Case Report

MILIARY TUBERCULOSIS
Presentator: Dinda Sartika F J
Supervisor: dr. Rita Evalina, Sp.A
Date of presentation: 31th March 2010

I. INTRODUCTION
The WHO estimates that during the 1990s there were 90 million new cases of tuberculosis
worldwide, with 30 million deaths caused by the disease. About 13 million new cases and 5
million deaths occurred among children younger than 15 years of age. More than 35% of the
worlds population is infected with M. tuberculosis.

According to World Health Organization (WHO) estimates, in 1990 there were 8 million new
cases of TB and 3 million deaths due to the disease worldwide; 1.3 million new cases and
450,000 deaths were among children under 15 years of age. WHO projects that 90 million
new cases and 30 million deaths - including 4.5 million deaths among children.
In developing countries, the risk for TB infection and disease is relatively uniform in the
population; annual rates of infection often exceed 2%. From 1987 to 1991, the number of TB
cases among children under 5 years of age in the United States increased by 49% from 674
cases to 1006. Although cases among children represent a small percentage of all TB cases,
infected children are a reservoir from which many adult cases will arise. The risk for
infection by Mycobacterium tuberculosis among children depends primarily on the level of
risk of developing infectious TB for the adults in their immediate environment, especially
their household.
In Indonesia, there has been an increases in the number of child diagnosed with
tuberculosis nowadays where it is estimated that around 1.3 million new tuberculosis cases
were detected in children below 15 years old was reported in 1995 and it accumulates 5
15% from all of the tuberculosis cases reported. In 2006, it has been reported that around
174.704 new patients was tested positive with Mycobacterium tuberculosis, which equals to
74% of the new cases detected in Indonesia (Case Detection Rate/CDR).2 Many of these

cases go undiagnosed and untreated and many of these children could be salvaged if there
were improvements in diagnosis and treatment available for children.
Miliary tuberculosis (TB) is the widespread dissemination of Mycobacterium
tuberculosis via hematogenous spread. Classic miliary TB is defined as millet-like (mean, 2
mm; range, 1-5 mm) seeding of TB bacilli in the lung, as evidenced on chest radiography.
This pattern is seen in 1%-3% of all TB cases. Miliary TB may occur in an individual organ
(very rare, <5%), in several organs, or throughout the whole body (>90%), including the
brain. The infection is characterized by a large amount of TB bacilli, although it may easily
be missed and is fatal if untreated. Up to 25% of patients with miliary TB may have
meningeal involvement.
In addition, miliary TB may mimic many diseases. In some case series, up to 50% of
cases are undiagnosed antemortem. Therefore, a high index of clinical suspicion is important
to obtain an early diagnosis and to ensure improved clinical outcomes. Early empirical
treatment for possible but not yet definitive miliary TB increases the likelihood of survival
and should never be withheld while test results are pending. On autopsy, multiple TB lesions
are detected throughout the body in organs such as the lungs, liver, spleen, brain, and others.3
Epidemiology
As in adults, infection with Mycobacterium tuberculosis (MTB) usually occurs by inhalation
of tubercle bacilli in aerosolised respiratory droplets derived from an infectious case of
pulmonary TB. Risk of infection is therefore dependent on the probability, duration and
proximity of exposure to an infectious case, and on the infectiousness of the source.
Social factors, community TB prevalence and age determine where exposure is most
likely to occur and may vary between communities. A household source is most commonly
implicated for young children; older children are increasingly likely to be infected outside the
household. Poverty, poor housing, urban environments and overcrowding are all associated
with increased transmission.
Of all patients with TB, 1.5% are estimated to have miliary TB. The World Health
Organization reports that 2-3 million patients die with and/or from all forms of TB each year.
Children younger than 5 years who acquire miliary TB are more likely to develop lifethreatening miliary and/or meningeal TB. The global burden of tuberculosis continues to
grow due to several factors, including the impact of HIV epidemics, population migration
patterns, increasing poverty, social upheaval and crowded living conditions in developing

countries, inadequate health coverage and poor access to health services and inefficient
tuberculosis control programs.
Patophysiology
The entry of M. tuberculosis for almost all children is the respiratory tract. Transmission is
from person to person, usually by droplet nuclei that become airborne when the ill individual
coughs, sneezes, laughs, sings, or even breathes heavily.
The tubercle bacilli multiply initially within alveoli and alveolar ducts. The alveolar
macrophage is the first line of defense in the innate immune response to TB and plays a
critical role in amplifying the response to infection. Antigen presentation by dendritic cells,
the major antigen-presenting cell (APC) in the lung, and the efficiency with which nave T
cells respond to antigen, also appears less effective in infants and may contribute to the delay
in initiating an appropriate antigen-specific response, resulting in development of active
disease.
Most of the bacilli are killed, but some survive within nonactivated macrophages, which
carry them through lymphatic vessels to the regional lymph nodes. When the primary
infection is in the lung, the hilar lymph nodes usually are involved, although an upper lobe
focus may drain into paratracheal nodes. The tissue reaction in the lung parenchyma and
lymph nodes intensifies over the next 212 wk as the organisms grow in number and tissue
hypersensitivity develops. The parenchymal portion of the primary complex often heals
completely by fibrosis or calcification after undergoing caseous necrosis and encapsulation.
Occasionally, this portion continues to enlarge, resulting in focal pneumonitis and pleuritis. If
caseation is intense, the center of the lesion liquefies and empties into the associated
bronchus, leaving a residual cavity.
During the development of the parenchymal and lymph node lesions, tubercle bacilli from the
primary complex spread via the bloodstream and lymphatics to many parts of the body. Sites
that are most commonly seeded are the apices of the lungs, liver, spleen, meninges,
peritoneum, lymph nodes, pleura, and bone. This dissemination can involve either large
numbers of bacilli, which leads to disseminated tuberculosis, or small numbers of bacilli that
create microscopic tuberculous foci scattered in the tissues. Initially, these metastatic foci are
clinically inapparent but they can be the origin of both extrapulmonary tuberculosis or
reactivation pulmonary tuberculosis in later life.(emed)

1.3 Clinical Manifestations

The majority of children with tuberculosis infection develop no signs or symptoms nonspecific making the diagnosis difficult. Occasionally, infection is marked by low-grade fever
and mild cough, and rarely by high fever, cough, malaise, and flulike symptoms that resolve
within 1 week. Ikatan Dokter Anak Indonesia (IDAI 2006) stated that these general signs and
symptoms are caused by tuberculosis at any site in the body and used clinically to diagnose
tuberculosis in children ( 3).5

There is often a history of an adult in the home with infectious pulmonary

tuberculosis in the last 6 months (a history of contact).

The tuberculin skin test is usually positive 10mm (but often negative in children
with malnutrition or HIV infection).

Failure to thrive with poor weight gain or weight loss. This may be first noticed when
the childs weight is plotted on the Road-to-Health Card.

A history of fever for more then 2 weeks, often with sweating, especially at night.

A history of chronic cough for more than 3 weeks.

Lymphadenopathy, especially in the neck. There may also be an enlarged liver and
spleen.

Scrofuloderma and/or phlyctenular conjunctivitis presents.

The chest X-ray is usually abnormal, suggesting tuberculosis infections of the lung.

The child often comes from a poor, overcrowded environment and has a weak
immune system (young, undernourished or infected with HIV or measles).

IDAI SCORING SYSTEM FOR TUBERCULOSIS

SYMPTOMS
History of Contact
Tuberculin Skin Test
FTT or Weight Loss
History of Fever
Cough
Lymphadenopathy
Bone / Joints
Chest X-Ray
TOTAL

0
Not
confirmed
Negative
Not
confirmed
Not
confirmed
< 3 weeks
Not
confirmed
Normal

1
-

2
AFB (-)

3
AFB (+)

Less BW

Positive
Malnourished -

Unknown
etiology
3 weeks
> 1 node
1 cm
Swollen
Abnormal

SCORE

The diagnosis of tuberculosis is establish in children if the IDAI scores are 6 and
usually depends on a positive tuberculin skin test, clinical or radiographic findings suggestive
of tuberculosis, and known contact with an adult case of tuberculosis, and the child should be
treated for tuberculosis disease.5
1.4 Tuberculin Skin Test
The Mantoux tuberculin skin test is the intradermal injection of 0.1 mL containing 5
tuberculin units of purified protein derivative (PPD) stabilized with Tween 80. T cells
sensitized by prior infection are recruited to the skin where they release lymphokines that
induce induration through local vasodilatation, edema, fibrin deposition, and recruitment of
other inflammatory cells to the area. (Nelson)
The Mantoux skin test must be read 2 to 3 days (48 to 72 hours) after it is done. The
widest transverse diameter (across the arm) of induration (raised, swollen, thickened area of
skin) is measured. It is important that the induration and not the area of redness is measured.
The diameter of the induration is best measured with a ruler. The result should be reported in
millimeters and not simply as positive or negative. The interpretation is as follows:
1.

If the diameter of induration is 0 to 4 mm the test is negative.

2.

A diameter of induration of 5 to 9 mm is intermediate and may be due to BCG or TB

infection. In a healthy HIV negative child this usually indicates that BCG has been given.
However, in HIV infected or severely malnourished children, it may indicate
tuberculosis.

3.

A diameter of induration of 10 mm or more is positive and indicates infection with TB

bacilli.
A Mantoux skin test of 10 mm or more indicates tuberculous infection. However, an

induration between 5 and 9 mm cannot differentiate between children who have a tuberculous
infection and those who have had BCG in the past 2 years. Furthermore, a result of 10 mm or
more cannot differentiate between a recent healed TB infection and active tuberculosis. It is
unfortunate that BCG may confuse the interpretation of the Mantoux skin test in the first 2
years. It is important to understand that a positive Mantoux test suggest tuberculous infection
but does not necessarily mean that the child has tuberculosis.6,7

1.5 Laboratory Findings

General laboratory tests such as a complete blood count and cell differential are
usually normal in children with tuberculosis. Common laboratory abnormalities include
normochromic anemia, leukopenia or leukocytosis, and hyponatremia. Most typically, there
are several hundred to several thousand white blood cells/mm 3 with an early predominance of
PMN cells followed by a high proportion of lymphocytes. The erythrocyte sedimentation rate
is elevated in approximately 50% of patients.3,4
The most important laboratory test for the diagnosis and management of tuberculosis
in child is the acid-fast stain and culture of sputum (GOLD standard). The best culture
specimen for pulmonary tuberculosis in the child is the early morning gastric aspirate
obtained before the child has arisen and peristalsis has emptied the stomach of the pooled
secretions that have been swallowed overnight.5,6
A number of new methods, such as PCR for Mycobacterium, promise quick, sensitive
and accurate methods of diagnosing tuberculosis, and may be an aid in establishing diagnosis
of extra pulmonary tuberculosis. 6
1.6 Imaging Studies

Chest radiography
o

A chest radiograph or CT scan reveals numerous 2 to 3 mm nodules scattered

throughout the lung (snow-storm appearance) in more than 85 percent of
patients.

Nodules characteristic of miliary TB may be better visualized on lateral chest

radiography (especially in the retrocardiac space).7

Chest CT scanning
o

This has higher sensitivity and specificity than chest radiography in displaying
well-defined randomly distributed nodules. High-resolution CT scanning with
1-mm cuts may be even better.7

1.7 Treatment
The basic principles of management of tuberculosis disease in children and
adolescents are the same as those in adults. Several drugs are used to effect a relatively rapid
cure and prevent the emergence of secondary drug resistance during therapy. The choice of
regimen depends on the extent of tuberculosis disease, the host, and the likelihood of drug
resistance.1

Antitubercular agents
Any regimen must contain multiple drugs to which TB is susceptible. In addition, drug
therapy must be taken regularly and continued for a sufficient period. Miliary TB has a high
number (load) of organisms; thus, the initial number of medications should be high.3,4
Commonly Used Drugs for the Treatment of Tuberculosis in Children
Twiceweekly
dosage
(mg/kg/dose
)
Maximum daily dose
50

2.5 g

2030

Daily, 300 mg; twice

weekly, 900 mg

2040

50

2g

1020

1020

Daily, 600 mg; twice

weekly, 900 mg

2040

2040

1g

Drug

Dosage forms

Daily
dosage
(mg/kg/day
)

Ethambutol

Tablets

1525

100 mg
400 mg
Isoniazid

Scored tablets

1015

100 mg
300 mg
Syrup

10 mg/ml
Pyrazinamide

Scored tablets
500 mg

Rifampin

Capsules
150 mg
300 mg
Syrup
Formulated
in
syrup
from
capsules

Streptomycin (IM Vials

administration)
1g
4g

Rifampicin
One of most important TB drugs. Used in combination with other antituberculous

drugs in the treatment of all forms of TB. Without rifampicin, the treatment duration is at

least 18 month. Rifampicin inhibits DNA-dependent RNA polymerase activity in

susceptible cells. Specifically, interacts with bacterial RNA polymerase but does not
inhibit mammalian enzyme. Paediatric dose : 10-20 mg/kg PO; not to exceed 600
mg/daily. Continue therapy for 6-9 month or until at least 6 month have elapsed from
conversion to sputum culture negativity.

Isoniazid
Best combination of effectiveness, low cost, and minor adverse effects. First-line drug

unless known resistance or another contraindication. Therapeutic regimens of <6 month

demonstrate unacceptably high relapse rate. Co-administration with pyridoxine
recommended if peripheral neuropathies develop secondary to INH therapy. Prophylactic
doses of 6-50 mg/d of pyridoxine are recommended. Paediatric dose : 10-20 mg/kg/d PO;
not to exceed 300 mg/daily.

Pyrazinamide
Pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M.

tuberculosis, depending on concentration of drug attained at site of infection; mechanism

of action is unknown. Administer for initial 2 mo of a 6-mo or longer treatment regimen
for drug-susceptible cases. Treat drug-resistant cases with individualized regimens.
Paediatric dose : 15-30 mg/kg/d PO; not to exceed 2 g/daily

Ethambutol
Diffuses into actively growing mycobacterial cells, such as tubercle bacilli. Impairs

cell metabolism by inhibiting synthesis of one or more metabolites, which, in turn, causes
cell death. Use in these patients in combination with second-line drugs that have not been
previously administered. Absorption is not significantly altered by food. Paediatric dose :
15-25 mg/kg/d (7 mg/lb/d) PO.

Streptomycin sulfate
For treatment of susceptible mycobacterial infections. Use in combination with other

antituberculous drugs (eg, INH, EMB, rifampicin). Total period of treatment for TB is a
minimum of 1 y; however, indications for terminating streptomycin therapy may occur at
any time. Recommended when less potentially hazardous therapeutic agents are
ineffective or contraindicated. May be used in patients with severe liver dysfunction
(transaminases >3- to 5-fold normal). Paediatric dose : 2 times/wk dosing: 20-40 mg/kg/d
IM; not to exceed 1 g/daily or 3 times/wk dosing: 25-30 mg/kg/d IM; not to exceed 1.5
g/daily

Corticosteroids
These are useful in the treatment of some children with tuberculosis disease. They are
most beneficial when the host inflammatory reaction contributes significantly to tissue
damage or impairment of organ function. There is convincing evidence that corticosteroids
decrease mortality rates and long-term neurologic sequelae in some patients with tuberculous
meningitis by reducing vasculitis, inflammation, and ultimately, intracranial pressure.
Lowering the intracranial pressure limits tissue damage and favors circulation of
antituberculosis drugs through the brain and meninges. However, the long-term course of
disease is probably unaffected. Some children with severe miliary tuberculosis have dramatic
improvement with corticosteroid therapy if the inflammatory reaction is so severe that
alveolo-capillary block is present. The most commonly prescribed regimen is prednisone, 1
2mg/kg/24hr in one to two divided doses orally for 46 wk, followed by gradual tapering.1
1.8 Prevention
Prevention has two aspects: stopping the spread of infection and treating early
infection before it becomes active disease.8
Stopping the Spread:
Because tuberculosis bacteria are airborne, good ventilation with fresh air lowers the
concentration of bacteria and limits their spread. Also, germicidal ultraviolet lamps can be
used to kill airborne tuberculosis bacteria in buildings where people at risk are gathered, such
as homeless shelters, jails, and hospital and emergency department waiting areas. Health care
workers who handle samples of infected tissue or interact with people who may be infected
wear special masks, called respirators, to help protect them. No precautions are needed if
people have no symptoms even if their skin or blood test for tuberculosis is positive.
After only a few days to weeks of treatment with the correct antibiotics, people are
less likely to spread the disease. They usually do not need to be isolated for longer than 2
weeks. However, if infected people live or work with people who are at high risk (such as
young children or people with AIDS), repeated analyses of sputum samples may be needed to
determine when the danger of spreading the infection is past. Also, people who continue to
cough during treatment, do not take their drugs as instructed, or have drug-resistant
tuberculosis may need to be isolated longer so that they do not spread the disease.
Treating Early Infection:

Because tuberculosis is spread only by people with active disease, early recognition
and treatment of active disease is one of the best ways to stop it from spreading. People who
have a positive tuberculin skin or blood test should be treated even if they are not yet ill. The
antibiotic isoniazid is very effective at stopping the infection before it becomes active
disease. It is given daily for 6 to 9 months. For some people, rifampin alone may be
prescribed daily for 4 months. In some countries, isoniazid and rifampin are used together for
3 months.
Preventive therapy definitely benefits younger people who have a positive tuberculin
skin test. It also is likely to help older people at high risk of tuberculosis (for example, if their
skin or blood test recently changed from negative to positive, if they have been recently
exposed, or if they have a weakened immune system). For older people with long-standing
latent infection, the risk of toxicity from the antibiotics may be greater than the risk of
developing tuberculosis. In such cases, doctors often consult an expert in the subject before
they decide whether to use preventive therapy.
If people with a positive skin or blood test become infected with HIV, the risk of
developing active infection is very high. Similarly, the risk is also high if people who have a
latent infection take corticosteroids or other drugs that suppress the immune system
(including some of the newer anti-inflammatory drugs). Such people usually need treatment
of latent tuberculosis infection.
In much of the developing world, a vaccine called bacille Calmette-Gurin (BCG) is
used to prevent development of serious complications, such as meningitis, in people who are
at high risk of becoming infected with Mycobacterium tuberculosis. The value of BCG is
debated, and the vaccine continues to be used only in countries where the likelihood of
contracting tuberculosis is very high. The vaccine may have a role in protecting health care
workers and others exposed to multidrug-resistant tuberculosis. Research is under way to
develop a more effective vaccine. About 10% of people who have received BCG at birth have
a positive reaction to the tuberculin skin test 15 years later, even if they are not infected with
tuberculosis bacteria. However, people vaccinated at birth often incorrectly attribute a
positive skin test later in life to the BCG vaccine. In most countries, tuberculosis is
stigmatized, and many people are reluctant to believe that they have even latent infection,
much less active disease. The newer tuberculosis blood tests are not affected by BCG
vaccination.8
1.9 Prognosis

Untreated, the mortality rate of miliary TB is assumed to be close to 100%. With early
and appropriate treatment, the mortality rate is reduced to less than 10%. The earlier the
diagnosis, the better the likelihood of a positive outcome. Early treatment for suspected TB
has shown to improve outcome. Most deaths occur within the first 2 weeks of admission to
the hospital. This may be related to delayed onset of treatment. Up to 50% of all cases of
disseminated TB detected at autopsy were missed antemortem in reported case series.3

II.

OBJECTIVE
The aim of this paper is to report

III.

CASE REPORT

A patient, YP, male, 1 year and 2 months of age, weighing 6.2 kg, with a body length of 68
cm, was admitted in to Haji Adam Malik General Hospital on February 27 th, 2010 at 12:45
pm with chief complaint of chronic coughing. The patient is a new patient in the infectious
unit of pediatrics department, Haji Adam Malik General Hospital. Patient has been suffering
from chronic cough since 2 months ago, and the symptom has been worsening in this past 2
weeks. Productive cough was not confirmed because the patient was not able to raise sputum.
History of contact with adults in the home with infectious pulmonary tuberculosis in the last
6 months was confirmed, as patients father had already been diagnosed with Pulmonary
Tuberculosis and was on regular tuberculosis medication for the past 4 months. History of
repeated fever was found for the past 3 months. For now the temperature is still high, around
38.00C. Loss of appetite and weight loss was confirmed since 1 month ago, with patients
previous body weight was 6.6 kg. Shortness of breath was not confirmed. History of vomiting
and diarrhea were denied by his parents. Defecation and urination are within normal limits.
History of spontaneous delivery was confirmed, aided by a midwife, full term with
spontaneous crying, birth weight was 2600 kg and bluish body was not confirmed.
History of basic immunization was not confirmed. History of previous illness was
unremarkable, with the history of asthma in the family was not confirmed. History of
previous medications were paracetamol and multivitamin.
History of nutritional status were breast milk administration from birth until 4 months
old, breast milk + filtered boiled rice 4-7 months old, breast milk + unfiltered boiled rice 7-11
months old and breast milk + regular food from 11 months old until now.

On Physical Examination, the following findings were confirmed. Body Weight was
6.2 kg, body height was 68 cm, and body temperature 38.00C.
Level of consciousness

: Alert
Dyspnoe, cyanosis, edema, icteric eyes, and anemia
not confirmed.

Head

: Eyes: Light reflexes +/+, isochoric pupil, lower eyelids pale were not
confirmed.
Mouth/Nose/Ears: Within normal limits.

Neck

: Lymph node enlargement was not confirmed.

Chest

: Symmetrical fusiformic, HR : 120 bpm, regularly, murmurs (-)

RR : 34 tpm, regularly, rales (+)

Abdomen

: Abdominal distension (+), normal peristaltic.

H/L : inpalpable

Extremities

: Pulse 120 bpm, regularly, Pressure/Volume was adequate. Lymph nodes

enlargement was not confirmed.

Genitalia

: Male, there were no abnormalities present.

Chest X-Ray findings (February 25th, 2010)

Conclusion : Miliary tuberculosis.
Laboratory findings (February 27th, 2010)
Routine Blood Examination
-

WBC

13.14 x 103/uL

RBC

3.89 x 106/uL

Hb

12.4 g/dL

PLT

462 x 103/uL

Liver Profile
-

Total Billirubin

0.324 mg/dl

Direct Billirubin

0.236 mg/dl

SGOT (AST)

25.2 u/L

SGPT (ALT)

25.7 u/L

Alkaline Phosphatase :

Kidney Profile

108

u/L

were

Ureum

23.9 mg/dl

Creatinine

0,39 mg/dl

Working Diagnosis : Miliary tuberculosis + severe malnutrition + FTT

Further Examinations :
-

Mantoux test

Medication :
-

Rifampicin 1 x 75mg

INH 1 x 50mg

Pyrazinamide 2 x 75mg

Ethambutol 1 x 100mg

Prednisone 12.5mg (1-1-)

Paracetamol 3 x cth

Regular meal diets 620 kcal with 12.4gr protein

Daily Follow Up
Follow Up February 28th 2010
S : Cough (+), fever (-)
O: Sens: CM, T: 36.60C, BW: 6.2 kg, BL: 68 cm
Head

: Eyes: Light reflexes +/+, isochoric pupil, lower eyelids pale were
not confirmed.
Mouth/Nose/Ears: Within normal limits.

Neck

: Lymph nodes enlargement (-)

Chest

: Symmetrical fusiformic, HR : 96 bpm, regularly, murmurs (-)

RR : 28 tpm, regularly, rales (+)

Abdomen : Soepel, normal peristaltic. H/L : inpalpable

Extremities: Pulse 96 bpm, regularly, Pressure/Volume was adequate. Lymph
nodes enlargement was not confirmed.
A : Miliary tuberculosis + severe malnutrition + FTT
P : - Rifampicin 1 x 75mg
-

INH 1 x 50mg

Pyrazinamide 2 x 75mg

Ethambutol 1 x 100mg

Prednisone 12.5mg (1-1-)

Paracetamol 3 x cth

Regular meal diets 620 kcal with 12.4gr protein

Suggestions :
-

Mantoux test

Division of Nutrition & Metabolic Disease consultation.

Division of Growth & Development - Social Pediatric consultation.

Follow Up March 1st 2010

S : Cough (+), fever (+)
O: Sens: CM, T: 37.80C, BW: 6.2 kg, BL: 68 cm
Head

: Eyes: Light reflexes +/+, isochoric pupil, lower eyelids pale were
not confirmed.
Mouth/Nose/Ears: Within normal limits.

Neck

: Lymph nodes enlargement (-)

Chest

: Symmetrical fusiformic, HR : 108 bpm, regularly, murmurs (-)

RR : 32 tpm, regularly, rales (+)

Abdomen : Soepel, normal peristaltic. H/L : inpalpable

Extremities: Pulse 108 bpm, regularly, Pressure/Volume was adequate. Lymph
nodes enlargement was not confirmed.
A : Miliary tuberculosis + severe malnutrition + FTT
P : - Rifampicin 1 x 75mg
-

INH 1 x 50mg

Pyrazinamide 2 x 75mg

Ethambutol 1 x 100mg

Prednisone 12.5mg (1-1-)

Paracetamol 3 x cth

Regular meal diets 620 kcal with 12.4gr protein

Follow Up March 2nd 2010

S : Cough (+), fever (-)
O: Sens: CM, T: 37.40C, BW: 6.2 kg, BL: 68 cm

Head

: Eyes: Light reflexes +/+, isochoric pupil, lower eyelids pale were
not confirmed.
Mouth/Nose/Ears: Within normal limits.

Neck

: Lymph nodes enlargement (-)

Chest

: Symmetrical fusiformic, HR : 110 bpm, regularly, murmurs (-)

RR : 28 tpm, regularly, rales (+)

Abdomen : Soepel, normal peristaltic. H/L : inpalpable

Extremities: Pulse 110 bpm, regularly, Pressure/Volume was adequate. Lymph
nodes enlargement was not confirmed.
A : Miliary tuberculosis + severe malnutrition + FTT
P : - Rifampicin 1 x 75mg
-

INH 1 x 50mg

Pyrazinamide 2 x 75mg

Ethambutol 1 x 100mg

Prednisone 12.5mg (1-1-)

Paracetamol 3 x cth

Regular meal diets 620 kcal with 12.4gr protein

Mantoux test (February 28th 2010)

Summary : Mantoux test with 5TU gave 8mm induration
The patient was discharged on March 2nd 2010 to be treated as an outpatient.

IV.

DISCUSSION
Miliary tuberculosis is a common disease in areas where tuberculosis is endemic.

Miliary tuberculosis is due to hematogenous spread of tubercle bacilli. The successful

dissemination of tuberculosis depends on the balance between mycobacterial virulence and
host immune defence. Although in children it is often the consequence of a recent primary
infection, in adults it may be due to either recent infection or reactivation of old disseminated
foci.
About 60% of tuberculosis cases in children in the world occur in infants and children
< 5 years of age. Of all patients with tuberculosis, 1.5% are estimated to have miliary
tuberculosis. Children younger than 5 years who acquire miliary TB are more likely to

develop life-threatening miliary and/or meningeal TB.3 In this case the patient was 1 year of
age, confirming the fact that miliary tuberculosis may occur in young children, especially
those under one year of age.
Ikatan Dokter Anak Indonesia (IDAI 2006) stated that these general signs and symptoms
are caused by tuberculosis at any site in the body and used clinically to diagnose tuberculosis
in children ( 3).5

There is often a history of an adult in the home with infectious pulmonary

tuberculosis in the last 6 months (a history of contact). In this case, history of contact
with adults in the home with infectious pulmonary tuberculosis in the last 6 months was
positive, as patients father had already been diagnosed with Pulmonary Tuberculosis and
was on regular tuberculosis medication for the past 4 months.

The tuberculin skin test is usually positive 10mm (but often negative in children
with malnutrition or HIV infection). In this case, the patient had undergo on a Mantoux
test on February 28th and the result was 8mm induration. Based on the normal
interpretation, a diameter of induration of 5 to 9 mm is intermediate and may be due to
BCG or TB infection. However, in HIV infected or severely malnourished children, it
may indicate tuberculosis. It was confirmed that this patient was suffering severe
malnutrition for years and with the history of not receiving any basic immunization
before.

Failure to thrive with poor weight gain or weight loss. It was confirmed that the
patient had complained on having loss of appetite and weight loss since 1 month ago, and
the patient had already been diagnosed with severe malnutrition + FTT.

A history of fever for more then 2 weeks, often with sweating, especially at night. It
has been reported that history of repeated fever was found for the past 3 months in this
case. For now the patients temperature is still high, around 38.00C.

A history of chronic cough for more than 3 weeks. Previously, the patient had been
admitted to Haji Adam Malik General Hospital with chief complaint of chronic cough
since 2 months ago.

Lymphadenopathy, especially in the neck. There may also be an enlarged liver and
spleen. Based on history taking and physical examination, it was confirmed that patient
did not suffer from any lymphadenopathy or hepatosplenomegaly.

Scrofuloderma and/or phlyctenular conjunctivitis presents. Both pathological features

in this patient were unclear due to the fact that both signs were not found when history
taking and physical examination were performed on this patient.

The chest X-ray is usually abnormal, suggesting tuberculosis infections of the lung. It
was confirmed that patient had undergo chest x-ray examination on February 25 th with
the conclusion suggesting of miliary tuberculosis (+).

IDAI SCORING SYSTEM FOR TUBERCULOSIS

SYMPTOMS

History of Contact

Not
confirmed
Negative
Not
confirmed
Not
confirmed
< 3 weeks
Not
confirmed

AFB (-)

AFB (+)

SCOR
E
3

Less BW

Malnourishe
d
-

Positive
-

3
2

1
0

0
1

Tuberculin Skin Test

FTT or Weight Loss
History of Fever
Cough
Lymphadenopathy
Bone / Joints
Chest X-Ray
TOTAL

Normal

Unknown
etiology
3 weeks
> 1 node
1 cm
Swollen
Abnormal

11

The diagnosis of tuberculosis is establish in children if the IDAI scores are 6 and
usually depends on a positive tuberculin skin test, clinical or radiographic findings suggestive
of tuberculosis, and known contact with an adult case of tuberculosis. 5 So, it is possible to
diagnose this patient with miliary tuberculosis based on the score 11 ( 6) with a positive
tuberculin skin test, clinical or radiographic findings suggestive of tuberculosis, and known
contact with an adult case of tuberculosis and this patient should be initially treated as soon as
possible with DOTS regiment in order to achieve a better outcome in this patient and prevent
him from falling into other severe complications which will lead to mortality, considering that
the patient was only a child of 1 year old and will have a long journey to face the future
brightly if early diagnosis and treatment was established.
The GOLD Standard for diagnosing and managing tuberculosis in children and adults
will always be culture of sputum. However, it had always been a dilemma in obtaining a
sample of sputum in a child because younger children under 6 years of age are usually unable
to cough up sputum to examine, as sputum is swallowed. Therefore, if a sputum sample is

needed in a child, it is easier to take a sample of gastric fluid which contains swallowed
sputum. The gastric aspirate is best collected early in the morning before the first feed, the
child having been nil per mouth for 6 hours. As gastric fluid is highly acidic, 4% sodium
bicarbonate in an equal volume to the gastric aspirate should be added to the specimen to
neutralize the acid. Otherwise the TB bacilli will be killed before they can be cultured. As
children usually cough up or swallow far fewer TB bacilli than adults do, positive cultures are
less common in children. Therefore, diagnosing tuberculosis in children is often done without
obtaining a sputum sample.1,4
Miliary tuberculosis is usually seen in young children under 2 years of age or children
with a weak immune system due to HIV infection or severe malnutrition. 3 Therefore, in this
case we should have a critical view that this patient maybe suffering miliary tuberculosis due
to HIV infection primarily, which can also cause severe malnutrition. An ELISA test should
be performed in this case, in order to exclude HIV infection as his primer disease, as the
earlier the diagnosis, the suitable management and medication are administer, the better the
likelihood of a positive outcome.
As time goes, tuberculosis disease patterns since have changed, with a higher
incidence of disseminated and extrapulmonary disease now found. Extrapulmonary sites of
infection commonly include central nervous system, lymph nodes, pleura, and osteoarticular
areas, although any organ can be involved. The diagnosis of extrapulmonary tuberculosis can
be elusive, necessitating a high index of suspicion. The most severe one that we should take
extra cautions is tuberculous meningitis. Tuberculous meningitis usually occurs a few months
after the primary TB infection, especially in small children below 3 years of age. It is the
most dangerous complication of pulmonary tuberculosis. The TB bacilli reach the meninges
via the blood stream, usually from the lungs. The risk of permanent brain damage
(hydrocephalus, paralysis, deafness, blindness, convulsions and mental retardation) or death
is high, especially if the diagnosis is made late. However, recovery can be complete with
early treatment.6 Therefore in this case, examination of the cerebrospinal fluid (CSF) obtained
by lumbar puncture should be considered as it is helpful in making the clinical diagnosis and
preventing the morbidity and mortality rate to raise higher in this patient. The diagnosis is
only confirmed by finding TB bacilli (by staining or culture) in the CSF.
The basic principles of management of tuberculosis disease in children and
adolescents are mostly based on the combination of multiple anti-tubercular agents and

corticosteroid. Several drugs such as Rifampicin, Isoniazid, Pyrazinamide, Ethambutol and

Streptomycin are used to effect a relatively rapid cure and prevent the emergence of
secondary drug resistance during therapy. It has been reported that some children, compared
to adults with severe miliary tuberculosis have dramatic improvement with corticosteroid
therapy if the inflammatory reaction is so severe that alveolo-capillary block is present. The
most commonly prescribed regimen is prednisone, 12mg/kg/24hr in one to two divided
doses orally for 46 wk, followed by gradual tapering. In this case, anti-tubercular agents
such as Rifampicin, Isoniazide, Pyrazinamide, Ethambutol and Prednisone were
administered, suitable with the DOTS regiment protocol for treating tuberculosis in children.
Preventive therapy definitely benefits younger people who have a positive tuberculin
skin test. It also is likely to help older people at high risk of tuberculosis (for example, if their
skin or blood test recently changed from negative to positive, if they have been recently
exposed, or if they have a weakened immune system). Prevention has two aspects: stopping
the spread of infection and treating early infection before it becomes active disease. A vaccine
called bacille Calmette-Gurin (BCG) is used to prevent development of serious
complications, such as meningitis, in people who are at high risk of becoming infected with
Mycobacterium tuberculosis.8 As referred in this case, the patient, diagnosed with severe
malnutrition, did not receive any basic immunization before and his father had already been
diagnosed with pulmonary tuberculosis for years without medications. Therefore, educational
support and preventive measures should be considered for ensuring that there is no
significance increase in the number of new cases detected, and stops the spreading of the
disease to others, especially our loved ones. His father with active tuberculosis can help
reduce the spread of bacteria by coughing into a tissue. Also, he should remain in isolation
until he responds to treatment and no longer coughing. His mother should be educated on the
benefits of giving BCG vaccine as a precaution plus the steps on how to maintain a balance
nutritional supports in children.
With early and appropriate treatment, the mortality rate is reduced to less than 10%.
The earlier the diagnosis, the better the likelihood of a positive outcome. Untreated, the
mortality rate of miliary TB is assumed to be close to 100%. Most deaths occur within the
first 2 weeks of admission to the hospital. Early treatment for suspected TB has shown to
improve outcome. Based on the fact above, the prognosis of this patient is good.

SUMMARY
It has been reported a case of a child with Miliary Tuberculosis + severe malnutrition
+ FTT. The diagnosis was established based on history taking, clinical sign and symptoms,
physical examination and chest x-ray examination. There has been an improvement in the
signs and symptoms from the day the patient was admitted until the day he was discharged.
Patient was discharged on March 2nd 2010 to be treated as an outpatient.