tb anak
DESCRIPTION
paper tentang tuberculosis pd anakTRANSCRIPT
3/14/2013 1
CHILDHOOD TB
3/14/2013 2
Childhood TB
• Why neglected?
– Not considered important in global program or
contributing to immediate transmission
– Not regarded as public health risk
– Difficult to diagnose
• Why is it important?
– Health problem in children
– May later contribute to epidemic
Childhood TB as Sentinel Event
• Indicates recent transmission in a community
• Rapid progression from infection to disease
“A deterioration in the control of TB thus immediately hurts the youngest generation” (Rieder, 1997)
• Children are future reservoir of disease
Rieder H. Anales Nestle, 1997
Leading Infectious Disease
Causes of Death, 1998
0
1
2
3
4
ARI
AID
S
Dia
rrhe
aTB
Malar
ia
Mea
sles
De
ath
in
millio
ns
Under age 5
Over age 5
3.5
2.3 2.2 1.5
1.1 0.9
WHO Report 2000
700
600
500
400
300
200
100
0 <1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54
Age (years)
Per
100,0
00 p
op
ula
tio
n
Male
Female
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Transmission rate (Shaw ’54)
adult TB patient
AFB(+) AFB(-)
culture(+) culture(-) CXR (+)
65% 26% 17%
Risk of Progression to Disease
• Age
– 43% in infants (children < 1year)
– 25% in children aged one to five years
– 15% in adolescents
– 10% in adults
• Recent Infection
• Malnutrition
• Immunosuppression, particularly HIV
Miller, 1963
3/14/2013 9 Figure. Pathogenesis of primary tuberculosis
droplet nuclei inhalation
alveoli ingestion by PAM’S
intracellular replication of bacilli
destruction of bacilli destruction of PAM’S
Tubercle formation Hilar lymph nodes
hematogenic spread
multiple organs remote foci
Lymphogenic spread
disseminated primary TB
acute hematogenic spread
occult hematogenic spread
primary focus lymphangitis lymphadenitis
primary
complex
CMI
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Incubation period
• first implantation primary complex
• 4-6 weeks (2-12 weeks) incubation period
• first weeks: logaritmic growth, : 103-10
4
elicit cellular response
• end of incubation period:
– primary complex formation
– cell mediated immunity
– tuberculin sensitivity
PrimaryTB infection has established
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Tuberculin test
TB infection
cellular immunity
delayed type hypersensitivity
tuberculin reaction
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Tuberculin
Mantoux 0.1 ml PPD intermediate strength
location : volar lower arm
reading time : 48-72 h post injection
measurement : palpation, marked, measure
report : in millimeter, even ‘0 mm’
Induration diameter :
0 - 5 mm : negative
5 - 9 mm : doubt
> 10 mm : positive
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Mantoux
tuberculin
skin test
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TB classification (ATS/CDC modified)
Class Contact Infection Disease Manage
ment
0 - - - -
1 + - - proph I
2 + + - proph II?
3 + + + therapy
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tubercle formation resolution
primary focus
calcification
2nd lung lesions
caseation
liquefaction
granuloma
Pathology
remote foci reg lymph node
tuberculoma
cavity
milliary seed
erodes airway
compresses airway
rupt to pleura rupt to airway bronchiectasis
fibrosis
br pl fistula
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Clinical types of pediatric TB
• Infection: TST (+), clinical (-), radiographic (-)
• Disease: – Pulmonary:
• primary pulmonary TB
• milliary TB
• pleuritis TB
• progr primary pulm TB: pneumonia, endobr TB
– Extrapulmonary: • lymph nodes
• brain & meninges
• bone & joint
• gastrointestinal
• other organs
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Clinical manifestation
• vary, wide spectrum
• factors:
– TB bacilli: numbers, virulence
– host: age, immune state
• clinical manifestation
– general manifestation
– organ specific manifestation
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General manifestation
• chronic fever, subfebrile
• anorexia
• weight loss
• malnutrition
• malaise
• chronic recurrent cough, think asthma!
• chronic recurrent diarrhea
• others
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Fever of Onset
Tuberculin Test Positive
Primary pulmonary TB
TB Meningitis
Miliary TB
TB Pleural effusion
Osteo-articular TB
Renal TB
Ph
lycte
nu
lar c
on
jun
ctiv
itis
Ery
the
ma
no
do
su
m
2 – 3 months
3 – 12 months
6 – 24 months
> 5 years
Time after
primary infection Clinical Manifestation
Figure 5. The Timetable of Tuberculosis
Donald PR et.al. In: Madkour MM, ed. Tuberculosis. Berlin; Springer;2003.p.243-64
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Organ specific
• Respiratory : cough, wheezing, dyspnea
• Neurology : convulsion, neck stiffness,
SOL manifestation
• Orthopedic : gibbus, crippled
• Lymph node : enlarge, scrofuloderma
• Gastrointestinal: chronic diarrhea
• Others
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Imaging diagnostic
• routine : chest X ray
• on indication : bone, joint, abdomen
• majority of CXR non suggestive TB
• pitfall in TB diagnostic
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Radiographic picture
• primary complex: lymph node enlargement
• milliary
• atelectasis
• cavity
• tuberculoma
• pneumonia
• air trapping - hyperinflation
• pleural effusion
• honeycombs – bronchiectasis
• calcification, fibrosis
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100
32
0
20
40
60
80
100
Diagnosed by X-
ray alone
Actual cases
Over diagnosis TB by CXR
Over- diagnosis
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The main problems
• Diagnosis – Clinical manifestations : not specific
both over/under diagnosis & over/under treatment
– diagnostic specimen : difficult to obtain
– No other definitive diagnostic tools
– TB infection or TB disease ? no diagnostic tool to distinguish
• Adherence / compliance – Drug discontinuation treatment failure
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Clinical setting management
Suspect TB
proveTB infection
Mantoux test
positive negative
not TB
Seek other etiologies
completed: Ro, lab Diagnosis TB
treatment
3/14/2013 26
Diagnosis of TB in children
• If you find the diagnosis of TB in children easy, you probably overdiagnosing TB
• If you find the diagnosis of TB in children difficult, you are not alone
• It is easy to over-diagnose TB in children
• It is also easy to miss TB in children
• Carefully assess all the evidence, before making the diagnosis
Anthony Harries & Dermot Maher, 1997
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Proposed IDAI scoring system
Feature 0 1 2 3 Score
Contact not clear reported, AFB(-)
- AFB(+)
TST - - - positive
BW (KMS) - <red line, BW
severe malnutrition
-
Fever - unexplained - -
Cough <3weeks >3weeks - -
Node enlargemnt
- >1 node, >1cm,painless
- -
Bone,joint - swelling - -
CXR normal sugestive - -
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Objectives of treatment
• Rapid reduction of the number
of bacilli
• Preventing acquired drug
resistance
• Sterilization to prevent relapses
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Treatment principles
Drug combination, not single drug
Two phases :
Initial phase (2 months) – intensive,
bactericidal effect
Maintenance phase (4 months / more)
– ‘sterilizing’ effect, prevent relaps
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Smear +
Culture +
Smear -
Culture +
Smear -
Culture -
108
107
106
105
104
103
102
101
100
Start of treatment
(isoniazid alone) Weeks of treatment
0 3 6 9 12 15 18 WHO 78351
Sensitive organisms Resistant organisms
Nu
mb
er
of
bacil
li p
er
ml o
f sp
utu
m
Toman K, Tuberculosis, WHO, 1979
The ‘fall and rise’ phenomenon
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Treatment principles
Long duration problem of
adherence (compliance)
Other aspects :
Nutrition improvement
prevent / search & treat other disease
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Hypothetical model of TB therapy
A
B
C
Bacteridal activity & ‘sterilizing’ effect
0 1 2 3 4 5 6
Pop A = rapidly multiplying (caseum)
Pop B = slowly multiplying (acidic)
Pop C = sporadically multiplying
Months of therapy
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Drug activities upon TB pop
TB Population
Multiplying rate
Drug
activities
A rapidly INH>>SM>
RIF>EMB
B slowly PZA>>RIF>>
INH
C sporadically RIF>>INH
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TB therapy regimen
2 mo 6 mo 9 mo 12mo
INH
RIF
PZA
EMB
SM
PRED
DOT.S !
3/14/2013 35
Treatment evaluation
• Clear improvement in clinical and supporting examination, especially in the first 2 month
• Main : clinical
• supporting exam as adjuvant
3/14/2013 36
DOTS with a SMILE
S : Supervised
M : Medication
I : In
L : a Loving
E : Environment (Grange JM, Int J Tuberc Lung Dis 1999; 3:360-
362)
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Trace
Child TB patient
Adult TB patient
centri- petal
centri- fugal
3/14/2013 38
case finding
centripetal
• trace the source
• adult people
• close contact
• by chest X ray
centrifugal
• trace other ‘victims’
• children
• close contact
• by tuberculin
3/14/2013 39
Kemoprofilaksis primer
• Mencegah infeksi
• Anak kontak dengan pasien TB aktif, tetapi
belum terinfeksi (uji tuberkulin negatif)
• Obat : INH 5 - 10 mg/kg BB/hari
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Kemoprofilaksis sekunder
Mencegah penyakit TB pada anak yang
terinfeksi :
1. Mantoux (+), Rö (-), klinis (-) : • Umur < 5 th
• Kortikosteroid lama
• Limfoma, Hodgkin, lekemi
• Morbili, pertusis
• Akil baliq
2. Konversi Mt (-) menjadi (+) dalam 12 bl, Rö (-),
klinis (-)
Obat INH 5 - 10 mg/kg BB/hari
3/14/2013 41
Question
pls?