BAB I

INTRODUCTION

Tuberculosis, one of the oldest diseases known to affect humans, is a major

cause of death worldwide. This disease, which is caused by bacteria of the
Mycobacterium tuberculosis complex, usually affects the lungs, although other
organs are involved in up to one-third of cases. If properly treated, tuberculosis
caused by drug-susceptible strains is curable in virtually all cases. If untreated, the
disease may be fatal within 5 years in 50–65% of cases. Transmission usually takes
place through the airborne spread of droplet nuclei produced by patients with
infectious pulmonary tuberculosis.1
More than 5 million new cases of tuberculosis (all forms, both pulmonary and
extrapulmonary) were reported to the World Health Organization (WHO) in 2005;
>90% of cases were reported from developing countries. The WHO estimated that 8.8
million new cases of tuberculosis occurred worldwide in 2005, 95% of them in
developing countries of Asia (4.9 million), Africa (2.6 million), the Middle East (0.6
million), and Latin America (0.4 million). It is further estimated that 1.6 million
deaths from tuberculosis occurred in 2005, 95% of them in developing countries.1
The key to the diagnosis of tuberculosis is a high index of suspicion.
Diagnosis is not difficult with a high-risk patient—e.g., a homeless alcoholic who
presents with typical symptoms and a classic chest radiograph showing upper-lobe
infiltrates with cavities. On the other hand, the diagnosis can easily be missed in an
elderly nursing home resident or a teenager with a focal infiltrate.2
Often, the diagnosis is first entertained when the chest radiograph of a patient
being evaluated for respiratory symptoms is abnormal. If the patient has no
complicating medical conditions that cause immunosuppression, the chest radiograph
may show typical upper-lobe infiltrates with cavitation. The longer the delay between
the onset of symptoms and the diagnosis, the more likely is the finding of cavitary
disease. In contrast, immunosuppressed patients, including those with HIV infection,

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may have "atypical" findings on chest radiography—e.g., lower-zone infiltrates
without cavity formation.2
A presumptive diagnosis is commonly based on the finding of AFB on
microscopic examination of a diagnostic specimen, such as a smear of expectorated
sputum or of tissue (e.g., a lymph node biopsy). Although rapid and inexpensive,
AFB microscopy has relatively low sensitivity (40–60%) in confirmed cases of
pulmonary tuberculosis. Most modern laboratories processing large numbers of
diagnostic specimens use auramine-rhodamine staining and fluorescence microscopy.
The more traditional method—light microscopy of specimens stained with Kinyoun
or Ziehl-Neelsen basic fuchsin dyes—is satisfactory, although more time-consuming.
For patients with suspected pulmonary tuberculosis, three sputum specimens,
preferably collected early in the morning, should be submitted to the laboratory for
AFB smear and mycobacterial culture. If tissue is obtained, it is critical that the
portion of the specimen intended for culture not be put in formaldehyde. The use of
AFB microscopy on urine or gastric lavage fluid is limited by the presence of
commensal mycobacteria that can cause false-positive results.3
Definitive diagnosis depends on the isolation and identification of M.
tuberculosis from a clinical specimen or the identification of specific sequences of
DNA in a nucleic acid amplification test (see below). Specimens may be inoculated
onto egg- or agar-based medium (e.g., Löwenstein-Jensen or Middlebrook 7H10) and
incubated at 37°C (under 5% CO2 for Middlebrook medium). Because most species of
mycobacteria, including M. tuberculosis, grow slowly, 4–8 weeks may be required
before growth is detected. Although M. tuberculosis may be presumptively identified
on the basis of growth time and colony pigmentation and morphology, a variety of
biochemical tests have traditionally been used to speciate mycobacterial isolates. In
modern, well-equipped laboratories, the use of broth-based culture for isolation and
speciation by molecular methods or high-pressure liquid chromatography of mycolic
acids has replaced isolation on solid media and identification by biochemical tests.

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These new methods have decreased the time required for bacteriologic confirmation
to 2–3 weeks.3
Several test systems based on amplification of mycobacterial nucleic acid are
available. These systems permit the diagnosis of tuberculosis in as little as several
hours, with high specificity and sensitivity approaching that of culture. These tests are
most useful for the rapid confirmation of tuberculosis in persons with AFB-positive
specimens but also have utility for the diagnosis of AFB-negative pulmonary and
extrapulmonary tuberculosis.4
In general, the initial isolate of M. tuberculosis should be tested for
susceptibility to isoniazid, rifampin, and ethambutol. In addition, expanded
susceptibility testing is mandatory when resistance to one or more of these drugs is
found or the patient either fails to respond to initial therapy or has a relapse after the
completion of treatment. Susceptibility testing may be conducted directly (with the
clinical specimen) or indirectly (with mycobacterial cultures) on solid or liquid
medium. Results are obtained most rapidly by direct susceptibility testing on liquid
medium, with an average reporting time of 3 weeks. With indirect testing on solid
medium, results may be unavailable for 8 weeks. Molecular methods for the rapid
identification of genetic mutations known to be associated with resistance to rifampin
and isoniazid have been developed but are not marketed in the United States.4
The initial suspicion of pulmonary tuberculosis is often based on abnormal
chest radiographic findings in a patient with respiratory symptoms. Although the
"classic" picture is that of upper-lobe disease with infiltrates and cavities, virtually
any radiographic pattern—from a normal film or a solitary pulmonary nodule to
diffuse alveolar infiltrates in a patient with ARDS—may be seen. MRI is useful in the
diagnosis of intracranial tuberculosis.4
Because so many incidents of people with TB, it is necessary a deeper
understanding of both history, clinical symptoms, physical examination, and other
disorders that accompany this disease, so identification and treatment become more
precise. For this reason we chose this case.

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 BAB II
CASE REPORT

2.1 Identification
Name : Mr. K
Age : 70 years old
Sex : Male
Status : Married
Job : Farmer
Resident : Musi Banyuasin
Religion : Moeslem
Hospitalized : December 25th, 2010

2.2 Anamnesis (Auto and Alloanamnesis on December, 30th 2010)

Chief complaint
Shortness of breath that worst about 2 weeks before admitted to the hospital.

History of illness
± 6 months before admitted to the hospital patient complaint fever
(+) , cough with mucous (+),mucoid(+), bleeding cough (-). Weakness (+),
decrease appetite (+), sweating at night (+).
± 1 month before admitted to the hospital patient complain difficulty of
breathing when he get cough. Difficulty of breathing didn’t correlate with
emotion, activity, and weather. Fever (+), weakness (+), decrease appetite
(+), decrease body weight (+) about 5 kg, sweating at night (+). Patient go to
BARI hospital . The doctor give drugs, that one of them make his urine
become red. Then patient get home medication. Patient only eat the drug for
2 weeks.

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 ± 3 days before admitted to the hospital patient complain severe short of
breathness. Shortness of breath didn’t correlate with activity, emotion, and
weather. Cough (+), mucous (+), fever (-). Patient admitted to RSMH.

History of past illness

 Hipertension (-)
 Asthma (-)

Familial disease history

 History of Asthma (-)
 History of the same disease (-)

2.3 Physical Examination

General Examination :
 General condition : moderate sickness
 Consciousness : compos mentis
 Blood pressure : 130/80 mmHg
 Pulse rate : 92 x/mnt
 Temperature : 36.8 ºC
 RR : 28 x/m
 Dehydration : no dehydration
 Nutrition : undernutrition
 Weight : 45 kg
 Height : 161 cm

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Specific Examination
 Skin
Skin colour is black brown, normal pigmentation, eflorescense (-), icteric
(-), sianotic (-), pale on palm and plantar (-), scar (-), hyperhidrosis
(-).Normal hair growth. Good turgor. Less fat layer. Warm in palpation.
Subcutaneous nodul (-).

 Lymph gland
There were no enlargement of the lymph nodes on submandibular, neck,
axillaries, and inguinal.

 Head
Oval, symmetrical, restless expression, deformity (-).

 Eye
Exophthalmus (-), enophthalmus (-), edematous palpebra superior (-),
pale on conjunctiva palpebra (+), icteric sclera (-), good light response on
both eyes. Symmetrical eyes movement. Blurry vision (-).

 Nose
Normal shape, normal nasal septum, normal mucous layer, secret (-),
epistaxis (-).

 Ears
Tophy (-), normal on both meatus accusticus externus, nyeri tekan
proc.mastoideus (-), selaput pendengaran tidak ada kelainan, good
hearing.

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 Mouth
There are no tonsil enlargement, no pale on the tongue, no papil atrophy,
no gum bleeding, no stomatitis, no rhagaden, no fetor oris.

  Neck
There are no lymph node enlargement, no thyroid gland enlargement, JVP
(5-2) cm H2O, no hypertrophy m.sternocleidomastoideus.

 Chest
Symmetric shape on both right and left side, no intercostal widen,
intercostal retraction (+), no gynekomastia, no venectasis and spider nevi.
Diameter transversal 30 cm, diameter anteroposterior 14 cm.

 Lung
Inspection : symmetrical on statis and dynamic both right and left are
equal, intercostal retraction (+) on ICS II and III
Palpation : Stemfremitus right = left
Percussion: dull on apex of both lung
Auscultation: Vesicular (+) decrease, soft wet rales (+) on both basal and
apex lung, wheezing (-)

 Cor
Inspection : Ictus cordis was not seen
Palpation : Ictus cordis was not palpable
Percussion : upper margin ICS II, right margin linea sternalis, left
margin linea midclavicula sinistra ICS 5.
Auscultation : HR: 116x/m, Murmur (-), gallop (-)

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  Abdomen
Inspection : flat, venectation (-), protrude umbilicus (-), spider
nevi (-).
Palpation : soft, tenderness (-), Hepar and Lien unpalpable,
undulation (-).
Percussion : tympani, shifting Dullness (-)
Auscultation : Bowel sound (+) Normal

 Extrimity
pale (-), palmar eritema (-),normal range of movement, eutony, edema (-),
clubbing finger (-)

 Eksternal Genital :
male, scrotal edem (-)

2.4 Additional Examination

Laboratory Findings
Hematologi (25 December 2010)
Hb : 10.3 g/dl (normal : 12 – 16 g/dl)
Ht : 30 vol% (normal : 40 – 48 vol%)
Leukosit : 6700 / mm3 (normal : 5000-10000/mm3)
LED : 87 mm/jam (normal : < 15 mm/jam)
Trombosit : 493.000/mm3 (normal : 200.000-500.000/mm3)
Diff count
Basofil : 0 (normal : 0-1 %)
Eosinofil : 2 (normal : 1-3%)
Batang : 1 (normal : 2-6%)
Segmen : 80 (normal : 50-70%)
Limfosit : 42 (normal : 20-40%)

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 Monosit : 4 (normal : 2-8%)
BSS : 135 mg/dl
Cholesterol total : 192 mg/dl (normal: < 200)
HDL Cholesterol: 46 mg/dl (normal: > 55)
LDL Cholesterol : 123 mg/dl (normal : < 130)
Triglycerida : 113 mg/dl (normal : < 150)
Uric Acid : 3,6 mg/dl
Ureum : 17 mg/dl
Creatinin : 1,0 mg/dl
Protein total : 7,2 g/dl
Albumin : 3,6 g/dl
Globulin : 4,2 g/dl

Urinalisa (27 December 2010)

Sedimen : sel epitel : (+)
Leukosit : 0-2/ LPB (N : 0-5/LPB)
Eritrosit : 0-1/LPB (N : 0-1/LPB)
Protein : negatif
Glucose : negatif
Keton : negatif
Bilirubin : negatif
Urobiliogen : negatif

Sputum BTA Examination (3 January 2011)

BTA I : negatif
BTA II : positif
BTA III : positif

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 Chest X-Ray

normal trachea position,

Intercostal space normal,
infiltrat in both pulmonal
apex and base of
pulmonal,
CTR ratio < 50%.
Interpretation :
TB pulmonal

2.5 Resume
± 6 months before admitted to the hospital patient complaint fever (+) ,
cough with mucous (+),mucoid(+), bleeding cough (-). Weakness (+), decrease
appetite (+), sweating at night (+).
± 1 month before admitted to the hospital patient complain difficulty of
breathing when he get cough. Difficulty of breathing didn’t correlate with
emotion, activity, and weather. Fever (+), weakness (+), decrease appetite (+),
decrease body weight (+) about 5 kg, sweating at night (+). Patient go to BARI
hospital . The doctor give drugs, that one of them make his urine become red.
Then patient get home medication.
± 3 days before admitted to the hospital patient complain severe short of
breathness. Shortness of breathdidn’t correlate with activity, emotion, and
weather. Cough (+), mucous (+), fever (-). Patient admitted to RSMH.
There were no history of hypertention and asthma and familial disease history.

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 Physical examination findings general condition moderate sickness,
consciousness compos mentis, blood pressure 130/80 mmHg, pulse rate 92
x/mnt, temperature 36.8 ºC, RR 28 x/m, nutrition undernutrition. On the chest
there was intercostal retraction. There was a soft wet rales on both side of lung.
From laboratory findings, Hb 10.3 g/dl, Ht 30 vol% , Leukosit 6700 /
mm3, LED 87 mm/jam, Trombosit 493.000/mm3. Diff count , Basofil 0, Eosinofil
2, Batang 1, Segmen 80 , Limfosit 12, Monosit 4. On the urinalysis, Sedimen sel
epitel (+), leukosit 0-2/ LPB, eritrosit 0-1/LPB, protein negatif, glucose negatif,
keton negatif, bilirubin negatif, urobiliogen negatif. Sputum BTA examination
find BTA I negatif, BTA II positif, BTA III positif. On the chest x-ray there was
infiltrat in both pulmonal apex and base of pulmonal.

2.6 Working Diagnosis

The new case of TB pulmonal with BTA (+)

2.7 Differential Diagnosis

- The new case of TB pulmonal with BTA (+) + Susp Pneumonia
- The new case of TB pulmonal with BTA (+) + Susp COPD
- The new case of TB pulmonal with BTA (+) + Susp Asthma Bronciale

2.8 Treatment
- O2 2 L/menit nasal
- IVFD D5% gtt X/menit macro
- Anti tuberculosis Drugs 1st cathegory
o Rifampicin 1 x 450 mg
o INH 1 x 300 mg
o Pirazinamide 3 x 500 mg
o Ethambutol 1 x 750 mg

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2.9 Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam

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FOLLOW UP
30 December 2010
S : Cough
O : General condition
Sensorium Compos Mentis
BP 120/80 mmHg
Pulse 80 x/m irreguler
RR 28x / m
Temperatur 36.8ºC

Spesific condition
Head Palpebra conjungtiva pale (-), ikteric sclera (-)

Neck JVP (5-2) cm H2O, Lymph node enlargement (-)

Thorax Cor :
HR : 80x/m irreguler, murmur (-), Gallop (-)
Pulmo :
I: static, dynamic symmetric right = left,
intercostal retraction (-),
P: stemfremitus right = left
P: dull at both apex
A: ves (+) decrease, RBS (+), wheezing (-)

Abdomen Soft, no tenderness, H/L unpalpable, BU (+)

normal
Ekstremitas Edema pretibial (-)
A : The new case of TB pulmonal with BTA (-)

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 P : - Istirahat
- O2 3L/menit
- IVFD NaCl 0,9% gtt XX/menit mikro
- Ambroxol 3x1 c

Planning:
- Sputum BTA I, II, III
- Kultur Sputum
- Urine rutin

31 December 2010
S : Cough
O : General condition
Sensorium Compos Mentis
BP 130/80 mmHg
Pulse 88 x/m irreguler
RR 28x / m
Temperatur 36,6ºC

Spesific condition
Head Palpebra conjungtiva pale (-), ikteric sclera (-)

Neck JVP (5-2) cm H2O, Lymph node enlargement (-)

Thorax Cor :
HR : 80x/m irreguler, murmur (-), Gallop (-)
Pulmo :
I: static, dynamic symmetric right = left,
intercostal retraction (-),

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 P: stemfremitus right = left
P: sonor
A: vesicular (+) decraese, RBS (+), wheezing (-)

Abdomen Soft, no tenderness, H/L unpalpable, BU (+)

normal
Ekstremitas
Edema pretibial (-)
A : The new case of TB pulmonal with BTA (-)
P : - Istirahat
- Diet NB 230 kal
- IVFD NaCl 0,9% : D5% gtt XX/menit
- Ambroxol 3x1 cc
- Lansoprazole 1 x 30 mg
- Clobazam 1 x 10 mg

Planning:
- Sputum BTA I, II, III
- Kultur Sputum
- Urine rutin

01 January 2011

S : Cough
O : General condition
Sensorium Compos Mentis
BP 110/70 mmHg
Pulse 80 x/m irreguler
RR 24x / m
Temperatur 36,9ºC

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 Spesific condition
Head Palpebra conjungtiva pale (-), ikteric sclera (-)

Neck JVP (5-2) cm H2O, Lymph node enlargement (-)

Thorax Cor :
HR : 80x/m irreguler, murmur (-), Gallop (-)
Pulmo :
I: static, dynamic symmetric right = left,
intercostal retraction (-),
P: stemfremitus right = left
P: sonor
A: vesicular (+) decraese, RBS (+), wheezing (-)

Abdomen Soft, no tenderness, H/L unpalpable, BU (+)

normal
Ekstremitas
Edema pretibial (-)
A : The new case of TB pulmonal with BTA (-)
P : - Istirahat
- Diet NB 230 kal
- IVFD NaCl 0,9% : D5% gtt XX/menit
- Ambroxol 3x1 cc
- Clobazam 1 x 10 mg
Planning:
- Sputum BTA I, II, III
- Kultur Sputum
- Urine rutin

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2 January 2011

S : Cough
O : General condition
Sensorium Compos Mentis
BP 120/80 mmHg
Pulse 88 x/m irreguler
RR 26x / m
Temperatur 36,8ºC

Spesific condition
Head Palpebra conjungtiva pale (-), ikteric sclera (-)

Neck JVP (5-2) cm H2O, Lymph node enlargement (-)

Thorax Cor :
HR : 80x/m irreguler, murmur (-), Gallop (-)
Pulmo :
I: static, dynamic symmetric right = left,
intercostal retraction (-),
P: stemfremitus right = left
P: sonor
A: vesicular (+) decraese, RBS (+), wheezing (-)

Abdomen Soft, no tenderness, H/L unpalpable, BU (+)

normal
Ekstremitas
Edema pretibial (-)

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 A : The new case of TB pulmonal with BTA (-)
P : - Istirahat
- O2 2L/menit
- IVFD NaCl 0,9% gtt XX/menit mikro
- Ambroxol 3x1 cc

Planning:
- Sputum BTA I, II, III
- Kultur Sputum

3 January 2011

S : Cough
O : General condition
Sensorium Compos Mentis
BP 120/80 mmHg
Pulse 88 x/m irreguler
RR 26x / m
Temperatur 36,8ºC

Spesific condition
Head Palpebra conjungtiva pale (-), ikteric sclera (-)

Neck JVP (5-2) cm H2O, Lymph node enlargement (-)

Thorax Cor :
HR : 80x/m irreguler, murmur (-), Gallop (-)
Pulmo :
I: static, dynamic symmetric right = left,

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 intercostal retraction (-),
P: stemfremitus right = left
P: sonor
A: vesicular (+) decraese, RBS (+), wheezing (-)

Abdomen Soft, no tenderness, H/L unpalpable, BU (+)

normal
Ekstremitas
Edema pretibial (-)

Sputum BTA Examination (3 January 2011)

BTA I : negatif
BTA II : positif
BTA III : positif
A : The new case of TB pulmonal with BTA (+)
P : - Istirahat
- O2 3L/menit
- IVFD NaCl 0,9% : D5% gtt XX/menit
mikro
- OBH syr 3x1 cc
- Lansoprazol 1 x 30 mg
- Clobazam 1x 10 mg

Planning:
- Kultur Sputum

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 CASE ANALYSE

Lung Tuberculosis

1. Definition

Pulmonal tuberculosis is chronic infection lung disease caused by

Mycobacterium tuberculosis, signed with granuloma forming and late tipe

hypersensitivity reaction.5,6

2. Clinical Symptom

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Divided into:

1. Systemic symptom

Night sweating, weakness, loss of appetite, and decrease body weight.

2. Respiratoric symptom

Cough, dyspnoe, and chest pain. Cough usually more than 3 weeks, dry until

productive with mukoid or purulent sputum. Bleeding cough could be

happened when vessel lacked, dyspnoe usually happened in late disease. 5,7

From anamnesis of this case, clinical symptom was appropriate with the

theory. Patient complained about respiratory symptom : cough 6 month ago

(more than 3 weeks) with mucoid sputum. It showed a chronis disease to this

patient. Dyspnoe (short of breathness) happened about 3 days before admitted

to the hospital it showed the late onset of this desease.

Patient complain about systemic symptom: fever since 6 month ago and he

often got sweating at night , it means there was infection process to this

patient. Patient also complained decreasing appetite and loss of body weight.

He complained weakness too. It showed catabolisme process because chronic

disease.

This was appropriate with lung tuberculosis clinical symptoms.

3. Physical diagnostic

Abnormality founding:

1. Assimetric chest, left movement of chest wall

2. Increasing stem fremitus

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 3. Dull percussion

4. Sound of breath : bronchial, amforik, decrease vesicular, wet rales.

5. Retraction chest wall

In this case, physical examination found:

Lung

Inspection: symmetrical on statis and dynamic both right and left are equal

(because both of lung was affected disease process).

Palpation : Stemfremitus right = left

Percussion : dull at apex of both lung
Auscultation : Vesicular (+) decrease, soft wet rales (+) on both basal and
apex lung, wheezing (-)
This physical examination appropriate with lung tuberculosis physical
examination.
4. Chest X-ray
Active lession : infiltrate in lung apex, millier patch, or pleural effusion.
Unactive lession : fibrotic, atelectasis, calcification, pleural thickening.
In this case chest X-ray show infiltrate on both apex and basal of both lung. It
means there were active lesion.

5. Laboratorium examination
Abnormality can be found are anemia, increase LED, increase leucosit, and
limfositosis.5,8
In this case laboratorium examination result show LED: 87 mm/jam
(increase), diff.count (0/2/1/80/42/4) it show shift to the right (chronic
infection) and limfositosis.

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6. BTA examination
It was important to diagnosis lung tuberculosis.
Lung tuberculosis with BTA (+), must be :
 BTA sputum (+) ≥ 2 x
 BTA sputum (+) at least 1 x with cultur M.tuberculosis (+)
 BTA sputum (+) at least 1 x, clinical/radiological appropriate with lung
tuberculosis.5,7
In this case BTA sputum (+) 2 x , clinical and radiological appropriate
with lung tuberculosis. So we can conclude it was new lung tuberculosis
case with BTA (+).

7. Therapy
We use OAT categorized 1 for new lung tuberculosis case with BTA (+),
divided into 2 phase.5,7
 Initial phase 2RHZE
 Late phase 4R3H3

REFERENCE

1. American Thoracic Society, Centers for Disease Control and

Prevention: Targeted tuberculin testing and treatment of latent tuberculosis
infection. Am J Respir Crit Care Med 161:S221, 2000.
2. American Thoracic Society, Infectious Diseases Society of America, Centers
for Disease Control and Prevention: Treatment of tuberculosis. Am J Respir
Crit Care Med 167:603, 2003.
3. Centers for Disease Control and Prevention: Control of tuberculosis in the
United States: Recommendations from the American Thoracic Society, CDC,
and the Infectious Diseases Society of America. MMWR 54:RR1, 2005.

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4. Pai M et al: New tools and emerging technologies for the diagnosis of
tuberculosis. Part I: Latent tuberculosis. Part II: Active tuberculosis and drug
resistance. Expert Rev Mol Diagn 6:413, 2006 [PMID: 16706743].
5. Ahmad, Zen. TBC Paru. Naskah Lengkap Work-Shop Pulmonology.
Palembang: FK UNSRI; 2002: 95-119.
6. Zulkifli. Tuberkulosis Paru. Dalam: Buku Ajar Ilmu Penyakit dalam Jilid 1
edisi IV . Jakarta: FK UI; 2006 : 988-994.   
7. Mansjoer, dkk. Tuberkulosis Paru. Dalam: Kapita Selekta Kedokteran.
Jakarta: FK UI; 2001: 472-475.
8. Price, Sylvia A. Patofisiologi: Konsep Klinis Proses-proses Penyakit. Jakarta:
EGC,1994.

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