Case presentation

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Asthma and Tuberculosis

By: Jessieca Liusen Lecturer: dr. Dahnul Elymbra,SpA
7/5/12

TUBERCULOSIS

Definition:
Direct communicable disease caused by

Mycobacterium 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
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disease and acute respiratory distress

Tuberculosis
Risk factor:
Contact with TB patients Young age Had HIV Severe malnutrition

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Pathophysiology
Droplet TB

nuclei inhalation alveolus inside macrofag

phagocyted by macrofrag a colony Gohn complex complex would become:

Replicated Form Gohn

Restitution ad integrum Cure with a scar such as fibrotic Spread : perkontinuitatum, bronchogenic,
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hematogenic, and lymphogenic

Pathophysiology
Wallgren

children:

divided 3 type of TB in

Limphohematogenic spread Endobronchial TB Chronic pulmonary TB

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Anamnesis

Physical Examination

Diagnosis

Further Investigation

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Ten Poin to suggest TB in children

Contact

to TB (+) BTA patients test positive > 10 mm days after BCG

Tuberculin Thorax

rontgen suggestive for TB

Eritema Cough

in 3-7 immunization > 3 weeks

Prolong Body
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fever with unknown cause

weight decreased without any clear cause or didnt get weight gain in 1

3 dari 1o item

Suggested TB

Gave OAT for 2 months and observed

Improved

Deteriorated/ constant

TB

Not TB

Drug resistant TB

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Reconciliate to hospital

Parameter

Scoring to diagnosis of TB in children

0 1 2 3 (+) contact to (+) contact to negative or positive BTA unknown BTA patients patients Positive 10mm or 5mm in immunosupresive patients Mild malnutrition Severe malnutrition

skor

Contact to TB patients

Tuberculin test

Negative

Nutrition

Fever with unknown cause Cough Limphadenopati coli, axilla, inguinal Swelling on bone, coxae, phalangs Thorax rontgen 7/5/12 Normal

2 weeks 3 weeks 1cm, 1 lymph node, no pain + Suggestive TB

Diagnosis Tuberculosis
Score Score

6 TB

= 5 admitted to hospital to further investigate test positive:

Natural TB infection
Laten TB TB infected and suffered TB Cured TB

Tuberculin

BCG immunization
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Mycobacterium atipic infection

Tuberculin Test Negative

No

infection for TB period of TB

Incubation Anergy

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Score 6

Gave OAT For 2 months and evaluate

(+) response continued theraphy

(-) response continued theraphy and searched for the exact cause

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Anti tuberculosis agent

1st

2 months: intensive phase

3 kinds of drugs Rifampicin Isoniazid Pyrazinamide

2nd

4 months: next phase

2 kinds of drugs Rifampicin

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Isoniazid

Drug Dosage
Name Isoniazid Rifampicin Pyrazinamid Etambuthol Streptomicin Dosage Maximal dosage 5-15 mg/kgBW/ day 300 mg/day 10-20 mg/kgBW/day 600 mg/day 15-30 mg/kgBW/day 2000 mg/day 15-20 mg/kgBW/day 1250 mg/day 15-40 mg/kgBW/day 1000 mg/day

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Follow Up
After

2 months got drugs improve clinical, weight gain, no fever, decrease cough continued theraphy

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Asthma
Definition:
Chronic

inflammation with respiratory tracts constriction

reversible

Epidemiology
Prevalence of the world 7,2% (6% for adult

and 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 7/5/12

Pathophysiology
Allergen

inflammation
Bronchoconstriction Hiperventilation Cough

respiratory

tracts

Released

inflammation mediators
additional respiratory

+ muscles contraction

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Cough + wheezing History Physical ex Tuberculin test

Suggest asthma: Episodic Nocurnal/ morning drip After exercise Atopic

No facility, Check peak flow meter or spirometer: Revercibility 15% Variability 15% Hiperreactivity 20%

Imprecise asthma: Start at neonate Failure to thrive Chronic infection Vomit/ choking Pulmonary focal disorder Cardiovascular system disorder

Consider: Thorax and sinus rontgen Pulmonal physiology test Bronchodilator response test Bronchus provocation test Sweat test Cilia motility test Esofagogaster reflux evaluation

Gave bronchodilator

ASTHMA
Grading and seacrhed for precipitate If episodic frequent/ persistent: rontgen thorax
Gave anti asthma drug: Unsuccefully reevaluate diagnosis and loyalty

Didnt support other diagnosis

Support other diagnosis

Diagnosis and treatment according to working diagnosis

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Consider asthma as participating disease

NOT ASTHMA

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 lagi serangan sedang

Serangan sedang (nebulisasi 2-3x, repons parsial) berikan O2 nilai ulang sedang Ruang Rawat 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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Boleh Pulang Bekali -agonis (hirupan / oral) Jika ada obat pengendali, teruskan Inf.virus (+), steroid oral 24-48 jam kontrol proevaluasi

Ruang Rawat Sehari Oksigen teruskan Steroid oral Nebulisasi / 2 jam 8-12 jam klinis stabil boleh pulang 12 jam tetap belum baik rawat inap

Catatan:
Jika menurut penilaian serangannya berat, nebulisasi 1x, langsung -agonis + antikolinergik Bila belum ada alatnya, nebulisasi awal dapat diganti dgn adrenalin sk. 0,01 ml/kgBB/kali, maksimal 0,3 ml/kali. Untuk serangan sedang dan terutama berat, O2 2-4L/mnt diberikan sejak awal, termasuk saat nebulisasi

Ruang Rawat Inap Oksigen 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 tetap tidak baik ICU

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Asma Episodik Jarang

4 6 minggu

Obat pereda: -agonis atau teofilin (hirupan atau oral) bila perlu > 3x dosis/ minggu 3x dosis/ minggu

Asma Episodik Sering

Tambahkan obat pengendali: steroid hirupan dosis rendah (-)

6-8 minggu, respons :

(+)

Asma Persisten

Pertimbangkan alternatif penambahan salah satu obat: - -agonis kerja panjang (LABA) - Teofilin lepas lambat - Antileukotrien Atau dosis steroid hirupan ditingkatkan (medium) 6-8 minggu, respons : (-) (+)

Steroid dosis medium ditambahkan salah satu obat: - -agonis kerja panjang - Teofilin lepas lambat - Antileukotrien - Atau dosis steroid hirupan ditingkatkan (tinggi) 6-8 minggu, respons : (-) Obat diganti steroid oral (+)

P E N G H I N D A R A N

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Case

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Patient Identity

Name : Chd. D : 1 year 9 months old : Sudadi/ Rina Javanese : Perawang 24 August 2011

Age

Parent Tribe :

Address Admitted:

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Anamnesis
Chief

complain

Dispnea that became deteriorate since 2

months before admittion

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Present Illness History

Since

2 months before admittion

Dispnea on the effort, if he took rest, it

became well
Productive cough happened at the same time

with dispnea
Fever with unknown cause, not too high, and

usually became higher at night.

Patient

got drugs from pediatric policlinic at RSUD AA

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Present Illness History

He No As

can drank mothers milk history of vomitting, choking

long as dispnea happened, his skin never became blue. weight loss since last 2 months

No

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Anamnesis
Past

Illness History Illness History Illness History history

Family Parent

Gestation Diet

history growth

Immunization Physical Mental

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growth and environment

Physical Examination
General

condition: moderate illness composmentis

Consciousness: Vital

sign

BP: 100/60 mmHg Temp : 36,80C HR RR

: 122x/minutes : 46x/minutes

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Physical Examination
Nutrition:

92% normal

Body height: 78 cm Body weight: 10 kg

Upper Head

arm circumference: 15 cm 47 cm

circumference: (normocephali)

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Physical Examination
Skin:

normally

Head: Hair: Eye:

normocephali, anterior fontanel already closed black, not easy to put off

Conjunctiva: normally Sclera: normally Pupils: isochor, 2 mm

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Pupil reflex : +/+

Physical Examination
Ears:

normally normally : moist, red normally normally moist

Nose: Lips:

Mucosa

Palatum: Tongue: Teeth: Neck:

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normally lymph node (-), stiffness (-)

Physical Examination
Thorax
Inspection: simetrical movement of thorax

wall
Palpation: fremitus right and left same Percussion: resonance, head alignment

normally
Auscultation: wheezing

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Physical Examination
Abdomen
Inspection: flat Palpation:

flexible, hepatosplenomegaly (-)

no

tenderness,

Percussion: tymphani Auscultation: bowel sound (+) at normal rate

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Physical Examination
Genitalia: Extremity:

male warm, red, CRT < 2 seconds

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Laboratory
Hb Ht :

: 9,9 g/dL 30,2 % 12600/uL : 594000/uL

Leukosit: Platelet LED Diff

: 50mm/jam

count:

Neutrophil: 37% Lymphocite: 53% 7/5/12 Monocyte:

9,1%

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Working Diagnosis
Asthma

and pulmonary TB

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Treatment
IVFD

KAEN1B 20 gtt injection 1/3 amp

Kalmetason

1st

2 months:

Rifampicin 150 mg 1x1 Pyrazinamid 200 mg 1x1 Isoniazid 200 mg 1x1 Vitamin B6 5 mg 1x1
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High calory and protein diet

 PROGNOSIS Quo Quo

ad vitam

: bonam

ad fungsionam : bonam

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Tanggal

Subjektif

Objektif

Assestment

Terapi

24/8/11

Sesak napas (+),T: 36,90C batuk (+) N: 124x/menit R: 50x/menit

Asma dan SuspIVFD KAEN1B 20 tpm TB paru Inj kalmetason 1/3 amp Foto thorax AP Asma dan TBIVFD KAEN1B dan paru Inj kalmetason off Foto thorax AP: KP duplex Rawat jalan Rifampisin 150 mg Pirazinamid 200 mg Isoniazid 200 mg Vit B6 5 mg

25/8/11

Sesak napas (-),T: 37,10C batuk (+) N: 121x/menit R: 46x/menit

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Case Analysis
Dispnea

became worst since 2 months before admittion

Asthma Pneumonia Bronchiolitis Congenital heard disease Corpus alienum aspiration Pulmonary TB

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Case Analysis
Precipitation Happened Fever

factor: activity

at same time with cough

since 2 months

Asthma Pneumonia Bronchiolitis TB

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pulmonary

 Patient No

ate and drank as usual

blue history when dispnea occurred

It

wasnt congenital heard disease or pneumonia

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 No

weight loss since last 2 months didnt mean that it wasnt TB family history for asthma

Positive

uncle
Complete

history of immunization mantoux test became false positive

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Parameter

Scoring to diagnosis of TB in children

0 1 2 3 (+) contact to (+) contact to negative or positive BTA unknown BTA patients patients

skor 2

Contact to TB patients

Tuberculin test

Negative

Positive 10mm 0 or 5mm in immunosupresive patients Mild malnutrition Severe malnutrition 0

Nutrition

Fever with unknown cause Cough Limphadenopati coli, axilla, inguinal Swelling on bone, coxae, phalangs Thorax rontgen 7/5/12 Normal

2 weeks 3 weeks 1cm, 1 lymph node, no pain + Suggestive TB

1 1 0 0 1

Ten Poin to suggest TB in children

Contact

to TB (+) BTA patients test positive > 10 mm days after BCG

Tuberculin Thorax Eritema Cough

rontgen suggestive for TB

in 3-7 immunization > 3 weeks

Prolong Body
7/5/12

fever with unknown cause

weight decreased without any clear cause or didnt get weight gain in 1

Analysis
More

than 3 poins suggest TB gave antituberculosis agent

7/5/12

Cough + wheezing History Physical ex Tuberculin test

Suggest asthma: Episodic Nocurnal/ morning drip After exercise Atopic

No facility, Check peak flow meter or spirometer: Revercibility 15% Variability 15% Hiperreactivity 20%

Imprecise asthma: Start at neonate Failure to thrive Chronic infection Vomit/ choking Pulmonary focal disorder Cardiovascular system disorder

Consider: Thorax and sinus rontgen Pulmonal physiology test Bronchodilator response test Bronchus provocation test Sweat test Cilia motility test Esofagogaster reflux evaluation

Gave bronchodilator

ASTHMA
Grading and seacrhed for precipitate If episodic frequent/ persistent: rontgen thorax
Gave anti asthma drug: Unsuccefully reevaluate diagnosis and loyalty

Didnt support other diagnosis

Support other diagnosis

Diagnosis and treatment according to working diagnosis

7/5/12

Consider asthma as participating disease

NOT ASTHMA

Asthma Treatment for the patient

Kalmetason/ Steroid

dexametason intravena 1/3 amp = 1,3 mg a day bolus mg/kgBW/day. dosage : 0,5-1

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Antituberculosis Agent
Rifampicin

150 mg 1x1, dosage 15 mg/kgBW/day 200 mg 1x1, dosage 20 mg/kgBW/day 200 mg 1x1, dosage 20 mg/kgBW/day B6 5 mg 1x1

Pyrazinamid Isoniazid Vitamin

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Thank You

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