Table of Contents

SECTION I ................................................................................................................................................... 2

IDENTITY .................................................................................................................................................... 2

ANAMNESIS ............................................................................................................................................... 3

PHYSICAL EXAMINATION...................................................................................................................... 6

General Status ........................................................................................................................................... 6

Anthropometry Status ............................................................................................................................... 6

Head to Toe Examination ......................................................................................................................... 7

Neurogical Examination ........................................................................................................................... 9

Meningeal Sign ..................................................................................................................................... 9

Motoric Examination ............................................................................................................................ 9

LABORATORY INVESTIGATION ................................................................................................. 10

SECTION II ................................................................................................................................................ 17

TUBERCULOSIS ....................................................................................................................................... 17

EPIDEMIOLOGY ...................................................................................................................................... 17

CLASIFICATION ...................................................................................................................................... 18

PATHOGENESIS ................................................................................................................................... 18

DIAGNOSIS ........................................................................................................................................... 21

TREATMENT ........................................................................................................................................ 28

Additional Management Decisions ............................................................................................................. 30

1
 SECTION I
CASE REPORT

IDENTITY
Patient
Name : Child RN
Birth Date : April 26nd 2002
Age : 17 years old
Gender : Male
Address : Jl. Bunga Rampai XI/2 189 Rt 13/6 Malaka Duren Sawit Jakarta Timur
Nationality : Indonesian
Religion : Islam
MR No. : 975651
Date of admission : July 27th 2018
Date of examination : July 28th 2018
Parents

Father Mother
Name Mr. C Mrs. L
Age 35 years old 29 years old
Job Employee Housewife
Nationality Indonesian Indonesian
Religion Islam Islam
Education Senior High School Junior High School
Address Jl. Bunga Rampai XI/2 189 Rt 13/6 Malaka Duren Sawit Jakarta
Timur

2
ANAMNESIS
The anamnesis was taken on July 28th 2018 using alloanamnesis method. It was taken at room
No. VI Cendrawasih 2, Bhayangkara Tk.I R. Said Sukanto Hospital, Jakarta.
Chief complaint : shortness of breath since one week before hospitalization
Additional Complaint : nausea and coughing.

History of Present Illness :

a 17-year-old boy came to the emergency department 7/28/2018 with a major complaint:
shortness of breath since one week before entering the hospital. Additional complaints: nausea
and coughing.
Since one month before being admitted to the hospital the patient complained of
coughing that was felt since ± 1 month before entering the hospital. Cough felt continuously,
there is a green colored sputum and found fresh blood red color from ± 2 weeks before
admission. Bloody cough is not accompanied by nausea or vomiting. The patient had previously
gone to the clinic for treatment but there was no improvement in coughing.
In addition, the patient also complained of shortness of breath and felt increasingly heavy.
Shortness of breath is slightly reduced if the patient is resting. Shortness is not accompanied by a
sound "ngik". Shortness is not affected by temperature, weather, or dust. In addition, patients
have felt pain in the left side of the chest like a skewer since 1 week ago.
The patient denies the spread of pain to the back and left hand. Chest pain is felt to be
reduced if the patient rests on his right side.
Patients also complained of decreased appetite since the last 1 month so that patients feel the
body getting thinner from 50kg to 45 kg. Sometimes the patient also complains that his body
feels weak so the patient cannot do the activity.
Normal urination with a frequency of 3-4x / day, clear yellow color, stone urine (-), pain when
BAK (-), blood (-). Normal chapter.

History of Past Illness

 Patients have never experienced symptoms like this before
 The patient has never been hospitalized before

3
Allergic History
 The patient have no allergy of medicine and food.

Birth History
Mother’s Pregnancy History
The mother routinely checked her pregnancy at local clinic with a midwife since she
knew she got pregnant and every months until she gave birth. She also said that she
consumed vitamins during pregnancy.

Child’s Birth History

- Labor : Local Clinic
- Birth attendants : Midwife
- Mode of delivery : Pervaginam
- Gestation : 39 weeks
- Infant state : Healty
- Birth weight : 2900 grams
- Body length : 48 cm
According to the mother, the baby was cried, there is no shortness of breath and cyanotic but
experiencing jaundice.

Development History
 First tooth growth: 8 months
 Tengkurap: 5 months
 Sit: 7 months
 Standing: 11 months
 Running: 12 months
 Speaking: 12 months
 Reading and Writing: 5 years
 Disorders Mental and emotional development: None
Impression: physical development of children according to age (normal).

4
History of Eating
- Breast milk : Exclusively 1 years 2 month
- Formula milk :-
- Baby biscuit :-
- Fruit and vegetables : Papaya

History Immunization
According to the mother, there was a complete of immunization.

Family History :
The patient's father was diagnosed with pulmonary tuberculosis and lymphadenitis with AFB (-)
examination. The patient's father is currently on treatment by the second month.

History of Sibling
- The patient is the 2nd child of the family
- The patient’s siblings: 1
- Born died : (-)
- Child dies : (-)
- Miscarriage : (-)

5
PHYSICAL EXAMINATION
General Status
- General condition : Mildly ill
- Consciousness : Compos Mentis
- Pulse : 107 x/min, regular
- Breathing rate : 26 x/min
- Temperature : 37 °C per axilla
Anthropometry Status
- Weight : 45 kg
- Height : 150 cm
- Head Circumference : 44 cm
Nutritional Status based on CDC :
- WFA (Weight for Age) : 45/65 x 100% = 65% (Berat Badan Kurang)
- LFA (Length for Age) : 150/175 x 100% = 85% (Tinggi Kurang)
- WFL (Weight for Length) : 45/65 x 100% = 69% (Gizi Kurang)

Conclution : The patient has a bad noutritional status

6
Head to Toe Examination
- Head
Normocephal, Brachychephaly, normal hair (black, normal distribution, not easily
removed), no sign of trauma.

7
- Eyes
Scleral icterus -/-, pale conjunctiva -/-, lacrimation +/+, pupil 3mm/3mm, isocor,rect
light response +/+, indirect light response +/+, upslanting palpebral fissure.
- Ears
Normal shape, no wound, no bleeding, no secretion, no cerumen.
- Nose
Flat nose, midline septum, secretion -/-.
- Mouth
Lips : dry
Teeth : complete teeth
Mucous : dry
Tongue : dirty tounge (-)
Tonsils : T2/T2, hyperemia
Pharinx : hyperemia
- Neck
Lymph node enlargement (-), scrofuloderma (-).
- Thorax
Inspection : Symmetric when breathing, retraction (-), ictus cordis is not visible
Palpation : Fremitus tactile +/+ symmetric, mass (-)
Percussion : Sonor on both lungs
Auscultation :
Cor : S1S2 Reguler , murmur (-), gallop (-)
Pulmo : vesicular +/+, rhonchi +/+, wheezing -/-
- Abdomen
Inspection : Relax, spider nevi (-)
Palpation :Abdominal mass (-), hepatomegaly (-) and splenomegaly (-),
Percussion : tympanic, shifting dullness (-)
Auscultation : bowel sound normal, bruit (-)
- Vertebra
There is kyphosis but no scoliosis, lordosis, and any mass along the vertebral line.

8
 - Extremity
There is hipermobility of joints, warm, capillary refill time <2 second, edema -/-.
Simian and klinodaktili in both of hand.
Neurogical Examination
Meningeal Sign
- Nuchal rigidity (-)
- Kernig sign (-)
- Lasegue sign (-)
- Brudzinski I (-)
- Brudzinski II (-)
Motoric Examination

Power
- Hand 5555/5555
- Feet 5555/5555
Tonus
- Hand Normotonus/ Normotonus
- Feet Normotonus / Normotonus
Trophy
- Hand Normotrophy / Normotrophy
- Feet Normotrophy / Normotrophy
Physiologic Reflex
Upper extremities
- Biceps +2 / +2
- Triceps +2 / +2
Lower extremities
- Patella +2 / +2
- Achilles +2 / +2
Pathologic Reflex
Upper extremities
- Hoffman -/-
- Trommer -/-

9
 Lower extremities
- Babinsky -/-
- Chaddock -/-
- Oppenheim -/-
- Gordon -/-
- Schaeffer -/-
Clonus
- Patella -/-
- Achilles -/-

LABORATORY INVESTIGATION
Hematology (July 27th, 2018)
Results Normal Value
Hemoglobin 12,3 13 – 16 g/dl
White blood cells 6.500 5.000 – 10.000 u/l
Hematocrit 38 40 – 48 %

Platelet count 281.000 150.000 –400.000 /ul

Kimia klinik (July 28th 2018)

Kimia Klinik Results Normal Value
SGOT/AST (37 C) 27,0 < 37
SGPT/ALT (37 C) 17,8 < 40

Serologi/Immunologi (July 28th 2018)

Widal
Results Normal Value
Thypi O +1/160* Negative
Parathypi AO Negative Negative

10
 Parathypi BO Negative Negative
Parathypi CO Negative Negative
Thypi H Negative Negative
Parathypi AH Negative Negative
Parathypi BH Negative Negative
Parathypi CH Negative Negative

Hematology (July 31th, 2018)

Results Normal Value
Hemoglobin 12,1 13 – 16 g/dl
White blood cells 6.600 5.000 – 10.000 u/l
Hematocrit 36 40 – 48 %

Platelet count 274.000 150.000 –400.000 /ul

Leucosit count
Basofil 0 0-1%
Eusinofil 0 1-3%
Batang 0 2-6%
Segmen 70 50-70%
Limfosit 14 20-40%
monosit 16 2-8%

Laju Endap Darah 26 <15 mm/hour

Eritrocite 4,61 4,5 – 5,5 juta/ul

11
MIKROBIOLOGI (July 31th, 2018)
BTA 3x Results Normal Value
BTA Sewaktu 1 Positive* Negative
BTA pagi 2 Positive* Negative
BTA Sewaktu Negative Negative

THORAK RONTGEN

July 31th, 2018

Thorax examination has been performed with the following results:

 Heart impression does not increase

 The superior aorta and mediastinum are not dilated
 The Trachea is in the middle, the two hilums are not thickened
 Lungs:

12
 o Both bronchovascular lung patterns are good,
o infiltrates in both lungs
 Left hemophrenic sinus is blunt
 Bone and soft tissue from the chest wall are good

Impression:
Tb milier
Cystic pleural effusion

WORKING DIAGNOSIS
Pulmonary Tuberculosis

MANAGEMENT
- IVFD Rl 500cc 14tpm/12jam

- Inj Rantin 2 x 50 mg

- Inj dexametason 2 x 1/2

- Ambroxol 3x1 tab

- Paracetamol 3x500 mg (kp)

- Neurobion 3 x 1000 mg

- INH 1 x 300 mg

- Izoniazid 3x300 mg (po)

- Rifampicin 1x450 mg (po)

- Pirazinamid 1 x1000 mg(po)

- Ethambuthol 1x1000mg(po)

- B6 2 x 1

13
SUGESSTION
Scoring TB
PROGNOSIS
- Quo ad vitam : Bonam
- Quo ad functionam : Bonam
- Quo ad sanationam : Dubia ad bonamFOLLOW UP

July 29th 2018, 2nd day of hospitalization

Cough
Cold
S
Abdominal pain
Dyspnea
Consciousness : Compos Mentis
General condition: Midly ill
Temperature :36 °C
Pulse :82 x/min
Respiratory rate : 20 x/min
Head : Normocephal
Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-),
Mouth : Dry lips, dry mucous, tonsils T1/T1, hyperemia pharynx (-),dirty tongue
Pulmonary: vesicular +/+ rhonchi +/+, wheezing -/-, retraction -
Cardio : S1S2 regullar, murmur (-), gallop (-)
Abdomen : Distention (-), bowel sound (+) normal, shifting dullness (-)
Extremity: Warm, CRT <2 seconds
A Suspect Pulmonary TB

- IVFD RL 14tpm/12 jam

- Inj. Ranitidin 2 x 50 mg
P
- Ambroxol 3 x 1 tab
- Paracetamol 3 x 500 mg

14
July 30th 2018, 3rd of hospitalization
Cough (+)
Influenza
S
Shortness of breath during night time
Abdominal pain after eating
Consciousness : Compos Mentis
General condition: Midly ill
Temperature :36,5 °C
Pulse :112 x/min
Respiratory rate : 25 x/min
O
Head : Normocephal,
Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-),
Mouth : Dry lips, dry mucous, tonsils T1/T1, hyperemia pharynx (-)
Pulmonary: vesicular +/+ rhonchi +/+, wheezing -/-, retraction -
Cardio : S1S2 regullar, murmur (-), gallop (-)
Abdomen : Distention (-), bowel sound (+) normal, shifting dullness (-)
Extremity: Warm, CRT <2 seconds
A Suspect pulmonary TB
- IVFD RL 14tpm/12 jam
- Inj. Ranitidin 2 x 50 mg
P
- Ambroxol 3 x 1 tab
- Sputum check

July 31th 2018, 4th of hospitalization

Cough +
S Dyspnea
Abdominal pain
Consciousness : Compos Mentis
General condition: Midly ill
O
Temperature :36,5 °C
Pulse :104 x/min
Respiratory rate : 26 x/min
Head : Normocephal

15
 Eyes : Pale conjungtiva (-), icteric sklera (-), sunken eyes (-)
Mouth :Dry lips (-), moist mucous, tonsils T1/T1, hyperemia pharynx (-)
Pulmonary: vesicular +/+ Rhonchi -/-, wheezing -/-, retraction -
Cardio : Reguler S1-S2, murmur (-), gallop (-)
Abdomen : Distention (-), normal bowel sound (+), shifting dullness (-)
Extremity: Warm, CRT <2 seconds
A Pulmonary TB
- IVFD RL 14tpm/12 jam
- Inj. Ranitidin 2 x 50 mg
- Inj. Dexametason 2 x 1/2
- Ambroxol 3 x 1 tab
- Neuribion 3 x 1000 mg
P
- Rifampicin 1x450 mg (po)
- INH 1 x 300 mg
- Etambutol 1 x 1000 mg
- Pyrazinamid 1 x 1000 mg
- B6 2 x 1

16
 SECTION II
LITERATURE AND REVIEW OF TUBERCULOSIS

TUBERCULOSIS
DEFINITION
Infection with Mycobacterium tuberculosis usually results from inhalation of
infected droplets produced by someone who has PTB and who is coughing. The most
infectious index cases are those with sputum smear-positive disease. The closer the
contact is to the source case, the greater the exposure and the greater the risk of
getting infected with tuberculosis.
TB infection is when a person carries the Mycobacterium tuberculosis bacteria
inside the body. Many people have TB infection and are well. A positive TST
indicates infection - but a negative TST does not exclude the possibility of infection.
TB disease occurs in someone with TB infection when the bacteria inside the
body start to multiply and become numerous enough to damage one or more organs
of the body. This damage causes clinical symptoms and signs and is referred to as
“tuberculosis” or active disease.

EPIDEMIOLOGY
It is estimated that one third of the world’s population is infected with
Mycobacterium tuberculosis (the bacterium that causes tuberculosis (TB). Each year,
about 9 million people develop TB, of whom about 2 million die. Of the 9 million
annual TB cases, about 15% occur in children (under 15 years of age). Kenya is
among the 22 TB high TB burden countries in the world and is among the top 5 from
sub Saharan Africa. 75% of these childhood cases occur annually in these 22 high-
burden countries that together account for 80% of the world’s estimated incident
cases. In 2012 Kenya reported a total of 99,159 cases of all forms of TB (case
notification rate of 241/100,000). Paediatric age group of less than 15 years
constituted 9.3% of all cases notified which is a significant proportion requiring

17
 special attention. In the last 5 years, Kenya has reported annual decline in the number
of reported TB cases at a rate of 1% possibly due to effective control interventions
coupled with the declining HIV prevalence in the population.

CLASIFICATION
TB is generally classified as either pulmonary tuberculosis (PTB) or extra-
pulmonary tuberculosis (EPTB). For each case, the patient is either a new TB case
(one who has never previously received TB treatment for a month or longer) or a
retreatment case (one who has previously been treated for TB for one month or longer
in the past). It can also be classified according to severity as in table 1 below.

Table 1: TB Classification in children

1. Non Severe TB

Pulmonary TB without extensive parenchymal lung disease

TB lymphadenitis
TB pleural effusion

2. Severe TB

PTB with extensive parenchymal lung disease

Miliary TB
TB bone or joint, TB meningitis, Pericardial TB, Abdominal
TB
All other forms of extra-pulmonary TB

3. Retreatment
4. Multi-drug resistant TB

PATHOGENESIS
The pathogenesis and transmission of TB are inter-related. M. tuberculosis is
almost exclusively a human pathogen. How it interacts with the human host
determines its survival. From the perspective of the bacterium a successful host-
pathogen interaction is one that results in pathogen transmission. Initial infection is
usually self-limited and followed by a variable period of latency, which ultimately, in
a proportion of those infected, results in infectious pulmonary TB. Transmission from
a case of infectious pulmonary TB is by the airborne route in minute droplets of
moisture that become increasingly reduced by evaporation, creating "droplet nuclei"

18
Evolution of Initial Infection and Host Response
At the time of initial infection, the distribution of inhaled droplet nuclei in the
lung is determined by the pattern of regional ventilation. It thus tends to follow the
most direct path to the periphery and to favour the middle and lower lung zones,
which receive most of the ventilation. In immunocompetent hosts, it is theorized that
alveolar macrophages ingest the M. tuberculosis organisms and may or may not
destroy them, depending on the degree to which phagocytosing cells are
nonspecifically activated, on host genetic factors and on resistance mechanisms in the
bacteria. If bacteria are successfully cleared, then test results will remain negative on
the tuberculin skin test (TST) or interferon-gamma release assay (IGRA).
When innate macrophage microbicidal activity is inadequate to destroy the initial
few bacteria of the droplet nucleus they replicate logarithmically, doubling every 24
hours until the macrophage bursts to release the bacterial progeny. New macrophages
attracted to the site engulf these bacilli, and the cycle continues. The bacilli may
spread from the initial lesion via the lymphatic and/or circulatory systems to other
parts of the body. After a period lasting from 3 to 8 weeks the host develops specific
immunity (cell-mediated immunity [CMI] and delayed-type hypersensitivity [DTH])
to the bacilli, and individuals typically show positive results on the TST or IGRA.
The resulting M. tuberculosis-specific lymphocytes migrate to the site of infection,
surrounding and activating the macrophages there. As the cellular infiltration
continues, the centre of the cell mass, or granuloma, becomes caseous and necrotic.
Radiographically demonstrable fibrocalcific residua of the initial infection include a
Ghon focus (a calcified granuloma in the lung) alone or in combination with a
calcified granulomatous focus in a draining lymph node (Ghon complex). Infection
and immune conversion are usually asymptomatic; any symptoms that do occur are
self-limited. In a small proportion of those infected, erythema nodosum (a cutaneous
immunologic response to an extracutaneous TB infection) or phlyctenular
conjunctivitis (a hypersensitivity reaction) may develop.

19
Early Disease Progression (Primary TB)
A proportion of those who are recently infected are unable to contain the infection
despite the stimulation of CMI and DTH, and there is progression to disease in a
matter of months. Such early disease progression is a function of age and
immunologic response, disease being especially likely to occur in young children and
the immunocompromised. A progressive Ghon focus, disseminated (miliary) disease
and central nervous system disease may occur as early as 2 to 6 months after infection
in infants and the severely immunocompromised. Uncomplicated and asymptomatic
lymph node disease (hilar or mediastinal lymphadenopathy without airway
involvement) may also occur in the first 2-6 months of infection, although there is
debate about whether this should be called active disease.
At 4-12 months after infection, early disease manifestations include complicated
lymph node disease (airway compression, expansile caseating pneumonia, infiltration
of adjacent anatomic structures), pleural disease (most commonly a lymphocyte-
predominant exudative effusion) and peripheral lymphadenitis (usually in the neck).
In immunocompetent children and adolescents early disease is more likely to
manifest as intrathoracic adenopathy and in adults as a unilateral pleural effusion. In
severely immunocompromised people of any age (e.g. those with advanced HIV or
AIDS), early disease may manifest as intrathoracic adenopathy. Rarely, in newly
infected people who are 10 years of age or older (pubertal) adult-type pulmonary
disease or other types of extrapulmonary TB (for example bone and joint TB) may
develop within the first 24 months of infection.
While early disease progression may or may not result from lympho-
hematogenous spread, late disease progression is almost always the result of the
lympho-hematogenous spread of bacilli. Recent infection with early disease
progression probably accounts for many cases of TB in recently arrived immigrants.
For purposes of disease reporting, everyone with a diagnosis of TB made within 18-
24 months of infection is considered to have "primary" disease (on balance about 5%
of those infected). Those newly infected people in whom TB does not develop within
this period of time will either be left with LTBI and will never experience disease (on

20
balance about 90% of those infected) or, after a variable period of latency, they will
develop late disease progression (on balance about 5% of those infected).

DIAGNOSIS
The diagnosis of TB in children relies on history physical examination as well as
any relevant investigations e.g. TST, CXR and sputum smear microscopy. Even
though microbiological diagnosis is not always feasible, all efforts should be made to
do sputum microscopy where possible in children with suspected pulmonary
tuberculosis. A trial treatment with anti- TB drugs is not recommended as a method
of diagnosing TB in children.

History
The key elements of History are:

a) History of contact with an adolescent or adult with proven or suspected TB.

Close contact is defined as living in the same household as or in frequent contact
with smear positive PTB index case. If no index case is identified, always ask about
anyone in the household / dormitory / classroom / school transport with chronic
cough- if present request assessment of that person for possible TB. Most children
will develop TB within one year of exposure

b) Symptoms suggestive of TB
The commonest symptoms associated with TB include the following:
 Progressive and non-remitting cough for more than 2 weeks

 Fever for more than 2 weeks

 Lethargy / reduced playfulness / less active for more than 2 weeks

 Weight loss, no weight gain or poor weight gain (failure to thrive)

21
 The diagnosis of TB in children relies on a careful history and thorough physical
examination

Physical examination
Respiratory system During the physical examination, the following features may be
found in the respiratory system:
 Child may have increased respiratory rate
 Child may have signs of respiratory distress
 Percussion may be normal. In pleural effusion have a stony dull percussion note
 Auscultation is frequently normal. May have abnormal sounds (e.g. wheezing,
crackles, bronchial breathing)

In some cases, there may be atypical clinical presentations of PTB. In this case the child
will present with features of: Acute severe pneumonia
 Presents with fast breathing and chest in-drawing
 Occurs especially in infants and HIV-infected children

Suspect PTB if response to antibiotic therapy is poor. If HIV infected also suspect other
HIV-related lung disease e.g. PCP. Wheeze Asymmetrical and persistent wheeze can be
caused by airway compression due to enlarged tuberculous hilar lymph nodes.
Suspect PTB when wheeze is asymmetrical, persistent and non responsive to
bronchodilator therapy.
PTB can also present acutely as bronchopneumonia in children with tachypnoea,
respiratory distress and crackles. A normal respiratory clinical finding does not rule
out PTB.

Other systems TB can affect any part of the body apart from the hair, nails and teeth.
Apart from the general physical features suggestive of TB, a child may also present with
features that are specific to the affected system e.g. in TB meningitis a child may have

22
features of raised intracranial pressure or neurological deficit. This further increases the
need to have a thorough physical examination.

Investigations
After history and physical examination, if investigations are available in the facility or
nearby, attempt should be made to investigate every child suspected to have TB as
follows:

a) Tuberculin Skin Test (Mantoux test)

A positive Mantoux test is evidence that one is infected with M. Tuberculosis, but doesn’t
necessarily indicate disease. Correct technique of administering, reading and
interpretation of Mantoux text is very important. Mantoux is positive if induration is:
 ≥10mm in a well nourished, HIV negative child
 ≥5mm in a malnourished, or HIV infected child

A negative Mantoux does not rule out TB (especially in the HIV positive or malnourished
child)

b) Chest X-Ray

Radiological features suggestive of PTB will include:

 Persistent lung opacification especially if focal
 Enlarged hilar or subcarinal lymph nodes
 Diffuse micronodular infiltrates (miliary pattern)
 Pleural effusions
 Upper lobe opacification with or without cavities especially in adolescents.

23
ALGORITHM FOR TB DIAGNOSIS IN CHILDREN

Notes:
1. All children with TB should be tested for HIV
2. Mantoux test should be regarded as positive if:
 >5mm diameter of induration in high risk children (includes HIV-infected,
immune-suppressed and severely malnourished children)
 >10 mm diameter of induration in other children ( whether they have received
vaccination or not)

24
3. Please note that a mantoux may be negative despite the child having TB especially in
severe disseminated TB, malnutrition and HIV disease.
4. Smear Positive result can be obtained from microscopy for ZN, TB culture, GeneXpert
5. A child in close contact with smear positive household member should be considered
TB infected and TST may not be necessary.

c) Laboratory diagnosis
This can be AFB microscopy and/or Gene Xpert and/or TB culture. As much as possible
collect the appropriate specimen for diagnosis:
 Suspected PTB: Sputum or gastric aspirate
 Suspected EPTB: Specimen from specific site - CSF, Fine needle aspirate of
lymph node, pleural aspirate, etc

These specimens should be subjected to the appropriate test as below:

 Microscopy for AFB (all specimens)
 Xpert MTB/RIF (currently used only with sputum )
 TB culture (all specimens from children under 5 years)
 Histopathology (FNAs/biopsies)

Whenever possible, it is particularly important to make a bacteriologic diagnosis in the

following situations:
 Suspected drug resistant TB
 Severe and complicated disease
 HIV infected
 Diagnostic uncertainties

d) HIV test
Making a diagnosis of HIV infection has obvious implications for the management of TB
and HIV. All children with suspected TB should be tested for HIV.

25
 After anamnesis, physical examination, investigation then performed weighting by
scoring system. Patients with total score > 6 (equal to or greater than 6), should be treated
as a TB patient and receive treatment with anti-tuberculosis (OAT) drugs. If the score is
less than 6 but clinically suspicious in the direction of strong TB it is necessary to
perform other tests as indicated, such as gastric rinses, anatomical pathology, lumbar
puncture, pleural puncture, bone and joint photographs, fundoscopy, CT-Scan etc.

Note:
• Diagnosis with a scoring system is established by a doctor
• When found skrofuloderma (tb on glands and skin ), immediately diagnosed with TB.
• Weight is assessed when the patient arrives (moment of hospitalization)
• Fever and Cough have no response to standard therapy
• Chest X-ray is not a major diagnostic tool in child TB
• All children with rapid BCG reaction (local reaction within <7 days after injection) should be
evaluated by TB tuberculosis scoring system
• Children diagnosed with TB if the total score is> 6 (maximum score 13)
• Patients aged under five who received a score of 5, were referred to the hospital

26
 Differential Diagnosis for child with Chronic Cough /Respiratory Symptoms
Other conditions to consider in a child with chronic cough /chronic respiratory symptoms
who does not fulfill the classical clinical picture of PTB include:

Possible diagnosis Clinical Presentation

Asthma Recurrent wheeze/cough – responds to
bronchodilators. Usually associated with other
allergies such as eczema, rhinitis
Upper airway conditions Allergic rhinitis Recurrent / persistent runny nose and /or nasal
Adenoid hypertrophy blockage and snoring Seasonal pattern Triggers
Foreign Body Inhalation Usually sudden onset in previously well child
May have history of choking Persistent cough
One sided respiratory signs – inspiratory
stridor, wheeze
Gastro-esophageal reflux disease Recurrent cough/wheeze Onset in early infancy
+/- hoarse voice
Bronchiectasis Severe persistent cough, much sputum (often
infected green or yellow in colour). Finger
clubbing CXR shows reticular or honey-comb
pattern
Congenital Heart Disease Easily fatigueability, breathlessness, Onset
early infancy
Acquired heart disease Older children, palpitations, easy fatiguability,
dyspnoea on exertion. +/- oedema
Congenital respiratory disorders Onset early infancy Commonly premature
baby Noisy breathing during inspiration not
responding to bronchodilators

27
TREATMENT
The main objectives of anti- TB treatment in children are to:
 Cure the child of TB
 Prevent death from TB
 Prevent the complications arising from TB disease
 Prevent TB relapse by eliminating the dormant bacilli
 Prevent the development of drug resistance by using a combination of drugs
 Decrease TB transmission to others

Some of the important points to note about TB treatment in children are:

 Children usually have paucibacillary disease, as cavitating disease is relatively
rare (about 6% or less) in children under 13 years of age and the majority of
the organisms in adult-type disease are found in cavities.

 Children develop extra-pulmonary TB (EPTB) more often than do adults.

 Severe and disseminated TB (e.g., TB meningitis and miliary TB) occur

especially in young children (less than 3 years old).

 Treatment outcomes in children are generally good even in the HIV infected
provided treatment is started promptly.

 Children generally tolerate the anti- TB drugs better than adults.

Standard Operating Procedures for Treatment

 Classify the case of child TB before starting treatment into pulmonary or extra-
pulmonary, new or retreatment. For extra-pulmonary forms, specify the site.
 Record the TB diagnostic category, treatment regimen and date anti-TB treatment was
started on road-to-health book as well as on TB treatment card and facility TB register
 A caregiver should be identified as the DOT supporter for all ages including older
children. Educate the DOT supporter on anti-TB regimen and adherence
 Take the child’s weight at each visit and record
 Calculate drug dosages at every visit according to the child’s current weight (note that
children gain weight while receiving anti-TB treatment)

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  Once treatment is started it must be completed; “trial of TB treatment” should never
be used as a diagnostic tool

Table 3: WHO Recommended Treatment Regimen TB disease category

Recommended regimen
Intensive Continuation phase
phase
All forms of TB except TB 2* RHZE 4 RH
meningitis, bone and joint TB
(osteoarticular TB)
TB meningitis Bone and joint TB 2 RHZE 10 RH
**Retreatment 3 RHZE 5 RHE
Drug resistant TB Refer to a DRTB specialist

*Numeral refers to number of months of the regimen e.g. 2 HRZE refers to two months of
Isoniazid, Rifampicin, Pyrazinamide and Ethambutol H= Isoniazid R= Rifampicin Z=
Pyrazinamide E= Ethambutol

Table 4: Dosage of Individual anti-TB drugs according to body weight

Drug Recommendations Range in mg/kg Maximum Dose
Average dose in mg/kg
Isoniazid 10 10 – 15 300 mg
Rifampicin 15 10 – 20 600 mg
Pyrazinamide 35 30 – 40 1.5 g
Ethambutol 20 15 – 25 1.6 g

Other important observations to note include:

 Treatment regimens are the same for HIV-infected and HIV-uninfected children
 Response to treatment in HIV infected may be slower.
 Report all children receiving anti-TB treatment to the National TB Program
 TB drugs are very well tolerated in children
 Side-effects may occur but are not common. The most important is hepatotoxicity

Ethambutol can be safely used in all children of all ages at recommended dosages of 20
mg/kg.

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Additional Management Decisions
a) Hospitalization:
The following categories of children with TB should be treated as in- patients
 Severe forms of PTB and EPTB (e.g. Spinal TB) for further investigation and initial
management.
 TB meningitis
 Severe malnutrition for nutritional rehabilitation
 Signs of severe pneumonia (i.e. chest in-drawing)
 Other co-morbidities e.g. severe anaemia
 Social or logistic reasons to ensure adherence
 Severe adverse reactions such as hepatotoxicity
b) Steroid therapy:
This should be given in the following situations:
 TB meningitis
 PTB with respiratory distress
 PTB with airway obstruction by hilar lymph nodes
 Severe Miliary TB
 pericardial effusion

Give prednisone at 2mg/kg once daily for 4 weeks, and then taper down over 2 weeks (1mg/kg
for 7 days, then 0.5mg/kg for 7 days)

c) For all HIV-infected children

Commence Cotrimoxazole prophylaxis (25 – 30mg/kg once daily, or see table 7 for dose in
weight bands) Commence antiretroviral therapy within 2 – 8 weeks of starting anti-TB therapy
Conduct family-based care/screening for HIV

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d) Immune re-constitution inflammatory syndrome (IRIS)
This is a paradoxical deterioration after initial improvement following treatment initiation. Seen
during the initial weeks of TB treatment with initial worsening of symptoms due to immune re-
constitution. IRIS is commonly seen in the severely immuno-compromised TB/HIV co- infected
child after initiating ARV treatment. Management: Continue anti-TB therapy; give non steroidal
anti- inflammatory drugs or/and prednisone until severe symptoms subside.

e) Referral of children with TB should be considered if

 Child has severe disease

 Diagnosis is uncertain
 Necessity for HIV-related care e.g. to commence ART
 Failure to respond to treatment despite good adherence

f) Pyridoxine
Give pyridoxine 5 – 10 mg once daily to:
 All malnourished children throughout the anti-TB therapy.
 HIV infected children
 Breast feeding infants.
 Pregnant Adolescents

Follow-up of a Child on anti-TB Therapy

This is a critical part of effective TB treatment.
Patients visit the health facility weekly during intensive phase and every two weeks during
continuation phase. During the visit, the child should be assessed for:
 Adherence
 Drug toxicity
 Weight gain
 Symptom assessment

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Sputum should be taken for AFBs at months 2, 4 and 6 for those who were smear positive at the
beginning of treatment. The following should be done at each visit:
 Weigh the child at each visit. Document the weight and adjust dosage if necessary
 Address Adherence issues
 Explain and emphasize to care-giver and child why they must take the full course of
treatment even if they are feeling better
 Note risk factors for poor adherence such as long distance to health facility, lack
of/transport costs, orphan ( especially if mother has died) or primary care-giver unwell
and adolescents
 Education and adherence support especially TB/HIV. Explain that anti-TB drugs in
children are well tolerated and safe.

CXR is not required in follow-up if the child is responding well to anti-TB treatment

Poor Response to Treatment

Most children with TB will start to show signs of improvement within 4 – 8 weeks of anti-TB
treatment. Weight gain is a sensitive indicator of good response to treatment. Potential causes of
poor response to treatment include:
 Poor adherence; this should be evaluated and problems addressed. HIV infection
 Wrong diagnosis
 Other concurrent chronic lung diseases
 Under dosage of drugs Resistant form of TB Complications e.g. neurological
complications

Consider treatment failure if child is receiving anti-TB treatment and:

 There is no symptom resolution or symptoms are getting worse. In this case, always
confirm adherence is good. If uncertain, a child can have health care worker DOT at the
health facility
 There is continued weight loss
 If smear positive at baseline and remains smear positive up to 5 months

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Refer children with suspected treatment failure for further assessment

Treatment Interruptions
If a child interrupts anti-TB treatment for a period less than 1 month, continue with their TB
treatment when they resume.

If the child interrupts anti-TB therapy for a period longer than 1 month, put them on a re-
treatment regimen when they resume.

Side effects of anti TB drugs in children

The most important side-effect is hepatitis which may present with nausea and vomiting.
Presence of abdominal pain, jaundice and tender enlarged liver suggest severe hepatotoxicity.
Stop the anti-TB drugs immediately and refer to hospital. INH may cause symptomatic
pyridoxine deficiency, particularly in severely malnourished children and HIV infected children
on highly active antiretroviral therapy (HAART). Supplemental pyridoxine is recommended.

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 REFERENCE

Ministry of health. National guidelines on management of tuberculosis in children. 2013.

Division of leprosy, tuberculosis and lung disease.
Rahajoe NN, Basir D, Kartasasmita CB, editor. Pedoman nasional tuberculosis anak. Jakarta :
UKK Pulmonologi PP IDAI; 2007.
Behrman, Kliegman, Arvin, editor Prof. Dr. dr. A. Samik Wahab, SpA(K) et al : Nelson, Ilmu
Kesehatan Anak, edisi 15, buku 2, EGC 2008, hal 1028 – 1042
Mansjoer A. Pulmologi anak. Dalam : Kapita selekta kedokteran. Edisi 3. Jakarta: Media
Aeculapius;2000; hal.459.
Long R, Schwartzman K. pathogenesis and transmission of tuberculosis. Canadian
TuberculosisStandarts 7th edition : 2014

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