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Transmission
Usually from adult TB patient with AFB (+)
Modes of transmission :
• airborne : >90%, droplet nuclei 1-5 
• orally : drink infected cow milk
• direct contact: skin wound
• congenital : during pregnancy, very rare

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 Etiology
• Mycobacterium tuberculosis
• Mycobacterium bovis
Characteristics :
1. acid fast
2. grows slowly
3. live in weeks in dry condition
4. sensitive to sunlight, ultraviolet light, temp >
600 C

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 Location of primary focus
in 2,114 cases, 1909-1928

Location %
Lung 95.93
Intestine 1.14
Skin 0.14
Nose 0.09
Tonsil 0.09
Middle ear (Eustachian tube) 0.09
Parotid 0.05
Conjungtiva 0.05
Undetermined 2.41

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 Inhalation Alveoli Ingestion by PAM’S

Intracellular multiplication Destruction

of bacilli of bacilli

Destruction of PAM’S

Resolution Tubercle formation Hilar lymph nodes

Calcification

Caseation Hematogenous spread

Ghon Complex

Liquefaction

Lesions in liver, spleen,

Secondary lung lesions kidneys, bone, brain,
other organs
Figure 1. Pathogenesis of tuberculosis. PAM’S, pulmonary alveolar macrophages
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Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20
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 Prognostic factors

A. TB bacilli :
– virulence
– infection dose
B. Patient :
– General condition
– age
– Nutritional state
– Dosis infeksi lain misalnya morbili
– Genetik
– Tekanan fisik dan psikis, misalnya trauma,
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 Klasifikasi dasar
0. Tidak ada kontak, tidak ada infeksi (uji
tuberkulin negatif)
I. Ada kontak, tidak ada infeksi (uji
tuberkulin negatif)
II. Ada infeksi, tidak ada penyakit TB
(uji tuberkulin positif)
III. Penyakit tuberkulosis

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 TB classification (ATS/CDC modified)
Diseas Manage
Class Contact Infetion
e ment
0 - - - -
I + - - proph I?
II + + - proph II?
III + + + therapy
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 Diagnosis
1. Tuberculin skin test
2. Chest X ray
3. Clinical manifestation
4. Microbiologic
5. Pathology
6. Hematological
7. Known infection source
8. others : serologic, lung function,
bronchoscopy
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 Tuberculin test

TB infection

cellular immunity

delayed type hypersensitivity

tuberculin reaction
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 TUBERCULIN
Tuberkulin PPD-S Tuberkulin OT
Strength PPD RT 23 2 TU mg/dosis Pengenceran
mg/dosis TU
1
First 0,00002 1 - 0,01
10,000
1
0,00001 5 2 -
2,000
Intermediate
1
- 10 5 0,1
1,000
1
Second 0,005 250 100 1,0
100

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 Tuberculin

PPD S
Strength PPD RT23
Seibert
first 1 TU 1 TU
intermediate
5-10 TU 2-5 TU
(standard dose)

second 250 TU 100 TU

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 Tuberculin delivery

1. Mantoux : intradermal injection

2. Multiple puncture :
• Heaf, special apparatus with 6 needles
• Tine, disposable, 4 needles
3. Patch test

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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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 Tuberculin positive

1. TB infection :
 infection without disease / latent TB infection
 infection and disease
 disease, post therapy
2. BCG immunization
3. Infection of Mycobacterium atypic

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 Anergi
Uji tuberkulin dapat negatif untuk sementara karena :
• TB berat misalnya TB milier
• PEM berat
• Mendapat kortikosteroid lama
• Penyakit virus : morbili, varicella
• Penyakit bakteri : typhus abdominalis, difteri,
pertusis
• Vaksinasi virus : morbili, polio
• Penyakit keganasan : penyakit Hodgkin
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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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 Gambaran radiologi paru
• Pembesaran kelenjar
• Fokus primer
• Atelektasis
• Kavitas
• Tuberkuloma
• Pneumonia
• “Air trapping”
• Trakeobronkitis
• Bronkiektasis
• Efusi pleura
• Gambara milier

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 Clinical manifestation
• None
• General manifestation
• Organ specific manifestation

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 General manifestation
• Chronic fever
• Anorexia dan BB / tidak naik
• Malnutrition
• Malaise
• Chronic cough
• Chronic / recurrent diarrhea
• Others

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 Gejala spesifik
sesuai organ yang terkena

• Respiratorik : batuk, sesak, mengi

• Nerologik : kejang, kaku kuduk
• Ortopedik : gibbus, pincang
• Kelenjar : membesar, skrofuloderma
• Gastrointestinal : diare berlanjut
• Lain-lain

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 Pemeriksaan mikrobiologis
• Memastikan D/ TB
• Hasil negatif tidak menyingkirkan D/ TB
• Hasil positif : 10 - 62 % (cara lama)
• Cara :
– cara lama,
– radiometrik,
– PCR

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 Hematological
• Not specific
• BSR could elevate
• Limphocyte could increase

Pathology
• Lymph node, hepar, pleura
• On indication
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 Infection source

• Known source of infection, has

diagnostic value
• Shaw (1954), level of infectiousness :
– AFB (+) : 62.5 %
– AFB (-), M tb (+) : 26.8 %
– AFB (-), M tb (-) : 17.6 %

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 Other examinations
• Uji faal paru
• Bronkoskopi
• Bronkografi
• Serologi
• MPB64

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 Complications of nodes
Complications of focus 1. Extension into bronchus
1. Effusion 2. Consolidation
2. Cavitation 3. Hyperinflation
3. Coin shadow

EVOLUTION AND TIMETABLE OF

UNTREATED PRIMARY TUBERCULOSIS
IN CHILDREN
MENINGITIS OR MILIARY
in 4% of children infected
under 5 years of age
LATE COMPLICATIONS
Renal & Skin
Most children Most after 5 years
become tuberculin BRONCHIAL EROSION
sensitive
3-9 months
Uncommon under 5 years of age Incidence decreases
PRIMARY COMPLEX 25% of cases within 3 months As age increased
A minority of children 75% of cases within 6 months
Progressive Healing
experience :
Most cases
1. Febrile illness
BONE LESION
2. Erythema Nodosum Most within
3. Phlyctenular Conjunctivitis
1 2 3 4 3 years
5 6

infection Resistance reduced :

1. Early infection
(esp. in first year)
2. Malnutrition
3. Repeated infections :
measles, whooping cough 24 months
4-8 weeks 3-4 weeks fever of onset 12 months streptococcal infections
4. Steroid therapy
Development
Of Complex DIMINISHING RISK
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But still possible
GREATEST RISK OF LOCAL & DISEMINATED LESIONS 90% in first 2 years Miller FJW. Tuberculosis in children, 1982
 Pengobatan TB
• Permulaan intensif
• Kombinasi 3 atau lebih OAT
• Teratur dan lama
• Pemberian gizi yang baik
• Pengobatan dan pencegahan penyakit lain

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 Obat Anti Tuberkulosis (OAT)
1. Isoniazid (INH) : 5 - 15 mg/Kg BB/hari, max. 300 mg/hari
oral 1 - 2 x / hari
2. Rifampisin : 10 - 20 mg/Kg BB/hari, max. 600 mg/hari
oral 1 - 2 x / hari, perut kosong
3. Pirazinamid : 15 - 30 mg/Kg BB/hari, max. 2 gram/hari
oral 1 - 2 x / hari (20 - 40 mg/Kg BB/hari)
4. Streptomisin : 20 - 40 mg /Kg BB/hari, max. 1gram/hari
intramuskulus
5. Etambutol : 15 - 20 mg/Kg BB/hari, max. 1,5 gram/hari
oral 1 x /hari, perut kosong
6. Lain-lain : Ethionamide, Kanamycin, Cycloserin,
Ciprofloxacin
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 Populasi basil TB pada
pasien
Kavitas, Dalam makrofag
Massa kiju
ekstrasel (intrasel)

Jumlah populasi 107 - 109 104 - 105 104 - 105

Metabolisme dan Lambat atau
Aktif Lambat
perkembang biak intermiten
pH Netral/basa Netral Asam
Obat paling efektif INH, RIF,
(berturut-turut)
RIF, INH PZA, RIF, INH
STREP

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 108
Number of bacilli per ml of sputum

107 Sensitive organisms Resistant organisms

106
Smear +
Culture +
105

104
Smear -
Culture +
103

102

101 Smear -
Culture -

100
0 3 6 9 12 15 18 WHO 78351
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(isoniazid alone) Toman K. Tuberculosis. WHO, 1979
 Regimen of Antituberculosis drugs

2 mo 6 mo 9 mo 12 mo

INH
RIF
PZA

EMB
STREP

PRED

Directly Observed Treatment Short course (DOT’S)

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 Corticosteroid
• Anti inflammation
• prednison : 1 - 3 mg/kg BB/hari, 3x/hari
oral 2 - 4 minggu, tapering off
• Indications :
– TB milier
– Meningitis TB
– Pleuritis TB with effusion

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 Pencegahan
• Perbaikan sosio ekonomi
• Kemoprofilaksis
• Imunisasi BCG

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 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
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INH 5 - 10 mg/kg BB/hari 36
 Imunisasi BCG
• Imunitas spesifik
• Uji tuberkulin menjadi (+)
• Mt (-) baru BCG
• Masal : langsung BCG tanpa Mt
• Reaksi lokal : membantu screening

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 Komplikasi tuberkulosis primer

1. Komplikasi komplex primer

– Fokus primer : kavitas, efusi pleura, dll
– Kelenjar : menekan bronkus, dll
2. Penyebaran hematogen
– Tuberkulosis milier
– Meningitis TB
– TB tulang dan sendi
– TB ginjal
– Lain-lain
3. Penyebaran limfogen
4. Per kontinuitatum
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 Tuberkulosis milier
• Penyebaran hematogen akut dan menyeluruh
• Dapat menjadi kronik
• Tanpa obat bisa fatal
• Lesi-lesi ke seluruh tubuh
• Demam, hepatomegali, splenomegali, tuberkel
koroid mata
• Pungsi lumbal

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 Pleuritis TB dengan efusi

• Pleuritis TB biasanya dengan efusi

• Terjadi karena :
– Perluasan fokus TB dekat pleura
– Penyebaran hematogen
• Hipersensitivitas terhadap tuberkulin efusi
pleura
• Pungsi pleura
• Dapat berupa empyema
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 Akibat pembesaran kelenjar

• Menekan bronkus :
– Atelektasis
– Emfisema
• Menembus bronkus :
– Penyebaran bronkogen
– Fistula
TB Tulang dan Sendi

Spondilitis
Koksilitis
Gonitis
Daktilitis (spina ventosa)

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 TB kelenjar superfisial
• Akibat penyebaran limfogen dan hematogen
• Dapat sembuh sendiri, dapat progresif
• Dapat merupakan bagian dari TB milier
• Biasanya multipel
• Lokasi : leher, axilla, inguinal, supraklavikuler,
submandibula
• Abses

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 TB Mata
• TB primer konjungtiva
pembesaran kelenjar preaurikuler
• TB koroid funduskopi
• Conjunctivitis phluctenularis :
– Fenomena hipersensitivitas
– Sakit, sangat mengganggu
– Rekuren
– Terjadi dalam 5-15 tahun
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 Mycobacterium atipic
(unclassified, anonymous, non tuberculous)

Runyon (1974) :
• Photochromogen : M kansasi, M marinum, M
siniae
• Scotochromogen : M scrofuloceum, M.szulgai,
M. xenopi
• Nonphotochromogen: M avium, M intracellulare
• Rapid growers : M fortuitum, M chelonei

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 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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