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Case Conference De Vera, Dela Cruz, Dela Cruz, Dela Cruz, Dela Rosa, Dimalala.

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Presentation on theme: "Case Conference De Vera, Dela Cruz, Dela Cruz, Dela Cruz, Dela Rosa, Dimalala."— Presentation transcript:

1 Case Conference De Vera, Dela Cruz, Dela Cruz, Dela Cruz, Dela Rosa, Dimalala

2 General Data J.T. 6 years and 2 months old, Female 416 Hernandez 2 nd St. Sampaloc Manila Roman Catholic Filipino Informant: Mother Reliability: Good

3 CHIEF COMPLAINT: Right lateral cervical mass

4 History of Present Illness 9 days PTC: patient had productive cough with whitish phlegm, no fever, no colds -no medications and consultations done -resolved after 2 days 7 days PTC: appearance of mass on the left lateral part of the neck. -progressed in size and became tender -sought consult = MUMPS no medications given -progression in size

5 REVIEW OF SYSTEMS No weight loss, no weight gain No rashes, no jaundice, no pruritus, alopecia No dizziness, no lacrimation, no hearing difficulties, no aural discharge, no toothache, no sore throat No chest pain, no difficulty of breathing No cyanosis, no easy fatigability No abdominal pain, change in bowel movements, melena, hematochezia No hematuria, no frequency, no discharge, no edema, anuria, oliguria, dysuria No tremors, no convulsions, no behavioral changes No polyuria, polydipsia, polyphagia, no heat/cold intolerance No weakness, no joint swellings, no limitation of motion No pallor, no bleeding, no easy bruisability

6 Family History (+) Hypertension – maternal and paternal grandparents (+) Diabetes – maternal aunt (+) Bronchial asthma – cousins (+) allergy – mother (fish) (-) tuberculosis, cancer, seizure, blood dyscrasia, renal, congenital anomalies

7 Past Medical History 2 years old: German measles No previous hospitalizations and operations

8 Family membersAgeOccupationCondition Father30 years oldEmployeeHealthy Mother29 years oldHousewifeHealthy Sibling (Justine Richie)7 years oldGrade 1Healthy Sibling (Jama Lian)3 years old Sibling (Jermaine)2 years old

9 Environmental History The patient lives with both parents and siblings in a concrete house, well-lit, and well ventilated. No factories are nearby. Pets: none Garbage is collected everyday by a garbage truck, not properly segregated

10 Physical Examination Conscious, coherent, alert, ambulatory, well looking, well hydrated, not in cardio- respiratory distress BP: 90/60 CR: 96, regular RR: 18, regular Temp: 36.5 C Ht: 115cm z = 0 Wt: 21.2 kg z = 0 BMI: z = 0

11 Physical Examination Skin: warm, moist skin, no lesions Head: normocephalic, thick shinny hair, no hair nits, no hair lice, no tenderness, no palpable masses Eyes: no swelling, lids not matted, pink palpebral conjunctiva, anicteric sclera, pupils 2-3 mm ERTL Ears: no swelling, no tragal tenderness, nonhyperemic EAC, impacted cerumen AU Nose: no discharge, turbinates not congested, midline septum Mouth/ Throat: moist buccal mucosa, nonhyperemic posterior pharyngeal wall, tonsils not enlarged, no dental caries, no oral ulcers

12 Neck: supple neck, (+) 5cm x 3cm non movable, tender mass on the left retroauricular extending up to the angle of the mandible Lung/ Chest: no intercostal and supraclavicular retractions, symmetrical chest expansion, clear breath sounds, equal vocal fremiti Heart: adynamic precordium, apex beat at 4 th Left ICS MCL, S1>S2 apex, S2>S1 base, no heaves, thrills, murmurs

13 Abdomen: flat abdomen, normoactive bowel sounds, soft, nontender, no palpable masses Extremities/ Pulses: pulses full and equal, no deformities, no cyanosis, no edema Neurologic examination: unremarkable

14 Salient Features: 6 years old Filipino Sampaloc, Manila (+) non productive cough (+) 5cm x 3cm non movable, tender mass on the left retroauricular extending up to the angle of the mandible (-) TB exposure


16 RIGHT LATERAL CERVICAL MASS Presenting Manifestation

17 Cervical Lymphadenopathy in children Infectious Bacterial Viral Non-infectious Connective tissue disorders Leukemia Lymphoma Kawasaki disease Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) Medications


19 Approach to Diagnosis History – Duration and laterality of adenopathy and change in size over time – Associated symptoms – Ill contacts – Ingestion of unpasteurized animal milk or undercooked meats – Dental problems or mouth sores – Skin lesions or trauma – Animal exposures – Immunization status – Medications – Geographic location and travel

20 Approach to Diagnosis Physical examination – Examination of the lymphatic system, including assessment of the liver, spleen, cervical lymph nodes, and noncervical lymph nodes should be performed. Hepatosplenomegaly with generalized adenitis indicates a possible infection with EBV, CMV, HIV, histoplasmosis, TB, or syphilis. These findings also may be signs of neoplastic disease, collagen vascular disease, or other noninfectious etiology

21 Approach to Diagnosis Physical examination – The lymph node number, location, size, shape, consistency, tenderness, mobility, and color should be recorded. "Reactive" lymph nodes are usually discrete, mobile, feel rubbery, and are minimally tender. Infected lymph nodes are usually isolated, asymmetric, tender, warm, and erythematous; they may be fluctuant; they are less mobile and discrete than reactive lymph nodes. Malignant lymph nodes often are hard, fixed or matted to the underlying structures; they are usually nontender. – Oral cavity periodontal disease, herpangina, gingivostomatitis, or pharyngitis – Eyes Conjunctival injection – Skin generalized rash, pustular or papular lesions

22 Differentials Non-Infectious Causes Patient: 6y.o./ FemaleCollagen vascular diseasesMalignancy (+) 5x3cm, unilateral, semi- solid, tender, cervical mass on the left retroauricular area, extending to the angle of the mandible 1 week duration nontender, firm, rubbery, and matted. Persistent or progressive lymphadenopathy that does not respond to antibiotic therapy suggests the need for more extensive evaluation Weeks to months (+) cough for 2 days (-) colds (-) fever (-) weight loss (-) failure of weight gain Prolonged fever, rash, and arthralgias Fever, weight loss, Musculoskeletal pain, headache, mediastinal mass, testicular enlargement, peripheral blood abnormalities

23 Differentials Infectious Causes Patient: 6y.o./ Female Bacterial InfectionViral InfectionTB Infection (+) 5x3cm – progressive in size, unilateral, semi- solid, tender (initially non- tender), fixed, mass on the left retroauricular area, extending to the angle of the mandible 1 week duration Most often unilateral; but can be bilateral; usually is 3 to 6 cm in diameter, tender, warm, erythematous, nondiscrete, and poorly mobile variable most often bilateral some can be generalized; small, rubbery, mobile, discrete, minimally tender, and without erythema or warmth variable unilateral nontender firm discrete mass or matted nodes, fixed sometimes accompanied by overlying skin induration; submandibular and supraclavicular lymph node involvement also occurs Weeks to months

24 Differentials Infectious Causes Patient: 6y.o./ Female Bacterial InfectionViral InfectionTB Infection (+) cough for 2 days (-) colds (-) fever (-) weight loss (-) failure to gain weight history of a recent URI or impetigo; fever, tachycardia, and malaise may be present, the patient usually does not appear toxic history of an ill contact and current or recent symptoms that may include sore throat, rhinorrhea, nasal congestion, and/or cough Cough/ wheezing of 2 or more weeks Unexplained fever of 2 or more weeks; loss of appetite, loss of weight, failure to gain weight; failure to regain previous state of health after infection; fatigue, reduced playfulness or activity

25 T/C PRIMARY TUBERCULOSIS Clinical Impression

26 Approach to Diagnosing a TB symptomatic child who has no/unknown exposure (+) signs/ symptoms of TB TB Close contact of a source case No/Unknown0-4 years old5-9 years oldYes… Tuberculosis in Infency and Childhood 3rd ed PPS, Inc. p.123

27 5-9 years old Can produce sputum? NOTSTNegative Evaluate further and refer PositiveTB DiseaseDSSMNegativePositive Tuberculosis in Infency and Childhood 3rd ed PPS, Inc. p.123


29 Traditional and New Diagnostic Approaches DIAGNOSTICSAPPLICATIONS Traditional approaches - Symptom-based -TST -TB Culture -- AFB smear -- Chest radiograph Probable active TB Evidence of MTB Infection Bacteriologic Confirmation of active TB Probable Active TB New Diagnostic Approaches ORGANISM BASED -Colorimetric cultures systems -- phage based test -- Microscopic- based observation drug susceptibility (MODs) assay Bacteriological confirmation of active TB Probable active Tb and detection of rifampin resistance Probable active TB and detection of resistance

30 Traditional and New Diagnostic Approaches DIAGNOSTICSAPPLICATIONS New Diagnostic Approaches ANTIGEN BASED ASSAYS -LAM detection assay IMMUNE BASED ASSAY -Antibody based assay --MPB-64 skin test -- T- Cell assays SYMPTON BASED -Symptom based screening -Refined symptom based Diagnosis Probable active TB Diagnosis of Latent TB infection Screening child contacts of adult TB cases Probable Active TB

31 Diagnosis of TB A positive culture with or without a positive smear for M. Tuberculosis is the gold standard for the diagnosis of TB In the absence of bacteriologic evidence, a child is presumed to have active TB if > 3 crteria are present: Exposure to an adult/Adolescence with active TB (EPIDEMIOLOGIC) Signs and symptoms suggestive of TB (CLINICAL) Positive tuberculin test (IMMUNOLOGIC) Abnormal chest radiograph suggestive of TB (RADIOLOGIC) Other lab findings suggestive of TB (LABORATORY)

32 OUR PATIENT TST – 12 mm induration Chest X –ray showed evidence of primary infection Signs and symptoms of TB

33 Chest X- ray of the patient 11/24/10

34 Management of Tuberculosis

35 Objectives of Drug Therapy in TB: 1.Cure the patient of TB 2.Prevent death from active TB 3.Prevent relapse of TB 4.Prevent the development of drug resistance 5.Decrease transmission

36 Phases of Treatment Intensive Phase - efficient killing of actively dividing organisms - relief of symptoms - terminates transmision - prevents emergence of drug resistance Continuation Phase - kills irregularly dividing bacilli - sterilizes lesions and prevent relapse

37 Drug Administartion The optimal dosing frequency for new patients with pulmonary TB is daily throughout the course of therapy. Alternative Regimens: (1)A daily intensive phase followed by tree times weekly continuation phase [2HRZE/4H 3 R 3 ], provided that each dose is directly observed (2)Three times weekly dosing throughout the therapy [2H 3 R 3 Z 3 E 3 /4H 3 R 3 ], provided that every dose is directly observed.

38 Essential Anti-Tuberculosis Drugs DRUGMOADOSE RANGE Single daily dose mkd 3X weekly mkd INH-Bactericidal agent --Acts on extracellular and intracellular bacillary populations -- presumed to inhibit biosynthesis of mycolic acid (cell wall component ) and effects glycolysis, nucleic acid synthesis Max 300 mg Max 900 mg Rifampicin-Bactericidal agent --Acts on extracellular and intracellular bacillary populations -- inhibits nucleic acid synthesis Max 600 mg Max 600 mg

39 Essential Anti-Tuberculosis Drugs DRUGMOADOSE RANGE Single daily dose mkd 3X weekly mkd Pyrazinamide-- weak bactericidal but with potent sterilizing activity within macrophages, areas of acute inflammation Max 2 g 50 mg Max 2 g Streptomycin- Bactericidal20-40 max 1 g Ethambutol-Bacteriostatic, but with some bactericidal action at higher doses -- acts on intra and extracellular bacillary populations -- presumed to inhibit synthesis of mycolic acid (cell wall component) Max 1.2 g Max 2.5 g

40 Essential Anti-Tuberculosis Drugs DRUGADVERSE REACTIONS INH -- peripheral neuropathy -Other neurological disturbance, optic neuritis, toxic psychosis, generalized convulsions -- systematic or cutaneous hypersensitivity reactions during the first week of treatment -- hepatotoxicity Rifampicin-Gastrointestinal intolerance -- if intermittent adminidtration: rash, fever, thrombocytopenia, flu like symptoms -- increases risk of hepatotoxicity if used with INH Pyrazinamide-- hypersensitivity reactions --moderate rise in trasaminase levels -- Hyperuricemia -- arthralgia, particularly of shoulders

41 Essential Anti-Tuberculosis Drugs DRUGADVERSE REACTIONS Streptomy cin -- sterile abscess -- vestibular, auditory function impairment -- hemolytic anemia Ethambut ol -- retrobulbar neuritis ( reduced visual acuity, contraction of visual fields, green red color blindness)

42 TREATMENT 21 kg Isoniazid 200 mg/5mL (10 mkd) Give 5.5 mL once daily 30 minutes before breakfast Rifampicin 200mg/5mL (10 mkd)- Give 5.5 mL once daily, 30 minutes before breakfast Pyrazinamide 500 mg/5mL (20 mkd) Give 4.5 mL once daily, 30 minutes before breakfast Ethambutol 400 mg/tab (20 mkd) - 1 tab Give 1 tab once daily, 30 minutes before breakfast

43 Supportive Management Multivitamins 5 mL once a day Anticipatory Guidance

44 Tuberculosis

45 Tuberculosis A Global Emergency One third of the worlds population is infected TB kills 5,000 people a day – 2-3 million each year HIV and TB co-infection is producing explosive epidemics Hundreds of thousands of children will become TB orphans this year MDR threatens global TB control

46 Background Tuberculosis (TB) is increasing among adults in many areas TB is major cause of childhood morbidity and mortality worldwide Limited information on epidemiology of TB in children

47 Childhood TB Why neglected? – Not considered important in global program or contributing to immediate transmission – Not regarded as public health risk – Difficult to diagnose Why is it important? – Health problem in children – May later contribute to epidemic

48 Leading Infectious Disease Causes of Death, WHO Report 2000

49 TB in Children WHO estimate of TB in children – 1.3 million annual cases – 450,000 deaths 15% of TB in low-income countries children vs. 6% in United States

50 Childhood TB as Sentinel Event Indicates recent transmission in a community Rapid progression from infection to disease A deterioration in the control of TB thus immediately hurts the youngest generation (Rieder, 1997) Children are future reservoir of disease Rieder H. Anales Nestle, 1997

51 Childhood TB diagnosed by: Combination of : Contact with infectious adult case Contact with infectious adult case Symptoms and signs Symptoms and signs Positive tuberculin skin test Positive tuberculin skin test Suspicious CXR Suspicious CXR Bacteriological confirmation Bacteriological confirmation Serology Serology

52 Risk factors : infection to disease HIVMalnutrition Recent exposure Young age Short incubation period More severe Highest risk More difficult to diagnose Host factors Effect of HIV?

53 Tuberculous Infection Among Children by Type of Contact and Bacteriologic Status of Index Case, British Columbia and Saskatchewan, Percent infected Grzybowski S, et al. Bull Int Union Tuberc 1975;50: Close Casual

54 Challenges for Surveillance Difficult diagnosis of childhood TB Lack of standard case definition Increased extrapulmonary disease Low public health priority of childhood TB

55 WHO Estimated Total Cases by Age, 2000 CountryTotal CasesCases <15 yrs% in Children India1,815,740185, China1,645,703 86, Indonesia 581,918 15, Bangladesh 325,110 33, Nigeria 261,404 32, Pakistan 244,736 61, Philippines 230,217 12, South Africa 220,486 35, Russian Fed. 183,373 7, Ethiopia 178,349 28, Dem. Rep. Congo 148,598 24,

56 WHO Estimated Total Cases by Age, 2000 CountryTotal CasesCases < 15 yrs% in Children Viet Nam 143,023 7, Kenya 137,60322, Tanzania 117,48918, Brazil 113,52823, Thailand 85,928 2, Myanmar 78,489 8, Zimbabwe 76,296 12, Uganda 75,250 12, Cambodia 75,045 3, Afghanistan 69,342 17, Mozambique 47,909 7, TOTAL6,856,537659,3979.6

57 Extrapulmonary TB in Children Proportion in a given country could be used as measure of case detection – 25-44% of all childhood TB in Ugandan study – 43% of children in Ethiopian study – 21.3% of childhood TB using US surveillance data

58 TB and BCG Vaccination Efficacy for adult pulmonary TB 0-80% in randomized clinical trials Best efficacy against serious childhood disease – 64% protection against TB meningitis – 78% protection effect against disseminated TB BCG important for young children, inadequate as single strategy Colditz GA et al. JAMA 1994; 271:

59 Relationship between TB and HIV HIV prevalence adults years Estimated TB incidence (per population) What about children? What about children?

60 History of M. tuberculosis Phthisis (Greek) known since ancient times Often thought of as a hereditary condition 1854 first sanatorium 1882 Koch demonstrated relationship between germ and disease 1895 Roentgen discovery of diagnostic x-ray 1940s-1950s chemotherapy

61 Around the World An estimated 1.58 million deaths occurred in 2005 from TB disease 8.8 million new TB cases estimated for /3 of world population has TB infection


63 High Burden Countries (WHO) Afghanistan Bangladesh Brazil Cambodia China Democratic Republic of the Congo Ethiopia India Indonesia Kenya Mozambique Myanmar Nigeria Pakistan Philippines Philippines Russian Federation South Africa Thailand Uganda United Republic of Tanzania Viet Nam Zimbabwe

64 Transmission and Pathogenesis

65 Pathogenesis Inhale droplet nuclei Bacteria multiplies Macrophages consume bacteria, then die Travel through the bloodstream, lymph system Containment-infection Multiplication-disease

66 Generation of TB Droplet Nuclei One cough produces 500 droplets The average TB patient generates 75,000 droplets per day before therapy This drops to 25 infectious droplets per day within 2 weeks of effective therapy

67 Factors Affecting TB transmission Characteristics of source case Environment Factors increasing risk for contacts

68 Classification System for TB


70 Risk Factors for the Development of TB Disease

71 Signs/Symptoms Productive cough 3 weeks or longer Shortness of breath Chest pain Hemoptysis Night sweats/fever/chills Unexplained weight loss Fatigue

72 Suspect TB: Chest x-ray Location of the infiltrate Presence of a cavity Hollow areas, dense areas, fluid on the lung or at margins Normal x-ray = usually no infectious TB disease

73 Chest Radiograph Abnormalities often seen in apical or posterior segments of upper lobe or superior segments of lower obe May have unusual appearnce in HIV+ patients

74 Sputum Collection Sputum specimens are essential to confirm TB Sputum: mucus from within the lung, not Saliva 3 specimens on 3 different days Spontaneous morning sputum more desirable than induced specimens

75 Sputum AFB Smear

76 AFB Smear: Tubercle bacilli

77 Cultures Use to confirm dx of TB Culture all specimen Result in 4-14 days when liquid medium systems used Susceptibility testing

78 Drug Susceptibility Testing

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