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  • YuLi <23> Dec 18, 2012
  • YuLi <23> Dec 18, 2012
  • YuLi <23> Dec 18, 2012
  • YuLi <23> Dec 18, 2012
  • YuLi <23> Dec 18, 2012
  • Case report pp

    1. 1. CASE REPORT:TUBERCULOSIS WITH SEVERE MALNUTRITION Presenter: Dinesha Paniselvam Tay Chiu Mei Supervisor: dr. H.Hakimi, Sp.A(K)
    2. 2. Definition Tuberculosis is a disease due to Mycobacteriumtuberculosis infection with systemic spread thus canaffect almost all organs, and the most frequent site isin the lung, which usually as the site of primaryinfection Etiology: Mycobacterium tuberculosis 
    3. 3. Host Exposure Doses /immune duration numbers Virulence Concentration state in the air Fac acq tors uir in inf ing ect Tb ion
    4. 4. Pathogenesis of primary tuberculosis Ingestion by PAM’S Droplet nuclei Alveoli inhalation Intracellular replication of bacilli Destruction Destruction of PAM’S of bacilli Tubercle formation Lymphogenic spread Hilar lymph nodes primary focus lymphangitis lymphadenitis Hematogenic spread Primary complex Acute hematogenic Occult hematogenic spread spread CMI Disseminated primary TB Multiple organs remote foci12/18/12 7
    5. 5. Systemic SpecificManifestation Manifestation
    6. 6. IDAI Pediatric TB scoring system 10
    7. 7. Notes for IDAI scoring systemDiagnosis: total score ≥6 (by doctor)BW at presentFever & cough no respons to standard txCXR is NOT a main diagnostic toolAccelerated BCG reaction: evaluated<5 y.o: Score 5 or strong suspicion referINH prophylaxis: score <6 with contact (+) 11
    8. 8. Mantoux 0.1 ml PPD intermediate strength- Location : volar lower arm- Reading time: 48-72 h post injection-Induration diameter :  0 - 5 mm : negative  5 - 9 mm : doubt  > 10 mm : positive
    9. 9. Rapid  reduction of  the number  of bacilli Objectives of treatmentSterilization  Preventing  to prevent  acquired  relapses drug  resistance
    10. 10. Treatment principles • Drug combination, not single drug • Two phases :  Initial phase (2 months) – intensive,  bactericidal effect  Maintenance phase (4 months / more) –  ‘sterilizing’ effect, prevent relaps12/18/12 14
    11. 11. Dosage of antituberculosis drug 2 Time/week Daily dose Drugs (mg/Kg/day) dose Adverse reactions (mg/Kg/dose)) Isoniazid 5-15 15-40 Hepatitis, peripheral neuritis, (INH) (300 mg)) (900 mg)) hypersensitivity Gastrointestinal upset,skin reaction, Rifampicin 10-15 10-20  hepatitis, thrombocytopenia, (RIF) (600 mg)) (600 mg) hepatic enzymes, including orange discolouraution of secretions Pyrazinamide 15 - 40 50-70 Hepatotoxicity, hyperuricamia, (PZA) (2 g) (4 g) arthralgia, gastrointestinal upset Optic neuritis, decreased visual Ethambutol 15-25 50 acuity, decreased red-green colour (EMB) (1,5 g) (1,5 g) discrimination, hypersensitivity, gastrointestinal upset Streptomycin 15 - 40 25-40 Ototoxicity nephrotoxicity (SM) (1 g) (1,5 g)When INH and RIF are used concurrently, the daily doses of the drugs are reduced 12/18/12 15 National consensus of tuberculosis in children, 2001
    12. 12. Systems for assessing the severity of malnutrition in underweight children Method Mild Moderate Severe Weight for age ≥90 % 75 to 89 % 60 to 74 % <60 % Weight for height ≥90 % 80 to 89 % 70 to 79 % <70 % Height for age ≥95 % 90 to 94 % 85 to 89 % <85 %Weight/height for age ≥90 % 85 to 89 % 75 to 84 % <75 % 18
    13. 13. Marasmus KwashiorkorAbsence of edema Presence of edemaInadequate intake of protein Fair-to-normal calorie intake and calories with inadequate protein intakeMarasmus-KwashiorkorA combination of both, kwashiorkor and marasmus. Signs and symptomps ofmarasmus could be found coincidently with kwashiorkor. The child look very thin withbones and ribs could be inspected very prominently, with mild edema foundminimally, particularly in the lower extremities. 19
    14. 14. MANAGEMENT OF SEVERE MALNUTRITION Stabilization Transition Rehabilitation Follow UpNo Treatment Day Day Week Week Week 2 1-2 3-7 3-6 7-261 Hypoglycemia ̸2 Hypothermia ̸3 Dehydration ̸4 Electrolyte Correction ̸ ̸ ̸5 Treatment of Infection ̸ ̸ ̸6 Micronutrition Defficiency Without Without Iron With Iron Iron With Iron Correction Supplementa- Without Iron Supplement- Supple- Supplementation Supplementation tion ation menta- tion7 Formula Formula 75 Initial Refeeding 75 Formula 75 to 1008 Correctional Refeeding Formula 100 Formula 100 (Catch Up Growth)9 Stimulation ̸ ̸ ̸ ̸ ̸10 Prepare for Discharge ̸ ̸ 20
    15. 15. TB AND MALNUTRITION TB Energy intakes Metabolic rate / Presence of are decreased resting rate increased pro-inflammatory cytokines Utilization of amino Increased energy needs acids & protein synthesis to meet the basic The cell mediated demands for body functionimmunity response is impaired MALNUTRITON 12/18/12 21
    16. 16. CASE REPORT
    17. 17. Loss of body weight since 1 year ago. According to herparents, the patient’s highest body weight was 25kg(October 2010) and it’s decreasing for the past 1 yearwith drastic weight loss (± 10kg) for the past 4 months.Decreased of appetite was found since 6 months ago.Fever was found since 2 year ago. The characteristic of thefever : intermittent and low grade fever; decrease temporarilywith consumption of paracetamol. History of intermittentfever was found since the patient was 9 years old.The patient was coughing for the past 2 years, Phlegm (+),white in color, bloody(-). History of contact with a tubercularpatient/prolonged coughing adult was found.Lesions were found on patients right neck which was noted bythe patient’s family 1 year ago. 2 small noduls with ᴓ 1,5cm,Initially, the lesion started as papules that progressed tonodules and pustules. 2 months ago, there was discharge fromthe lesion. The discharge from the lesion was serous, bloody(-)and its painless.Distention of the patients’s stomach was realized by patient’s mother since 6months ago.History of diarrhea (+), vomiting(-), loss of concentration for the past 2 days.Normal mictuation and defecation.
    18. 18. History of feeding :0 to 4 mth : Breast milk4 mths- 1 year: Breast milk + Porridge1 year till now : Normal meals
    19. 19. Physical Examination
    20. 20. • Face: old man face (+) • Eyes: Light reflex +/+, isochoric pupil,conjunctiva palpebra inferiorHead pale (+/+) • Nose: Nasal flare (-) Mouth: Paleness of mucous (-), cyanosis (-) Ears : Secrete (-) • Lymph node enlargement (-), Scrofuloderma (+) on regio colli dextra,( Neck 2 noduls with serous discharge ᴓ ± 1.5cm), JVP: R-2 cm H2O • Symmetrical fusiform, retraction (-), intercostal ribs can be seen clearly.Thorax HR: 96 bpm regular, murmur (-) RR: 20 tpm regular, rales (-) • Ascites (+),Shifting dullness (+),Double sound(+), Normal peristalticAbdomen • Liver and spleen was not palpable • Pulse 96 bpm regular, adequate pressure and volume, warm acral, CRT < 3’, BP: 100/60 mmHg, clubbing fingers (-), cyanotic (-),Extremities pale(+) Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+) • Normal physiology reflex, Pathologic reflexes (-)Genitalia • Female, within normal limit
    21. 21. Old man faceIntercostal ribs can be seen clearlyDried scrofuloderma lesions Stomach distended Thin subcutaneous fatsHypotrophy muscle
    22. 22. Laboratory Findings: (Adam Malik General Hospital:  31/10/2011) Complete Blood Count Results Normal ValueHemoglobin (Hb) 6,50 g% 11.3-14.1g %Erytrocyte (RBC) 3,18 x106/mm3 4.40– 4,48 x106/mm3Leukocyte (WBC) 8.31 x 103/mm3 4.5-13.5x103/mm3Hematocrite 23,280 % 37 – 41 %Trombocyte (PLT) 236 103/mm3 150 – 450 x103/mm3MCV 73,10 fl 81 – 95 fLMCH 20,40 pg 25 – 29 pgGLUCOSE Ad RandomBlood glucose 89 mg/dl <200 mg/dlELECTROLITENatrium 131 135 - 155Kalium 3,5mEq/L 3,6 - 5,5Klorida 10 mEq/L 96 - 106 28
    23. 23. Working Diagnosis:Pulmonary Tuberculosis +Scrofuloderma with Severe malnuturion marasmic- kwashiorkor type
    24. 24. RADIOLOGY Interpretation of the chest X-Ray:CTR < 50%, Aorta and pulmonal segment is  Interpretation of the abdominal photo : not elongated. Infiltration can be seen on  Homogenous consolidation can be seen on  whole lung field.  the abdominal space which enforces air  Results: Bronchopneumonia,   from intestines towards central.  Results:  DD: - active specific process  Ascites          
    25. 25. Date 1 November 2011 S Fever (-), Abdomen distended (+) O Sens :Alert, T:37,30C, BW:15kg, BL: 130 cm, BW/BL: 55.55% LLT:57cm LLD:54cm Head Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conjunctiva inferior palpebra (+/+), icteric sclera(-/-). Ear/Nose/Mouth : within normal limit Lymph nodes enlargement(-)Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O Neck Thorax Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. Abdomen Distented(+), Ascites(+), Shifting dullness(+),Double sound(+), normal peristaltic. Liver and spleen: not palpated.Extremities Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+),Normal physiology reflex: APR/KPR (+) ,Pathologic reflexes (-) A Pulmonary Tuberculosis + Scrofuloderma with Severe malnuturion marasmic-kwashiorkor type P - O2 1-2L per minute (if needed) - IVFD D5% NaCl 0.45% 4gtt/min -Isoniazid 1 x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg D1 - Folic Acid 1x5 mg 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral Further - Consult to Metabolic & Nutrition Divisionevaluation - Consult to Pediatric Respirology : •Mantoux test (at 1400 WIB, Interpretation on 3/11/2011) - Gaster lavage - BTA culture ( 3 days continuously) - Scrofuloderma lesion culture
    26. 26. Date 2 November 2011 S Fever (-), Abdomen distended (+) O Sens :Alert, T:37,30C, BW:15kg, BL: 130 cm, BW/BL: 55.55% LLT:57cm LLD:52cm Face: Old man face (+) Eye: Light reflexes (+),isochoric pupil (R=L), paleness of conjunctiva inferior palpebra (+/+), icteric Head sclera(-/-) Ear/Nose/Mouth : within normal limit Neck Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O Thorax Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. Abdomen Distented(+), Ascites(+), Shifting dullness (+),Double sound(+),normal peristaltic Liver and spleen: not palpated.Extremities Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+), Pathologic reflexes (-) A Pulmonary Tuberculosis + Scrofuloderma with Severe malnuturion marasmic-kwashiorkor type P - O2 1-2L per minute (if needed) - IVFD D5% NaCl 0.45% 4gtt/min -Isoniazid 1 x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg D2 - Ethambutol 1 x 300 mg Consultation from Dermatology: - Zinc tablet 1 x 20mg Lesions were found on patients dextra colli region which was - Folic Acid 1x1 mg - Multivitamin without Ferum 1 x Cth II noted by the patient’s family 1 year ago. 2 small noduls with ᴓ - F75 diet 200cc/2hrs/oral 1,5cm, Initially, the lesion started as papules that progressed to nodules and pustules. 2 months ago, there was discharge from Further - Gaster lavage the lesion. The discharge from the lesion was serous, bloody(-)evaluation - BTA culture ( 3 days continuously) - Scrofuloderma lesion culture and its painless. Diagnose: Scrofuloderma Therapy: Compress with Nacl 0,9% for 15 menits every 4 hours and apply Gentamicin cream 2x/day.
    27. 27. ate 3 November 2011 4 November 2011S Fever (-), Abdomen distended (+) Fever (-), Abdomen distended (+)O Sens :Alert, T:37,30C, BW:16kg, BL: 130 cm, BW/BL: 55.57% Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.57%d Face: Old man face (+) Eye: Light reflex (+), isochoric pupil (Right=Left), Face: Old man face (+) Eye: Light reflex (+), isochoric pupil (R=L), paleness of conj. inf. palpebra (+/+), icteric sclera(-). Ear/Nose/Mouth:within paleness of conj. inf. palpebra (+/+), icteric sclera(-). Ear/Nose/Mouth: normal limit within normal limit Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2k with serous discharge ± 1.5cm), JVP: R-2 cm H2O noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2Oax Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.men Distented(+),normal peristaltic,Ascites(+), Shifting dullness (+),Double sound(+) Distented(+),normal peristaltic, Ascites(+), Shifting dullness (+),Doublemities Liver and spleen: not palpated. sound(+), Liver and spleen: not palpated. Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+ ) hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+)A Pulmonary Tuberculosis + Scrofuloderma with severe malnutrition marasmic- Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition kwashiorkor type marasmic-kwashiorkor typeP - O2 1-2L per minute (if needed) - O2 1-2L per minute (if needed) - IVFD D5% NaCl 0.45% 4gtt/min aff - Isoniazid 1x 150 mg - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg D4 - Pyrazinamid 1 x 450 mg D3 - Ethambutol 1 x 300 mg -Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - Vitamin A 1 x 200.000 IU - F75 diet 200cc/2hrs/oral BW:16 kg BW/BH: 55.57% - Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral - Compress the lesion with NaCl 0,9% for 15 menits every 4 hours. - Gentamicin cream 2x/day - Gentamicin cream 2x/day Treatment: - Compress the lesion with NaCl 0,9% for 15 menits every 4 hours. Consultation from Gastroenterology: - IVFD D5% NaCl 0.45% 4gtt/min aff - Albumin correction and re-check - Vitamin albumin level after correction Laboratorium Result: A 1 x 200.000 IU (1 day)r Mantoux test Results : Negative - Gaster lavageion - BTA culture ( 3 days continuously) - Albumin Correction:150cc of Liver: - Total Bilirubin : 0,93mg/dL - Scrofuloderma lesion culture - Direct Bilirubin : 0,78mg/dL Plasbumin 20% Mantoux test Results : Negative - Alkaline Phosphate(ALP) : 142U/L - AST/SGOT : 28 U/L Laboratorium Result: Albumin 1,0 g/dL - ALT/SGPT - Albumin : 15 U/L : 1,0 g/dL Albumin needed=(3,5-1,0) x 16x 0,8=32g Plasbumin 25% = 32/25x 100 = 128 cc Plasbumin 20% = 32/20x 100 = 160 cc
    28. 28. Date 5-6 November 2011 7 November 2011 S Abdomen distended (+) Abdomen distended(+) O Sens :Alert, T:36,80C, BW:16kg, BL: 130 cm, BW/BL: 55.57% Sens :Alert, T:37,50C, BW:16,5kg, BL: 130 cm, BW/BL: 55.6% Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil Head (R=L), paleness of conj.inferior palpebra (+/+),icteric sclera(-/-). (Right=Left), paleness of conj.inferior palpebra(+/+),icteric sclera Ear/Nose/Mouth :within normal limit (-/-) Ear/Nose/Mouth : within normal limit Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli Lymph nodes enlargement(-) Dried lesion can be seen on the right Neck dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O neck, JVP: R-2 cm H2O Symmetrical fusiform, retraction (-) HR: 120 bpm, regular, murmur Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) Thorax (-) RR: 24 tpm, regular, rales (-/-), Intercostal ribs can be seen RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. clearly.Abdomen Distented(+), Ascites(+), Shifting dullness (+),Double sound(+), normal peristaltic. Liver and spleen: not palpated. -BW:16,5kg, BL: 130 cm, Distented(+), Ascites(+), Shifting dullness (+),Double sound(+), normal peristaltic. Liver and spleen: not palpated. Pulse:120bpm, regular, adequate pressure and volume, warm acral, BW/BL: 55.6% Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, Extremity oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal - Dried lesion can be seen on the hypotrophy muscle (+), thin subcutaneous fats(+), Normal - F100 diet 240cc/3hrs/oral physiology reflex:APR/KPR(+) Pathologic reflexes( -) physiology reflex:APR/ KPR (+) Pathologic reflexes (-) right neck, A -Albumin Correction: 50 cc of Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type - F100 diet 240cc/3hrs/oral marasmic-kwashiorkor type P Plasbumin 20% - O2 1-2L per minute (if needed) - O2 1-2L per minute (if needed) - Albumin Correction: 50 cc of -Isoniazid 1x 150 mg -Isoniazid 1x 150 mg Laboratorium Result: - Rifampicin 1 x 300 mg Plasbumin 20% - Rifampicin 1 x 300 mg - Albumin : 2,0 g/dL - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg D5,6 -Pyrazinamid 1 x 450 mg Laboratorium Result: - Ethambutol 1 x 300 mg D7 - Zinc tablet 1 x 20mg - Vitamin B6 1 x 20 mg - Folic Acid 1 x1 mg - Albumin : 2,0 g/dL - Zinc tablet 1 x 20mg - Multivitamin without Ferum 1 x Cth II - Folic Acid 1 x1 mg - F100 diet 240cc/3hrs/oral (D1),(D2) Albumin Correction: 100cc of - Multivitamin without Ferum 1 x Cth II - Gentamicin cream 2x/day Plasbumin 20% - F100 diet 240cc/3hrs/oral (D3) - Gentamicin cream 2x/dayFurther -Albumin Correction: 50 cc of Plasbumin 0% (05/11/2011; 1750 - Waiting for the results of gaster lavage,evaluation WIB) BTA culture and Scrofuloderma lesion -Waiting for the results of gaster lavage, BTA culture and culture Scrofuloderma lesion culture Albumin Correction:100cc of Plasbumin 20% Laboratorium Result: - Albumin : 2,0 g/dL Albumin needed=(3,5-2) x 16x 0,8 ≈20g Plasbumin 25% = 20/25 x 100 = 80 cc Plasbumin 20% = 20/20 x 100 = 100 cc
    29. 29. Date 8-10 November 2011 11 November 2011 S Abdomen distended (reduced) Fever (-), Diarrhea (6x/day) O Sens :Alert, T:36,80C, BW:18kg, BL: 130 cm, BW/BL: 55.57% LLT:55cm LLD:52cm Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.55% Face: Old man face (+) Eye: Light reflexes (+),isochoric pupil (R=L) paleness of Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness Head conjunctiva inferior palpebra (+/+), Ear/Nose/Mouth : within normal limit of conjunctiva inferior palpebra (+/+). Ear/Nose/Mouth : within normal limit S:Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R-2 cm H O nodes enlargement(-) Dried lesion can be seen on the right neck, JVP: R-2 cm H O Abdomen distended (reduced) 2 2 Lymph Neck BW:18kg, BW/BL: 55.57% LLT:55cm LLD:52cm fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) Symmetrical fusiform, retraction (-) HR: 136 bpm, regular, murmur (-) Symmetrical RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. Thorax P:Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and spleen: not 09/11) Meropenem Inj. 300 mg/8hr/iv (Starting on Distension(+),ascites(+), shifting dullness (+) normal peristaltic, Liver and spleen: not palpated. palpated S: Diarrhea (6x/day)Abdomen Pulse: 136 regular, adequate pressure and volume, warm acral, oedema CRT: < of gaster lavage: (08/11/2011) BP: Pulse: 3’, BP: BW:16kg, BW/BL: 55.55% Results3’,bpm, 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin (-), pale(+) CRT: <92 bpm, 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin (-), pale(+) regular, adequate pressure and volume, warm acral, oedemaExtremities Day 1 No fats(+), Normal physiology reflex:APR/KPR(+). Pathologicjamur,yeast cell(+) - Normal physiology reflex:APR/KPR(+).Pathologic reflexes (-) subcutaneous bacteriaes were found.Growth of reflexes (-) subcutaneous fats(+), Lacto B 3 x 1 sachet P: A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- Epitel: 0-2 kwashiorkor type Leucocytes: 1-2 BTA: 2/100 LP kwashiorkor type P Day 2&3: minute bacteriaes were found. Growth of jamur, yeast minute (if needed) - O 1-2L per No (if needed) 2 - O 1-2L per 2 -Resomal 100cc/xdiarrhea - Isoniazid 1x 150 mg - Isoniazid 1x 150 mg - Rifampicin cell(+) 1 x 300 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Pyrazinamid 1 x 450 mg Results of1lesion culture: (09/11/2011) Aerob bacteriEthambutol 1 xresult: Albumin: 2,3g/dL - Ethambutol x 300 mg - wasLab 300 mg - Vitamin B6 1 x 20 mg - Vitamin B6 1 x 20 mg found;tablet 1 x 20mg - Zinc Enterobacter Clocal - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - F100 diet 240cc/3hrs/oral Lab result: Hb = 4,4 - Gentamicin cream 2x/day Albumin: 2,0g/dL - Gentamicin cream 2x/day - Meropenem Inj. 300 mg/8hr/iv (D 3) Transfusion Inj. 300 mg/8hr/iv (starting on 09/11/2011) Meropenem of PRC: -Lacto B 3 x 1 sachet Transfusion of PRC 100cc I (08/11) -Resomal 100cc/xdiarrhea Transfusion of PRC 100cc II (09/11) Further Laboratorium Result (08/11/2011): Albumin of PRC:evaluation Hb/Ht/L/PltCorrection : = 4,4/ 15,2/7990/348000 Plasbumin 20% = 22/20x 100 = 110 cc Albumin: 2,0g/dL Transfusion Laboratorium Result: (12-4,4) x 19 x 4 = 570 cc ≈ 600 cc Availability : 5 x 19= 95cc ≈ 100 cc Albumin : 2,3 g/dL Transfusion of PRC 100cc I (08/11) Transfusion of PRC 100cc II (09/11) Albumin Correction : Albumin needed=(3,5-2,0) x 18x 0,8=22g Albumin Correction : Plasbumin 25% = 22/25x 100 = 88 cc Plasbumin 20% = 22/20x 100 = 110 cc Albumin needed= 10g Plasbumin 25% = 50cc Plasbumin 20% = 40cc
    30. 30. Date 12-13 November 2011 14-16 November 2011 S Diarrhea(+)Abdomen distended(reduced) Diarrhea(-) Abdomen distended O Sens :Alert, T:36,8 C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:54cm 0 Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.55% LLD:52cm Head Face: Old man face (+) Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inf. palp.(+/ Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inf. palp -/- +),icteric sclera(-/-). Ear/Nose/Mouth : within normal limit Ear/Nose/Mouth : within normal limit Neck Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R- S: Eye: paleness of Conj.Inf.Palp (-) Lymph nodes enlargement(-) Dried lesion can be seen on the right neck, Thorax 2 cm H2O Extremities: pale(-) JVP: R-2 cm H2O Symmetrical fusiform, retraction (-) HR: 90 bpm, regular, murmur (-) RR: 28 Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) RR:Abdomen tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. S: Diarrhea (+) P: - Lacto B 3 x 1 sachet 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. Distension(+),ascites(+), shifting dullness (+) normal peristaltic, Distension(+),ascites(+), shifting dullness (+) normal peristaltic. BW:17kg, BW/BL: 55.57%Extremities Liver and spleen: not palpated. Liver and spleen: not palpated. P: - Lacto B 3 x 1 sachet Pulse: 90 bpm, regular, adequate pressure and volume, warm acral, oedema (-), -Resomal 100cc/xdiarrhea Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema pale(+) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex: APR/KPR(+) - Repeat Chest X-Ray (-), pale(-) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+) Normal physiology reflex A -Resomal 100cc/xdiarrhea Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- Pulmonary Tuberculosis + Scrofuloderma with test malnutrition - Blood culture, sensitivity Severe kwashiorkor type marasmic-kwashiorkor type Antibiotics with -Combination of P - O2 1-2L per minute (if needed) O2 1-2L per minute (if needed) Lab Result (12/11/2011): - Meropenem Inj. 300 mg/8hr/iv - Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg Hb : 12,8 Albumin: 2,9 g/dL Amikasin (16/11/2011): - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Rifampicin 1 x 300 mg -Nasograstric tube (NGT) was inserted - Pyrazinamid 1 x 450 mg Day 1: 20 mg/kgBW – 320 mg/day/iv - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg on 13/11/2011 because the patient did - Zinc tablet 1 x 20mg Day 2: 15 mg/kgBW – 240 mg/day/iv - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Folic Acid 1 x1 mg not eat for the whole day - Multivitamin without Ferum 1 x Cth II - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - F100 diet 240cc/3hrs/oral or NGT - Gentamicin cream 2x/day - Gentamicin cream 2x/day - Lacto B 3 x 1 sachet - Lacto B 3 x 1 sachet - Resomal 100-200 cc/x diarrhea - Resomal 100-200 cc/x diarrhea Further - Laboratorium Result (12/11/2011): - Repeat Chest X-Rayevaluation Hb/Ht/L/Plt : 12,8/ 38,9/17410/305000 - Blood culture, sensitivity test Albumin : 2,9 g/dL -Combination of Antibiotics with Na / K / Cl : 128/ 2,8/ 92 Amikasin (16/11/2011): -Nasograstric tube (NGT) was inserted on 13/11/2011 because the patient did not Day 1: 20 mg/kgBW – 320 mg/day/iv eat for the whole day Day 2: 15 mg/kgBW – 240 mg/day/iv
    31. 31. Date 17-20 November 2011 21-26 November 2011 S Diarrhea(-) Abdomen distended Diarrhea(-) Abdomen distended O Sens :Alert, T:36,8 C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:52cm 0 Sens :Alert, T:36,80C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:52cm LLD:50cm LLD:50cm Head Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil paleness of conjunctiva inferior palpebra (-/-), icteric sclera(-/-). (R=L), paleness of conjunctiva inferior palpebra (-/-), icteric sclera(-/-). Ear/Nose/Mouth : within normal limit Ear/Nose/Mouth : within normal limit Neck Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R- Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, Thorax 2 cm H2O JVP: R-2 cm H2O Symmetrical fusiform, retraction (-) HR: 96 bpm, regular, murmur (-) RR: Symmetrical fusiform, retraction (-) HR: 96 bpm, regular, murmur (-) Abdomen 26 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. RR: 26 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.Extremities Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and spleen: not palpated. spleen: not palpated. Pulse: 96 bpm, regular, adequate pressure and volume, warm acral, oedema (-), Pulse: 96 bpm, regular, adequate pressure and volume, warm acral, oedema pale(-) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex :APR/ KPR (+),Pathologic (-), pale(-) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy reflexes (-) muscle (+), thin subcutaneous fats(+), Normal physiology reflex : APR/KPR (+), Pathologic reflexes(-) A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition kwashiorkor type marasmic-kwashiorkor type P - O2 1-2L per minute (if needed) - O2 1-2L per minute (if needed) - Meropenem Inj. 300 mg/8hr/iv - Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg The patient was discharged from Adam - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg Malik Hospital on her own request on 26 - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg th - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral of November 2011 - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day - Gentamicin cream 2x/day - Lacto B 3 x 1 sachet - Lacto B 3 x 1 sachet - Resomal 100-200 cc/x diarrhea aff(17/11) - Amikasin 250 mg/day/iv - Amikasin 350 mg/day/iv (D1:17/11/11) Further Re-check lab evaluation
    32. 32. DISCUSSION
    33. 33. THEORY CASEChildren are most vulnerable to the effects of S, 11 years old girl, with 15 kg body weight andundernutrition in infancy and early childhood and 130 cm body height originated fromglobally the most important risk factor for illness Indonesia(developing country).and death, contributing to more than half of deathsin children worldwide. In developing countries,more than 50% of the 10 million deaths each yearare either directly or indirectly secondary tomalnutritionThe diagnosis of TB in children relies on The diagnosis of tuberculosis in this patient wascareful and thorough assessment of all the evidence made based on history taking where a low gradederived from a careful history, clinical fever and mild cough was experienced by theexamination and relevant investigations, e.g. patient since 2 years ago and weight loss since 1Tuberculin Skin Test(TST), chest X-ray year ago. History of contact with a tubercularand sputum smear microscopy. patient/prolonged coughing adult was also found. Chest X-Ray shows a result of an active specific process and mantoux test was also done.Most children who develop tuberculosis disease Patient has lesions on her right neck with serousexperience pulmonary manifestations, but 25-35 discharge and the dermatologist diagnosed it aspercent of children have an extrapulmonary scrofuloderma(cutaneous tuberculosis)presentation.
    34. 34. THEORY DISCUSSIONThe diagnosis of malnutrition can be made from The patient experienced weight loss since 1history taking, physical examination, year ago , decreased of appetite was alsoantropometrical measurement and laboratory found since 6 months ago. According to physicalfinding. In physical examination, we look for findings in this case, it was found that the patientsign of dehydration, fever, skin changes, muscle has an old man face, pale conjunctivahypotrophy, and oedema.The antropometrical palpebra inferior, intercostal ribs can bemeasurement will show the growth failure of the seen clearly, ascites, baggy pants,child. The child’s weight for her height under 70%. hypotrophy muscle and thin subcutaneous fats. In antropometrical measurement. the childs weight for her height is 55,55 % which indicates of severe malnutrition.Management of severe malnutrition are by doing This patient was firstly treated in the stabilization10 essential steps in line with the guideline of phase in which dehydration were assesed andmalnutrition management from Department treated subsequently. IVFD D5% NaCl 0.45% wasof Health Republic of Indonesia . given for electrolyte balance. To treat or prevent dehydration, this patient is given ReSoMal 100 cc each time diarrhea occurrs . To correct micronutrients deficiencies, this patient was given Zinc, vitamin A 100.000 IU, and multivitamin without ferum. Feeding started by giving milk-based formula F-75 containing 75 kcal/100 cc and in the rehabilitation phase, milk-based F-100 contains 100 kcal is given to achieve very high intakes and rapid weight gain.

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