1. CASE CONFERENCE Ang, Kevin Aningalan, Arvin Antonio, Aby Aramburo, Jan Cruel, Anna

2. General Data J.R. 1 yr and 11 mos, Female Santa Cruz, Manila Filipino, Roman Catholic Informant: Mother Reliability: 85%

3. History of Present Illness Mother palpated 1x1cm movable, firm, non-tender mass over R lateral aspect of neck No other symptoms noted 6 weeks PTC

4. History of Present Illness Patient experienced intermittent low- grade fever (37.8°C), occurring at night time, not relieved by paracetamol No accompanying symptoms – no anorexia – no weight loss – no cough – no colds – no medications given – no consult given 2 weeks PTC

5. History of Present Illness Patient experienced fever, now accompanied with cough and colds with clear discharge (-) anorexia (-) weight loss (-) irritable (-) difficulty of breathing 8 days PTC

6. History of Present Illness Patient sought consult at OPD – (+) boggy turbinates – (+) cervical lymphadenopathy, 1x1cm movable, firm, non-tender over R lateral aspect of neck Assessment: to r/o PTB Plans: PPD, CXR, to follow-up with results 5 days PTC

7. History of Present Illness PPD test: 10mm CXR PA and Lateral: suggestive of Primary Koch’s Consult

8. Review of Systems (-) weight loss, (-)anorexia (-) itchiness, pigmentation, rash, active dermatoses (-) blurring of vision, redness, itchiness, Iacrimation (-) deafness, tinnitus, aural discharge (-) anosmia, epistaxis, sinusitis, nasal discharge (-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion (-) chest pain, nocturnal dyspnea, palpitation, syncope, edema (-) phlebitis, varicosities, claudication (-) dysphagia, nausea, vomiting, retching, hematemesis, melena, hematochezia, belching, indigestion, diarrhea, constipation (-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia (-) joint stiffness, joint pain, muscle pain, cramps (-) heat-cold intolerance, polydipsia, polyphagia, polyuria (-) headache, depression, seizures

9. Past Medical History No Previous Surgeries Past Medical Illnesses – Acute pyelonephritis (January 2009) – Acute rhinitis (February 2009) – Acute nasopharyngitis, probably viral (September 2009) Immunizations: complete Hepa B1,2,3 Hib 1,2,3 DPT 1,2,3 booster BCG OPV 1,2,3 booster Measles Allergies: none

10. Family History (+) Hypothyroidism – mother (+) Hypertension – mother (+) DM – grandfather (+) PTB – uncle who stays at home with patient (-) Cardiovascular diseases, stroke

11. Family Profile FamilyAgeOccupationHealth Status Father: V.R.34SeamanHealthy Mother: M.R.31HousewifeHealthy Sister: L.R.4N/AHealthy

12. Gestational and Birth History Patient born to a 31 y/o G2P1 unemployed housewife married to a 34 y/o seaman With regular prenatal check-up since 7 weeks AOG. Denied illnesses during the entire pregnancy Known case of hypothyroidism, maintained on levothyroxine Outcome was live term singleton female delivered via NSD AS 8,9 MT 38-39 wks AGA BW 3.01 BL 47 HC 33.5 CC 31.5 AC 30. No complications Advised to have TSH, T3 and T4 on the 72 nd HOL.

13. TSH, T3, T4 ValueInterpretationNormal Values T30.5 nM/LDecreased1.16-4.00 nM/L T4191 nM/LNormal106-256 nM/L TSH6.13 uiU/mlNormal0.7-15.4 uIU/ml

14. Physical Examination General Survey: Conscious, awake, not in cardiorespiratory distress Vital Signs: HR 90bpm RR 20cpm T 36.7 o C Anthropometric Data: 82.5cm (Z score above 0) Weight: 15kg (Z score above 0) HC: 48 CC: 48 AC: 49 BMI: 21.77 Skin: Warm moist skin, no rashes, no jaundice, no active dermatosis Head: Normocephalic, pink palpebral conjunctiva, anicteric sclera, isochoric pupils, midline septum, no alar flaring, (+) nasoaural discharge, turbinates congested, no oral ulcers, moist buccal mucosa, non- hyperemic pharyngeal wall, tonsils not enlarged, no aural pits or tags, no tragal tenderness, nonhyperemic EAC, intact TM, AU

15. Physical Examination Adynamic precordium, apex beat at 4 th LICS, MCL, no lifts, no heaves, no thrills, S1>S2 at the apex, S2>S1 at the base, (-) S3, (-) murmurs Supple neck, (+) cervical lymphadenopathy, trachea at midline Symmetrical chest expansion, no barrel chest, no supraclavicular retractions, clear breath sounds, (-) wheezes, (-) crackles Abdomen flabby, no scars, normoactive bowel sounds, tympanitic all over, no direct or rebound tenderness, no masses

16. Salient Features SUBJECTIVEOBJECTIVE 1 year and 11 mos, Female Exposure to relative with PTB disease at home (+) 2 week duration of intermittent low-grade fever (37.8°C), occurring at night time, not relieved by paracetamol (+) 8 day duration of cough, colds, clear discharge (+) cervical lymphadenopathy in R lateral aspect of neck PPD: 10mm CXR suggestive of Primary Koch’s infection

17. Approach to Diagnosis

18. Presenting Manifestation (+) cervical lymphadenopathy 1x1cm movable, firm, non-tender over R lateral aspect of neck 2 week history of cough and colds with intermittent low-grade fever (37.8 o C), occurring at night time PPD test: 10mm CXR PA and Lateral: Normal PE (+) nasoaural discharge, turbinates congested

19. History Key points we have to consider: – First, are there localizing symptoms or signs to suggest infection or neoplasm in a specific site? – Second, are there constitutional symptoms such as fever, weight loss, fatigue or night sweats to suggest disorders such as tuberculosis, lymphoma, collagen vascular diseases, unrecognized infection or malignancy? – Third, are there epidemiologic clues such as occupational exposures, recent travel or high-risk behaviors that suggest specific disorders?

20. Physical examination When lymphadenopathy is localized, the clinician should examine the region drained by the nodes for evidence of infection, skin lesions or tumors Other nodal sites should also be carefully examined to exclude the possibility of generalized rather than localized lymphadenopathy Lymph node Characteristics: – Size – Pain/ Tenderness – Consistency – Matting – Location

21. Lymphadenopathy Regional Lymphadenopathy General Lymphadenopathy Infectious EtiologyNon infectious Etiology Viral Infection Bacterial Infection Mycobacterial Infection Malignancy Kawasaki disease Cervical Lymphadenopathy

22. Common problem in children. Cervical nodes drain the tongue, external ear, parotid gland, and deeper structures of the neck, including the larynx, thyroid, and trachea. Adenopathy is most common in cervical nodes in children and is usually related to infectious etiologies.

23. PatientLymphomaGroup A Sreptococcal infections ( pharyngitis, otitis media, cellulitis, impetigo) Infectious Mononucleos is Mycobacteria l Clinical findings 2 weeks Fever Colds Fever, night sweats, weight loss in 20 to 30% of patients Fever, sorethroat Fatigue, malaise, fever, sorethroat Fever/ cough > 2 weeks Poor weight gain PE findings movable, firm, non-tender R lateral aspect of neck Congested nasal turbinates Tonsils not enlarged Very firm, rubbery nodes Cervical nodes warm, erythematous, and tender Pharyngeal exudates Firm tender nodes that are not warm or erythematous Hepat osplenomegal y Painless, firm/matted cervical nodes

24. Primary Tuberculosis Infection Epidemiology: TB is endemic in the Philippines The majority of children with tuberculosis infection develop no signs or symptoms at any time. Non-specific signs & symptoms

25. Signs and Symptoms Cough of more than 2 weeks duration Fever of more than 2 weeks duration Painless cervical and/or other lymphadenopathies Poor weight gain Failure to make a quick return to normal health after infection Failure to respond to appropriate antibiotics

26. Tuberculin Skin test Screening test of high risk individuals Used to determine – Latent TB infection – Infected persons Measure of a person’s cellular immune responsiveness

27. Interpretation ≥ 5mm – Non BCG vaccinated – < 5 years old ≥ 10mm – BCG vaccinated – < 5 years old with positive exposure ≥ 15mm – > 5 years old with or without BCG

28. Assessment Pulmonary tuberculosis Disease

29. Diagnosis Skin tests AFB Staining Culture and sensitivity Chest x-ray Chest CT scan and MRI

30. Tuberculin Skin Test The recommended TST is the Mantoux test. The dosage of 0.1 mL or 5 TU purified protein derivative (PPD) should be injected intradermally into the volar aspect of the forearm using a 27-gauge needle. 48-72 hours after administration measure the amount of induration and not erythema

31. Tuberculin Skin Test Induration of 5 mm or more is considered a positive TST result in the following children: Children having close contact with known or suspected contagious cases of the disease, including those with household contacts with active tuberculosis whose treatment cannot be verified before exposure Children with immunosuppressive conditions (eg, HIV) or children who are on immunosuppressive medications Children who have an abnormal chest radiography finding consistent with active tuberculosis, previously active tuberculosis, or clinical evidence of the disease

32. Tuberculin Skin Test Induration of 10 mm or more is considered a positive TST result in the following children: Children who are at a higher risk of dissemination of tuberculous disease, including those younger than 5 years or those who are immunosuppressed because of conditions such as lymphoma, Hodgkin disease, diabetes mellitus, and malnutrition Children with increased exposure to the disease, including those who are exposed to adults in high-risk categories (eg, homeless, HIV infected, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized persons); those who were born in or whose parents were born in high- prevalence areas of the world; and those with travel histories to high-prevalence areas of the world

33. Tuberculin Skin Test Induration of 15 mm or more is considered a positive TST result in children aged 5 years or older without any risk factors for the disease

34. Tuberculin Skin Test – False-positive reactions often are attributed to asymptomatic infection by environmental nontuberculous mycobacteria (due to cross- reactivity). – False-negative results may be due to vaccination with live-attenuated virus, anergy, immunosuppression, immune deficiency, or malnutrition.

35. AFB Staining staining of AFB provides preliminary confirmation of the diagnosis Staining can also give a quantitative assessment of the number of bacilli being excreted (eg, 1+, 2+, 3+).

36. Culture and Sensitivity Definitive diagnosis of tuberculosis depends on isolation of the organism from secretions or biopsy specimens. Culture of mycobacterium is the definitive method to detect bacilli Gastric aspirates are used in lieu of sputum in very young children (<6 y) who usually do not have a cough deep enough to produce sputum for analysis

37. Chest X-ray classic diagnostic tool when evaluating patients for pulmonary tuberculosis. Radiologic findings: Parenchymal involvement (acinar consolidation, atelectasis) Lymph node involvement ( hilar or paratracheal LN enlargement) Airway involvement ( hyperaeration, segmental atelectasis, collapse) Pleural involvement

38. CT scan and MRI not routinely indicated when chest radiography findings are unremarkable can help demonstrate hilar lymphadenopathy, endobronchial tuberculosis, pericardial invasion, and early cavitations or bronchiectasis.

39. First Line Anti-TB drugs Isoniazid(H) Rifampicin(R) Pyrazinamide(Z) Streptomycin(S) Ethambutol(E)

40. Treatment a 6-month course of isoniazid (INH) and rifampin, supplemented during the first 2 months with pyrazinamide. Because poor adherence to these regimens is a common cause of treatment failure, directly observed therapy (DOT) is recommended for treatment of tuberculosis.

41. Treatment

43. Plans Prescribed with: – Isoniazid 200mg/5ml, 1.5 ml (5mg/kg/d) OD – Rifampicin 200mg/5ml, 3 ml (10mg/kg/d) OD – Pyrazinamide 250mg/5ml, 3.5 ml (15mg/kg/d) OD – Streptomycin 1g/2ml, 0.5 ml IM (22mg/kg/d) OD