Asma bronkial + TB kasus anak

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7/5/12

Case presentation

Asthma and Tuberculosis

By:Jessieca Liusen

Lecturer:dr. Dahnul Elymbra,SpA


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TUBERCULOSIS

Definition:

Direct communicable disease caused byMycobacterium tuberculosis

Epidemiology TB in Indonesia

3rd highest score of the world 250.000 new

case and 140.000 die because of it.

1st killer among the communicable disease

3rd killer among other disease after heart

disease and acute respiratory distress


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Tuberculosis

Risk factor:

Contact with TB patients

Young age

Had HIV

Severe malnutrition


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Pathophysiology

Droplet nuclei inhalation alveolus

TB phagocyted by macrofrag

Replicated inside macrofag Form a colony Gohn complex

Gohn complex would become:

Restitution ad integrum

Cure with a scar such as fibrotic

Spread : perkontinuitatum, bronchogenic,

hematogenic, and lymphogenic


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Pathophysiology

Wallgren divided 3 type of TB inchildren:

Limphohematogenic spread

Endobronchial TB

Chronic pulmonary TB


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AnamnesisPhysical

Examination

FurtherInvestigationDiagnosis


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Ten Poin to suggest TBin children Contact to TB (+) BTA patients

Tuberculin test positive > 10 mm

Thorax rontgen suggestive for TB Eritema in 3-7 days after BCG

immunization

Cough > 3 weeks Prolong fever with unknown cause

Body weight decreased without any

clear cause or didnt get weight gain in 1


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TBNot TB

3 dari 1oitem

Suggested TB

Gave OAT for 2months and

observed

Improved Deteriorated/constant

Drugresistant TB

Reconciliate

to hospital


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Scoring to diagnosis of TB inchildrenParameter 0 1 2 3 skor

Contact to TB patients - (+) contact tonegative or

unknown BTA

patients

(+) contact topositive BTA

patients

Tuberculin test Negative Positive 10mm

or 5mm in

immunosupresivepatients

Nutrition Mild malnutrition Severe

malnutrition

Fever with unknown cause 2 weeks

Cough 3 weeks

Limphadenopati coli,

axilla, inguinal

1cm, 1 lymph

node, no pain

Swelling on bone, coxae,

phalangs

+

Thorax rontgen Normal Suggestive TB


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Diagnosis Tuberculosis

Score 6 TB

Score = 5 admitted to hospital tofurther investigate

Tuberculin test positive:

Natural TB infection

Laten TB

TB infected and suffered TB

Cured TB

BCG immunization

M cobacterium ati ic infection


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Tuberculin Test Negative

No infection for TB

Incubation period of TB

Anergy


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Score 6

Gave OAT

For 2 months and evaluate

(+) response continued

theraphy

(-) response continued

theraphy and searched for theexact cause


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Anti tuberculosis agent

1st 2 months: intensive phase

3 kinds of drugs

Rifampicin

Isoniazid

Pyrazinamide

2nd 4 months: next phase2 kinds of drugs

Rifampicin

Isoniazid


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Drug Dosage

Name Dosage Maximal dosage

Isoniazid 5-15 mg/kgBW/ day 300 mg/day

Rifampicin 10-20 mg/kgBW/day 600 mg/day

Pyrazinamid 15-30 mg/kgBW/day 2000 mg/day

Etambuthol 15-20 mg/kgBW/day 1250 mg/day

Streptomicin 15-40 mg/kgBW/day 1000 mg/day


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Follow Up

After 2 months got drugs improveclinical, weight gain, no fever, decreasecough continued theraphy


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Asthma

Definition:

Chronic inflammation with reversiblerespiratory tracts constriction

Epidemiology

Prevalence of the world 7,2% (6% for adultand 10% for children)


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Risk factor

Gender:

Male: female ratio: 3:2 for 6-11 years old

Male female ratio: 8:5 for 12-17 years old

Age

Young age persistent asthma

Atopic Environment

Race

Smoke


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Pathophysiology

Allergen respiratory tractsinflammation

Released inflammation mediators

Bronchoconstriction

Hiperventilation + additional respiratorymuscles contraction

Cough

Cough +


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Cough +wheezingHistory

Physical exTuberculin test

Suggest asthma:EpisodicNocurnal/ morning drip

After exerciseAtopic

Imprecise asthma:Start at neonateFailure to thriveChronic infectionVomit/ chokingPulmonary focal disorderCardiovascular system disorder

No facility, Check peak flowmeter or spirometer:

Revercibility 15%Variability 15%

Hiperreactivity 20%

Consider:Thorax and sinus rontgenPulmonal physiology testBronchodilator response testBronchus provocation testSweat testCilia motility testEsofagogaster reflux evaluation

Gave bronchodilator

ASTHMA

Grading and seacrhed forprecipitateIf episodic frequent/persistent: rontgen thorax

Gave anti asthma drug:Unsuccefully reevaluatediagnosis and loyalty

Didnt support other diagnosis Support other diagnosis

Diagnosis and treatmentaccording to working diagnosis

Consider asthma asparticipating disease NOT ASTHMA

Al it S A


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Algoritme Serangan Asma

Klinik / IGD

Nilai Derajat Serangan

Tata Laksana Awal Nebulisasi -agonis 3x, selang 20

Nebulisasi ke-3 + antikolinergik

Serangan Ringan(nebulisasi 1x,respons baik

bertahan 1-2 jam,boleh pulang gejala timbul lagiserangan sedang

Serangan sedang (nebulisasi 2-3x,

repons parsial) berikan O2

nilai ulang se-dang RuangRawat Sehari

pasang infus

Serangan berat(nebulisasi 3x,

respons buruk)O2 sejak awal pasang infus nilai ulang berat,Ruang Rawat Inap

foto Ro toraks


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Ruang RawatSehariOksigen teruskan Steroid oral Nebulisasi / 2 jam 8-12 jam klinisstabil boleh pulang 12 jam tetap belumbaik rawat inap

Ruang Rawat InapOksigen teruskan Atasi dehidrasi &

asidosis jika ada Steroid IV tiap

6-8 jam Nebulisasi/1-2 jam Aminofilin IV awal,

lanjutkan rumatan Nebulisasi 4-6x

baik, interval 4-6 j 24 jam stabil boleh pulang Dengan steroid &

aminofilin IV tetaptidak baik ICU

Boleh PulangBekali -agonis(hirupan / oral)

Jika ada obat pengendali,teruskan Inf.virus (+),steroid oral

24-48 jam kontrolproevaluasi

Catatan:Jika menurut penilaian serangannya berat, nebulisasi 1x,

langsung -agonis + antikolinergik Bila belum ada alatnya, nebulisasi awal dapat diganti dgnadrenalin sk. 0,01 ml/kgBB/kali, maksimal 0,3 ml/kali.

Untuk serangan sedang dan terutama berat, O2 2-4L/mntdiberikan sejak awal, termasuk saat nebulisasi


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Obat pereda: -agonis atau teofilin (hirupanatau oral) bila perlu

Tambahkan obat pengendali:

steroid hirupan dosis rendah

Pertimbangkan alternatif penambahansalah satu obat:- -agonis kerja panjang (LABA)- Teofilin lepas lambat- AntileukotrienAtau dosis steroid hirupan ditingkatkan(medium)

Steroid dosis medium ditambahkan salah

satu obat:- -agonis kerja panjang- Teofilin lepas lambat- Antileukotrien- Atau dosis steroid hirupan ditingkatkan

(tinggi)

Obat diganti steroid oral

Asma Episodik Jarang

4 6 minggu > 3x dosis/minggu

3x dosis/minggu

6-8 minggu, respons :

Asma Episodik Sering

(-) (+)

(-) (+)

(-) (+)



Asma Persisten

PE

NGHINDARAN


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Case


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Patient Identity

Name : Chd. D

Age : 1 year 9 months old

Parent : Sudadi/ Rina Tribe : Javanese

Address : Perawang

Admitted: 24 August 2011


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Anamnesis

Chief complain

Dispnea that became deteriorate since 2months before admittion


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Present Illness History

Since 2 months before admittion

Dispnea on the effort, if he took rest, itbecame well

Productive cough happened at the same timewith dispnea

Fever with unknown cause, not too high, andusually became higher at night.

Patient got drugs from pediatric policlinicat RSUD AA


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Present Illness History

He can drank mothers milk

No history of vomitting, choking

As long as dispnea happened, his skinnever became blue.

No weight loss since last 2 months


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Anamnesis

Past Illness History

Family Illness History

Parent Illness History Gestation history

Diet history

Immunization Physical growth

Mental growth

House and environment


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Physical Examination

General condition: moderate illness

Consciousness: composmentis

Vital signBP: 100/60 mmHg

Temp : 36,80C

HR : 122x/minutes

RR : 46x/minutes


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Nutrition: 92% normal

Body height: 78 cm

Body weight: 10 kg

Upper arm circumference: 15 cm

Head circumference: 47 cm(normocephali)


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Skin: normally

Head: normocephali, anterior fontanelalready closed

Hair: black, not easy to put off

Eye:

Conjunctiva: normally

Sclera: normally

Pupils: isochor, 2 mm

Pupil reflex : +/+


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Ears: normally

Nose: normally

Lips: moist Mucosa : moist, red

Palatum: normally

Tongue: normally Teeth: normally

Neck: lymph node (-), stiffness (-)


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Thorax

Inspection: simetrical movement of thoraxwall

Palpation: fremitus right and left same

Percussion: resonance, head alignmentnormally

Auscultation: wheezing


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Abdomen

Inspection: flat

Palpation: flexible, no tenderness,

hepatosplenomegaly (-)

Percussion: tymphani

Auscultation: bowel sound (+) at normal rate


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Genitalia: male

Extremity: warm, red, CRT < 2 seconds


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Laboratory

Hb : 9,9 g/dL

Ht : 30,2 %

Leukosit: 12600/uL Platelet : 594000/uL

LED : 50mm/jam

Diff count:Neutrophil: 37%

Lymphocite: 53%

Monocyte: 9,1%


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Working Diagnosis

Asthma and pulmonary TB


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Treatment

IVFD KAEN1B 20 gtt

Kalmetason injection 1/3 amp

1st 2 months:

Rifampicin 150 mg 1x1

Pyrazinamid 200 mg 1x1Isoniazid 200 mg 1x1

Vitamin B6 5 mg 1x1

High calory and protein diet


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PROGNOSIS

Quo ad vitam : bonam

Quo ad fungsionam : bonam


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Tanggal Subjektif Objektif Assestment Terapi

24/8/11 Sesak napas (+),

batuk (+)

T: 36,90C

N: 124x/menit

R: 50x/menit

Asma dan Susp

TB paru

IVFD KAEN1B 20 tpm

Inj kalmetason 1/3 amp

Foto thorax AP

25/8/11 Sesak napas (-),

batuk (+)

T: 37,10C

N: 121x/menit

R: 46x/menit

Asma dan TB

paru

IVFD KAEN1B dan

Inj kalmetason off

Foto thorax AP: KP duplex

Rawat jalan

Rifampisin 150 mg

Pirazinamid 200 mg

Isoniazid 200 mg

Vit B6 5 mg


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Case Analysis

Dispnea became worst since 2 monthsbefore admittion

Asthma

Pneumonia

Bronchiolitis

Congenital heard disease

Corpus alienum aspiration

Pulmonary TB


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Case Analysis

Precipitation factor: activity

Happened at same time with cough

Fever since 2 months

Asthma

Pneumonia Bronchiolitis

TB pulmonary


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Patient ate and drank as usual

No blue history when dispnea occurred

It wasnt congenital heard disease orpneumonia


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No weight loss since last 2 months didnt mean that it wasnt TB

Positive family history for asthma uncle

Complete history of immunization mantoux test became false positive


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Scoring to diagnosis of TB inchildrenParameter 0 1 2 3 skor

Contact to TB patients - (+) contact to

negative or

unknown BTA

patients

(+) contact to

positive BTA

patients

2

Tuberculin test Negative Positive 10mm

or 5mm in

immunosupresive

patients

0

Nutrition Mild malnutrition Severe

malnutrition

0

Fever with unknown cause 2 weeks 1

Cough 3 weeks 1

Limphadenopati coli,

axilla, inguinal

1cm, 1 lymph

node, no pain

0

Swelling on bone, coxae,

phalangs

+ 0

Thorax rontgen Normal Suggestive TB 1

Ten Poin to s ggest TB


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Ten Poin to suggest TBin children Contact to TB (+) BTA patients

Tuberculin test positive > 10 mm

Thorax rontgen suggestive for TB

Eritema in 3-7 days after BCGimmunization

Cough > 3 weeks Prolong fever with unknown cause

Body weight decreased without any

clear cause or didnt get weight gain in 1


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Analysis

More than 3 poins suggest TB gave antituberculosis agent

Cough +wheezing


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HistoryPhysical ex

Tuberculin test

Suggest asthma:EpisodicNocurnal/ morning dripAfter exerciseAtopic

Imprecise asthma:Start at neonateFailure to thriveChronic infectionVomit/ chokingPulmonary focal disorderCardiovascular system disorder

No facility, Check peak flowmeter or spirometer:

Revercibility 15%Variability 15%

Hiperreactivity 20%

Consider:Thorax and sinus rontgenPulmonal physiology testBronchodilator response testBronchus provocation testSweat testCilia motility testEsofagogaster reflux evaluation

Gave bronchodilator

ASTHMA

Grading and seacrhed forprecipitateIf episodic frequent/persistent: rontgen thorax

Gave anti asthma drug:Unsuccefully reevaluatediagnosis and loyalty

Didnt support other diagnosis Support other diagnosis

Diagnosis and treatmentaccording to working diagnosis

Consider asthma asparticipating disease NOT ASTHMA

Asthma Treatment for


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Asthma Treatment forthe patient Kalmetason/ dexametason intravena 1/3

amp = 1,3 mg a day

Steroid bolus dosage : 0,5-1

mg/kgBW/day.


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Antituberculosis Agent

Rifampicin 150 mg 1x1, dosage 15mg/kgBW/day

Pyrazinamid 200 mg 1x1, dosage 20

mg/kgBW/day Isoniazid 200 mg 1x1, dosage 20

mg/kgBW/day

Vitamin B6 5 mg 1x1


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Thank You

Asma bronkial + TB kasus anak

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