Simposium Online IDAI - Tuberkolosis Anak

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Presentasi Simposium IDAI, 6 April 2011.
Judul presentasi : Tuberkolosis pada Anak.

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  • An evaluation of the reliability of x-ray diagnosis under programme conditions in India indicated that more than half of patients who were diagnosed as having tuberculosis on the basis of x-ray did not actually have the disease. These patients are subjected to unnecessary, expensive, and potentially toxic medicines. Source: Nair SS. Significance of patients with x-ray evidence of active tuberculosis not bacteriologically confirmed. Ind J Tub 1974;21:3-5.
  • Nodes are part of the ghon complex
  • uncommon in children younger than 6 years and rare in those younger than 2 years Other features of this effusion includes: WE WILL MENTION THE CHEMISTRY AND MICRO FINDINGS OF THE FLID AND HOW TO DISTINGUISE FROM PARAPNEUMONIC AND EMPYEMA specific gravity 1.012 to 1.025, protein 2 to 4 g/dL, glucose 20 to 40 mg/dL, white blood cell counts ranging from 100 to 1000 cells/mm3 , with early predominance of polymorphonuclear cells followed by a high proportion of lymphocytes.
  • Usually with in 6 months after infection Incidence proven to be reduced by BCG in HIV negative children Tubercles can be in the lungs, meningitis , liver, spleen, kidney (rare), skin Look for features of dissemination in these children ie hepar, spleen, consider LP
  • Simposium Online IDAI - Tuberkolosis Anak

    1. 1. dr. Nastiti Kaswandani, SpA UKK Respirologi – PP IDAI
    2. 3. Masalah utama TB anak <ul><li>Diagnosis </li></ul><ul><ul><li>gejala klinis umum tidak khas  over diagnosis & over treatment </li></ul></ul><ul><ul><li>spesimen diagnostik sulit didapat </li></ul></ul><ul><ul><li>membedakan infeksi / sakit ?  belum ada perangkat diagnostiknya </li></ul></ul><ul><li>Tata Laksana </li></ul><ul><ul><li>Keteraturan (adherence/compliance) </li></ul></ul><ul><ul><li>Jenis, dosis dan cara pemberian </li></ul></ul>
    3. 4. kelas kontak infeksi sakit tindakan 0 - - - - I + - - prof I II + + - prof II III + + + terapi
    4. 5. Infeksi TB dan Sakit TB <ul><li>Infeksi TB: CMI dapat mengendalikan infeksi TB </li></ul><ul><ul><li>k omple ks prim er (+) </li></ul></ul><ul><ul><li>cell mediated immunity (+) </li></ul></ul><ul><ul><li>tuberculin sensitivity (DTH) (+) </li></ul></ul><ul><ul><li>jumlah kuman TB sedikit </li></ul></ul><ul><ul><li>tidak ada manifestasi klinis dan radiologis </li></ul></ul><ul><li>Sakit TB: CMI gagal mengendalikan infeksi TB </li></ul><ul><li>infe ksi + manifestasi klinis dan/atau radiologis </li></ul>
    5. 6. TB infection TB CMI
    6. 7. TB disease TB CMI
    7. 8. Risk factors for developing TB <ul><li>Risk factors: </li></ul><ul><ul><li>Close, prolonged exposure </li></ul></ul><ul><ul><li>Exposure to a smear positive case </li></ul></ul><ul><ul><li>Age; the younger the greater </li></ul></ul><ul><ul><li>Decreased immunity </li></ul></ul><ul><ul><ul><li>HIV </li></ul></ul></ul><ul><ul><ul><li>Severe malnutrition </li></ul></ul></ul>
    8. 9. Age specific risk for disease after recent primary infection
    9. 10. Bagaimana menegakkan diagnosis TB Anak? <ul><li>D iperlukan 3 elemen menegakkan diagnosis: </li></ul><ul><ul><li>Bukti adanya infeksi </li></ul></ul><ul><ul><ul><li>Sumber penularan </li></ul></ul></ul><ul><ul><ul><li>Uji tuberkulin positif </li></ul></ul></ul><ul><ul><li>Kumpulan gejala </li></ul></ul><ul><ul><ul><li>Demam > 2 minggu </li></ul></ul></ul><ul><ul><ul><li>Penurunan BB / BB tidak naik </li></ul></ul></ul><ul><ul><ul><li>Batuk persisten </li></ul></ul></ul><ul><ul><ul><li>Multi- L </li></ul></ul></ul><ul><ul><li>Foto Rontgen menyokong ke arah TB </li></ul></ul><ul><ul><li>Bakteriologis </li></ul></ul>
    10. 12. Bagaimana menegakkan diagnosis TB Anak? <ul><li>Diperlukan 3 elemen untuk menegakkan diagnosis: </li></ul><ul><ul><li>Bukti adanya infeksi </li></ul></ul><ul><ul><ul><li>Sumber penularan </li></ul></ul></ul><ul><ul><ul><li>Uji tuberkulin positif </li></ul></ul></ul><ul><ul><li>Kumpulan gejala </li></ul></ul><ul><ul><ul><li>Demam > 2 minggu </li></ul></ul></ul><ul><ul><ul><li>Penurunan BB / BB tidak naik </li></ul></ul></ul><ul><ul><ul><li>Batuk persisten </li></ul></ul></ul><ul><ul><ul><li>Multi- L </li></ul></ul></ul><ul><ul><li>Foto Rontgen menyokong ke arah TB </li></ul></ul><ul><ul><li>Bakteriologis </li></ul></ul>
    11. 13. TB infection risk Home Environment Adapted from Etkind S., Veen J., In Reichman-Hershfield: Tuberculosis: A Comprehensive International Approach, 2000 Index Case Close Casual Leisure Environment Work/School Environment
    12. 14. Shaw JB, Am Rev Tuberc 1954;69:724-32 Grzybowski S, et al. Bull Int Union Tuberc 1975;50:90-106 Van Geuns HA, Bull Int Union Tuberc 1975;50:107-21 Percent infected Risk of M.tb transmission
    13. 16. Uji tuberkulin, dasar <ul><li>hipersensitivitas thp tuberkuloprotein </li></ul><ul><li>sistem imun TB utama : seluler </li></ul><ul><li>uji tuberkulin, dasar : imunitas seluler </li></ul><ul><li>Purified Protein Derivative  sel Tmemory  tipe 4 (delayed type ) hypersensitivity  sebukan sel inflamasi  indurasi </li></ul><ul><li>sensitivitas 100%, spesifisitas 99% </li></ul>
    14. 17. Uji tuberkulin , pembacaan <ul><li>dilakukan 48-72 jam pasca injeksi </li></ul><ul><li>dituliskan dalam mm ( misalkan ‘0’ mm, bukan hanya disebut ‘negatif’) </li></ul><ul><ul><li>< 5 mm : negatif </li></ul></ul><ul><ul><li>5 – 9 mm : meragukan </li></ul></ul><ul><ul><li>> 10 mm : positif </li></ul></ul>
    15. 18. Uji tuberkulin positif <ul><li>infeksi TB alamiah </li></ul><ul><li>BCG (infeksi TB buatan) </li></ul><ul><li>infeksi M. atipik </li></ul><ul><li>positif palsu </li></ul>
    16. 19. Uji tuberkulin negatif <ul><li>tidak ada infeksi TB </li></ul><ul><li>dalam masa inkubasi (2-12 minggu) </li></ul><ul><li>anergi : </li></ul><ul><ul><li>infeksi virus : morbili, varisela </li></ul></ul><ul><ul><li>gizi buruk (bukan gizi kurang) </li></ul></ul><ul><ul><li>sakit TB berat : TB milier, meningitis TB </li></ul></ul><ul><ul><li>infeksi bakteri berat : tifoid, pertusis, difteria </li></ul></ul><ul><ul><li>malignansi </li></ul></ul><ul><ul><li>imunokompromais : terapi steroid, sitostatik, HIV </li></ul></ul>
    17. 20. Berapa lama PPD dapat digunakan setelah dibuka ?
    18. 24. Bagaimana menegakkan diagnosis TB Anak? <ul><li>Diperlukan 3 elemen untuk menegakkan diagnosis: </li></ul><ul><ul><li>Bukti adanya infeksi </li></ul></ul><ul><ul><ul><li>Sumber penularan </li></ul></ul></ul><ul><ul><ul><li>Uji tuberkulin positif </li></ul></ul></ul><ul><ul><li>Kumpulan gejala </li></ul></ul><ul><ul><ul><li>Demam > 2 minggu </li></ul></ul></ul><ul><ul><ul><li>Penurunan BB / BB tidak naik </li></ul></ul></ul><ul><ul><ul><li>Batuk persisten </li></ul></ul></ul><ul><ul><ul><li>Multi- L </li></ul></ul></ul><ul><ul><li>Foto Rontgen menyokong ke arah TB </li></ul></ul><ul><ul><li>Bakteriologis </li></ul></ul>
    19. 25. Gejala dan tanda klinis umum : <ul><li>BB turun / sulit naik, tanpa sebab jelas </li></ul><ul><li>nafsu makan kurang </li></ul><ul><li>demam kronik dan berulang </li></ul><ul><li>batuk kronik berulang </li></ul><ul><li>malaise </li></ul><ul><li>diare persisten </li></ul><ul><li>keringat malam ? </li></ul>
    20. 28. Gejala dan tanda klinis lokal (sesuai organ yang terkena) : <ul><li>p> kgb superfisialis (servikal, aksila, inguinal) </li></ul><ul><li>konjuntivitis fliktenularis </li></ul><ul><li>kaku kuduk </li></ul><ul><li>skrofuloderma : servikal, inguinal </li></ul><ul><li>gibbus, kifosis </li></ul><ul><li>paraparesis, paraplegia </li></ul><ul><li>pincang, nyeri pangkal paha / lutut </li></ul><ul><li>PARU : umumnya dijumpai dlm batas normal </li></ul>
    21. 29. TB kelenjar TB kulit
    22. 30. TB tulang
    23. 33. Bagaimana menegakkan diagnosis TB Anak? <ul><li>Diperlukan 3 elemen untuk menegakkan diagnosis: </li></ul><ul><ul><li>Bukti adanya infeksi </li></ul></ul><ul><ul><ul><li>Sumber penularan </li></ul></ul></ul><ul><ul><ul><li>Uji tuberkulin positif </li></ul></ul></ul><ul><ul><li>Kumpulan gejala </li></ul></ul><ul><ul><ul><li>Demam > 2 minggu </li></ul></ul></ul><ul><ul><ul><li>Penurunan BB / BB tidak naik </li></ul></ul></ul><ul><ul><ul><li>Batuk persisten </li></ul></ul></ul><ul><ul><ul><li>Multi- L </li></ul></ul></ul><ul><ul><li>Foto Rontgen menyokong ke arah TB </li></ul></ul><ul><ul><li>Bakteriologis </li></ul></ul>
    24. 34. Foto Rontgen toraks <ul><li>tidak khas ! </li></ul><ul><li>baku : AP dan lateral </li></ul><ul><li>terbanyak : infiltrat minimal (tidak sugestif) </li></ul><ul><li>Rontgen toraks sugestif TB : lebih jarang </li></ul>
    25. 35. Rontgen toraks sugestif TB <ul><li>p> kgb hilus & mediastinum </li></ul><ul><li>atelektasis lobus medius </li></ul><ul><li>gambaran milier </li></ul><ul><li>pneumonia </li></ul><ul><li>efusi pleura </li></ul><ul><li>kavitas </li></ul><ul><li>pleuropneumoni </li></ul>
    26. 36. Over diagnosis TB by CXR Over- diagnosis
    27. 39. Ghon focus
    28. 40. Complicated Ghon focus
    29. 41. Lymph node disease AP
    30. 42. Cardiac Catheterization
    31. 43. Lymph node disease Lat
    32. 44. Pleural effusion
    33. 45. Disseminated (miliary) disease
    34. 46. Mikrobiologik <ul><li>Gold standard diagnostik </li></ul><ul><li>sulit memperoleh spesimen </li></ul><ul><li>pemeriksaan langsung : BTA </li></ul><ul><li>biakan : </li></ul><ul><ul><li>konvensional : hasilnya lama </li></ul></ul><ul><ul><li>Bactec : fluoresensi radioaktif, mahal </li></ul></ul><ul><li>PCR ( Polymerase chain reaction ) : </li></ul><ul><ul><li>sens: 92%; spes: 99% </li></ul></ul><ul><ul><li>belum klinis praktis </li></ul></ul>
    35. 47. Serologi (diagnostik humoral) <ul><li>pitfall diagnostik TB pada anak </li></ul><ul><li>PAP Tb, ICT, Mycodot, ELISA, A60, </li></ul><ul><li>anti IFN  , 38kD </li></ul><ul><li> sensitivitas & spesifisitas ? </li></ul><ul><li> sens & spes tinggi pada pasien confirmed </li></ul><ul><li>TB, rendah pada populasi umum </li></ul><ul><li> hanya menunjukkan ada infeksi : tidak </li></ul><ul><li>lebih unggul dibanding uji tuberkulin </li></ul>
    36. 48. QuantiFERON-TB QuantiFERON-TB Gold QuantiFERON-TB Gold in tube T-SPOT.TB www.cellestis.com www.oxfordimmunotec.com New Kits on the block…..
    37. 50. IDAI Pediatric TB scoring system Feature 0 1 2 3 Score Contact not clear - reported, AFB(-) AFB(+) TST - - - positive BW (KMS) - <red line, BW  severe malnutrition - Fever - unexplained - - Cough <3weeks > 3weeks - - Node enlargemnt - > 1 node, > 1cm, painless - - Bone,joint - swelling - - CXR normal sugestive - - Total score
    38. 51. IDAI scoring system <ul><li>D iagnosis TB: total score ≥ 6 (by doctor) </li></ul><ul><li>BW at present </li></ul><ul><li>Fever & cough no respons to standard tx </li></ul><ul><li>CXR is NOT a main diagnostic tool </li></ul><ul><li>Accelerated BCG reaction : evaluated </li></ul><ul><li><5 y.o: Score 5 or strong suspicion  refer </li></ul><ul><li>INH prophylaxis : score <6 with contact (+) </li></ul>
    39. 53. TB treatment many years ago … 04/06/11
    40. 54. Sun bathing ….. 04/06/11
    41. 55. TB treatment now … 04/06/11
    42. 56. FDC with IDAI formulation
    43. 57. Pengobatan <ul><li>kombinasi OAT, jangan tunggal </li></ul><ul><li>awal (2 bulan) - intensif </li></ul><ul><li>lama, ketaatan </li></ul><ul><li>aspek lain : </li></ul><ul><ul><li>perbaikan gizi </li></ul></ul><ul><ul><li>cegah / obati penyakit lain </li></ul></ul>
    44. 58. 2 mo 6 mo 9 mo 12mo INH RIF PZA EMB SM PRED DOT.S !
    45. 60. IDAI FDC (H/R/Z:50/75/150 & H/R:50/75) Note: BW < 5kg should be referred and need tailored dosing B W (kg) Intensive , 2 mo (tablet) Continuation , 4 mo (tablet) 05 - 09 1 1 10 - 14 2 2 15 - 19 3 3 20 - 33 4 4
    46. 61. Evaluasi pengobatan <ul><li>perubahan nyata (klinis / penunjang) : dalam 2 bulan awal </li></ul><ul><li>utama : klinis , penunjang hanya tambahan </li></ul><ul><li>perbaikan klinis : </li></ul><ul><ul><li>peningkatan berat badan </li></ul></ul><ul><ul><li>hilang / berkurangnya gejala (demam, batuk dll) </li></ul></ul><ul><li>penunjang : </li></ul><ul><ul><li>foto Rontgen toraks : 2 / 6 bulan (atas indikasi) </li></ul></ul><ul><ul><li>pemeriksaan darah: LED </li></ul></ul><ul><ul><li>uji tuberkulin : jangan diulang ! </li></ul></ul>
    47. 62. 3/4
    48. 63. From Epidemiology. Katzenellenbogen et al. OUP
    49. 64. *If TB is suspected, investigate as per guidelines ‡ unless the child is HIV-infected (in which case INH 6/12)
    50. 65. pasien TB anak Pasien TB dws sentri- petal sentri- fugal
    51. 66. Kesimpulan <ul><li>Untuk menegakkan diagnosis TB Anak diperlukan anamnesis dan pemeriksaan fisis yang cermat, terutama tentang riwayat kontak dengan pasien TB dewasa, gambaran demam, batuk, letargi serta gangguan pertumbuhan </li></ul><ul><li>Uji tuberkulin harus dikerjakan untuk membuktikan adanya infeksi </li></ul><ul><li>Sistem skoring dapat membantu penegakan TB Anak </li></ul><ul><li>Anti tuberkulosis pada anak jarang menimbulkan hepatotoksisitas, dosis yang diberikan harus sesuai panduan WHO </li></ul>
    52. 67. Dr. Nastiti Kaswandani, SpA <ul><li>Lahir : Surabaya, 12 November 1970 </li></ul><ul><li>Pendidikan : </li></ul><ul><ul><li>Dokter , FKUI, 1995 </li></ul></ul><ul><ul><li>Dr Spesialis Anak , FKUI, 2004 </li></ul></ul><ul><li>Pekerjaan/jabatan : </li></ul><ul><ul><li>- Staf Pengajar Dept. Anak </li></ul></ul><ul><ul><li>FKUI / RSCM </li></ul></ul><ul><ul><li>Sekretaris UKK Respirolog i – PP IDAI </li></ul></ul><ul><ul><li>Anggota Pokja TB Anak DepKes </li></ul></ul>
    53. 68. M. tuberculosis inhalation phagocytosis by PAM live bacilli multiplies primary focus formation lymphogenic spread hematogenic spread 1) Primary complex 2) Cell mediated immunity (+) TST (+) incubation period (2-12 weeks) P r i m a r y T B 3) primary complex complication hematogenic spread complication lymphogenic complication TB disease Dead Optimal immunity TB infection Cured TB disease 4) immunity  reactivation/reinfecktion bacilli dead TB pathogenesis
    54. 69. WHO FDC (H/R/Z:30/60/150 & H/R:30/60) B W ( kg) Intensive , 2 mo (tablet) Continuation , 4 mo (tablet) <7 1 1 8-9 1,5 1,5 10-14 2 2 15-19 3 3 20-24 4 4 25-29 5 5

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