Evelyn Phangkawira

Dokter Spesialis Anak

RS Santo Antonius
Tuberculosis Incidence

World Health Organization, 2018

WHO, 2015
 1.INDIA
2.CHINA
3.INDONESIA
 PATOGENESIS INFEKSI TUBERKULOSIS

Petunjuk Teknis Manajemen dan Tatalaksana TB Anak, 2016

PITFALLS TUBERCULOSIS IN CHILDREN
A hidden or
unsuspected
difficulty
Underdiagnosis
Diagnosis
Overdiagnosis
Pitfalls TB

Treatment Misstreatment
DIAGNOSIS
TUBERCULOSIS IS A GREAT IMITATOR

TB TB
Paru Ekstraparu
 PITFALLS DIAGNOSIS TUBERCULOSIS
• No Gold Standard
• Smear microscopy (+) only 10-15%
• Mycobacterium tuberculosis culture (+) only
30-40%

Marais BJ, Pai M. Arch Dis Child. 2007;92:446-52

 International Standard for
Tuberculosis Care (ISTC)
Intrathoracic tuberculosis in children:
1. Adult TB contact Not for
2. Positive Mantoux test endemic
3. Radiologic finding suggestive TB area

Clinical and
radiologic
Latent Tuberculosis Infection (LTBI) finding

World Health Organization, 2006

 Classic Signs of TB
• Cough
• Night sweat
• Weight loss
ADULT
• Fever
• Loss of appetite
• Cervical nodes enlargement CHILDREN
????
 Cough
Weight Loss
Night Sweat
Fever
Cervical
Nodes
Enlargement
Etiology of Cough in Children
Reccurent Viral Pulmonary TB
Infection

Asthma
Pertussis
Cough
Bronchiolitis
Bronchiectasis
Pneumonia
Cough Mechanism

Nodes enlargement attach to bronchus cough

Location of childhood TB majorly in parenchym
No cough receptor
Marais BJ, Gie RP, Obihara CC, Hesseling AC, Schaaf HS, Beyers N. Arch Dis Child 2005;90:1162–5
 Night sweat
• Considered night sweat: if too much sweating
till the child need to change his clothes
• Growth hormone is excreted during night
metabolism ↑ night sweat
• Tuberculosis infection body
metabolism↑ sweating

Marais BJ et al. Arch Dis Child 2005;90:1166–70

 M. tuberculosis

IL-1, IL-2, IL-4, IL-6

Night Sweat
Not Common in
Children
Marais BJ et al. Arch Dis Child 2005;90:1166–70
Mold JW, et al. J Am Board Fam Med. 2012;25(6):878-93
Demam Berkepanjangan
In vitro study

Fever

Zhang Y et al. J Clin Invest. 1993;91:2076-83

Objective Weight
Persistent
Loss
Non Remittent Cough:
• Crossing• atLasting
least one
for centile
3 weeksline
or more
in preceeding
3 months• Without remission and or
• Loss more
• Repeated
than 10% 3oforbodyweight
more episode
(minimum
in 3 1
kg) over anyconsecutive
time interval
month
• Show no respons with first line drugs

Fever
> 38 ͦ C more than 2 weeks

Marais BJ et al. Arch Dis Child 2005;90:1166–70

Crossing at least one centile line in preceeding 3 months
 PEMERIKSAAN BAKTERIOLOGIS
• Pemeriksaan sputum atau aspirat lambung
• Pewarnaan BTA
• Tes cepat molekuler (TCM) GeneXpert
Pewarnaan BTA
TES CEPAT MOLEKULER /GeneXpert
• Mendeteksi DNA M tuberculosis
• Mutasi genetik resisten rifampisin
• Hasil < 2 jam
 TB Ekstraparu

TB
TB meningitis TB Kelenjar
Tulang/Sendi

TB Ginjal TB Abdomen TB Jantung

TB Pleura Skrofuloderma
TB Meningitis
TB KELENJAR dan Skrofuloderma

Diagnosis definitif : BIOPSI

Fine Needle Aspiration Biopsy
TB Tulang
Mantoux Test
GAMBARAN RADIOLOGIS

Air space opacification in the left

upper lobe in a 20 month old male
HIV-uninfected infant
GAMBARAN RADIOLOGIS

Bilateral bronchoneumonia in
an 5 month old male HIV
infected TB case
GAMBARAN RADIOLOGIS

Bilateral bronchoneumonia
with perihilial lymph node in an
5 month old male HIV infected
TB case
GAMBARAN RADIOLOGIS

Right sided pleural

effusion with no
signs of primary
disease in a 19
month old female
HIV positive
patient
GAMBARAN RADIOLOGIS

Airway compression
and displacement of
the left main bronchus
with some
consolidation in the
left inferior lobe in a
17 month old HIV
negative female
TATALAKSANA
 TATALAKSANA

TERAPI PROFILAKSIS

PRIMER

SEKUNDER
TERAPI
TERAPI
TERAPI
 FIXED DOSE
COMBINATION
RIF

INH

? INH RIF

Singh S, Bhutani H, Mariappan TT. Indian J Tuberc.2006;53:201-5)

 ANTI TUBERCULOSIS DRUGS
INH RIF INH RIF
• Regression of radiographic abnormalities in
pulmonary TB is a slow process
• Resolution requires
– From 6 months to 2 years on radiographs
– Up to 15 months on CT scans
• Lymphadenopathy may persist for several
years after treatment
Leung AN. Pulmonary tuberculosis: state of the art. Radiology 1999;210:307–22.
 How to evaluate TB therapy?
CLINICAL IMPROVEMENT
• Gain weight
• No cough
• Rarely sick
 PITFALLS TUBERCULOSIS
• PITFALLS DIAGNOSIS
– History taking: symptoms are not well defined
– Tuberculosis diagnosis only based on radiographic
abnormalities
– Wrong procedure of gastric aspiration
– Wrong procedure and interpretation of Mantoux
test
• PITFALLS THERAPY
– Not adequate dose
– Wrong regimen
– Wrong drug formulation
– Continuation of therapy based on radiologic
evaluation or palpable nodes
THANK YOU