Case report pp

CASE REPORT: TUBERCULOSIS WITH SEVERE MALNUTRITION

Presenter: Dinesha Paniselvam

Tay Chiu Mei

Supervisor: dr. H.Hakimi, Sp.A(K)

Definition

Tuberculosis is a disease due to Mycobacterium tuberculosis infection with systemic spread thus can affect almost all organs, and the most frequent site is in the lung, which usually as the site of primary infection

Etiology:Mycobacterium tuberculosis

Factors in acquiring Tb infection

Host immune

state

Exposure duration

Doses / numbers Virulence

Concentration in the air

12/18/12 7

Droplet nuclei inhalation Alveoli

Ingestion by PAM’S

Intracellular replicat ionof bacil l i

Destruction of bacil l iDestruction 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 lymphangit is lymphadenit is

Primary complex

CMI

Pathogenesis of primary tuberculosis

Specific Manifestation

Systemic Manifestation

IDAI Pediatric TB scoring system

10

Notes for IDAI scoring systemDiagnosis: total score ≥6 (by doctor)BW at presentFever & cough no respons to standard txCXR is NOT a main diagnostic tool Accelerated BCG reaction: evaluated <5 y.o: Score 5 or strong suspicion referINH prophylaxis: score <6 with contact (+)

11

Mantoux 0.1 ml PPD intermediate strength

- Location : volar lower arm

- Reading time: 48-72 h post injection

-Induration diameter : 0 - 5 mm : negative 5 - 9 mm : doubt > 10 mm : positive

Objectives of

treatment

Sterilization to prevent relapses

Rapid reduction of the number

of bacilli

Preventing acquired

drug resistance

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

12/18/12 14

12/18/12 15

DrugsDaily dose

(mg/Kg/day) Adverse reactions2 Time/week

dose(mg/Kg/dose))

Isoniazid(INH)

5-15(300 mg))

Hepatitis, peripheral neuritis,hypersensitivity

15-40(900 mg))

Rifampicin(RIF)

10-15(600 mg))

Gastrointestinal upset,skin reaction, hepatitis, thrombocytopenia,

hepatic enzymes, including orangediscolouraution of secretions

10-20(600 mg)

Pyrazinamide(PZA)

15 - 40(2 g)

Hepatotoxicity, hyperuricamia,arthralgia, gastrointestinal upset

50-70(4 g)

Ethambutol(EMB)

15-25(1,5 g)

Optic neuritis, decreased visualacuity, decreased red-green colour

discrimination, hypersensitivity,gastrointestinal upset

50(1,5 g)

Streptomycin(SM)

15 - 40(1 g)

Ototoxicity nephrotoxicity25-40(1,5 g)

When INH and RIF are used concurrently, the daily doses of the drugs are reduced

National consensus of tuberculosis in children, 2001

Dosage of antituberculosis drug

Systems for assessing the severity of malnutrition in underweight children

18

Method Mild Moderate Severe

Weight for age ≥90 % 75 to 89 % 60 to 74 % <60 %

Weight for height ≥90 % 80 to 89 % 70 to 79 % <70 %

Height for age ≥95 % 90 to 94 % 85 to 89 % <85 %

Weight/height for age ≥90 % 85 to 89 % 75 to 84 % <75 %

Marasmus KwashiorkorAbsence of edemaInadequate intake of protein

and calories

Presence of edema Fair-to-normal calorie intake

with inadequate protein intake

19

A combination of both, kwashiorkor and marasmus. Signs and symptomps of marasmus could be found coincidently with kwashiorkor. The child look very thin with bones and ribs could be inspected very prominently, with mild edema found minimally, particularly in the lower extremities.

Marasmus-Kwashiorkor

No Treatment

Stabilization Transition Rehabilitation Follow Up

Day

1-2

Day

3-7Week 2

Week

3-6

Week

7-26

1 Hypoglycemia ̸

2 Hypothermia ̸

3 Dehydration ̸

4 Electrolyte Correction ̸ ̸ ̸

5 Treatment of Infection ̸ ̸ ̸

6 Micronutrition Defficiency

Correction

Without Iron

Supple-menta-

tion

Without Iron

Supplementa-

tion

Without Iron Supplementation

With Iron Supplementation

With Iron

Supplement-

ation

7Initial Refeeding

Formula

75

Formula 75Formula 75 to 100

8 Correctional Refeeding

(Catch Up Growth)

Formula 100 Formula 100

9 Stimulation ̸ ̸ ̸ ̸ ̸

10 Prepare for Discharge ̸ ̸

MANAGEMENT OF SEVERE MALNUTRITION

20

12/18/12 21

TB

TB AND MALNUTRITION

Metabolic rate / resting rate increased

Increased energy needs to meet the basic

demands for body function

Energy intakes are decreased

Presence of pro-inflammatory

cytokines

Util ization of amino acids & protein synthesis

MALNUTRITON

The cell mediated immunity response

is impaired

CASE REPORT

Loss of body weight since 1 year ago. According to her parents, the patient’s highest body weight was 25kg (October 2010) and it’s decreasing for the past 1 year with drastic weight loss (± 10kg) for the past 4 months.

Decreased of appetite was found since 6 months ago.

Fever was found since 2 year ago. The characteristic of the fever : intermittent and low grade fever; decrease temporarily with consumption of paracetamol. History of intermittent fever was found since the patient was 9 years old.

The patient was coughing for the past 2 years, Phlegm (+), white in color, bloody(-). History of contact with a tubercular patient/prolonged coughing adult was found.

Lesions were found on patients right neck which was noted by the patient’s family 1 year ago. 2 small noduls with 1,5cm, ᴓInitially, the lesion started as papules that progressed to nodules and pustules. 2 months ago, there was discharge from the lesion. The discharge from the lesion was serous, bloody(-) and its painless.

Distention of the patients’s stomach was realized by patient’s mother since 6 months ago. History of diarrhea (+), vomiting(-), loss of concentration for the past 2 days.Normal mictuation and defecation.

History of feeding : 0 to 4 mth : Breast milk4 mths- 1 year: Breast milk + Porridge1 year till now : Normal meals

Physical Examination

Head• Face: old man face (+)• Eyes: Light reflex +/+, isochoric pupil,conjunctiva palpebra inferior

pale (+/+)• Nose: Nasal flare (-) Mouth: Paleness of mucous (-), cyanosis (-) Ears :

Secrete (-)

Neck

Thorax

Abdomen

Extremities

Genitalia

• Lymph node enlargement (-), Scrofuloderma (+) on regio colli dextra,( 2 noduls with serous discharge ± 1.5cm)ᴓ , JVP: R-2 cm H2O

• Symmetrical fusiform, retraction (-), intercostal ribs can be seen clearly.HR: 96 bpm regular, murmur (-) RR: 20 tpm regular, rales (-)

• Ascites (+),Shifting dullness (+),Double sound(+), Normal peristaltic• Liver and spleen was not palpable

• Pulse 96 bpm regular, adequate pressure and volume, warm acral, CRT < 3’, BP: 100/60 mmHg, clubbing fingers (-), cyanotic (-),

pale(+) Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+)• Normal physiology reflex, Pathologic reflexes (-)

• Female, within normal limit

Old man face

Thin subcutaneous fats

Stomach distended

Hypotrophy muscle

Intercostal ribs can be seen clearly

Dried scrofuloderma lesions

Complete Blood Count Results Normal Value

Hemoglobin (Hb) 6,50 g% 11.3-14.1g %

Erytrocyte (RBC) 3,18 x106/mm3 4.40– 4,48 x106/mm3

Leukocyte (WBC) 8.31 x 103/mm3 4.5-13.5x103/mm3

Hematocrite 23,280 % 37 – 41 %

Trombocyte (PLT) 236 103/mm3 150 – 450 x103/mm3

MCV 73,10 fl 81 – 95 fL

MCH 20,40 pg 25 – 29 pg

GLUCOSE Ad Random

Blood glucose 89 mg/dl <200 mg/dl

ELECTROLITE

Natrium 131 135 - 155

Kalium 3,5mEq/L 3,6 - 5,5

Klorida 10 mEq/L 96 - 106

Laboratory Findings: (Adam Malik General Hospital: 31/10/2011)

28

Working Diagnosis: Pulmonary Tuberculosis + Scrofuloderma with Severe

malnuturion marasmic-kwashiorkor type

RADIOLOGY

Interpretation of the chest X-Ray:

CTR < 50%, Aorta and pulmonal segment is not elongated. Infiltration can be seen on

whole lung field.

Results: Bronchopneumonia,

DD: - active specific process

Interpretation of the abdominal photo :

Homogenous consolidation can be seen on the abdominal space which enforces air from intestines towards central. Results:

Ascites

Date 1 November 2011S Fever (-), Abdomen distended (+)O

Head

Neck

Thorax

Abdomen

Extremities

Sens :Alert, T:37,30C, BW:15kg, BL: 130 cm, BW/BL: 55.55% LLT:57cm LLD:54cm

Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conjunctiva inferior palpebra (+/+), icteric sclera(-/-). Ear/Nose/Mouth : within normal limit

Lymph nodes enlargement(-)Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O

Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.

Distented(+), Ascites(+), Shifting dullness(+),Double sound(+), normal peristaltic. Liver and spleen: not palpated.

Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+),Normal physiology reflex: APR/KPR (+) ,Pathologic reflexes (-)

A Pulmonary Tuberculosis + Scrofuloderma with Severe malnuturion marasmic-kwashiorkor type

P - O2 1-2L per minute (if needed)- IVFD D5% NaCl 0.45% 4gtt/min -Isoniazid 1 x 150 mg- Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1x5 mg 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral

Further evaluation

- Consult to Metabolic & Nutrition Division- Consult to Pediatric Respirology :•Mantoux test (at 1400 WIB, Interpretation on 3/11/2011)- Gaster lavage- BTA culture ( 3 days continuously)- Scrofuloderma lesion culture

D1

Date 2 November 2011

S Fever (-), Abdomen distended (+)

O

Head

Neck

Thorax

Abdomen

Extremities

Sens :Alert, T:37,30C, BW:15kg, BL: 130 cm, BW/BL: 55.55% LLT:57cm LLD:52cm Face: Old man face (+) Eye: Light reflexes (+),isochoric pupil (R=L), paleness of conjunctiva inferior palpebra (+/+), icteric sclera(-/-) Ear/Nose/Mouth : within normal limit

Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O


Distented(+), Ascites(+), Shifting dullness (+),Double sound(+),normal peristaltic Liver and spleen: not palpated.

Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+), Pathologic reflexes (-)

A Pulmonary Tuberculosis + Scrofuloderma with Severe malnuturion marasmic-kwashiorkor type

P - O2 1-2L per minute (if needed) - IVFD D5% NaCl 0.45% 4gtt/min -Isoniazid 1 x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1x1 mg - Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral

Further evaluation

- Gaster lavage - BTA culture ( 3 days continuously) - Scrofuloderma lesion culture

D2Consultation from Dermatology: Lesions were found on patients dextra colli region which was noted by the patient’s family 1 year ago. 2 small noduls with ᴓ1,5cm, Initially, the lesion started as papules that progressed to nodules and pustules. 2 months ago, there was discharge from the lesion. The discharge from the lesion was serous, bloody(-) and its painless.Diagnose: ScrofulodermaTherapy: Compress with Nacl 0,9% for 15 menits every 4 hours and apply Gentamicin cream 2x/day.

Date 3 November 2011 4 November 2011

S Fever (-), Abdomen distended (+) Fever (-), Abdomen distended (+)

O Head Neck Thorax Abdomen Extremities

Sens :Alert, T:37,30C, BW:16kg, BL: 130 cm, BW/BL: 55.57% Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.57%

Face: Old man face (+) Eye: Light reflex (+), isochoric pupil (Right=Left), paleness of conj. inf. palpebra (+/+), icteric sclera(-). Ear/Nose/Mouth:within normal limit

Face: Old man face (+) Eye: Light reflex (+), isochoric pupil (R=L), paleness of conj. inf. palpebra (+/+), icteric sclera(-). Ear/Nose/Mouth: within normal limit





Distented(+),normal peristaltic,Ascites(+), Shifting dullness (+),Double sound(+) Liver and spleen: not palpated.

Distented(+),normal peristaltic, Ascites(+), Shifting dullness (+),Double sound(+), Liver and spleen: not palpated.

Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+ )

Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+)

A Pulmonary Tuberculosis + Scrofuloderma with severe malnutrition marasmic-

kwashiorkor type Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type

P - O2 1-2L per minute (if needed) - IVFD D5% NaCl 0.45% 4gtt/min aff- Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg- Pyrazinamid 1 x 450 mg -Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Vitamin A 1 x 200.000 IU - Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral - Compress the lesion with NaCl 0,9% for 15 menits every 4 hours. - Gentamicin cream 2x/day

- O2 1-2L per minute (if needed)- Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral - Compress the lesion with NaCl 0,9% for 15 menits every 4 hours. - Gentamicin cream 2x/day

Further evaluation

Mantoux test Results : Negative Laboratorium Result: Liver: - Total Bilirubin : 0,93mg/dL - Direct Bilirubin : 0,78mg/dL - Alkaline Phosphate(ALP) : 142U/L - AST/SGOT : 28 U/L - ALT/SGPT : 15 U/L - Albumin : 1,0 g/dL Albumin needed=(3,5-1,0) x 16x 0,8=32g Plasbumin 25% = 32/25x 100 = 128 cc Plasbumin 20% = 32/20x 100 = 160 cc

- Gaster lavage - BTA culture ( 3 days continuously) - Scrofuloderma lesion culture

D 4D 3

Consultation from Gastroenterology: - Albumin correction and re-check albumin level after correction - Albumin Correction:150cc of Plasbumin 20%

BW:16 kg BW/BH: 55.57%Treatment:

- IVFD D5% NaCl 0.45% 4gtt/min aff- Vitamin A 1 x 200.000 IU (1 day)

Mantoux test Results : Negative Laboratorium Result: Albumin 1,0 g/dL

Date 5-6 November 2011 7 November 2011S Abdomen distended (+) Abdomen distended(+) O

Head Neck Thorax

Abdomen Extremity

Sens :Alert, T:36,80C, BW:16kg, BL: 130 cm, BW/BL: 55.57% Sens :Alert, T:37,50C, BW:16,5kg, BL: 130 cm, BW/BL: 55.6% Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inferior palpebra (+/+),icteric sclera(-/-). Ear/Nose/Mouth :within normal limit

Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conj.inferior palpebra(+/+),icteric sclera (-/-) Ear/Nose/Mouth : within normal limit


Lymph nodes enlargement(-) Dried lesion can be seen on the right neck, JVP: R-2 cm H2O



Distented(+), Ascites(+), Shifting dullness (+),Double sound(+), normal peristaltic. Liver and spleen: not palpated.

Distented(+), Ascites(+), Shifting dullness (+),Double sound(+), normal peristaltic. Liver and spleen: not palpated.

Pulse:120bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+) Pathologic reflexes( -)

Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/ KPR (+) Pathologic reflexes (-)

A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type

Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type

P - O2 1-2L per minute (if needed)-Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral (D1),(D2)- Gentamicin cream 2x/day

- O2 1-2L per minute (if needed)-Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg -Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Vitamin B6 1 x 20 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II- F100 diet 240cc/3hrs/oral (D3)- Gentamicin cream 2x/day

Further evaluation

-Albumin Correction: 50 cc of Plasbumin 0% (05/11/2011; 1750 WIB)-Waiting for the results of gaster lavage, BTA culture and Scrofuloderma lesion cultureLaboratorium Result: - Albumin : 2,0 g/dLAlbumin needed=(3,5-2) x 16x 0,8 ≈20gPlasbumin 25% = 20/25 x 100 = 80 cc Plasbumin 20% = 20/20 x 100 = 100 cc

- Waiting for the results of gaster lavage, BTA culture and Scrofuloderma lesion cultureAlbumin Correction:100cc of Plasbumin 20%

D5,6 D7

- F100 diet 240cc/3hrs/oral-Albumin Correction: 50 cc of Plasbumin 20% Laboratorium Result: - Albumin : 2,0 g/dL

-BW:16,5kg, BL: 130 cm, BW/BL: 55.6%

- Dried lesion can be seen on the right neck,

- F100 diet 240cc/3hrs/oral- Albumin Correction: 50 cc of Plasbumin 20% Laboratorium Result: - Albumin : 2,0 g/dLAlbumin Correction: 100cc of Plasbumin 20%

Date 8-10 November 2011 11 November 2011S Abdomen distended (reduced) Fever (-), Diarrhea (6x/day)O

Head

Neck

Thorax

Abdomen

Extremities

Sens :Alert, T:36,80C, BW:18kg, BL: 130 cm, BW/BL: 55.57% LLT:55cm LLD:52cm Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.55%

Face: Old man face (+) Eye: Light reflexes (+),isochoric pupil (R=L) paleness of conjunctiva inferior palpebra (+/+), Ear/Nose/Mouth : within normal limit

Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conjunctiva inferior palpebra (+/+). Ear/Nose/Mouth : within normal limit

Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R-2 cm H2O




Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and spleen: not palpated.

Distension(+),ascites(+), shifting dullness (+) normal peristaltic, Liver and spleen: not palpated

Pulse: 136 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+). Pathologic reflexes (-)

Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+).Pathologic reflexes (-)

A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- kwashiorkor type


P - O2 1-2L per minute (if needed) - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Vitamin B6 1 x 20 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day Meropenem Inj. 300 mg/8hr/iv (starting on 09/11/2011)

- O2 1-2L per minute (if needed) - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Vitamin B6 1 x 20 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day - Meropenem Inj. 300 mg/8hr/iv (D 3) -Lacto B 3 x 1 sachet -Resomal 100cc/xdiarrhea

Further evaluation

Laboratorium Result (08/11/2011): Hb/Ht/L/Plt = 4,4/ 15,2/7990/348000 Albumin: 2,0g/dL Transfusion of PRC: (12-4,4) x 19 x 4 = 570 cc ≈ 600 cc Availability : 5 x 19= 95cc ≈ 100 cc Transfusion of PRC 100cc I (08/11) Transfusion of PRC 100cc II (09/11) Albumin Correction : Albumin needed=(3,5-2,0) x 18x 0,8=22g Plasbumin 25% = 22/25x 100 = 88 cc Plasbumin 20% = 22/20x 100 = 110 cc

Laboratorium Result:

Albumin : 2,3 g/dL

Albumin Correction :

Albumin needed= 10g

Plasbumin 25% = 50cc

Plasbumin 20% = 40cc

S: Abdomen distended (reduced) BW:18kg, BW/BL: 55.57% LLT:55cm LLD:52cm P: Meropenem Inj. 300 mg/8hr/iv (Starting on 09/11)

Results of gaster lavage: (08/11/2011)Day 1 No bacteriaes were found.Growth of jamur,yeast cell(+) Epitel: 0-2 Leucocytes: 1-2 BTA: 2/100 LP Day 2&3: No bacteriaes were found. Growth of jamur, yeast cell(+) Results of lesion culture: (09/11/2011) Aerob bacteri was found; Enterobacter Clocal

Lab result: Hb = 4,4 Albumin: 2,0g/dL Transfusion of PRC: Transfusion of PRC 100cc I (08/11) Transfusion of PRC 100cc II (09/11) Albumin Correction : Plasbumin 20% = 22/20x 100 = 110 cc

S: Diarrhea (6x/day) BW:16kg, BW/BL: 55.55% P: - Lacto B 3 x 1 sachet -Resomal 100cc/xdiarrhea

Lab result: Albumin: 2,3g/dL

Date 12-13 November 2011 14-16 November 2011

S Diarrhea(+)Abdomen distended(reduced) Diarrhea(-) Abdomen distended

O

Head

Neck

Thorax

Abdomen

Extremities


Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.55%

Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inf. palp.(+/+),icteric sclera(-/-). Ear/Nose/Mouth : within normal limit

Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inf. palp -/- Ear/Nose/Mouth : within normal limit





Distension(+),ascites(+), shifting dullness (+) normal peristaltic, Liver and spleen: not palpated.

Distension(+),ascites(+), shifting dullness (+) normal peristaltic.Liver and spleen: not palpated.

Pulse: 90 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex: APR/KPR(+)

Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(-) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+) Normal physiology reflex



P - O2 1-2L per minute (if needed)- Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg- Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day- Lacto B 3 x 1 sachet - Resomal 100-200 cc/x diarrhea

O2 1-2L per minute (if needed)- Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg- Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral or NGT - Gentamicin cream 2x/day- Lacto B 3 x 1 sachet - Resomal 100-200 cc/x diarrhea

Further evaluation

- Laboratorium Result (12/11/2011): Hb/Ht/L/Plt : 12,8/ 38,9/17410/305000 Albumin : 2,9 g/dL Na / K / Cl : 128/ 2,8/ 92-Nasograstric tube (NGT) was inserted on 13/11/2011 because the patient did not eat for the whole day

- Repeat Chest X-Ray - Blood culture, sensitivity test-Combination of Antibiotics with Amikasin (16/11/2011): Day 1: 20 mg/kgBW – 320 mg/day/iv Day 2: 15 mg/kgBW – 240 mg/day/iv

S: Diarrhea (+) BW:17kg, BW/BL: 55.57% P: - Lacto B 3 x 1 sachet -Resomal 100cc/xdiarrhea

Lab Result (12/11/2011): Hb : 12,8 Albumin: 2,9 g/dL -Nasograstric tube (NGT) was inserted on 13/11/2011 because the patient did not eat for the whole day

S: Eye: paleness of Conj.Inf.Palp (-) Extremities: pale(-) P: - Lacto B 3 x 1 sachet -Resomal 100cc/xdiarrhea - Repeat Chest X-Ray - Blood culture, sensitivity test-Combination of Antibiotics with Amikasin (16/11/2011): Day 1: 20 mg/kgBW – 320 mg/day/ivDay 2: 15 mg/kgBW – 240 mg/day/iv

Date 17-20 November 2011 21-26 November 2011

S Diarrhea(-) Abdomen distended Diarrhea(-) Abdomen distended

O

Head

Neck

Thorax

Abdomen

Extremities



Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conjunctiva inferior palpebra (-/-), icteric sclera(-/-). Ear/Nose/Mouth : within normal limit

Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conjunctiva inferior palpebra (-/-), icteric sclera(-/-). Ear/Nose/Mouth : within normal limit







Pulse: 96 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(-) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex :APR/ KPR (+),Pathologic reflexes (-)

Pulse: 96 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(-) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex : APR/KPR (+), Pathologic reflexes(-)



P - O2 1-2L per minute (if needed)- Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg- Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day- Lacto B 3 x 1 sachet - Resomal 100-200 cc/x diarrhea aff(17/11)- Amikasin 350 mg/day/iv (D1:17/11/11)

- O2 1-2L per minute (if needed) - Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day - Lacto B 3 x 1 sachet - Amikasin 250 mg/day/iv

Further evaluation

Re-check lab

The patient was discharged from Adam Malik Hospital on her own request on 26th of November 2011

DISCUSSION

THEORY CASEChildren are most vulnerable to the effects of undernutrition in infancy and early childhood and globally the most important risk factor for illness and death, contributing to more than half of deaths in children worldwide. In developing countries, more than 50% of the 10 million deaths each year are either directly or indirectly secondary to malnutrition

S, 11 years old girl, with 15 kg body weight and 130 cm body height originated from Indonesia(developing country).

The diagnosis of TB in children relies on careful and thorough assessment of all the evidence derived from a careful history, clinical examination and relevant investigations, e.g. Tuberculin Skin Test(TST), chest X-ray and sputum smear microscopy.

The diagnosis of tuberculosis in this patient was made based on history taking where a low grade fever and mild cough was experienced by the patient since 2 years ago and weight loss since 1 year ago. History of contact with a tubercular patient/prolonged coughing adult was also found. Chest X-Ray shows a result of an active specific process and mantoux test was also done.

Most children who develop tuberculosis disease experience pulmonary manifestations, but 25-35 percent of children have an extrapulmonary presentation.

Patient has lesions on her right neck with serous discharge and the dermatologist diagnosed it as scrofuloderma(cutaneous tuberculosis)

THEORY DISCUSSIONThe diagnosis of malnutrition can be made from history taking, physical examination, antropometrical measurement and laboratory finding. In physical examination, we look for sign of dehydration, fever, skin changes, muscle hypotrophy, and oedema.The antropometrical measurement will show the growth failure of the child. The child’s weight for her height under 70%.

The patient experienced weight loss since 1 year ago , decreased of appetite was also found since 6 months ago. According to physical findings in this case, it was found that the patient has an old man face, pale conjunctiva palpebra inferior, intercostal ribs can be seen clearly, ascites, baggy pants, hypotrophy muscle and thin subcutaneous fats. In antropometrical measurement. the child's weight for her height is 55,55 % which indicates of severe malnutrition.

Management of severe malnutrition are by doing 10 essential steps in line with the guideline of malnutrition management from Department of Health Republic of Indonesia .

This patient was firstly treated in the stabilization phase in which dehydration were assesed and treated subsequently. IVFD D5% NaCl 0.45% was given for electrolyte balance. To treat or prevent dehydration, this patient is given ReSoMal 100 cc each time diarrhea occurrs . To correct micronutrients deficiencies, this patient was given Zinc, vitamin A 100.000 IU, and multivitamin without ferum. Feeding started by giving milk-based formula F-75 containing 75 kcal/100 cc and in the rehabilitation phase, milk-based F-100 contains 100 kcal is given to achieve very high intakes and rapid weight gain.

Case report pp

Education

Transcript of Case report pp