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CASE CONFERENCE. Ang, Kevin Aningalan , Arvin Antonio, Aby Aramburo , Jan Cruel, Anna. General Data. J.R. 1 yr and 11 mos , Female Santa Cruz, Manila Filipino, Roman Catholic Informant: Mother Reliability: good. History of Present Illness. 6 weeks PTC.

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CASE CONFERENCE

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Case conference

CASE CONFERENCE

Ang, Kevin

Aningalan, Arvin

Antonio, Aby

Aramburo, Jan

Cruel, Anna


General data

General Data

  • J.R.

  • 1 yr and 11 mos, Female

  • Santa Cruz, Manila

  • Filipino, Roman Catholic

  • Informant: Mother

  • Reliability: good


History of present illness

History of Present Illness

6 weeks PTC

  • Mother palpated multiple movable, firm, non-tender masses over lateral aspects of neck

  • No other symptoms noted

  • No consult was done


History of present illness1

History of Present Illness

2 weeks PTC

  • Patient experienced intermittent low-grade fever (37.8°C), occurring at night time, not relieved by intake of Paracetamol

  • No accompanying symptoms

    • no anorexia

    • no weight loss

    • no cough

    • no colds

    • no medications given

      no consult done


History of present illness2

History of Present Illness

8 days PTC

  • Patient experienced cough and colds with clear discharge

  • (-) anorexia

  • (-) weight loss

  • (-) difficulty of breathing


History of present illness3

History of Present Illness

5 days PTC

  • Patient sought consult at OPD

    • (+) boggy turbinates

    • (+) multiple cervical lymphadenopathy, movable, firm, non-tender over lateral aspects of neck

  • Assessment: to r/o PTB

  • Plans: PPD, CXR, to follow-up with results


History of present illness4

History of Present Illness

Consult

  • PPD test: 10mm

  • Chest X-Ray PA and Lateral: suggestive of Primary Koch’s


Review of systems

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


Past medical history

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 MMR

    DPT 1,2,3 booster BCG

    OPV 1,2,3 booster Measles

    Allergies: none


Family history

Family History

(+) Hypertension – mother

(+) DM – grandfather

(+) PTB – uncle who stays at home with patient

(-) Cardiovascular diseases, stroke


Family profile

Family Profile


Gestational and birth history

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

  • 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


Socioeconomic and environmental history

Socioeconomic and Environmental History


Physical examination

Physical Examination

General Survey: Awake, alert, not in cardiorespiratory distress, well-nourished, well-hydrated

Vital Signs:HR 90bpm RR 20cpm T 36.7oC

Anthropometric Data: 82.5cm (Z score above 0) Weight:15kg (Z score above 0) HC: 48 cm WFL: above zero

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, (+) nasoauraldischarge, 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


Physical examination1

Physical Examination

Adynamicprecordium, apex beat at 4th LICS, MCL, no lifts, no heaves, no thrills, S1>S2 at the apex, S2>S1 at the base, (-) S3, (-) murmurs

Supple neck, (+) multiple cervical lymphadenopathies, 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


Salient features

Salient Features


Approach to diagnosis

Approach to Diagnosis


Presenting manifestation

Presenting Manifestation

  • 2 week history of intermittent low grade fever (37.8 C), occurring at night time

  • 8 day history of cough and colds

  • (+) multiple cervical lymphadenopathies

  • Exposure to PTB

  • PPD test: 10mm

  • Chest X-Ray PA and Lateral: suggestive of Koch’s infection


  • Approach to diagnosis1

    Approach to Diagnosis

    • A presenting manifestation pointing to the least number of diseases

    • Fever + Cervical Lymphadenopathy

      • PTB

      • Group A Strep Pharyngitis

      • Lymphoma

      • Kawasaki disease


    Primary tuberculosis infection

    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


    Signs and symptoms

    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


    Tuberculin skin test

    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


    Interpretation

    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


    Tuberculosis disease

    Tuberculosis Disease

    At least 3 of the following:

    • (+) exposure to PTB

    • (+) TST

    • Clinical signs and symptoms of PTB

    • Radiographic Findings of PTB


    Assessment

    Assessment

    • Pulmonary Tuberculosis Disease


    Tuberculin skin test1

    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


    Treatment plans

    Treatment Plans

    Curative:

    • 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

    • Refer to DOTS

    • Refer to ENT


    Treatment plans1

    Treatment Plans

    • Supportive

      • Multivitamins

      • Dietary advice given


    Preventive

    Preventive

    • Advise the patient to strictly comply and complete the regimen

    • Anticipatory guidelines

    • Follow-up on vaccination

    • Avoid overcrowded and unsanitary areas


    Case conference

    • Follow up after 2 weeks


    First line anti tb drugs

    First Line Anti-TB drugs

    • Isoniazid(H)

    • Rifampicin(R)

    • Pyrazinamide(Z)

    • Streptomycin(S)

    • Ethambutol(E)


    Treatment

    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.


    Treatment1

    Treatment


    Treatment2

    Treatment


    Brief discussion of the diagnosis

    Brief discussion of the diagnosis


    Tuberculosis

    Tuberculosis

    • Mycobacterium tuberculosis is the most important cause of tuberculosis disease in humans.

    • Other causes include: M. bovis, M. africanum, M. microti, M. Canetti.


    Latent tuberculosis infection

    Latent Tuberculosis infection

    • Occurs after inhalation of infective droplet nuclei containing Mycobacterium tuberculosis.

    • Reactive tuberculin skin test (TST) and absence of clinical and radiographic manifestation are the hallmark of this stage

    • Disease occurs when signs and symptoms and radiographic changes become apparent

    • Untreated LTB have up to 40% likelihood of developing TB in children.


    Transmission

    Transmission

    • Person to person

    • By airborne mucus droplet 4-5um in diameter

    • Increased when patient has positive AFB smear, extensive upper lobe infection/cavity, copious production of thin sputum and severe and forceful cough

    • Young children rarely infect others because tubercle bacilli are sparse in the endobronchial secretions of children with PTB and cough is often absent or lack tussive force required to suspend infectious particles for transmission.


    Pathogenesis

    Pathogenesis

    • Primary complex includes local infection at the portal of entry and the regional lymph nodes that drain the area

    • Tubercle bacilli multiply initially within the alveoli and alveolar ducts, most of the bacilli are killed, but some survive within nonactivated macrophages, which carry them through lymphatic vessels to the regional lymph nodes.


    Case conference

    • Tissue reaction in the lung parenchyma and lymph nodes intensifies over the next 2-12 weeks.

    • The parenchymal portion of the primary complex often heals completely by fibrosis or calcification after undergoing caseous necrosis and encapsulation.


    Tuberculin skin testing tst

    Tuberculin Skin Testing (TST)

    • The development of delayed type hypersensitivity reaction in most individuals infected with tubercle bacillus makes the TST a useful diagnostic tool.

    • The Mantoux Tuberculin Skin Test is the intradermal injection of 0.1mL containing 5 tuberculin units of purified protein derivative (PPD.

    • T cells sensitized by prior infection are recruited to the skin where they release lymphokines that induce induration through local vasodilatation, edema, fibrin depositon and recruitment of other inflammatory cells to the area.


    Case conference

    • TST should be read by a trained person 48-72 hours after administration.

    • Occasional patients will have the induration >72 hours after placement, this is also a positive result.

    • Immediate hypersensitivity reaction are shortlived (<24 hours) and are not considered a positive result.


    Case conference

    • Tuberculin sensitivity develops 3 weeks to 3 months after inhalation of organism

    • Factors that can depress skin test reaction:

      • Very young age

      • Malnutrition

      • Immunosuppresion

      • Viral infection

      • Vaccines with live virus

      • Overwhelming tuberculosis


    Case conference

    • False positive reaction to TST can be caused by cross sensitization to antigens on non tuberculousmycobacteria

    • Previous BCG (Especially if 2 doses of BCG are already given)

    • In general, a > or equal to 10mm in a BCG vaccinated child indicates infection


    Tuberculin skin test2

    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


    Tuberculin skin test3

    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


    Tuberculin skin test4

    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


    Clinical manifestations

    Clinical Manifestations

    • Majority develop no signs or symptoms

    • Occasionaly, with low grade fever and mild cough

    • Rarely with high fever, cough, malaise and flu like symptoms.


    Primary pulmonary disease

    Primary Pulmonary Disease

    • Primary complex includes parenchymal pulmonary focus and regional lymph nodes

    • Initial parenchymal inflammation is usually not visible on chest radiograph

    • Hallmark of primary tuberculosis in the lungs is the relatively large size of regional lymphadenitis compared with the relatively small size of the intial lung focus


    Case conference

    • Usual sequence is hilarlymphadenopathy, focal hyperinflation, and then atelectasis

      • The resulting radiographic shadows has been called collapse-consolidation

    • The symptoms and physical signs of primary pulmonary tuberculosis in children are meager considering the degree of radiographic changes seen


    Case conference

    • Non-productive cough and mild dyspnea are the most common symptoms

    • Systemic complaints such as fever, and night sweats are seen less often

    • Pulmonary signs are even less common.


    Diagnosis

    Diagnosis

    • Most specific confirmation of pulmonary TB is isolation of Mycobacterium tuberculosis

    • For infants who can’t expectorate sputum, a jet nebulizer, chest percussion followed by nasopharngeal suctioning can be done.

    • The traditional culture specimen is the early morning gastric acid obtained just before the child has arisen


    Case conference

    • However, 3 consecutive morning gastric aspirate yield organism in only less than 50% of cases

    • Negative culture should never exclude the diagnosis in children

    • Diagnosis can be made if:

      • Positive TST

      • Abnormal chest radiograph findings suggestive of TB

      • History of exposure


    Treatment3

    Treatment

    • Insert table from NElsons


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