Respirology Division

Department of Child Health

Faculty of Medicine University of
Indonesia
Respirologi IKA FKUI -
RSCM
Transmision
Usually from adult TB patient with AFB (+)
Modes of transmission :
airborne : >90%, droplet nuclei 1-5 m
orally : drink infected cow milk
direct contact: skin wound
congenital : during pregnancy, very rare
Respirologi IKA FKUI -
RSCM
Etiology
Mycobacterium tuberculosis
Mycobacterium bovis
Characteristics :
1. acid fast
2. grows slowly
3. live in weeks in dry condition
4. sensitive to sunlight, ultraviolet
light, temp > 600 C
 Location of primary focus
Respirologi IKA FKUI -
RSCM
in 2,114 cases, 1909-
1928
Location %
Lung 95.93
Intestine 1.14
Skin 0.14
Nose 0.09
Tonsil 0.09
Middle ear (Eustachian tube) 0.09
Parotid 0.05
Conjungtiva 0.05
Undetermined 2.41

Source: Adapted from Ghon and Kudlich, in Engel and Pirquet (eds.),
Handbuch de Kindertuberkulose, Georg Thieme Verlag, Stuttgart, 1930, Vol 1
 Inhalation Alveoli Ingestion by PAMS
Respirologi IKA FKUI -
RSCM

Intracellular multiplication Destruction

of bacilli of bacilli

Destruction of PAMS

Resolution Tubercle formation Hilar lymph nodes

Calcification

Caseation Hematogenous spread

Ghon Complex

Liquefaction

Lesions in liver, spleen,

Secondary lung lesions kidneys, bone, brain,
other organs
Figure 1. Pathogenesis of tuberculosis. PAMS, pulmonary alveolar macrophages

Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20

Respirologi IKA FKUI -
RSCM
Respirologi IKA FKUI -
RSCM
Prognostic factors
A. TB bacilli :
virulence
infection dose
B. Patient :
General condition
age
Nutritional state
Dosis infeksi lain misalnya morbili
Genetik
Tekanan fisik dan psikis, misalnya trauma,
tindakan bedah
Respirologi IKA FKUI -

Classification
RSCM

0. No contact, no infection (tuberculin

negative)
I. Contact, no infection (tuberculin
negative)
II. Contact, infection (tuberculin positive),
no disease
III. Tuberculosis (disease)
 TB classification
Respirologi IKA FKUI -
RSCM
(ATS/CDC
modified)
Infectio Diseas Manage
Class Contact
n e ment

0 - - - -
I + - - proph I?
proph
II + + - II?
III + + + therapy
Respirologi IKA FKUI -
RSCM
Diagnosis
1. Tuberculin skin test
2. Chest X ray
3. Clinical manifestation
4. Microbiologic
5. Pathology
6. Hematological
7. Known infection source
8. Others : serologic, lung
function, bronchoscopy
Respirologi IKA FKUI -
RSCM
Tuberculin test
TB infection

cellular immunity

delayed type hypersensitivity

tuberculin reaction
Respirologi IKA FKUI -
RSCM
TUBERCULIN
tuberculin PPD-S tuberculin OT
Strength
mg/dosis TU PPD RT 23 2 TU mg/dosis dilution
1
First 0,00002 1 - 0,01
10,000
1
0,00001 5 2 -
2,000
Intermediate
1
- 10 5 0,1
1,000
1
Second 0,005 250 100 1,0
100
Respirologi IKA FKUI -
RSCM
Tuberculin
PPD S
Strength PPD RT23
Seibert

first 1 TU 1 TU

intermediate
5-10 TU 2-5 TU
(standard dose)

second 250 TU 100 TU

 Tuberculin delivery
Respirologi IKA FKUI -
RSCM

1. Mantoux : intradermal injection

2. Multiple puncture :
Heaf, special apparatus with 6
needles
Tine, disposable, 4 needles
3. Patch test
 Tuberculin
Respirologi IKA FKUI -
RSCM

Mantoux 0.1 ml PPD intermediate strength

location : volar lower arm
reading time : 48-72 h post injection
measurement : palpation, marked, measure
report : in millimeter, even 0 mm
Induration diameter :
0 - 5 mm : negative
5 - 9 mm : doubt
> 10 mm : positive
Respirologi IKA FKUI -
RSCM
Tuberculin positive
1. TB infection :
infection without disease / latent TB
infection
infection and disease
disease, post therapy
2. BCG immunization
3. Infection of Mycobacterium atypic
Respirologi IKA FKUI -
RSCM
Anergi
tuberculin temporarily give false negative :
Severe TB, eg miliary TB
Severe malnutrition
Steroid therapy for long term
Certain viral infection : morbili, varicella
Certain bacterial infection : typhus abdominalis,
diphtery, pertussis
Vaccination with live virus : morbili, polio
Malignancy : Hodgkin disease, leukemia
Respirologi IKA FKUI -
RSCM
Imaging diagnostic

routine : chest X ray

on indication : bone, joint,
abdomen
majority of CXR non suggestive TB
pitfall in TB diagnostic
 Radiologic
appearance
Respirologi IKA FKUI -
RSCM

Lymph node enlargement

Primary focus
Atelectasis
Cavity
Tuberculoma
Pneumonia
Air trapping
Tracheobronchitis
Bronchiectasis
Pleural effusion
Miliary spread
 Clinical
manifestation
Respirologi IKA FKUI -
RSCM

None
General manifestation
Organ specific manifestation
Respirologi IKA FKUI -
RSCM
General manifestation
Chronic fever
Anorexia dan BB / tidak naik
Malnutrition
Malaise
Chronic cough
Chronic / recurrent diarrhea
Others
Respirologi IKA FKUI -
RSCM
Specific manifestation
according the involved organ

Respiratory : cough, dyspnea, wheezing

Neurologic : convulsion, neck stiffness
Orthopedic : gibbus, pincang
Lymph node : enlargement, skrofuloderma
Gastrointestinal : prolonged diarrhea
 Pemeriksaan
mikrobiologis
Respirologi IKA FKUI -
RSCM

Memastikan D/ TB
Hasil negatif tidak menyingkirkan D/ TB
Hasil positif : 10 - 62 % (cara lama)
Cara :
cara lama,
radiometrik,
PCR
Respirologi IKA FKUI -
RSCM
Hematological
Not specific
BSR could elevate
Limphocyte could increase

Pathology
Lymph node, hepar, pleura
On indication
Respirologi IKA FKUI -
RSCM
Infection source
Known source of infection, has diagnostic
value
Shaw (1954), level of infectiousness :
AFB (+) : 62.5 %
AFB (-), M tb (+) : 26.8 %
AFB (-), M tb (-) : 17.6 %
Respirologi IKA FKUI -
RSCM
Other examinations
Uji faal paru
Bronkoskopi
Bronkografi
Serologi
MPB64
 Complications of nodes
Complications of focus 1. Extension into bronchus
1. Effusion 2. Consolidation
Respirologi IKA FKUI -
RSCM 2. Cavitation 3. Hyperinflation
3. Coin shadow

EVOLUTION AND TIMETABLE OF

UNTREATED PRIMARY TUBERCULOSIS
IN CHILDREN
MENINGITIS OR MILIARY
in 4% of children infected
under 5 years of age
LATE COMPLICATIONS
Renal & Skin
Most children Most after 5 years
become tuberculin BRONCHIAL EROSION
sensitive
3-9 months
Uncommon under 5 years of age Incidence decreases
PRIMARY COMPLEX 25% of cases within 3 months As age increased
A minority of children 75% of cases within 6 months
Progressive Healing
experience :
Most cases
1. Febrile illness
BONE LESION
2. Erythema Nodosum Most within
3. Phlyctenular Conjunctivitis
1 2 3 4 3 years
5 6

infection Resistance reduced :

1. Early infection
(esp. in first year)
2. Malnutrition
3. Repeated infections :
measles, whooping cough 24 months
4-8 weeks 3-4 weeks fever of onset 12 months streptococcal infections
4. Steroid therapy
Development
Of Complex DIMINISHING RISK

But still possible

GREATEST RISK OF LOCAL & DISEMINATED LESIONS 90% in first 2 years Miller FJW. Tuberculosis in children, 1982
Respirologi IKA FKUI -
RSCM
Pengobatan TB
Permulaan intensif
Kombinasi 3 atau lebih OAT
Teratur dan lama
Pemberian gizi yang baik
Pengobatan dan pencegahan penyakit lain
 Obat Anti Tuberkulosis
(OAT)
Respirologi IKA FKUI -
RSCM

1. Isoniazid (INH) : 5 - 15 mg/Kg BB/hari, max. 300 mg/hari

oral 1 - 2 x / hari
2. Rifampisin : 10 - 20 mg/Kg BB/hari, max. 600 mg/hari
oral 1 - 2 x / hari, perut kosong
3. Pirazinamid : 15 - 30 mg/Kg BB/hari, max. 2 gram/hari
oral 1 - 2 x / hari (20 - 40 mg/Kg BB/hari)
4. Streptomisin : 20 - 40 mg /Kg BB/hari, max. 1gram/hari
intramuskulus
5. Etambutol : 15 - 20 mg/Kg BB/hari, max. 1,5 gram/hari
oral 1 x /hari, perut kosong
6. Lain-lain : Ethionamide, Kanamycin, Cycloserin,
Ciprofloxacin
 Populasi basil TB pada
pasien
Respirologi IKA FKUI -
RSCM

Kavitas, Dalam makrofag

Massa kiju
ekstrasel (intrasel)

Jumlah populasi 107 - 109 104 - 105 104 - 105

Metabolisme dan Lambat atau
Aktif Lambat
perkembang biak intermiten
pH Netral/basa Netral Asam
Obat paling efektif INH, RIF,
RIF, INH PZA, RIF, INH
(berturut-turut) STREP
 8
10
Respirologi
RSCM
IKA FKUI -
Number of bacilli per ml of sputum

107 Sensitive organisms Resistant organisms

106
Smear +
Culture +
105

104
Smear -
Culture +
103

102

101 Smear -
Culture -

100
0 3 6 9 12 15 18 WHO 78351
Start of treatment Weeks of treatment
(isoniazid alone) Toman K. Tuberculosis. WHO, 1979
 Regimen of Antituberculosis
Respirologi IKA FKUI -
RSCM
drugs
2 mo 6 mo 9 mo 12 mo

INH
RIF
PZA

EMB
STREP

PRED

Directly Observed Treatment Short course (DOT

Respirologi IKA FKUI -
RSCM
Corticosteroid
Anti inflammation
prednison : 1 - 3 mg/kg BB/hari, 3x/hari
oral 2 - 4 minggu, tapering off
Indications :
TB milier
Meningitis TB
Pleuritis TB with effusion
Respirologi IKA FKUI -
RSCM
Pencegahan
Perbaikan sosio ekonomi
Kemoprofilaksis
Imunisasi BCG
 Kemoprofilaksis
primer
Respirologi IKA FKUI -
RSCM

Mencegah infeksi
Anak kontak dengan pasien TB aktif, tetapi belum
terinfeksi (uji tuberculin negatif)
Obat : INH 5 - 10 mg/kg BB/hari
 Kemoprofilaksis
sekunder
Respirologi IKA FKUI -
RSCM

Mencegah penyakit TB pada anak yang terinfeksi :

1. Mantoux (+), R (-), klinis (-) :
Umur < 5 th
Kortikosteroid lama
Limfoma, Hodgkin, lekemi
Morbili, pertusis
Akil baliq
2. Konversi Mt (-) menjadi (+) dalam 12 bl, R (-), klinis (-)
Obat INH 5 - 10 mg/kg BB/hari
Respirologi IKA FKUI -
RSCM
Imunisasi BCG
Imunitas spesifik
Uji tuberculin menjadi (+)
Mt (-) baru BCG
Masal : langsung BCG tanpa Mt
Reaksi lokal : membantu screening
 Komplikasi tuberkulosis
Respirologi IKA FKUI -
RSCM
primer
1. Komplikasi komplex primer
Fokus primer : kavitas, efusi pleura, dll
Kelenjar : menekan bronkus, dll
2. Penyebaran hematogen
Tuberkulosis milier
Meningitis TB
TB tulang dan sendi
TB ginjal
Lain-lain
3. Penyebaran limfogen
4. Per kontinuitatum
Respirologi IKA FKUI -
RSCM
Tuberkulosis milier
Penyebaran hematogen akut dan menyeluruh
Dapat menjadi kronik
Tanpa obat bisa fatal
Lesi-lesi ke seluruh tubuh
Demam, hepatomegali, splenomegali, tuberkel koroid
mata
Pungsi lumbal
 Pleuritis TB dengan
efusi
Respirologi IKA FKUI -
RSCM

Pleuritis TB biasanya dengan efusi

Terjadi karena :
Perluasan fokus TB dekat pleura
Penyebaran hematogen
Hipersensitivitas terhadap tuberculin
efusi pleura
Pungsi pleura
Dapat berupa empyema
 Akibat pembesaran
kelenjar
Respirologi IKA FKUI -
RSCM

Menekan bronkus :
Atelektasis
Emfisema
Menembus bronkus :
Penyebaran bronkogen
Fistula
Respirologi IKA FKUI -
RSCM
TB Tulang dan Sendi
Spondilitis
Koksitis
Gonitis
Daktilitis (Spina ventosa)
Respirologi IKA FKUI -
RSCM
TB kelenjar superfisial
Akibat penyebaran limfogen dan hematogen
Dapat sembuh sendiri, dapat progresif
Dapat merupakan bagian dari TB milier
Biasanya multipel
Lokasi : leher, axilla, inguinal, supraklavikuler,
submandibula
Abses
Respirologi IKA FKUI -
RSCM
TB Mata
TB primer konjungtiva pembesaran
kelenjar preaurikuler
TB koroid funduskopi
Conjunctivitis phluctenularis :
Fenomena hipersensitivitas
Sakit, sangat mengganggu
Rekuren
Terjadi dalam 5-15 tahun
 Mycobacterium atipic
Respirologi IKA FKUI -
RSCM (unclassified, anonymous, non
tuberculous)
Runyon (1974) :
Photochromogen : M kansasi, M marinum,
M siniae
Scotochromogen : M scrofuloceum, M.szulgai,
M. xenopi
Nonphotochromogen: M avium, M intracellulare
Rapid growers : M fortuitum, M chelonei
Respirologi IKA FKUI -
RSCM
DOTS with a
S
SMILE
: Supervised
M : Medication
I : In
L : a Loving
E : Environment
(Grange JM, Int J Tuberc Lung Dis 1999; 3:360-362)
Respirologi IKA FKUI -
RSCM
Ilustrasi kasus
I, laki-laki 9 tahun, BB 22,500 kg
Kontak hemoptoe (TB ?)
Klinis baik, alergi (+)
Mt (-), R : konsolidasi
Feces : telur ascaris (+)
Terapi : Antihistamin
Obat cacing
Ulang R : konsolidasi hilang
Respirologi IKA FKUI -
RSCM
Ilustrasi kasus
F, laki-laki 4 bulan, BB 7,200 kg
Kontrol bayi sehat
Minta BCG Mt (+)
R : ada kelainan
Respirologi IKA FKUI -
RSCM
Ilustrasi kasus
LS, perempuan 4 8/12 tahun, BB 12,500 kg
Keluhan : panas lama
keringat malam
lesu
anorexia, BB
kadang-kadang batuk bereak
Sumber infeksi : hemoptoe
Pemeriksaan : gizi kurang, BCG (-), Mt (+)
R : kelainan minimal / normal
LED : 23 mm/ 1 jam
Biakan M.tb : (+)
Respirologi IKA FKUI -
RSCM
Ilustrasi kasus
MF, perempuan 2,5 bulan, BB 4,550 kg
Keluhan : panas 1,5 bulan
Batuk (-)
D/ ISK Th/ ISK panas terus
Diare berulang
Mt (+), R : gambaran milier
Urine : AFB (+)