Chapter 4 Cough or difficult breathing Case III

Case study: Mary is an 10 year old girl with cough and weight loss for some weeks

What are the stages in the management in Mary’s case?

Stages in the management of a sick child (Ref. Chart 1, p. xxii) Triage Emergency treatment History and examination Laboratory investigations, if required Main diagnosis and other diagnoses Treatment Supportive care Monitoring Plan discharge Follow-up

Triage: emergency or priority signs? Temperature: 38.3 0C Pulse: 136/min RR: 44/min with mild chest indrawing and use of accessory muscles to breathe Thin looking. Speaks in short sentences, but with a quiet voice. Pulse oximetry (SpO2): 93% at rest, falls to 88% on exertion.

Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns

History Mary has had cough for months. She has difficult breathing on exertion, and her mother said she had not been playing as much as before, and had not attended school for 3 weeks. She had received 2 courses of medicine, the last one 2 weeks ago, but the cough persisted. She sometimes felt hot and perspired a lot according to her mother. Mary’s appetite had been poor in recent weeks, and she had lost weight. Mary’s grandmother had been treated for TB when Mary was 4 years of age. Mary’s parents and younger brother (age 4) and sister (age 2) are well .

Additional questions on history Night sweats? Purulent sputum? Wheeze? Personal or family history of asthma? Paroxysms of cough? Other symptoms of HIV (e.g. persistent diarrhoea, mouth sores) Vaccinations (? BCG, ? DTP) (Ref. p. 110)

Examination Mary had fast breathing, mild chest indrawing, and use of accessory muscles, which increased when she moved to sit up on the bed. She had no cyanosis, but had finger clubbing. MUAC: 14.5 cm, Weight 22 kg, Height 130 cm BMI = 22 / 1.32 = 13 (<18 = severe underweight) Chest: dullness to percussion and increased breath sounds over right chest at the back, crackles throughout Cardiovascular: two heart sounds heard, but chest very crackly Abdomen: palpable liver 4 cm below the RCM Neurology: tired but alert

Differential diagnoses of chronic cough TB Asthma Foreign body Pertussus HIV Bronchiectasis Lung abscess (Ref. p. 110)

What investigations would you like to do to make your diagnosis ?

Investigations Chest x-ray: (Ref. p. 116)

Investigations Mantoux test Sputum smear for acid fast bacilli In younger children, gastric aspirate or induced sputum smear microscopy for acid-fast bacilli GeneXpert MTB/Rif if available and if MDR suspected HIV testing should be offered (Ref. p. 115-116)

Diagnosis Summary of findings: Cough for months, unresponsive to antibiotics Family history of TB Chest crackles Clubbing Pulmonary Tuberculosis (Ref. 4.7.2, p. 115)

How would you treat Mary?

Treatment How many drugs in Intensive Phase for Mary’s PTB, and what does this depend on? (check p. 117) Intensive Phase: Four drugs for 2 months if: high HIV prevalence or high H resistance, or severe lung disease Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E) – now dispensed as Fixed Dose Combination Therapy (see Standard Treatment Manual for exact doses) Maintenance Phase: RH for 4 months

What supportive care and monitoring are required?

Supportive Care Oxygen Nutritional support Ready-to-use-therapeutic feeds (Plumpy-nut), balanced diet Schooling, entertainment and privacy while in hospital Mary should stay in hospital for the full 2 months of the Intensive Phase Many children relapse if sent home before completing IP, and develop worse forms of TB Staff protection: wear N95 mask until sputum smear negative (check weekly)

Monitoring treatment and complications Adherence: Direct observation of each dose Temperature SpO2 Weight gain Exercise tolerance (Ref. p. 117)

Public health measures Register every TB patient with National TB Program and Disease Control Office Check all household contacts, and school contacts if appropriate, for undetected TB Who should receive Isoniazid preventative therapy? (Ref. p. 118) <5 years of age, household or close contacts No active TB 6 months Isoniazid preventative therapy (Ref. p. 117)

When to suspect MDR History of previous treatment for TB within the past 6-12 months Close contact with MDR-TB Close contact with a person who has died from TB, or failed TB treatment Failure to improve clinically after 2 months of DS-TB treatment, including: Persistence of +ve smears or cultures Persistence of symptoms Failure to gain weight (x-ray changes often are slower to improve) (Ref. p. 117)

Contact screening On further questioning Mary’s mother had cough, and sputum smear was heavily positive for TB Mary’s sister and brother were clear of symptoms, and were well nourished and active Mary’s father was well, normal chest xray Contact screening can be “symptom-based screening” if x-ray and sputum microscopy not available If no symptoms and child <5 years, start IPT If symptoms refer for CXR, Mantoux. (Ref. p. 117)

Follow-up When can Mary be discharged? Completed Intensive Phase (2 months) Nutrition improved Not hypoxic, with good exercise tolerance Family screening done Reliable and committed community treatment supervisor identified A program of “active follow-up”, where a TB outreach nurse visits Mary and her family at their home, can reduce defaulting from TB treatment. During follow-up at home or in the hospital, TB outreach nurse can do the following things… (Ref. p. 118)

Summary Mary, 10 year old girl with weight loss and chronic cough. Pulmonary TB. Severe lung disease (so 4 drugs in intensive phase), HIV negative. Can only be properly treated by 2 full months of hospital care during the IP – so make hospitals child friendly and safe. While in hospital identify a reliable and committed community treatment supervisor Regular follow-up in the home by a TB outreach nurse

Summary A missed opportunity for prevention, as Mary did not have screening and IPT when her grandmother was treated for TB Active case finding and follow-up needed for Mary’s family: TB treatment for mother, ITP for sister and brother