Tuberculin negatiCe

1. ,o TB infection

;. -ncubation period?.Anerg8

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Anerg8Patient /ith primar8 comple@ do not giCe

reaction to TST due to supression of 1+- : SeCere TB: miliar8 TB TB meningitis SeCere malnutrition Steroid long term use 1ertain Ciral infection: morbili Caricella SeCere bacterial infection: t8phus

abdominalis diphteria pertussis Jiral Caccination: morbili polio +alignanc8: 4odg$in leu$emia ...

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Algorithm for arl8 Detection and 0eferral for1hildhood Tuberculosis in -ndonesia

Sus3e.ted TB/ 1lose contact /ith adult /ith A(B sputum 5 6 arl8 reaction of B1* 5in ?', da8s6 Leight loss /ith no apparent cause or under/eight

/ith no improCement in ! month /ith ade uatenutritional support 5failure to thriCe6

Prolonged recurrent feCer /ith no apparent cause 1ough more than ? /ee$s Speci7c enlargement of super7cial l8mph node Scrofuloderma (l8chten conjunctiCitis Tuberculin test positiCe 5M !< mm6 0adiological 7ndings suggestiCe TB

-f M ? positiCe e@t page

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1onsidered TB

*iCe anti'TB therap8#bserCation in ; months

1linical response 5 6 o clinicalresponse /orsening

TB

1ontinue anti'TB therap8

ot TB +D0 TB

0efer to hospital

Ree4aluation in Referral 5os3ital/1linical signs

Tuberculin test0adiological 7ndings+icrobiolog8 and serolog8e@amination4istopatolog8 e@aminationDiagnostic procedure and therap8

according to each hospitalGs protocol

6TT78TI98Presence of an8 dangerous signs: SeiIure Decreased leCel of consciousness ec$ sti9ness#r signs such as: Spinal tumor lump 3imping Dam board phenomenon

Send to hospital)KK Pulmonologi -DA-. 2a$arta>;

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ncountered problem&ncreasing demands o' / drugs'or Pediatric /

&ncreasing diagnosis o' Pediatric/ using the &D & algorhitmver diagnosis 3

,eed im rovement &D & scorings stem

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-DA- Pediatric TB scoring

s8stemFeature 0 1 2 3 ScoreContact notclear

' reportedA(B5'6

A(B56

TST ' ' ' positiCe

BW (KMS) ' Nred lineBL

seCeremalnutritio

n

'

Fever ' une@plained ' 'Cough N?/ee$

s

M?/ee$s ' '

Nodeenlargemn

t

' M! nodeM!cm painle

ss

' '

Bone, o!nt ' s/elling ' '

C"# normal sugestiCe ' '

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otes for -DA- scorings8stem Diagnosis b8 doctor

BL assessement at present (eCer & cough no respons to standard t@ 1H0 is #T a main diagnostic tool in children All accelerated B1* reaction should be

eCaluated /ith scoring s8stem TB diagnosis total score M

Score = in underO child or strong suspicionrefer to hospital - 4 proph8la@is for A(B5 6 contact /ith score

NO

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+asalah baru Sistem S$oring

TB :

Dep$essetengah hati

FT 03A3)G

diterima

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+asalah baru Sistem

S$oring TB

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Sarana #K SD+ #K

Analisis #K

(asilitas$esehata

n

terbatas

TB ana$overdiagnosis

(asilitas$esehata

n

leng$ap

Saranaterbatas

SD+ terbatas

TB ana$diagnosis tepat

Sistem S$oring TB ana$

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Sistem S$oring TB di 0S

end point#

entr8 point

S

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S$rofuloderma

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*ibbus pada Spondilitis TB

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TB tulang bela$ang TB

lutut

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*onitis TB

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Treatment

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The main problems Diagnosis

1linical manifestations : not speci7c bothover/under diagnosis & over/undertreatmentdiagnostic specimen : diQcult to obtain

TB infection or TB disease R no diagnostictool to distinguish

TreatmentAdherence compliance Drug discontinuation treatment failure+ulti drug resistance 5+D06

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Pediatric TB therap8

regimen mo : mo + mo ! mo

I85

R1PP;6

7TBS1

PR7D8IS98D9TS