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1. Data pribadi

2.

3.

DAFTAR RIWAYAT HIDUP

Nama : Prof. Dr. dr. HMS Chandra kusuma, Sp.A(K)


NIP
: 194607161974111001
Tempat/tgl lahir : Bangkalan,16 juli 1946
Agama : Islam
Status Perkawinan : kawin
Nama istri : Batul Fatimah
Jumlah anak:3
Pangkat /Gol : pembina/IVC
Jabatan
: Guru Besar
Riwayat Pendidikan
Pendidikan Dasar dan Menengah
1959 Taman Sekolah Rakyat, Bangkalan
1962 Tamat Sekolah Menegah Pertama di Bangkalan
1965 Tamat Sekolah Menegah Atas Negeri III B di Malang
Pendidikan Tinggi
1973
Lulus Dokter di FK UNAIR Surabaya
1986 Spesialis Ilmu Kesehatan Anak, FK UNAIR, Surabaya
2000 Konsultan Respirologi Anak, Kolegium Ilmu Kesehatan Anak
2005 Doktor Ilmu Kedokteran ,Program Pasca Sarjana, UNAIR, Surabaya
Pendidikan Tambahan
1. Asthma Diagnostic Procedeure, Spyrometry Interpretation and Application in Children, Adelaide,
1993
2. Diagnostic Procedure of Pulmonary Disease, Sydney, 1996
3. Pulmonary Function and Pletysmograph in Children and Young Children, Praha, 2000
4. Pulmonary Disease Imaging : CT scan Procedure, Interpretation and Application, Niece, 2001
5. genetic Disease, DNA Extracsion, HLA, and Protein Sequencing, Seattle, 2002
6. Electronic Diarrhoe and Vitalograph Spyrometry in Childhood Asthma, Hawaii, 2003
7. Immunobiology of the Human MHC ; HLA sequencing, Sydney, 2005

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PENDAHULUAN

PATOGENESIS

DIAGNOSIS

PENATALAKSANAAN

PENUTUP
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PENDAHULUAN
WHO:
1,3 juta anak menderita TB/tahun 11% seluruh
kasus TB
Nelson, 2004; WHO, 2006
Indonesia:
of Health
& Family Welfare, 2001; WHO,
Peringkat ke-3Ministry
tertinggi
di dunia

2006

TB pada anak kurang diperhitungkan:


Anak mendapat infeksi M.tuberkulosis dari
dewasa
Tidak berperan dalam penyebaran penyakit
Lewinshon, 2004; Mubarik,
2000

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PENDAHULUAN
Kegagalan dlm mengidentifikasi dan terapi TB pada
anak meningkatkan angka kematian pada anak
usia < 3 tahun.
Lewinshon, 2004; Mubarik,
2000

Infeksi TB pada anak:


Asimptomatis >>
Konfirmasi bakteriologis jarang sulitnya
pengumpulan spesimen
Diagnosis kombinasi dari px klinis, X-thorax
foto, tes tuberkulin yg , riwayat kontak dng
penderita TB aktif dewasa, computed tomografi &
bronkoskopi (>> negara-negara industri).
Eamranond, 2001; Marais, 2005; Salazar,5
2001

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PENDAHULUAN
Interpretasi tes Tuberkulin pada anak dipengaruhi :
Vaksinasi BCG
Malnutrisi
Supresi imun
Pemeriksaan radiologis pd anak bervariasi

Marais,
Pemeriksaan
serodiagnostik
2005

infeksi M.tuberkulosis:
Sensitivitas & spesivisitas rendah terutama pd anak
Data seroreaktivitas TB pd anak juga rendah
Penelitian terbaru evaluasi multiple antigen
menggunakan ELISA, multiantigen print immunoassay
pd manusia (-)
6

Dayal, 2005; Demkow, 2006; Gennaro, 2000; Marais, 2007; Pai, 2006; Steingart, 2007

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PENDAHULUAN

PATOGENESIS

DIAGNOSIS

PENATALAKSANAAN

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PATOGENESIS
droplet nuclei
inhalation

alveoli

ingestion by PAMS

intracellular replication
of bacilli

destruction
of bacilli

destruction of PAMS
Tubercle formation

Lymphogenic spread

Hilar lymph nodes

primary focus

lymphangitis

lymphadenitis

hematogenic spread
acute hematogenic
spread

occult hematogenic
spread

disseminated primary TB

multiple organs
remote foci

primary
complex

Figure. Pathogenesis of primary tuberculosis

CMI

PATOGENESIS
M tuberculosis inoculation

M tb destroyed

phagocytocis by PAM
M tb survive, replicate
primary focus formation
lymphogenic spread
hematogenous spread

tuberculin test
(+)
TB disease

primary
complex
CMI (+)

complication of:
(1)primary complex,
(2)lymphogenic and
(3)hematogenous spread

death

cure
d

incubatio
n period
212weeks

TB infection
optimal
immunity

reactivatio
n/
reinfection

TB disease

primar
y TB

post
primar
y TB

Complications of focus
1. Effusion
2. Cavitation
3. Coin shadow

Complications of nodes
1. Extension to bronchus
2. Consolidation
3. Hyperinflation
MENINGITIS OR MILIARY
in 4% of children infected
under 5 years of age

LATE COMPLICATIONS
Renal & Skin
Most after 5 years

Most children
become tuberculin
sensitive

BRONCHIAL EROSION
3-9 months

A minority of children
experience :
1. Febrile illness
2. Erythema Nodosum
3. Phlyctenular Conjunctivitis

PRIMARY COMPLEX
Progressive Healing
Most cases

Uncommon under 5 years of age


25% of cases within 3 months
75% of cases within 6 months

infection

4-8 weeks

3-4 weeks fever of onset

Incidence decreases
As age increased

12 months

Development
Of Complex
GREATEST RISK OF LOCAL & DISEMINATED LESIONS

Resistance reduced :
1. Early infection
(esp. in first year)
2. Malnutrition
3. Repeated infections :
measles, whooping cough
streptococcal infections
4. Steroid therapy

BONE LESION
Most within
3 years

24 months

DIMINISHING RISK
But still possible
90% in first 2 years

Miller FJW. Tuberculosis in children, 1982

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TB Extra Paru Pada Anak

WHO, Guidance for national TB programmes , 2006

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PENDAHULUAN

PATOGENESIS

DIAGNOSIS

PENATALAKSANAAN

PENUTUP
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DIAGNOSIS

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Langkah Diagnosis TB Pada Anak

WHO, Guidance for national TB programmes , 2006

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Sugestif TB ?

WHO, Guidance for national TB programmes , 2006

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Faktor Resiko

WHO, Guidance for national TB programmes , 2006

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Ax :
Febris lama
Batuk lama
Bb
Lesu
Aktifitas

Sumber penularan:
Sulit
Penting :
Untuk dx
Berhasil/tidaknya tx

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PEMERIKSAAN FISIK
Tbc primer : sering asymptomatik
Gx. Paru/r : ~ INFEKSI LAIN

Cari
Tbc extrathoracal

Scrofuloderma

Cold absces
Tbc tulang/
Sendi

Pembesaran
kelenjar
Men-ser

Conjunctivitis
phlyctenularis

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Mantoux Test
Test
Mantoux

Sangatpenting
pentinguntuk
untukdiagnostik
diagnostik
Sangat
Dipakai::
Dipakai
Ot0,9
0,9mg
mg
Ot
Ppd55tu
tu
Ppd

R ::
R
Tidakspesifik
spesifik
Tidak
Fotobersih
bersih::tidak
tidakmenyangkal
menyangkalada
adaproses
proses
Foto
Dx.TBC
TBCTIDAK
TIDAKDAPAT
DAPATDIBUAT
DIBUATATAS
ATASDASAR
DASARr
r
Dx.
Persangkaankuat
kuattbc
tbc::
Persangkaan
Gbrmiliair
miliair
Gbr
Pembesarankelenjar
kelenjarparatracheal
paratracheal
Pembesaran

INTERPRETASI
INTERPRETASIMANTOUX
MANTOUX
0-4 mm
NEGATIF

> 10 mm
POSITIF

5-9 ragu

Klinis :
sedang/pernah
terinfeksi

Klinis : infeksi
Tidak perlu diulang, kecuali
ada dugaan keras tbc

Klinis :
-Teknik salah
-Ada infeksi
-Cross reaksi
Psot bcg/crp

Aktif, bila :

< 6 th
Tx
Bcg

Diulang dgn dosis sama

> 10 mm

Infeksi
Ket : konversi

Tetap

Tetap tanda-tanda lain

Cross reaksi post bcg

:I. 0 2 mm
II. BERTAMBAH > 10 mm

Konverse :

Dlm 1 th
Tx
Bcg

MUNGKIN 5x TBC

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Interpretasi Tes Mantoux

Hoskyin W, Pediatric Tuberculosis, 2002

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DIAGNOSIS
Negara-negara berkembang:
Diagnosis TB pd anak

sistem skoring

Mathur, 1974; Narayan, 2003; Stegen, 1969; Van Beekhuizen,


1998)

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WHO TB score for use


in the diagnosis of TB
In children
A score of 7 or more
indicates a high likelihood
of TB, treatment
is justified

Ahmed T,et all. Childhood


Tuberculosis, 2008
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Skor Keith Edwards


A score of

7 or more is
indicative of
tuberculosis

Narayan S, et all. Keith Edwards Score for Diagnosis of TB, 2003

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Modified KennethJones' criteria for


the diagnosis
of TB in children
According to this scoring

system,
or more points
indicate
unquestionable TB; 5-6
points indicate probable TB,
therapy
may be justified; 3-4 points
indicate that further
investigations
are needed

Ahmed T,et all.


Childhood Tuberculosis,
2008
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DIAGNOSIS

Ahmed T,et all. Childhood


Tuberculosis, 2008
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DIAGNOSIS

Ahmed T,et all.


Childhood Tuberculosis,
2008

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DIAGNOSIS

Ahmed T,et all. Childhood


Tuberculosis, 2008
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DIAGNOSIS

Ahmed T,et all. Childhood


Tuberculosis, 2008
32

SISTEM SKORING DIAGNOSIS TUBERKULOSIS ANAK (IDAI) TAHUN 2008

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Catatan Sistem Skoring TB IDAI 2008

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Diagnosis dengan sistem skoring ditegakkan oleh dokter


Jika dijumpai skrofuloderma, langsung didiagnosis tuberkulosis
Berat badan dinilai saat pasien datang (moment opname)
Demam dan batuk tidak ada respons terhadap terapi sesuai baku
puskesmas.
Foto rontgen toraks bukan alat diagnostik utama pada Tb anak
Semua anak dengan reaksi cepat BCG harus dievaluasi dengan
sistem skoring Tb anak
Didiagnosis Tb jika skor 6 (skor maksimal 13).
Pasien usia balita yang mendapat skor 5, dirujuk ke RS untuk
evaluasi lebih lanjut.
Gambaran sugestif TB : pembesaran kelenjar hilus atau paratrakeal
dengan/tanpa infiltrat;konsolidasi segmental/lobar;milier;kalsifikasi
dengan infiltrat;atelektasis;tuberkuloma.

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DIAGNOSIS

Ahmed T,et all.


Childhood Tuberculosis,
2008

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Batuk akut dengan kesembuhan yang lama


Batuk akut berulang
Persisten, non- remitting cough

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PENDAHULUAN

PATOGENESIS

DIAGNOSIS

PENATALAKSANAAN

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Objectives of TB therapy
Rapid reduction of the bacilli number, to cure the
patient
Sterilization to prevent relapses
to achieve two phases:
Initial phase (2 months) intensive, bacilli
eradication
Maintenance phase (4 months / more)
sterilizing effect, prevent relaps
Prevention of acquired drug resistance,
to achieve: principles of therapy

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Ped TB therapy principles


Multi drug, NOT single drug (monotherapy)
to prevent drug resistance
risk of fall and rise phenomenon
each TB drug has specific action to certain TB
bacilli population
Long term, continue, uninterrupted problem of
adherence (compliance)
The drug is taken daily and regularly

Dosage of antituberculosis
drug
Drugs
Adverse reactions
Isoniazid
(INH)

Daily dose
(mg/Kg/day)

2 Time/week
dose
(mg/Kg/dose))

5-15
(300 mg))

15-40
(900 mg))

Hepatitis, peripheral neuritis,


hypersensitivity

Rifampicin
(RIF)

10-15
(600 mg))

10-20
(600 mg)

Gastrointestinal upset,skin reaction,


hepatitis, thrombocytopenia,
hepatic enzymes, including orange
discolouraution of secretions

Pyrazinamide
(PZA)

15 - 40
(2 g)

50-70
(4 g)

Hepatotoxicity, hyperuricamia,
arthralgia, gastrointestinal upset

Ethambutol
(EMB)

15-25
(2,5 g)

50
(2,5 g)

Optic neuritis, decreased visual


acuity, decreased red-green colour
discrimination, hypersensitivity,
gastrointestinal upset

Streptomycin
(SM)

15 - 40
(1 g)

25-40
(1,5 g)

Ototoxicity nephrotoxicity

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

National consensus of tuberculosis in children, 2001

TB therapy regimen
2 mo

6 mo

9 mo

12mo

INH
RIF
PZA
ETB
SM
PRED
DOT.S !

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KORTIKOSTEROID
Anti inflamasi
Prednison : oral, 1-2mg/kgBW/day, tid
2-4 weeks, tap off
Indikasi :
TB Miliar
Meningitis TB
Pleuritis TB dengan efusi

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TB drugs & pharmaceutical formulation

Isoniazid (H)
Rifampicin (R)

monosubstanc
e
combi-packs

Pyrazinamide
(Z)
Ethambutol (E)

fixed dose
comb

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KOMBIPAK
2 macam obat terpisah dalam satu
kemasan

FDC with IDAI formulation

FDC tablet formulation

WHO
H : 30 mg
R : 60 mg
Z : 150 mg

IDAI
H : 50 mg
R : 75 mg
Z : 150 mg

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Anti-tuberculosis Lini Kedua

WHO, Guidance for national TB programmes , 2006

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PENDAHULUAN

PATOGENESIS

DIAGNOSIS

PENATALAKSANAAN

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