TUBERCULOSIS

In Children
 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
 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
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 PAM’S

Intracellular multiplication Destruction

of bacilli of bacilli

Destruction of PAM’S

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. PAM’S, pulmonary alveolar macrophages

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

 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
 Classification
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 (ATS/CDC modified)
Manage
Class Contact Infection Disease
ment

0 - - - -
1 + - - proph I
proph
2 + + - II?
3 + + + therapy
 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
 Tuberculin test

TB infection

cellular immunity

delayed type hypersensitivity

tuberculin reaction
 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
 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

1. Mantoux : intradermal injection

2. Multiple puncture :
• Heaf, special apparatus with 6 needles
• Tine, disposable, 4 needles
3. Patch test
 Tuberculin
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
 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
 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
 Imaging diagnostic

• routine : chest X ray

• on indication : bone, joint, abdomen
• majority of CXR non suggestive TB
• pitfall in TB diagnostic
 Radiologic appearance
• Lymph node enlargement
• Primary focus
• Atelectasis
• Cavity
• Tuberculoma
• Pneumonia
• “Air trapping”
• Tracheobronchitis
• Bronchiectasis
• Pleural effusion
• Miliary spread
 Clinical manifestation
• None
• General manifestation
• Organ specific manifestation
 General manifestation
• Chronic fever
• Anorexia dan BB / tidak naik
• Malnutrition
• Malaise
• Chronic cough
• Chronic / recurrent diarrhea
• Others
 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
• Memastikan D/ TB
• Hasil negatif tidak menyingkirkan D/ TB
• Hasil positif : 10 - 62 % (cara lama)
• Cara :
– cara lama,
– radiometrik,
– PCR
 Hematological
• Not specific
• BSR could elevate
• Limphocyte could increase

Pathology
• Lymph node, hepar, pleura
• On indication
 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 %
 Other examinations
• Uji faal paru
• Bronkoskopi
• Bronkografi
• Serologi
• MPB64
 Complications of nodes
Complications of focus 1. Extension into bronchus
1. Effusion 2. Consolidation
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

Resistance reduced :
infection 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
 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)
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

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
 108
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 drugs

2 mo 6 mo 9 mo 12 mo

INH
RIF
PZA

EMB
STREP

PRED

Directly Observed Treatment Short course (DOT’S)

 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
 Pencegahan
• Perbaikan sosio ekonomi
• Kemoprofilaksis
• Imunisasi BCG
 Kemoprofilaksis primer
• Mencegah infeksi
• Anak kontak dengan pasien TB aktif, tetapi belum
terinfeksi (uji tuberculin negatif)
• Obat : INH 5 - 10 mg/kg BB/hari
 Kemoprofilaksis sekunder
Mencegah penyakit TB pada anak yang terinfeksi :
1. Mantoux (+), Rö (-), klinis (-) :
• Umur < 5 th
• Kortikosteroid lama
• Limfoma, Hodgkin, lekemi
• Morbili, pertusis
• Akil baliq
2. Konversi Mt (-) menjadi (+) dalam 12 bl, Rö (-), klinis (-)
Obat INH 5 - 10 mg/kg BB/hari
 Imunisasi BCG
• Imunitas spesifik
• Uji tuberculin menjadi (+)
• Mt (-) baru BCG
• Masal : langsung BCG tanpa Mt
• Reaksi lokal : membantu screening
 Komplikasi tuberkulosis 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
 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

• 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
• Menekan bronkus :
– Atelektasis
– Emfisema
• Menembus bronkus :
– Penyebaran bronkogen
– Fistula
 TB Tulang dan Sendi
• Spondilitis
• Koksitis
• Gonitis
• Daktilitis (Spina ventosa)
 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
 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
(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
DOTS with a SMILE
S : Supervised
M : Medication
I : In
L : a Loving
E : Environment
(Grange JM, Int J Tuberc Lung Dis 1999; 3:360-362)
 Ilustrasi kasus
I, laki-laki 9 tahun, BB 22,500 kg
Kontak hemoptoe (TB ?)
Klinis baik, alergi (+)
Mt (-), Rö : konsolidasi
Feces : telur ascaris (+)
Terapi : Antihistamin
Obat cacing
Ulang Rö : konsolidasi hilang
 Ilustrasi kasus
F, laki-laki 4 bulan, BB 7,200 kg
Kontrol bayi sehat
Minta BCG Mt (+)
Rö : ada kelainan
 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 (+)
Rö : kelainan minimal / normal
LED : 23 mm/ 1 jam
Biakan M.tb : (+)
 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 (+), Rö : gambaran milier
Urine : AFB (+)