CASE CONFERENCEAng, Kevin

Aningalan, ArvinAntonio, Aby

Aramburo, JanCruel, Anna

General Info

• J.R.• 1 yr and 11 mos, Female• Santa Cruz, Manila

History of Present Illness• Mother palpated 1x1cm movable, firm,

non-tender mass over R lateral aspect of neck

• No other symptoms noted

6 weeks PTC

History of Present Illness• Patient experienced intermittent low-

grade fever (37.8°C), occurring at night time, not relieved by paracetamol

• No accompanying symptoms– no anorexia– no weight loss– no cough– no colds– no medications given– no consult given

2 weeks PTC

History of Present Illness• Patient experienced fever, now

accompanied with colds with clear discharge

• (-) cough• (-) anorexia• (-) weight loss• (-) irritable• (-) difficulty of breathing

8 days PTC

History of Present Illness• Patient sought consult at OPD

– (+) boggy turbinates– (+) cervical lymphadenopathy, 1x1cm

movable, firm, non-tender over R lateral aspect of neck

• Assessment: to r/o PTB• Plans: PPD, CXR, to follow-up with

results

5 days PTC

History of Present Illness• PPD test: 10mm• CXR PA and Lateral: suggestive of

Primary Koch’s

Consult

Review of Systems(-) weight loss, (-)anorexia(-) itchiness, pigmentation, rash, active dermatoses(-) blurring of vision, redness, itchiness, Iacrimation(-) deafness, tinnitus, aural discharge(-) anosmia, epistaxis, sinusitis, nasal discharge(-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion(-) chest pain, nocturnal dyspnea, palpitation, syncope, edema(-) phlebitis, varicosities, claudication(-) dysphagia, nausea, vomiting, retching, hematemesis, melena,

hematochezia, belching, indigestion, diarrhea, constipation(-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia (-) joint stiffness, joint pain, muscle pain, cramps(-) heat-cold intolerance, polydipsia, polyphagia, polyuria(-) headache, depression, seizures

Past Medical History

No Previous SurgeriesPast Medical Illnesses– Acute pyelonephritis (January 2009)– Acute rhinitis (February 2009)– Acute nasopharyngitis, probably viral (September 2009)

Immunizations: complete Hepa B1,2,3 Hib 1,2,3 DPT 1,2,3 booster BCG OPV 1,2,3 booster Measles Allergies: none

Family History

(+) Hypothyroidism – mother(+) Hypertension – mother(+) DM – grandfather(+) PTB – uncle who stays at home with patient(-) Cardiovascular diseases, stroke

Family Profile

• invent

Gestational and Birth History

• Patient born to a 31 y/o G2P1 unemployed housewife married to a 34 y/o seaman

• With regular prenatal check-up since 7 weeks AOG.• Denied illnesses during the entire pregnancy• Known case of hypothyroidism, maintained on

levothyroxine • Outcome was live term singleton female delivered via NSD

AS 8,9 MT 38-39 wks AGA BW 3.01 BL 47 HC 33.5 CC 31.5 AC 30.

• No complications• Advised to have TSH, T3 and T4 on the 72nd HOL.

TSH, T3, T4Value Interpretation Normal Values

T3 0.5 nM/L Decreased 1.16-4.00 nM/L

T4 191 nM/L Normal 106-256 nM/L

TSH 6.13 uiU/ml Normal 0.7-15.4 uIU/ml

Physical ExaminationGeneral Survey: Conscious, awake, not in cardiorespiratory distressVital Signs: BP 90/60mmHg HR 90bpm, regular RR 20cpm, regular T 36.7oC Length: 82.5cm (Z score above 0) Weight: 15kg (Z score above 0) BMI: 21.77Skin: Warm moist skin, no rashes, no jaundice, no active dermatosisHead: Normocephalic, pink palpebral conjunctiva, anicteric sclera, isochoric pupils, midline septum, no alar flaring, (+) nasoaural discharge, turbinates congested, no oral ulcers, moist buccal mucosa, non-hyperemic pharyngeal wall, tonsils not enlarged, no aural pits or tags, no tragal tenderness, nonhyperemic EAC, intact TM, AU

Physical Examination

Adynamic precordium, apex beat at 4th LICS, MCL, no lifts, no heaves, no thrills, S1>S2 at the apex, S2>S1 at the base, (-) S3, (-) murmurs

Supple neck, (+) cervical lymphadenopathy, trachea at midlineSymmetrical chest expansion, no barrel chest, no supraclavicular

retractions, clear breath sounds, (-) wheezes, (-) cracklesAbdomen flabby, no scars, normoactive bowel sounds,

tympanitic all over, no direct or rebound tenderness, no masses

Salient FeaturesSUBJECTIVE OBJECTIVE

1 year and 11 mos, FemaleExposure to relative with PTB disease at home(+) 2 week duration of intermittent low-grade fever (37.8°C), occurring at night time, not relieved by paracetamol (+) ___ colds, clear discharge

(+) cervical lymphadenopathy in R lateral aspect of neckPPD: 10mmCXR suggestive of Primary Koch’s infection

Approach to Diagnosis

Presenting Manifestation• (+) cervical lymphadenopathy

• 1x1cm movable, firm, non-tender over R lateral aspect of neck• 2 week history of cough and colds with intermittent low-grade fever

(37.8oC), occurring at night time• PPD test: 10mm• CXR PA and Lateral: NormalPE (+) nasoaural discharge, turbinates congested

History

• Key points we have to consider:– First, are there localizing symptoms or signs to suggest

infection or neoplasm in a specific site? – Second, are there constitutional symptoms such as

fever, weight loss, fatigue or night sweats to suggest disorders such as tuberculosis, lymphoma, collagen vascular diseases, unrecognized infection or malignancy?

– Third, are there epidemiologic clues such as occupational exposures, recent travel or high-risk behaviors that suggest specific disorders?

Physical examination

• When lymphadenopathy is localized, the clinician should examine the region drained by the nodes for evidence of infection, skin lesions or tumors

• Other nodal sites should also be carefully examined to exclude the possibility of generalized rather than localized lymphadenopathy

• Lymph node Characteristics:– Size– Pain/ Tenderness– Consistency– Matting – Location

Cervical Lymphadenopathy

• Common problem in children.

• Cervical nodes drain the tongue, external ear, parotid gland, and deeper structures of the neck, including the larynx, thyroid, and trachea.

• Adenopathy is most common in cervical nodes in children and is usually related to infectious etiologies.

Patient Lymphoma Group A Sreptococcal infections ( pharyngitis, otitis media, cellulitis, impetigo)

Infectious Mononucleosis

Mycobacterial

Clinical findings

2 weeks FeverColds

Fever, night sweats, weight loss in 20 to 30% of patients

Fever, sorethroat

Fatigue, malaise, fever, sorethroat

Fever/ cough > 2 weeksPoor weight gain

PE findings •movable, firm, non-tender R lateral aspect of neck•Congested nasal turbinates•Tonsils not enlarged

•Very firm, rubbery nodes

•Cervical nodes warm, erythematous, and tender•Pharyngeal exudates

•Firm tender nodes that are not warm or erythematous•Hepat osplenomegaly

•Painless, firm/matted cervical nodes

Primary Tuberculosis Infection

• Epidemiology: TB is endemic in the Philippines• The majority of children with tuberculosis

infection develop no signs or symptoms at any time.

• Non-specific signs & symptoms

Signs and Symptoms

• Cough of more than 2 weeks duration• Fever of more than 2 weeks duration • Painless cervical and/or other

lymphadenopathies• Poor weight gain• Failure to make a quick return to normal

health after infection• Failure to respond to appropriate antibiotics

Tuberculin Skin test

• Screening test of high risk individuals• Used to determine– Latent TB infection– Infected persons

• Measure of a person’s cellular immune responsiveness

Interpretation

• ≥ 5mm – Non BCG vaccinated– < 5 years old

• ≥ 10mm – BCG vaccinated– < 5 years old with positive exposure

• ≥ 15mm – > 5 years old with or without BCG

Assessment

• Pulmonary tuberculosis Disease

Diagnosis

• Skin tests• AFB Staining• Culture and sensitivity• Chest x-ray• Chest CT scan and MRI

Tuberculin Skin Test

• The recommended TST is the Mantoux test.• The dosage of 0.1 mL or 5 TU purified protein

derivative (PPD) should be injected intradermally into the volar aspect of the forearm using a 27-gauge needle.

• 48-72 hours after administration• measure the amount of induration and not

erythema

Tuberculin Skin Test

• Induration of 5 mm or more is considered a positive TST result in the following children:

• Children having close contact with known or suspected contagious cases of the disease, including those with household contacts with active tuberculosis whose treatment cannot be verified before exposure

• Children with immunosuppressive conditions (eg, HIV) or children who are on immunosuppressive medications

• Children who have an abnormal chest radiography finding consistent with active tuberculosis, previously active tuberculosis, or clinical evidence of the disease

Tuberculin Skin Test

Induration of 10 mm or more is considered a positive TST result in the following children: • Children who are at a higher risk of dissemination of tuberculous

disease, including those younger than 5 years or those who are immunosuppressed because of conditions such as lymphoma, Hodgkin disease, diabetes mellitus, and malnutrition

• Children with increased exposure to the disease, including those who are exposed to adults in high-risk categories (eg, homeless, HIV infected, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized persons); those who were born in or whose parents were born in high-prevalence areas of the world; and those with travel histories to high-prevalence areas of the world

Tuberculin Skin Test

• Induration of 15 mm or more is considered a positive TST result in children aged 5 years or older without any risk factors for the disease

AFB Staining

• staining of AFB provides preliminary confirmation of the diagnosis

• Staining can also give a quantitative assessment of the number of bacilli being excreted (eg, 1+, 2+, 3+).

Culture and Sensitivity

• Definitive diagnosis of tuberculosis depends on isolation of the organism from secretions or biopsy specimens.

• Culture of mycobacterium is the definitive method to detect bacilli

• Gastric aspirates are used in lieu of sputum in very young children (<6 y) who usually do not have a cough deep enough to produce sputum for analysis

Chest X-ray

• classic diagnostic tool when evaluating patients for pulmonary tuberculosis.

Radiologic findings:• Parenchymal involvement (acinar consolidation,

atelectasis)• Lymph node involvement ( hilar or paratracheal LN

enlargement)• Airway involvement ( hyperaeration, segmental

atelectasis, collapse)• Pleural involvement

CT scan and MRI

• not routinely indicated when chest radiography findings are unremarkable

• can help demonstrate hilar lymphadenopathy, endobronchial tuberculosis, pericardial invasion, and early cavitations or bronchiectasis.

First Line Anti-TB drugs

• Isoniazid(H)• Rifampicin(R)• Pyrazinamide(Z)• Streptomycin(S)• Ethambutol(E)

Treatment

• a 6-month course of isoniazid (INH) and rifampin, supplemented during the first 2 months with pyrazinamide.

• Because poor adherence to these regimens is a common cause of treatment failure, directly observed therapy (DOT) is recommended for treatment of tuberculosis.

Treatment

Treatment

Plans

• Prescribed with:– Isoniazid 200mg/5ml, 1.5 ml (5mg/kg/d) OD– Rifampicin 200mg/5ml, 3 ml (10mg/kg/d) OD– Pyrazinamide 250mg/5ml, 3.5 ml (15mg/kg/d) OD– Streptomycin 1g/2ml, 0.5 ml IM (22mg/kg/d) OD