case report pp
TRANSCRIPT
CASE REPORT: TUBERCULOSIS WITH SEVERE MALNUTRITION
Presenter: Dinesha Paniselvam
Tay Chiu Mei
Supervisor: dr. H.Hakimi, Sp.A(K)
Definition
Tuberculosis is a disease due to Mycobacterium tuberculosis infection with systemic spread thus can affect almost all organs, and the most frequent site is in the lung, which usually as the site of primary infection
Etiology:Mycobacterium tuberculosis
Factors in acquiring Tb infection
Host immune
state
Exposure duration
Doses / numbers Virulence
Concentration in the air
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Droplet nuclei inhalation Alveoli
Ingestion by PAM’S
Intracellular replicat ionof bacil l i
Destruction of bacil l iDestruction of PAM’S
Tubercle formation Hilar lymph nodes
Hematogenic spread
Multiple organs remote foci
Lymphogenic spread
Disseminated primary TB
Acute hematogenic spread
Occult hematogenic spread
primary focus lymphangit is lymphadenit is
Primary complex
CMI
Pathogenesis of primary tuberculosis
Specific Manifestation
Systemic Manifestation
IDAI Pediatric TB scoring system
10
Notes for IDAI scoring systemDiagnosis: total score ≥6 (by doctor)BW at presentFever & cough no respons to standard txCXR is NOT a main diagnostic tool Accelerated BCG reaction: evaluated <5 y.o: Score 5 or strong suspicion referINH prophylaxis: score <6 with contact (+)
11
Mantoux 0.1 ml PPD intermediate strength
- Location : volar lower arm
- Reading time: 48-72 h post injection
-Induration diameter : 0 - 5 mm : negative 5 - 9 mm : doubt > 10 mm : positive
Objectives of
treatment
Sterilization to prevent relapses
Rapid reduction of the number
of bacilli
Preventing acquired
drug resistance
Treatment principles
• Drug combination, not single drug• Two phases :
Initial phase (2 months) – intensive, bactericidal effect
Maintenance phase (4 months / more) – ‘sterilizing’ effect, prevent relaps
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DrugsDaily dose
(mg/Kg/day) Adverse reactions2 Time/week
dose(mg/Kg/dose))
Isoniazid(INH)
5-15(300 mg))
Hepatitis, peripheral neuritis,hypersensitivity
15-40(900 mg))
Rifampicin(RIF)
10-15(600 mg))
Gastrointestinal upset,skin reaction, hepatitis, thrombocytopenia,
hepatic enzymes, including orangediscolouraution of secretions
10-20(600 mg)
Pyrazinamide(PZA)
15 - 40(2 g)
Hepatotoxicity, hyperuricamia,arthralgia, gastrointestinal upset
50-70(4 g)
Ethambutol(EMB)
15-25(1,5 g)
Optic neuritis, decreased visualacuity, decreased red-green colour
discrimination, hypersensitivity,gastrointestinal upset
50(1,5 g)
Streptomycin(SM)
15 - 40(1 g)
Ototoxicity nephrotoxicity25-40(1,5 g)
When INH and RIF are used concurrently, the daily doses of the drugs are reduced
National consensus of tuberculosis in children, 2001
Dosage of antituberculosis drug
Systems for assessing the severity of malnutrition in underweight children
18
Method Mild Moderate Severe
Weight for age ≥90 % 75 to 89 % 60 to 74 % <60 %
Weight for height ≥90 % 80 to 89 % 70 to 79 % <70 %
Height for age ≥95 % 90 to 94 % 85 to 89 % <85 %
Weight/height for age ≥90 % 85 to 89 % 75 to 84 % <75 %
Marasmus KwashiorkorAbsence of edemaInadequate intake of protein
and calories
Presence of edema Fair-to-normal calorie intake
with inadequate protein intake
19
A combination of both, kwashiorkor and marasmus. Signs and symptomps of marasmus could be found coincidently with kwashiorkor. The child look very thin with bones and ribs could be inspected very prominently, with mild edema found minimally, particularly in the lower extremities.
Marasmus-Kwashiorkor
No Treatment
Stabilization Transition Rehabilitation Follow Up
Day
1-2
Day
3-7Week 2
Week
3-6
Week
7-26
1 Hypoglycemia ̸
2 Hypothermia ̸
3 Dehydration ̸
4 Electrolyte Correction ̸ ̸ ̸
5 Treatment of Infection ̸ ̸ ̸
6 Micronutrition Defficiency
Correction
Without Iron
Supple-menta-
tion
Without Iron
Supplementa-
tion
Without Iron Supplementation
With Iron Supplementation
With Iron
Supplement-
ation
7Initial Refeeding
Formula
75
Formula 75Formula 75 to 100
8 Correctional Refeeding
(Catch Up Growth)
Formula 100 Formula 100
9 Stimulation ̸ ̸ ̸ ̸ ̸
10 Prepare for Discharge ̸ ̸
MANAGEMENT OF SEVERE MALNUTRITION
20
12/18/12 21
TB
TB AND MALNUTRITION
Metabolic rate / resting rate increased
Increased energy needs to meet the basic
demands for body function
Energy intakes are decreased
Presence of pro-inflammatory
cytokines
Util ization of amino acids & protein synthesis
MALNUTRITON
The cell mediated immunity response
is impaired
CASE REPORT
Loss of body weight since 1 year ago. According to her parents, the patient’s highest body weight was 25kg (October 2010) and it’s decreasing for the past 1 year with drastic weight loss (± 10kg) for the past 4 months.
Decreased of appetite was found since 6 months ago.
Fever was found since 2 year ago. The characteristic of the fever : intermittent and low grade fever; decrease temporarily with consumption of paracetamol. History of intermittent fever was found since the patient was 9 years old.
The patient was coughing for the past 2 years, Phlegm (+), white in color, bloody(-). History of contact with a tubercular patient/prolonged coughing adult was found.
Lesions were found on patients right neck which was noted by the patient’s family 1 year ago. 2 small noduls with 1,5cm, ᴓInitially, the lesion started as papules that progressed to nodules and pustules. 2 months ago, there was discharge from the lesion. The discharge from the lesion was serous, bloody(-) and its painless.
Distention of the patients’s stomach was realized by patient’s mother since 6 months ago. History of diarrhea (+), vomiting(-), loss of concentration for the past 2 days.Normal mictuation and defecation.
History of feeding : 0 to 4 mth : Breast milk4 mths- 1 year: Breast milk + Porridge1 year till now : Normal meals
Physical Examination
Head• Face: old man face (+)• Eyes: Light reflex +/+, isochoric pupil,conjunctiva palpebra inferior
pale (+/+)• Nose: Nasal flare (-) Mouth: Paleness of mucous (-), cyanosis (-) Ears :
Secrete (-)
Neck
Thorax
Abdomen
Extremities
Genitalia
• Lymph node enlargement (-), Scrofuloderma (+) on regio colli dextra,( 2 noduls with serous discharge ± 1.5cm)ᴓ , JVP: R-2 cm H2O
• Symmetrical fusiform, retraction (-), intercostal ribs can be seen clearly.HR: 96 bpm regular, murmur (-) RR: 20 tpm regular, rales (-)
• Ascites (+),Shifting dullness (+),Double sound(+), Normal peristaltic• Liver and spleen was not palpable
• Pulse 96 bpm regular, adequate pressure and volume, warm acral, CRT < 3’, BP: 100/60 mmHg, clubbing fingers (-), cyanotic (-),
pale(+) Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+)• Normal physiology reflex, Pathologic reflexes (-)
• Female, within normal limit
Old man face
Thin subcutaneous fats
Stomach distended
Hypotrophy muscle
Intercostal ribs can be seen clearly
Dried scrofuloderma lesions
Complete Blood Count Results Normal Value
Hemoglobin (Hb) 6,50 g% 11.3-14.1g %
Erytrocyte (RBC) 3,18 x106/mm3 4.40– 4,48 x106/mm3
Leukocyte (WBC) 8.31 x 103/mm3 4.5-13.5x103/mm3
Hematocrite 23,280 % 37 – 41 %
Trombocyte (PLT) 236 103/mm3 150 – 450 x103/mm3
MCV 73,10 fl 81 – 95 fL
MCH 20,40 pg 25 – 29 pg
GLUCOSE Ad Random
Blood glucose 89 mg/dl <200 mg/dl
ELECTROLITE
Natrium 131 135 - 155
Kalium 3,5mEq/L 3,6 - 5,5
Klorida 10 mEq/L 96 - 106
Laboratory Findings: (Adam Malik General Hospital: 31/10/2011)
28
Working Diagnosis: Pulmonary Tuberculosis + Scrofuloderma with Severe
malnuturion marasmic-kwashiorkor type
RADIOLOGY
Interpretation of the chest X-Ray:
CTR < 50%, Aorta and pulmonal segment is not elongated. Infiltration can be seen on
whole lung field.
Results: Bronchopneumonia,
DD: - active specific process
Interpretation of the abdominal photo :
Homogenous consolidation can be seen on the abdominal space which enforces air from intestines towards central. Results:
Ascites
Date 1 November 2011S Fever (-), Abdomen distended (+)O
Head
Neck
Thorax
Abdomen
Extremities
Sens :Alert, T:37,30C, BW:15kg, BL: 130 cm, BW/BL: 55.55% LLT:57cm LLD:54cm
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conjunctiva inferior palpebra (+/+), icteric sclera(-/-). Ear/Nose/Mouth : within normal limit
Lymph nodes enlargement(-)Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Distented(+), Ascites(+), Shifting dullness(+),Double sound(+), normal peristaltic. Liver and spleen: not palpated.
Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+),Normal physiology reflex: APR/KPR (+) ,Pathologic reflexes (-)
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnuturion marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed)- IVFD D5% NaCl 0.45% 4gtt/min -Isoniazid 1 x 150 mg- Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1x5 mg 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral
Further evaluation
- Consult to Metabolic & Nutrition Division- Consult to Pediatric Respirology :•Mantoux test (at 1400 WIB, Interpretation on 3/11/2011)- Gaster lavage- BTA culture ( 3 days continuously)- Scrofuloderma lesion culture
D1
Date 2 November 2011
S Fever (-), Abdomen distended (+)
O
Head
Neck
Thorax
Abdomen
Extremities
Sens :Alert, T:37,30C, BW:15kg, BL: 130 cm, BW/BL: 55.55% LLT:57cm LLD:52cm Face: Old man face (+) Eye: Light reflexes (+),isochoric pupil (R=L), paleness of conjunctiva inferior palpebra (+/+), icteric sclera(-/-) Ear/Nose/Mouth : within normal limit
Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Distented(+), Ascites(+), Shifting dullness (+),Double sound(+),normal peristaltic Liver and spleen: not palpated.
Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+), Pathologic reflexes (-)
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnuturion marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed) - IVFD D5% NaCl 0.45% 4gtt/min -Isoniazid 1 x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1x1 mg - Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral
Further evaluation
- Gaster lavage - BTA culture ( 3 days continuously) - Scrofuloderma lesion culture
D2Consultation from Dermatology: Lesions were found on patients dextra colli region which was noted by the patient’s family 1 year ago. 2 small noduls with ᴓ1,5cm, Initially, the lesion started as papules that progressed to nodules and pustules. 2 months ago, there was discharge from the lesion. The discharge from the lesion was serous, bloody(-) and its painless.Diagnose: ScrofulodermaTherapy: Compress with Nacl 0,9% for 15 menits every 4 hours and apply Gentamicin cream 2x/day.
Date 3 November 2011 4 November 2011
S Fever (-), Abdomen distended (+) Fever (-), Abdomen distended (+)
O Head Neck Thorax Abdomen Extremities
Sens :Alert, T:37,30C, BW:16kg, BL: 130 cm, BW/BL: 55.57% Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.57%
Face: Old man face (+) Eye: Light reflex (+), isochoric pupil (Right=Left), paleness of conj. inf. palpebra (+/+), icteric sclera(-). Ear/Nose/Mouth:within normal limit
Face: Old man face (+) Eye: Light reflex (+), isochoric pupil (R=L), paleness of conj. inf. palpebra (+/+), icteric sclera(-). Ear/Nose/Mouth: within normal limit
Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O
Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Distented(+),normal peristaltic,Ascites(+), Shifting dullness (+),Double sound(+) Liver and spleen: not palpated.
Distented(+),normal peristaltic, Ascites(+), Shifting dullness (+),Double sound(+), Liver and spleen: not palpated.
Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+ )
Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+)
A Pulmonary Tuberculosis + Scrofuloderma with severe malnutrition marasmic-
kwashiorkor type Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed) - IVFD D5% NaCl 0.45% 4gtt/min aff- Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg- Pyrazinamid 1 x 450 mg -Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Vitamin A 1 x 200.000 IU - Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral - Compress the lesion with NaCl 0,9% for 15 menits every 4 hours. - Gentamicin cream 2x/day
- O2 1-2L per minute (if needed)- Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F75 diet 200cc/2hrs/oral - Compress the lesion with NaCl 0,9% for 15 menits every 4 hours. - Gentamicin cream 2x/day
Further evaluation
Mantoux test Results : Negative Laboratorium Result: Liver: - Total Bilirubin : 0,93mg/dL - Direct Bilirubin : 0,78mg/dL - Alkaline Phosphate(ALP) : 142U/L - AST/SGOT : 28 U/L - ALT/SGPT : 15 U/L - Albumin : 1,0 g/dL Albumin needed=(3,5-1,0) x 16x 0,8=32g Plasbumin 25% = 32/25x 100 = 128 cc Plasbumin 20% = 32/20x 100 = 160 cc
- Gaster lavage - BTA culture ( 3 days continuously) - Scrofuloderma lesion culture
D 4D 3
Consultation from Gastroenterology: - Albumin correction and re-check albumin level after correction - Albumin Correction:150cc of Plasbumin 20%
BW:16 kg BW/BH: 55.57%Treatment:
- IVFD D5% NaCl 0.45% 4gtt/min aff- Vitamin A 1 x 200.000 IU (1 day)
Mantoux test Results : Negative Laboratorium Result: Albumin 1,0 g/dL
Date 5-6 November 2011 7 November 2011S Abdomen distended (+) Abdomen distended(+) O
Head Neck Thorax
Abdomen Extremity
Sens :Alert, T:36,80C, BW:16kg, BL: 130 cm, BW/BL: 55.57% Sens :Alert, T:37,50C, BW:16,5kg, BL: 130 cm, BW/BL: 55.6% Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inferior palpebra (+/+),icteric sclera(-/-). Ear/Nose/Mouth :within normal limit
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conj.inferior palpebra(+/+),icteric sclera (-/-) Ear/Nose/Mouth : within normal limit
Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O
Lymph nodes enlargement(-) Dried lesion can be seen on the right neck, JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 120 bpm, regular, murmur (-) RR: 24 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Distented(+), Ascites(+), Shifting dullness (+),Double sound(+), normal peristaltic. Liver and spleen: not palpated.
Distented(+), Ascites(+), Shifting dullness (+),Double sound(+), normal peristaltic. Liver and spleen: not palpated.
Pulse:120bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+) Pathologic reflexes( -)
Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/ KPR (+) Pathologic reflexes (-)
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type
Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed)-Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral (D1),(D2)- Gentamicin cream 2x/day
- O2 1-2L per minute (if needed)-Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg -Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Vitamin B6 1 x 20 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II- F100 diet 240cc/3hrs/oral (D3)- Gentamicin cream 2x/day
Further evaluation
-Albumin Correction: 50 cc of Plasbumin 0% (05/11/2011; 1750 WIB)-Waiting for the results of gaster lavage, BTA culture and Scrofuloderma lesion cultureLaboratorium Result: - Albumin : 2,0 g/dLAlbumin needed=(3,5-2) x 16x 0,8 ≈20gPlasbumin 25% = 20/25 x 100 = 80 cc Plasbumin 20% = 20/20 x 100 = 100 cc
- Waiting for the results of gaster lavage, BTA culture and Scrofuloderma lesion cultureAlbumin Correction:100cc of Plasbumin 20%
D5,6 D7
- F100 diet 240cc/3hrs/oral-Albumin Correction: 50 cc of Plasbumin 20% Laboratorium Result: - Albumin : 2,0 g/dL
-BW:16,5kg, BL: 130 cm, BW/BL: 55.6%
- Dried lesion can be seen on the right neck,
- F100 diet 240cc/3hrs/oral- Albumin Correction: 50 cc of Plasbumin 20% Laboratorium Result: - Albumin : 2,0 g/dLAlbumin Correction: 100cc of Plasbumin 20%
Date 8-10 November 2011 11 November 2011S Abdomen distended (reduced) Fever (-), Diarrhea (6x/day)O
Head
Neck
Thorax
Abdomen
Extremities
Sens :Alert, T:36,80C, BW:18kg, BL: 130 cm, BW/BL: 55.57% LLT:55cm LLD:52cm Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.55%
Face: Old man face (+) Eye: Light reflexes (+),isochoric pupil (R=L) paleness of conjunctiva inferior palpebra (+/+), Ear/Nose/Mouth : within normal limit
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conjunctiva inferior palpebra (+/+). Ear/Nose/Mouth : within normal limit
Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R-2 cm H2O
Lymph nodes enlargement(-) Dried lesion can be seen on the right neck, JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 136 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and spleen: not palpated.
Distension(+),ascites(+), shifting dullness (+) normal peristaltic, Liver and spleen: not palpated
Pulse: 136 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+). Pathologic reflexes (-)
Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+).Pathologic reflexes (-)
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- kwashiorkor type
Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed) - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Vitamin B6 1 x 20 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day Meropenem Inj. 300 mg/8hr/iv (starting on 09/11/2011)
- O2 1-2L per minute (if needed) - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Vitamin B6 1 x 20 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day - Meropenem Inj. 300 mg/8hr/iv (D 3) -Lacto B 3 x 1 sachet -Resomal 100cc/xdiarrhea
Further evaluation
Laboratorium Result (08/11/2011): Hb/Ht/L/Plt = 4,4/ 15,2/7990/348000 Albumin: 2,0g/dL Transfusion of PRC: (12-4,4) x 19 x 4 = 570 cc ≈ 600 cc Availability : 5 x 19= 95cc ≈ 100 cc Transfusion of PRC 100cc I (08/11) Transfusion of PRC 100cc II (09/11) Albumin Correction : Albumin needed=(3,5-2,0) x 18x 0,8=22g Plasbumin 25% = 22/25x 100 = 88 cc Plasbumin 20% = 22/20x 100 = 110 cc
Laboratorium Result:
Albumin : 2,3 g/dL
Albumin Correction :
Albumin needed= 10g
Plasbumin 25% = 50cc
Plasbumin 20% = 40cc
S: Abdomen distended (reduced) BW:18kg, BW/BL: 55.57% LLT:55cm LLD:52cm P: Meropenem Inj. 300 mg/8hr/iv (Starting on 09/11)
Results of gaster lavage: (08/11/2011)Day 1 No bacteriaes were found.Growth of jamur,yeast cell(+) Epitel: 0-2 Leucocytes: 1-2 BTA: 2/100 LP Day 2&3: No bacteriaes were found. Growth of jamur, yeast cell(+) Results of lesion culture: (09/11/2011) Aerob bacteri was found; Enterobacter Clocal
Lab result: Hb = 4,4 Albumin: 2,0g/dL Transfusion of PRC: Transfusion of PRC 100cc I (08/11) Transfusion of PRC 100cc II (09/11) Albumin Correction : Plasbumin 20% = 22/20x 100 = 110 cc
S: Diarrhea (6x/day) BW:16kg, BW/BL: 55.55% P: - Lacto B 3 x 1 sachet -Resomal 100cc/xdiarrhea
Lab result: Albumin: 2,3g/dL
Date 12-13 November 2011 14-16 November 2011
S Diarrhea(+)Abdomen distended(reduced) Diarrhea(-) Abdomen distended
O
Head
Neck
Thorax
Abdomen
Extremities
Sens :Alert, T:36,80C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:54cm LLD:52cm
Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.55%
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inf. palp.(+/+),icteric sclera(-/-). Ear/Nose/Mouth : within normal limit
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inf. palp -/- Ear/Nose/Mouth : within normal limit
Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R-2 cm H2O
Lymph nodes enlargement(-) Dried lesion can be seen on the right neck, JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 90 bpm, regular, murmur (-) RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Distension(+),ascites(+), shifting dullness (+) normal peristaltic, Liver and spleen: not palpated.
Distension(+),ascites(+), shifting dullness (+) normal peristaltic.Liver and spleen: not palpated.
Pulse: 90 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex: APR/KPR(+)
Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(-) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+) Normal physiology reflex
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type
Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed)- Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg- Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day- Lacto B 3 x 1 sachet - Resomal 100-200 cc/x diarrhea
O2 1-2L per minute (if needed)- Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg- Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral or NGT - Gentamicin cream 2x/day- Lacto B 3 x 1 sachet - Resomal 100-200 cc/x diarrhea
Further evaluation
- Laboratorium Result (12/11/2011): Hb/Ht/L/Plt : 12,8/ 38,9/17410/305000 Albumin : 2,9 g/dL Na / K / Cl : 128/ 2,8/ 92-Nasograstric tube (NGT) was inserted on 13/11/2011 because the patient did not eat for the whole day
- Repeat Chest X-Ray - Blood culture, sensitivity test-Combination of Antibiotics with Amikasin (16/11/2011): Day 1: 20 mg/kgBW – 320 mg/day/iv Day 2: 15 mg/kgBW – 240 mg/day/iv
S: Diarrhea (+) BW:17kg, BW/BL: 55.57% P: - Lacto B 3 x 1 sachet -Resomal 100cc/xdiarrhea
Lab Result (12/11/2011): Hb : 12,8 Albumin: 2,9 g/dL -Nasograstric tube (NGT) was inserted on 13/11/2011 because the patient did not eat for the whole day
S: Eye: paleness of Conj.Inf.Palp (-) Extremities: pale(-) P: - Lacto B 3 x 1 sachet -Resomal 100cc/xdiarrhea - Repeat Chest X-Ray - Blood culture, sensitivity test-Combination of Antibiotics with Amikasin (16/11/2011): Day 1: 20 mg/kgBW – 320 mg/day/ivDay 2: 15 mg/kgBW – 240 mg/day/iv
Date 17-20 November 2011 21-26 November 2011
S Diarrhea(-) Abdomen distended Diarrhea(-) Abdomen distended
O
Head
Neck
Thorax
Abdomen
Extremities
Sens :Alert, T:36,80C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:52cm LLD:50cm
Sens :Alert, T:36,80C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:52cm LLD:50cm
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conjunctiva inferior palpebra (-/-), icteric sclera(-/-). Ear/Nose/Mouth : within normal limit
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conjunctiva inferior palpebra (-/-), icteric sclera(-/-). Ear/Nose/Mouth : within normal limit
Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R-2 cm H2O
Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 96 bpm, regular, murmur (-) RR: 26 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Symmetrical fusiform, retraction (-) HR: 96 bpm, regular, murmur (-) RR: 26 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and spleen: not palpated.
Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and spleen: not palpated.
Pulse: 96 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(-) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex :APR/ KPR (+),Pathologic reflexes (-)
Pulse: 96 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(-) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex : APR/KPR (+), Pathologic reflexes(-)
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type
Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed)- Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg- Rifampicin 1 x 300 mg- Pyrazinamid 1 x 450 mg- Ethambutol 1 x 300 mg- Zinc tablet 1 x 20mg- Folic Acid 1 x1 mg- Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day- Lacto B 3 x 1 sachet - Resomal 100-200 cc/x diarrhea aff(17/11)- Amikasin 350 mg/day/iv (D1:17/11/11)
- O2 1-2L per minute (if needed) - Meropenem Inj. 300 mg/8hr/iv - Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg - Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II - F100 diet 240cc/3hrs/oral - Gentamicin cream 2x/day - Lacto B 3 x 1 sachet - Amikasin 250 mg/day/iv
Further evaluation
Re-check lab
The patient was discharged from Adam Malik Hospital on her own request on 26th of November 2011
DISCUSSION
THEORY CASEChildren are most vulnerable to the effects of undernutrition in infancy and early childhood and globally the most important risk factor for illness and death, contributing to more than half of deaths in children worldwide. In developing countries, more than 50% of the 10 million deaths each year are either directly or indirectly secondary to malnutrition
S, 11 years old girl, with 15 kg body weight and 130 cm body height originated from Indonesia(developing country).
The diagnosis of TB in children relies on careful and thorough assessment of all the evidence derived from a careful history, clinical examination and relevant investigations, e.g. Tuberculin Skin Test(TST), chest X-ray and sputum smear microscopy.
The diagnosis of tuberculosis in this patient was made based on history taking where a low grade fever and mild cough was experienced by the patient since 2 years ago and weight loss since 1 year ago. History of contact with a tubercular patient/prolonged coughing adult was also found. Chest X-Ray shows a result of an active specific process and mantoux test was also done.
Most children who develop tuberculosis disease experience pulmonary manifestations, but 25-35 percent of children have an extrapulmonary presentation.
Patient has lesions on her right neck with serous discharge and the dermatologist diagnosed it as scrofuloderma(cutaneous tuberculosis)
THEORY DISCUSSIONThe diagnosis of malnutrition can be made from history taking, physical examination, antropometrical measurement and laboratory finding. In physical examination, we look for sign of dehydration, fever, skin changes, muscle hypotrophy, and oedema.The antropometrical measurement will show the growth failure of the child. The child’s weight for her height under 70%.
The patient experienced weight loss since 1 year ago , decreased of appetite was also found since 6 months ago. According to physical findings in this case, it was found that the patient has an old man face, pale conjunctiva palpebra inferior, intercostal ribs can be seen clearly, ascites, baggy pants, hypotrophy muscle and thin subcutaneous fats. In antropometrical measurement. the child's weight for her height is 55,55 % which indicates of severe malnutrition.
Management of severe malnutrition are by doing 10 essential steps in line with the guideline of malnutrition management from Department of Health Republic of Indonesia .
This patient was firstly treated in the stabilization phase in which dehydration were assesed and treated subsequently. IVFD D5% NaCl 0.45% was given for electrolyte balance. To treat or prevent dehydration, this patient is given ReSoMal 100 cc each time diarrhea occurrs . To correct micronutrients deficiencies, this patient was given Zinc, vitamin A 100.000 IU, and multivitamin without ferum. Feeding started by giving milk-based formula F-75 containing 75 kcal/100 cc and in the rehabilitation phase, milk-based F-100 contains 100 kcal is given to achieve very high intakes and rapid weight gain.