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7/5/12
Case presentation
Asthma and Tuberculosis
By:Jessieca Liusen
Lecturer:dr. Dahnul Elymbra,SpA
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TUBERCULOSIS
Definition:
Direct communicable disease caused byMycobacterium tuberculosis
Epidemiology TB in Indonesia
3rd highest score of the world 250.000 new
case and 140.000 die because of it.
1st killer among the communicable disease
3rd killer among other disease after heart
disease and acute respiratory distress
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Tuberculosis
Risk factor:
Contact with TB patients
Young age
Had HIV
Severe malnutrition
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Pathophysiology
Droplet nuclei inhalation alveolus
TB phagocyted by macrofrag
Replicated inside macrofag Form a colony Gohn complex
Gohn complex would become:
Restitution ad integrum
Cure with a scar such as fibrotic
Spread : perkontinuitatum, bronchogenic,
hematogenic, and lymphogenic
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Pathophysiology
Wallgren divided 3 type of TB inchildren:
Limphohematogenic spread
Endobronchial TB
Chronic pulmonary TB
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AnamnesisPhysical
Examination
FurtherInvestigationDiagnosis
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Ten Poin to suggest TBin children Contact to TB (+) BTA patients
Tuberculin test positive > 10 mm
Thorax rontgen suggestive for TB Eritema in 3-7 days after BCG
immunization
Cough > 3 weeks Prolong fever with unknown cause
Body weight decreased without any
clear cause or didnt get weight gain in 1
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TBNot TB
3 dari 1oitem
Suggested TB
Gave OAT for 2months and
observed
Improved Deteriorated/constant
Drugresistant TB
Reconciliate
to hospital
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Scoring to diagnosis of TB inchildrenParameter 0 1 2 3 skor
Contact to TB patients - (+) contact tonegative or
unknown BTA
patients
(+) contact topositive BTA
patients
Tuberculin test Negative Positive 10mm
or 5mm in
immunosupresivepatients
Nutrition Mild malnutrition Severe
malnutrition
Fever with unknown cause 2 weeks
Cough 3 weeks
Limphadenopati coli,
axilla, inguinal
1cm, 1 lymph
node, no pain
Swelling on bone, coxae,
phalangs
+
Thorax rontgen Normal Suggestive TB
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Diagnosis Tuberculosis
Score 6 TB
Score = 5 admitted to hospital tofurther investigate
Tuberculin test positive:
Natural TB infection
Laten TB
TB infected and suffered TB
Cured TB
BCG immunization
M cobacterium ati ic infection
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Tuberculin Test Negative
No infection for TB
Incubation period of TB
Anergy
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Score 6
Gave OAT
For 2 months and evaluate
(+) response continued
theraphy
(-) response continued
theraphy and searched for theexact cause
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Anti tuberculosis agent
1st 2 months: intensive phase
3 kinds of drugs
Rifampicin
Isoniazid
Pyrazinamide
2nd 4 months: next phase2 kinds of drugs
Rifampicin
Isoniazid
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Drug Dosage
Name Dosage Maximal dosage
Isoniazid 5-15 mg/kgBW/ day 300 mg/day
Rifampicin 10-20 mg/kgBW/day 600 mg/day
Pyrazinamid 15-30 mg/kgBW/day 2000 mg/day
Etambuthol 15-20 mg/kgBW/day 1250 mg/day
Streptomicin 15-40 mg/kgBW/day 1000 mg/day
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Follow Up
After 2 months got drugs improveclinical, weight gain, no fever, decreasecough continued theraphy
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Asthma
Definition:
Chronic inflammation with reversiblerespiratory tracts constriction
Epidemiology
Prevalence of the world 7,2% (6% for adultand 10% for children)
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Risk factor
Gender:
Male: female ratio: 3:2 for 6-11 years old
Male female ratio: 8:5 for 12-17 years old
Age
Young age persistent asthma
Atopic Environment
Race
Smoke
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Pathophysiology
Allergen respiratory tractsinflammation
Released inflammation mediators
Bronchoconstriction
Hiperventilation + additional respiratorymuscles contraction
Cough
Cough +
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Cough +wheezingHistory
Physical exTuberculin test
Suggest asthma:EpisodicNocurnal/ morning drip
After exerciseAtopic
Imprecise asthma:Start at neonateFailure to thriveChronic infectionVomit/ chokingPulmonary focal disorderCardiovascular system disorder
No facility, Check peak flowmeter or spirometer:
Revercibility 15%Variability 15%
Hiperreactivity 20%
Consider:Thorax and sinus rontgenPulmonal physiology testBronchodilator response testBronchus provocation testSweat testCilia motility testEsofagogaster reflux evaluation
Gave bronchodilator
ASTHMA
Grading and seacrhed forprecipitateIf episodic frequent/persistent: rontgen thorax
Gave anti asthma drug:Unsuccefully reevaluatediagnosis and loyalty
Didnt support other diagnosis Support other diagnosis
Diagnosis and treatmentaccording to working diagnosis
Consider asthma asparticipating disease NOT ASTHMA
Al it S A
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Algoritme Serangan Asma
Klinik / IGD
Nilai Derajat Serangan
Tata Laksana Awal Nebulisasi -agonis 3x, selang 20
Nebulisasi ke-3 + antikolinergik
Serangan Ringan(nebulisasi 1x,respons baik
bertahan 1-2 jam,boleh pulang gejala timbul lagiserangan sedang
Serangan sedang (nebulisasi 2-3x,
repons parsial) berikan O2
nilai ulang se-dang RuangRawat Sehari
pasang infus
Serangan berat(nebulisasi 3x,
respons buruk)O2 sejak awal pasang infus nilai ulang berat,Ruang Rawat Inap
foto Ro toraks
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Ruang RawatSehariOksigen teruskan Steroid oral Nebulisasi / 2 jam 8-12 jam klinisstabil boleh pulang 12 jam tetap belumbaik rawat inap
Ruang Rawat InapOksigen teruskan Atasi dehidrasi &
asidosis jika ada Steroid IV tiap
6-8 jam Nebulisasi/1-2 jam Aminofilin IV awal,
lanjutkan rumatan Nebulisasi 4-6x
baik, interval 4-6 j 24 jam stabil boleh pulang Dengan steroid &
aminofilin IV tetaptidak baik ICU
Boleh PulangBekali -agonis(hirupan / oral)
Jika ada obat pengendali,teruskan Inf.virus (+),steroid oral
24-48 jam kontrolproevaluasi
Catatan:Jika menurut penilaian serangannya berat, nebulisasi 1x,
langsung -agonis + antikolinergik Bila belum ada alatnya, nebulisasi awal dapat diganti dgnadrenalin sk. 0,01 ml/kgBB/kali, maksimal 0,3 ml/kali.
Untuk serangan sedang dan terutama berat, O2 2-4L/mntdiberikan sejak awal, termasuk saat nebulisasi
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Obat pereda: -agonis atau teofilin (hirupanatau oral) bila perlu
Tambahkan obat pengendali:
steroid hirupan dosis rendah
Pertimbangkan alternatif penambahansalah satu obat:- -agonis kerja panjang (LABA)- Teofilin lepas lambat- AntileukotrienAtau dosis steroid hirupan ditingkatkan(medium)
Steroid dosis medium ditambahkan salah
satu obat:- -agonis kerja panjang- Teofilin lepas lambat- Antileukotrien- Atau dosis steroid hirupan ditingkatkan
(tinggi)
Obat diganti steroid oral
Asma Episodik Jarang
4 6 minggu > 3x dosis/minggu
3x dosis/minggu
6-8 minggu, respons :
Asma Episodik Sering
(-) (+)
(-) (+)
(-) (+)
6-8 minggu, respons :
6-8 minggu, respons :
Asma Persisten
PE
NGHINDARAN
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Case
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Patient Identity
Name : Chd. D
Age : 1 year 9 months old
Parent : Sudadi/ Rina Tribe : Javanese
Address : Perawang
Admitted: 24 August 2011
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Anamnesis
Chief complain
Dispnea that became deteriorate since 2months before admittion
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Present Illness History
Since 2 months before admittion
Dispnea on the effort, if he took rest, itbecame well
Productive cough happened at the same timewith dispnea
Fever with unknown cause, not too high, andusually became higher at night.
Patient got drugs from pediatric policlinicat RSUD AA
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Present Illness History
He can drank mothers milk
No history of vomitting, choking
As long as dispnea happened, his skinnever became blue.
No weight loss since last 2 months
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Anamnesis
Past Illness History
Family Illness History
Parent Illness History Gestation history
Diet history
Immunization Physical growth
Mental growth
House and environment
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Physical Examination
General condition: moderate illness
Consciousness: composmentis
Vital signBP: 100/60 mmHg
Temp : 36,80C
HR : 122x/minutes
RR : 46x/minutes
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Physical Examination
Nutrition: 92% normal
Body height: 78 cm
Body weight: 10 kg
Upper arm circumference: 15 cm
Head circumference: 47 cm(normocephali)
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Physical Examination
Skin: normally
Head: normocephali, anterior fontanelalready closed
Hair: black, not easy to put off
Eye:
Conjunctiva: normally
Sclera: normally
Pupils: isochor, 2 mm
Pupil reflex : +/+
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Physical Examination
Ears: normally
Nose: normally
Lips: moist Mucosa : moist, red
Palatum: normally
Tongue: normally Teeth: normally
Neck: lymph node (-), stiffness (-)
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Physical Examination
Thorax
Inspection: simetrical movement of thoraxwall
Palpation: fremitus right and left same
Percussion: resonance, head alignmentnormally
Auscultation: wheezing
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Physical Examination
Abdomen
Inspection: flat
Palpation: flexible, no tenderness,
hepatosplenomegaly (-)
Percussion: tymphani
Auscultation: bowel sound (+) at normal rate
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Physical Examination
Genitalia: male
Extremity: warm, red, CRT < 2 seconds
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Laboratory
Hb : 9,9 g/dL
Ht : 30,2 %
Leukosit: 12600/uL Platelet : 594000/uL
LED : 50mm/jam
Diff count:Neutrophil: 37%
Lymphocite: 53%
Monocyte: 9,1%
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Working Diagnosis
Asthma and pulmonary TB
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Treatment
IVFD KAEN1B 20 gtt
Kalmetason injection 1/3 amp
1st 2 months:
Rifampicin 150 mg 1x1
Pyrazinamid 200 mg 1x1Isoniazid 200 mg 1x1
Vitamin B6 5 mg 1x1
High calory and protein diet
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PROGNOSIS
Quo ad vitam : bonam
Quo ad fungsionam : bonam
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Tanggal Subjektif Objektif Assestment Terapi
24/8/11 Sesak napas (+),
batuk (+)
T: 36,90C
N: 124x/menit
R: 50x/menit
Asma dan Susp
TB paru
IVFD KAEN1B 20 tpm
Inj kalmetason 1/3 amp
Foto thorax AP
25/8/11 Sesak napas (-),
batuk (+)
T: 37,10C
N: 121x/menit
R: 46x/menit
Asma dan TB
paru
IVFD KAEN1B dan
Inj kalmetason off
Foto thorax AP: KP duplex
Rawat jalan
Rifampisin 150 mg
Pirazinamid 200 mg
Isoniazid 200 mg
Vit B6 5 mg
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Case Analysis
Dispnea became worst since 2 monthsbefore admittion
Asthma
Pneumonia
Bronchiolitis
Congenital heard disease
Corpus alienum aspiration
Pulmonary TB
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Case Analysis
Precipitation factor: activity
Happened at same time with cough
Fever since 2 months
Asthma
Pneumonia Bronchiolitis
TB pulmonary
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Patient ate and drank as usual
No blue history when dispnea occurred
It wasnt congenital heard disease orpneumonia
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No weight loss since last 2 months didnt mean that it wasnt TB
Positive family history for asthma uncle
Complete history of immunization mantoux test became false positive
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Scoring to diagnosis of TB inchildrenParameter 0 1 2 3 skor
Contact to TB patients - (+) contact to
negative or
unknown BTA
patients
(+) contact to
positive BTA
patients
2
Tuberculin test Negative Positive 10mm
or 5mm in
immunosupresive
patients
0
Nutrition Mild malnutrition Severe
malnutrition
0
Fever with unknown cause 2 weeks 1
Cough 3 weeks 1
Limphadenopati coli,
axilla, inguinal
1cm, 1 lymph
node, no pain
0
Swelling on bone, coxae,
phalangs
+ 0
Thorax rontgen Normal Suggestive TB 1
Ten Poin to s ggest TB
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Ten Poin to suggest TBin children Contact to TB (+) BTA patients
Tuberculin test positive > 10 mm
Thorax rontgen suggestive for TB
Eritema in 3-7 days after BCGimmunization
Cough > 3 weeks Prolong fever with unknown cause
Body weight decreased without any
clear cause or didnt get weight gain in 1
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Analysis
More than 3 poins suggest TB gave antituberculosis agent
Cough +wheezing
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HistoryPhysical ex
Tuberculin test
Suggest asthma:EpisodicNocurnal/ morning dripAfter exerciseAtopic
Imprecise asthma:Start at neonateFailure to thriveChronic infectionVomit/ chokingPulmonary focal disorderCardiovascular system disorder
No facility, Check peak flowmeter or spirometer:
Revercibility 15%Variability 15%
Hiperreactivity 20%
Consider:Thorax and sinus rontgenPulmonal physiology testBronchodilator response testBronchus provocation testSweat testCilia motility testEsofagogaster reflux evaluation
Gave bronchodilator
ASTHMA
Grading and seacrhed forprecipitateIf episodic frequent/persistent: rontgen thorax
Gave anti asthma drug:Unsuccefully reevaluatediagnosis and loyalty
Didnt support other diagnosis Support other diagnosis
Diagnosis and treatmentaccording to working diagnosis
Consider asthma asparticipating disease NOT ASTHMA
Asthma Treatment for
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Asthma Treatment forthe patient Kalmetason/ dexametason intravena 1/3
amp = 1,3 mg a day
Steroid bolus dosage : 0,5-1
mg/kgBW/day.
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Antituberculosis Agent
Rifampicin 150 mg 1x1, dosage 15mg/kgBW/day
Pyrazinamid 200 mg 1x1, dosage 20
mg/kgBW/day Isoniazid 200 mg 1x1, dosage 20
mg/kgBW/day
Vitamin B6 5 mg 1x1
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Thank You