Nurul Sylvana Long Case Baru-1 (1) - 1

TIMELINE DIAGRAM
Observation by
candidate
October October
October November
23th2021 31th2020
23th 2021 9th 2021
Patient was Patient was Final

admitted to admitted to Observation by
emergency unit Pediatric Ward candidate Report
at “W” Hospital of “W” Hospital
1
PATIENT’S IDENTITY
Name :I
Gender : Male
Age : 14 years 7 months old
Date of birth : March 05th 2007
Medical record : 339xxx
Address : Makassar, West Sulawesi.
Admission date : October 23th 2021
Hospital length of stay : 9 days
PARENT’S IDENTITIES :
Father Mother
Name : Mr. S Mrs. H
Age : 60 years old 56 years old
Last education : Elementary School Junior High School
Occupation : Entrepreneur Housewife
Address : Makassar Makassar
a
Initial observation by candidate began on October23th 2021
PATIENT’S HISTORY (Anamnesis and alloanamnesis from both parents)

Chief Complaint:
Hemoptysis
History of present illness
Hemoptysis since one day before admitted to the hospital with
volume around 500 cc. Cough had occurred since 4 months before
admitted to “W” Hospital, with productive cough without blood, and without
dyspnea. There was no fever nor seizure. There was no vomiting. He had
decreased appetite since 10 months and for the last one week he did not
want to eat any food, and just drank water and sweet tea. There was
weight loss since 10 months ago with a reduction of 12 kg body weight. He
did not complain about urination and defecation. There was no history of
decrease of consciousness, sweating at night, frequent diarrhea, recurrent
2
white patches in mouth, discharge from the ear, pale, bleeding, and
transfusion.
History of previous illness
There was history of close contact with adult tuberculosis (his 30-
year-old cousin), when the patient was 13 years old (1 years ago), now the
patient is 14 years old. His cousin lived with the patient and had history of
being diagnosed with bacteriological tuberculosis and human
immunodeficiency virus (HIV) infection in Malaysia but did not received
any treatment and passed away in March 2021.
There was history of decreased appetite since 10 months ago. He
usually ate food only two times a day. His body weight was not
significantly increased according to his parents. The patient had
experienced productive cough since 4 months ago. About 3 months before
admission, the patient had frequent fever. He was treated in a primary
health center and was given cough medicine (the family did not know the
name of the medicine). After 1 month of being treated in a primary health
center, the cough was still present, but the patient only continued to buy
cough medicine at the pharmacy. The cough began to relieve but still
persisted. The patient’s family were satisfied at that moment and never
control again. One day before entering the hospital the patient had
hemoptysis so he was admitted to the W hospital.
Conclusion: This patient was diagnosed with suspected pulmonary
tuberculosis and severe malnutrition.
History of illness in the family

The mother said that there was family history of the same illness
with the patient (patient’s cousin), 1 year ago when the patient was 13
years old. Patient’s cousin was diagnosed with tuberculosis with confirmed
bacteriologic in Malaysian hospital but did not received any treatment.
3
Patient’s family pedigree
Note : Male
: Female
: Patient
: Patient’s cousin with history of the same illness 1 year ago
and closed contact
Conclusion: there was history of illness in the family as the source
of primary infection of tuberculosis.
Patient’s personal and social history

a) Prenatal history
During pregnancy, the mother had routine control at the midwives,
and was given vitamin and iron supplementation, she never had any
herbal nor drugs other than prescription from medical professional. She
felt healthy enough with term pregnancy, and never experienced any
trauma or other problems during the pregnancy.
Conclusion: Mother had a normal prenatal history.
b) History of delivery
Patient was born at a hospital. He was term, spontaneous vaginal
delivery, assisted by midwives. The baby cried immediately, no
cyanosis. Birth weight 2700 grams, birth length and head
circumference were forgotten.
Conclusion: Patient was born term, normal birth weight, with
normal history of delivery.
4
c) Post-natal history
Patient received vitamin K1 injection. Hepatitis B vaccination was
given on the first day and oral polio at the discharge time. No history of
cyanosis, pale, jaundice, seizure nor bleeding. The mother stayed at the
hospital for two more days after delivery.
Conclusion: post-natal history was unremarkable.
d) Feeding history
Patient was breastfed since birth up to 2 months old, formula feed
was given after that until 2 years old. Complementary food was first
introduced at 6 months of age in a form of milk porridge, followed by
steamed rice by the age of 9 months old and had family meal since 1-
year-old. About 10 months before, he had decreased appetite and just
eat two times a day, with rice, meat/chicken, fish, egg, vegetables,
fruits, and biscuits. At the moment patient did not want to eat any food
for last one week. The mother said, he had poor appetite since around
10 months ago and worsened the last 2 months.
Conclusion: Patient did not have adequate quality and quantity of
intake.
e) Growth and developmental history

Growth
Up until the patient was 2 years old, the mother routinely took him
to posyandu, there was no Kartu Menuju Sehat (KMS), but the mother
never complained about the growth of child until now. At the age of 14
years old, the mother felt that her child did not gain enough weight.
Developmental
Patient was able to show responsive smile at the age of 2 months
old, rolled over at 4 months old, sat without support at 7 months old,
stood alone at 12 months old, was able to walk well by the age of 14
months old and was able to speak at 12 months old.
5
We use Pediatric Symptom Checklist (PSC-17) to detect risk of
mental and behavioral disturbance that might happen due to the
disease (appendix 4). Total score was 9.
f) History of immunization
The immunizations that has been obtained were hepatitis B 5 times
(age 0 day, 2,4,6 and 18 months), oral polio 5 times (age 2 days, 2,4,6
months and booster at 18 months), BCG at 1 month, DPT 5 times (age
2,4,6 months and booster at 18 months and 6 years), and measles (age
9 months), diphtery tetanus vaccine/ Dt ( 6 years old), tetanus
diphtheria/ Td (age 7 and 10 years old)
Conclusion: Complete basic and booster immunization
g) Basic needs
Physical-bio medic needs
Patient’s main caregiver was his mother. Regarding health care,
mother seemed worried about the condition of his child. Patient taken to
W hospital because of cough for 4 months and hemoptysis.
The family can provide adequate food, but the patient had bad
appetite since 10 months ago. Clothing needs was also fulfilled.
Conclusion: Patient’s parent is able to fulfill all of the patient’s
physical-bio medic needs adequately.
Emotional needs
Parents-child relationship seems close and lovingly. Both mother
and father love the patient very much. The mother is patient enough
and tried to give concern more about her child illness.
Conclusion: Adequate emotional needs from both parents.
Mental stimulation needs

Early stimulations were given by both parents since early age that
includes touch and hug, playing together, and talking. She also likes to
play with her brothers.
6
Conclusion: Mental stimulation needs are fulfilled.
h) Family socio-economy history/environment/ housing

The father is 60-year-old, a Muslim, graduated with Elementary
school and works as entrepreneur with monthly income around
Rp.4.000.000. The mother is 56 years old, a Muslim, graduated from
junior high school, and a housewife. Patient lives with her parents and
4 brothers and 2 sisters in a permanent house, around 8 x 13 m2,
consisted of 4 bedrooms,1 living room, 1 kitchen and 1 bathroom.
Source of the family drinking water is from refill water product.
Water for daily activities such as for washing and bath are from water
supply company (PDAM). Electricity source is coming from national
electricity company (PLN). Ventilation and light at the house are
sufficient. The nearest health facility from the patient’s house is primary
health center (Puskesmas) about ± 500 m away. Hospital bill is covered
by national health insurance.
Conclusion: Patient comes from a middle economic class. Health
facility is easily accessible and health care fees are covered by
government.
PATIENT’S HOSPITAL ADMISSION SUMMARY

There was history of close contact with adult tuberculosis (his 30 -
years -old cousin), when the patient was 13 years old (1 years ago), now
is 14 years old. His cousin lives with the patient and has history of being
diagnosed with bacteriological tuberculosis and human immunodeficiency
virus (HIV) infection in Malaysia but not undergoing treatment and passed
away in March 2021.
About 4 months before, there was a recurrent productive cough,
without blood nor dyspnue. He was treated to a primary health center and
never control. He only buys medicine at the pharmacy and got improved,
but the cough still persists.
He had decreased appetite since 10 months ago and worsened the
last 2 months. He usually eats food only two times a day. His body weight
7
not significantly increase according to his parents. At the moment,
especially one week, he did not want to eat any food. There was a weight
loss with a reduction of 12 kg body weight.
He was not fever when admitted, but there was history of recurrent
fever since 3 months ago. Patient was taken to “W” Hospital with
hemoptysis.
PHYSICAL EXAMINATION
General condition : Severely ill
Consciousness : Glasgow coma scale 15 (E4M6V5)
Vital signs
Blood pressure : 100/60 mmHg (between P50-90)
Heart rate : 92 beat per minute, regular, adequate
volume
Respiratory rate : 22 breaths per minute, regular, no
chest in drawing
Oxygen saturation : 99% with room air.
Temperature : 36,9oC
Pain scale : 0 NRS (Numeric Rating Scale)
Anthropometric status
Actual BW : 53 kg
Ideal BW : 68 kg
Body Height : 177 cm (P75CDC-NCHS 2000
Chart, appendix 2)
Head circumference (HC) : 53 cm (-2 SD<HC<0 SD,Nellhaus
curve) (Appendix 2)
Weight-for-Height : 77,9% with wasting (Malnutrition
/severely wasted, CDC NCHS 2000
chart) (Appendix 3)
Height-for-age (H/A) : 105,3% (Normal, CDC-NCHS 2000
chart) (Appendix 3)
8
Weight-for-age (W/A) : 96,3% (normal, CDC-NCHS 2000
chart) (Appendix 3)
Height Age (HA) : 18 years 6 months old.
RDA from HA : 50 K Cal/kg BW/day
Father’s height : 175 cm
Mother’s height : 160 cm
Genetic potential height : 165,5– 182,5cm (<P3 – P25,
CDC-NCHS 2000 chart)
Mid-parental height : 174 cm
Conclusion: Severe malnutrition, normal stature.
Table 1. General examination
System Description
Skin No crazy pavement dermatosis, no cyanosis, no
erythema, no purpura, good turgor, no striae, no
jaundice, no pale. BCG Scar positive on right deltoid.
Head Normocephal, mesocephal, closed fontanelle, no
deformities.
Hair Black, evenly distributed, easily plucked.
Face No old man face, no dysmorphic, no cranial nerves
palsy, no erythema on the cheeks.
Eyes No edema palpebra, no anemic conjunctiva, no icteric
sclera. Eye movement is within normal, no
strabismus, pupil round, isochoric, diameter
2,5mm/2,5mm, normal light reflex.
Nose Septum nasal in the middle, no secret, mucosa not
hyperemic.
Ear No secret, intact tympanic membrane.
Mouth No dry lips, no oral ulcer, no stomatitis.
Teeth No carries dentis.
Throat Pharyngs not hyperemic, no tonsillar enlargement.
Neck No nuchal rigidity. Normal jugular vein pressure.
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Chest Shape and movement are symmetric, with piano
chest,no deformities,no chest retraction.
Lung Vocal fremitus symmetrical, percussion sonor,
vesicular breath sound, no additional breath sound
(wheezing and rhales).
Heart Ictus cordis was not visible and palpable, heart
sound I-II normal, no murmur nor gallop.
Abdominal Supple, normal bowel sound, liver and spleen not
palpable, Abdominal circumference (AC) 57 cm. No
ascites.
Genitalia Boy, pubertal status A3G3P3
Lymph nodes There are no lymphadenopathies.
Spine No gibbus
Extremities Wasting. No Baggy pants. No edema. Warm
extremities, capillary refill timeless than 2 seconds, no
edema. BCG scar + 5 mm on deltoid region right
upper arm. Motoric: muscle strength and tonus are
within normal limit, normal physiological reflexes, no
pathologic reflexes.
No spontaneous bleeding manifestation.
Tuberculosis score : 7
Contact :3
Nutritional Status : 2
Fever :0
Cough :1
Lymphadenopathy : 0
Chest X-Ray :1
Joint :0
Tuberculin test : not yet
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LABORATORY EXAMINATION
Blood examination, October 23th 2021:
Hemoglobin 11,1 gr/dl, MCV 75 fL, MCH 23 pg, MCHC 31 g/dL,
Leucocytes 10.000/mm3, Neutrophil 57,2%, Lymphocyte 13,3%, Monocyte
8,9%, eosinophyl 10,3%, Absolute Neutrophil Count 5.720 /mm3,Platelet
420.000/mm3, Blood Sugar 99 mg/dL,Creatinine 0,74 mg/dL, Ureum 18
mg/dL, SGOT 28 U/L, SGPT 25 U/L, Albumin 4,1 g/dL, Natrium 137
mmol/l, Potassium 4,3 mmol/L, Chloride 106 mmol/L.
X-RAY EXAMINATION
Chest X-Ray October 23th 2021 :
Pneumonia bilateral suspected specific.
Resume
A boy, 14 years - 7 months old, hospitalized with chief complaint
cough about past 4 months before admitted, with productive cough without
blood and dyspnue. There was no fever and no seizures. No vomiting. He
had decreased appetite since 10 months ago. There was weight loss with
a reduction of 12 kg body weight. Normal urination and defecation.
There was history of close contact with adult tuberculosis (his 30 -
year -old cousin), when the patient was 13 years old (1 years ago), now
was 14 years old. His cousin lived with the patient and has history of being
diagnosed with bacteriological tuberculosis and human immunodeficiency
virus (HIV) infection in Malaysia but did not receive treatment and passed
away in March 2021.
He looked severely ill, with severe wasted, GCS 15, vital sign within
normal limit. There were BCG scar on right deltoid. There were easily
plucked hair, piano chest and wasting. There were no crazy pavement
dermatosis, old man face, baggy pants, stomatitis, nuchal rigidity, and
edema. There are no lymphadenopathies. No pale, no icteric, no bleeding
manifestation. There were no chest retraction, no rhales, no wheezing.
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There was anemia with hemoglobin level 11,7 g/dL, hypochromic
microsites. There were pneumonia bilateral from chest X-Ray.
Tuberculosis score was 7.
Diagnosis
1. Pulmonary Tuberculosis [A15.0]
2. Severe Malnutrition [E43]
3. Anemia of Chronic Disease [D63] differential diagnosis Iron
Deficiency Anemia [D50.9]
Problems
1. Pulmonary Tuberculosis
2. Severe Malnutrition
3. Anemia of Chronic Disease differential diagnosis Iron
Deficiency Anemia
Management planning
1. Pulmonary Tuberculosis
Diagnostic • History taking and physical examination
• Laboratory: Positive Acid-fast Bacilli test and The
Genexpert test
• Chest X-Ray
• Tuberculin test
• Tuberculosis score ≥ 6
Therapy • Planning to give Anti-tuberculosis Drugs.
Notes: (Wait for the result of acid-resistance bacilli test to
choose the regimen of anti-tuberculosis drugs)
• Counseling and rapid test for human immunodeficiency
virus non reactive
Monitoring • Result Acid-fast bacilli test and tuberculin test
• Cough
• Appetite
• Body weight
• General condition
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• Consciousness
• Vital signs
• Make sure the medicine is taken
• Sign of icteric
• Drugs tolerance
• Side effect of anti-tuberculosis drugs
Education • Red/orange color urinary is normal
• Consume drugs on an empty stomach
• Routine control every 2 weeks on intensive phase (first 2
months) and every month on advanced phase (next 4
months)
• Acid-fast bacilli test on 2 months prior treatment, then 5
months and 6 months (if there is confirmed bacteriological)
2. Severe Malnutrition
Diagnostic • History taking, Physical Examination
• Anthropometry: Weight for Height based on CDC-NCHS
2000 chart <70%
Therapy Management of severe malnutrition
• Stabilization phase (1st day)
• Energy 50% x BBI x RDA (from HA) = 1700 K Cal/day
with Protein 70 grams
• 06:00 F75 milk 210 ml/oral
• 08:00 F75 milk 210 ml/oral
• 10:00 F75 milk 210 ml/oral
• 12:00 F75 milk 210 ml/oral
• 14:00 F75 milk 210 ml/oral
• 16:00 F75 milk 210 ml/oral
• 18:00 F75 milk 210 ml/oral
• 21:00 F75 milk 210 ml/oral
• Vitamin A 200.000 International Unit/oral
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• Folic Acid 5 mg/oral
• Vitamin B Complex 1 tablet/12 hours/oral
• Vitamin C 50 mg/12 hours/oral
• Ceftriaxone 100 mg/kg BW/day = 2gram/ 24
hours/intravenous (1st day)
• Gentamicin 5 mg/kg BW/day = 80 mg/12
hours/intravenous (1st day)
Monitoring • General condition
• Vital sign
• Body weight
• Feeding acceptability and tolerance
• Sign of infection
• Edema
Education • Personal and environmental hygienic lifestyle
• Important to feed according to schedule
3. Anemia of Chronic Disease differential diagnosis Iron Deficiency

Anemia
Diagnostic • Ferritin, reticulocytes, blood smear, complete blood count,
MCV, MCH.
Therapy • Wait for further result to differentiate cause of anemia
Monitoring • Vital sign
• Pale
• Signs of tissue anoxia
• Laboratory results for anemia diagnostic
Education • Inform the parents that their child’s hemoglobin level below
standard from the age of the child
• Planned to differentiate the cause of anemia with several
laboratory examination
• Transfusion only needed if the patient gets tissue anoxia
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OBSERVATION, October 24th-October 29th, 2021
October 24th2021 (2nd day of hospitalization)
S - There was hemoptysis, no dyspnea
- No fever and seizures
- No vomiting
- He still had decreased appetite and drank only milk
O Compos mentis
Blood pressure : 100/60 mmHg
Heart rate : 98 beats per minute, regular, adequate volume
Respiratory rate : 24 breaths per minute, regular, adequate depth
Temperature : 37OC
BW: 53 kg
No edema
No lymphadenopathies
Piano chest, no chest indrawing
Lung, Heart, and Abdomen within normal limit
Extremity: Wasting, felt warm, capillary refill time < 2 seconds.
Laboratory : October 24th 2021:
Blood smear: Anemia normocytic normochromic due to infection.
Reticulocyte 1,22 %, Ferritin 292,22 ng/ml
Urinalysis : Specific Gravity 1,012, Protein negative, Blood negative, Leucocyte
negative, Bacteria negative, Nitrite negative.
Routine stool examination: Soft consistency, yellow color, no blood, no leucocyte,
no bacteria, no worm.
A • Pulmonary Tuberculosis
• Severe Malnutrition
• Anemia of Chronic Disease
P • Tuberculin test done October 24th 2021, result at October26th 2021, on right
15
volar.
• Acid-fast bacilli test I and II was done
• Management of severe malnutrition
• Stabilization phase (2nd day)
• Energy 50% x BBI x RDA (from HA) = 1700 K Cal/day with
Protein 70 grams
06:00 F75 milk 210 ml/oral
21:00 F75 milk 210 ml/oralFolic Acid 1 mg/oral
• Ceftriaxone 100 mg/kg BW/day = 1 gram/ 24 hours/intravenous (2nd day)
• Gentamicin 5 mg/kg BW/day = 80 mg/12 hours/intravenous (2nd day)
• Treat for the chronic disease and monitor for signs of tissue anoxia
• Education:
• Educate to drink according to schedule
• Educate to change personal hygienic lifestyle
October 25th 2021 (3rd day of hospitalization)
S - There was cough and hemoptysis, no dyspnea
- No fever and seizures
- No vomiting
- He drank milk and still lazy to eat.
O Compos mentis
16
Temperature : 36,8OC
BW: 53 kg
No edema
P • Tuberculin test done October 24th 2021, result at October 26th 2021, on right
volar.
• Acid-resistance bacilli test III was done
• Transitional phase (1st day)
• Energy 75% BBI x RDA (from HA) = 2550 Cal/day with Protein 140 grams
06:00 F100 milk 320 ml/enteral
• Ceftriaxone 100 mg/kg BW/day = 1 gram/ 24 hours/intravenous (3rd day)
• Gentamicin 5 mg/kg BW/day = 80 mg/12 hours/intravenous (3rd day)
17
• Education:
October26th 2021 (4th day of hospitalization)
- No fever, no seizures
- No vomiting
- He drank milk and still lazy to eat.
O Compos mentis
Temperature : 37OC
BW: 53 kg
No edema
Tuberculin test result: 20 mm
P • Wait for acid-resistance bacilli result
• Transition phase (2nd day)
18
• Ceftriaxone 100 mg/kg BW/day = 1 gram/ 24 hours/intravenous (4 th day)
• Gentamicin 5 mg/kg BW/day = 80 mg/12 hours/intravenous (4th day)
• Education:
October 27th 2021 (5th day of hospitalization)

- No vomiting
- He wanted to drink and lazy to eat
O Compos mentis
BW: 53,2 kg
No edema
19
Result of acid-resistance bacilli test I, II, III : Positive
Result GeneXpert MTB/RIF (M. tuberculosis/rifampicin): Positive and
sensitive to rifampicin
A • Pulmonary Tuberculosis (Confirmed)
P • Anti-tuberculosis Drugs 2 (R/H/Z/E) + 4 (R/H) Intensive phase 1st month 1st
day
• Rifampicin (R) (10-20) mg/kg BW/day = 600 mg/24 hours/oral
• Isoniazid (H) (7-15) mg/kg BW/day = 300 mg/24 hours/oral
• Ethambuthol (E) (15-25) mg/kg BW/day = 1100 mg/24 hous/oral
• Pyrazinamide (Z) (30-40) mg/kg BW/day = 1600 mg/24 hours/oral
Fixed dose combination 4 tablets/ 24 jam / oral
• Transition phase (3rd day)
20
• Education:
• Educate for red/orange color urinary is normal
• Educate to consume anti-tuberculosis drugs on an empty stomach
- No vomiting
- He wanted drink but lazy to eat
O Compos mentis
BW: 53,3 kg
No edema
Extremity: Wasting, felt warm, capillary refill time < 2 seconds. No baggy pants.
P • Anti-tuberculosis Drugs 2 (R/H/Z/E) + 4 (R/H) Intensive phase 1st month
2nd day
21
• Transition phase (4th day)
• Ceftriaxone 100 mg/kg BW/day = 1 gram/ 24 hours/intravenous (6th day)
• Education:
• Educate to eat and drink according to schedule
S - No cough, no dyspnea
- No vomiting
- He wanted drink but lazy to eat
O Compos mentis
22
BW: 53,4 kg
No edema
Laboratorium:
Hemoglobin 10,9 gr/dl, MCV 75 fL, MCH 23 pg, MCHC 31 g/dL, Leucocytes
11.600/mm3, Neutrophil 62,2%, Lymphocyte 17,3%, Monocyte 8,3%, eosinophyl
8,3%, Absolute Neutrophil Count 7.215 /mm3,Platelet 424.000/mm3, Blood Sugar
103 mg/dL,Creatinine 0,75 mg/dL, Ureum 26 mg/dL, SGOT 22 U/L, SGPT 9 U/L,
Albumin 3,8 g/dL, Natrium 139 mmol/l, Potassium 4,2 mmol/L, Chloride 98
mmol/L
P • Anti-tuberculosis Drugs 2 (R/H/Z/E) + 4 (R/H) Intensive phase 1st month 3rd
day
• Transition phase (5th day)
23
• Education:
• Educate to eat and drink according to schedule
PROGNOSIS
Quo ad vitam : dubious ad bonam
Quo ad sanationem : dubious ad bonam
Quo ad functionem : dubious ad bonam
24
SUMMARY OF HISTORY OF ILLNESS AND HOSPITALIZATION
During observation by candidate
First symptoms of “W” Hospital at

decreased appetite Pediatric Ward
February 2021 October 23th 2021 -now
• Reccuren fever (2 months) • Hemoptysis, decreased appetite, reduced body weight.

• Cough (4 months) • Piano chest, wasting
• Weight for height 77,9% moderately wasted
• Decreased appetite (10 months) • Hemoglobin 11,1 gr/dl, MCV 75 fL, MCH 23 pg, MCHC
• Reduced body weight about 12 31 g/dL, Leucocytes 10.000/mm3, Platelet
3
420.000/mm , Blood Sugar 99 mg/dL, Creatinine 0,74
kg last 10 months mg/dL, Ureum 18 mg/dL, SGOT 28 U/L, SGPT 25 U/L,
• Treated in community health Albumin 4,1 g/dL, Natrium 137 mmol/l, Potassium 4,3
mmol/L, Chloride 106 mmol/L, reticulocyte 1,22%,
center 4 months cough still ferritin 292,22 ng/ml, blood smear normocytic
persist until hemoptysis normochrome anemia due to infection
• Chest X-ray : pneumonia bilateral suspected specific
• Close contact acid-fast bacilli.
• Tuberculin test : 20 mm
• Acid- fast bacillus test positive
• GeneXpert MTB/RIF: Positive and sensitive to rifampin
• Tuberculosis sco
Diagnosis: Pulmonary Tuberculosis

(Confirmed), severe malnutrition, anemia of
chronic disease
• Anti-tuberculosis drugs
• Management of severe nutrition
• Monitoring
• Education
25
CASE ANALYSIS
A 14-year-7-months old boy
P Tuberculosis exposure Decreased appetite and reduced body
R weight
Martinez L et al, Pediatric TB Contact Studies Recurrent cough Hemoptysis
O Consortium. The risk of tuberculosis in children
B after close exposure: a systematic review and
L individual-participant meta-analysis. 2020 (LoE
2a)
E
M
History taking Weight-for-Height: 77,9%
Tuberculin test : 20 mm Physical examination Piano chest, wasting
Acid-resistance bacilli test : positve Hb 11,1 g/dL, MCV 75 fl, MCH 23 pg,
D Tuberculosis score : 10 Laboratory finding
Radiology finding Bloodsmear : Normocytic normochrome
I Chest X-ray : pneumonia bilateral
Anemia due to infection, Ferritin 292,22 ng/ml
A s
G s
N s
O u
S Pulmonary Tuberculosis Severe Malnutrition Anemia of Chronic Disease
s
I
S Kunkel, A., et al. Smear positivity in paediatric and adult p Feleke BE et al. Nutritional Santana LG, Cruz LAB, Arriaga MB,
tuberculosis: systematic review and meta-analysis. e status of tuberculosis Miranda PFC, et al. Tuberculosis-
dn 2016.(LoE 1a)
associated anemia is linked to a
Reddy D, et al. Severe undernutrition in children affectsc patients, a comparative
T tuberculin skin test performance in Southern India. 2021. t cross-sectional study. 2019. distinct inflammatory profile that
H (Loe 3a) (Loe 3b) persists after initiation of
e antitubercular therapy. Salvador:
E
R d Springer Nature. 2018.(LoE 2a)
A Anti TB drugs Management severe
P s malnutrition
Y Laghari, et al. Epidemiology p Williams PCM, Berkley JA.
of tuberculosis and treatment e Guidelines for the treatment of severe
P outcomes among children in acute malnutrition: a systematic
R c review of the evidence for
Pakistan: A 5 year
O retrospective study. 2018 i antimicrobial therapy. 2018 (LoE 1a) Quo ad vitam : dubious ad bonam
G f Quo ad sanationem : dubious ad bonam
N i Quo ad functionam :dubious ad bonam
O c
S Jenkins, et al. Mortality in children diagnosed with
tuberculosis: a systematic review and meta-analysis. 2017(LoE
I
b 1a)
S
i Munthali, Tet al. Tuberculosis caseload in children with severe
l acute malnutrition related with high hospital based mortality in
Lusaka, Zambia. 2017 (LoE 3b)
a
t
e 26
r
a
l
DISCUSSION
This patient was diagnosed with Pulmonary Tuberculosis (clinical) based on
clinical presentation and supported by laboratory and radiology findings. Clinical
findings showed recurrent cough and decreased appetite in past 4 months. He also
had hemoptysis since 1 day before hospitalization. He also had reduced of body
weight in this past 10 months. There was history of close contact of adult
tuberculosis with confirmed bacteriologically and with HIV infection but no treatment
was given until the patient passed away in March 2021.Tuberculin test was 20 mm,
with acid-fast bacilli smear test was positive. Tuberculosis score was 7.
Clinical manifestation of tuberculosis in children are recurrent fever (40-80%
cases), then followed by anorexia, reduction body weight or stagnant body weight,
malaise. Recurrent cough usually happened in adolescent, rare in children less
than 5 years old.The expectoration of blood-tinged sputum and mild or moderate
hemoptysis has to be distinguished from massive hemoptysis. The literature
definitions of the amount of blood that has to be coughed up for the hemoptysis to
count as massive vary between 100 and 1000 mL in 24 h, but most are in the range
of 300 to 600 mL Among the many different causes of hemoptysis, the most
frequent worldwide is tuberculosis.1 Diagnosed of tuberculosis for children in
Indonesia with scoring system ≥ 6.2 Tuberculosis exposure and asses for other risk
factors to diagnosis tuberculosis in children is the most important. 3 (Level of
evidence 1a)
Tuberculin test for this patient was 20 mm. Reddy et al, reported the
prevalence of Tuberculin test positivity in well-nourished, undernourished, and
severely undernourished children decreased from 135/251 (53.8%), 32/68 (47.1%)
to 7/23 (30.4%).4 (Level of evidence 3b) The tuberculin skin test is positive for
severely malnourished and HIV-infected children with an induration diameter of 5
mm or more and in patients without malnutrition and HIV with an induration
diameter of 10 mm or more.5
Acid-fast bacilli test for this patient was positive. In children, there is a difficulty
to find M. tuberculosis on this test. The cause of this event is paucibacillary and
difficulty to get sputum/specimen in children. Acid-fast bacilli test is said to be
27
positive, if total M. tuberculosis around 5.000 in 1 ml sputum/specimen.2Paediatric
TB cases are sputum smear positive percentage varies greatly depending on the
age of the children, with the percentage smear positive just 0.5 % among children
aged 0–4 years compared with 14.0 % among children aged 5–14 years.6 (Level
of evidence 1a) Definitive diagnosis (gold standard) of tuberculosis is M.
tuberculosis found in acid-resistance bacilli test or culture on sputum, gastric
lavage, cerebrospinal fluid, pleural fluid, and biopsy.2
The GeneXpert MTB/RIF for this patient is positive and sensitive to
rifampicine. The GeneXpert MTB/RIF assay is an automated, closed system and
real-time PCR that is used in addition to Ziehl–Neelsen smears and mycobacterial
culture. The GeneXpert system has been approved by the WHO to be a widely
used molecular diagnostic platform for the rapid detection of TB in several
countries. GeneXpert is capable of detecting rifampicin resistance in pulmonary and
extrapulmonary specimens from clinical cases of TB. The GeneXpert can detect
mutations in the rpoB gene and show the results in <2 hours. The Xpert MTB/RIF
assay had a sensitivity of 68% (95% CI, 50%-82%) and specificity of 100% (95%
CI, 97%-100%) and detecting 1.7 times more culture -confirmed cases than smear
microscopy with a similar time to detection.7,8 (Level of evidence 3a)
Chest X-ray in this patient is pneumonia bilateral suspected specific. This
result is more likely called suspect specific infection, especially tuberculosis.
Pathogenesis of primary tuberculosis in children is primary complex formation. This
formation contained by Gohn focus, lymphangitis, and lymphadenopathy (parahillar
or paratracheal). There were many other radiologic findings to suspected
tuberculosis in children, such as milier, calcification, ateletaxis, cavity, pleural
effusion, tuberculoma, or severe radiologic findings that not followed by severe
clinical condition.2
28
Table 1. Tuberculosis Score.2
Children with suspected or confirmed pulmonary TB or tuberculosis peripheral

lymphadenitis and/or children with extensive pulmonary disease, living in settings
where the prevalence of HIV is high and/or the prevalence of isoniazid resistance is
high 1 should be treated with a four-drug regimen (HRZE) for 2 months followed by
a two-drug regimen (HR) for 4 months.9
29
Table 2. Regimens of treatment tuberculosis in children.10
Anti-tuberculosis drugs have been given to this patient with calculated dose
(see table 3 below). There are some side effects of anti-tuberculosis drugs.
Monitoring general condition, clinical manifestation, side effects, and some
laboratory examination are needed. Monitoring anti-tuberculosis drugs consumption
is the key to prevent drop out.2
Table 3. Dose and side effect of anti-tuberculosis drugs.2
Evaluation of treatment is done after 2 months. For children with culture-

positive respiratory specimens, repeat TB microscopy and culture are attempted
every 2 months until culture conversion. Chest X-ray are repeated at week 24, for
suspected treatment failure or TB recurrence, and if clinically indicated.11
30
Patient was diagnosed anemia of chronic disease. The prevalence of anemia
among TB patients was 88.52%.12Tuberculosis can cause anemia of inflammatory
cytokines. Chronic inflammation caused this condition. Laboratory finding for this
patient revealed hemoglobin level 11,1 g/dl, MCV 75 fl, MCH 23 pg, blood smear
normocytic normochromic anemia due to infection, reticulocyte 1,22%, and ferritin
292,22 ng/ml.13 (Level of evidence 2a)
The mechanisms of anemia of chronic disease are iron accumulation in
reticuloendothelial system and decrease iron in blood circulation. Activation of
immune cells and cytokine cause disturbance of erythropoietin production then
decrease erythropoiesis and also dysregulation of iron. Interleukin-6 is one of
inflammatory mediators for chronic disease that can cause anemia. It increases
hepcidin expression, then hepcidin inhibits iron transport that called ferroportin-1, so
iron cannot transport to blood circulation from reticuloendothelial system and also
inhibits iron absorption from duodenum.14
This patient did not have signs of tissue anoxia and did not given transfusion.
Anemia of chronic disease can be resolved, with management of chronic disease, it
means control chronic inflammation that cause anemia. In order to decrease the
risk of transfusion complications, Chegondi et al, found that in 637 stable patients a
transfusion threshold of 7 g/dl rather than a liberal threshold of 9.5 g/dl reduced
transfusion requirements by 44%.A hemoglobin threshold of 8 g/dl or less is
recommended for transfusion if patients are symptomatic.15 (Level of evidence 2b)
This patient has been diagnosed severe malnutrition. Based on CDC-NCHS
2000 chart weight for height 77,9% (<70%). There were some clinical
manifestations in this patient, such as piano chest, and wasting. The association
between TB and malnutrition is bi-directional, TB predisposes the patient to
malnutrition,this is because TB infection increases the anabolic process and
consumes additional energy, additionally, TB infection manifests with a reduction in
appetite, nutrient malabsorption, finally increasing the risk of underweightand
malnutrition increases the risk of developing active TB by 6 to 10 folds. Feleke et al,
found that 33.8% of excess malnutrition was observed as a result of TB.12 (Level of
evidence 3b)
31
Management of severe malnutrition is based on 10 step malnutrition treatment
and care. The patient given diet gradually, 2 days stabilization phase (50% total
calories), then 5 days transition phase (75% total calories).16,17 F75 and F100 are
specially formulated milks used in inpatient settings to treat SAM. F75 is given in
the stabilization phase of inpatient treatment and F100 is given during the
rehabilitation phase of inpatient treatment of SAM, providing children with
approximately 100–200 kcal/kg/d.18 Antibiotics was given to this patient to treat
infection in severe malnutrition children. For complicated SAM, there is
inconsistency in the first-line therapy recommended, including ampicillin/amoxicillin,
gentamicin and alternatives that comprise a wide spectrum of antibiotics including
third-generation cephalosporins, ciprofloxacin, co-amoxiclav, metronidazole and
even amikacin. For complicated SAM, there is limited evidence suggesting that
third-generation cephalosporins might be more effective than ampicillin/gentamicin
as parenteral therapy during stabilisation.19 (Level of evidence 1a)
Table 4. 10 steps to manage severe malnutrition.15
Tuberculosis caused nearly a quarter of a million deaths in children younger

than 15 years of age in 2015. Case fatality ratios in young children (aged 0–4
years) were consistently higher than those in older children (5–14 years). In studies
in the recent era, when most children had tuberculosis treatment, the case fatality
ratio was 0,9% (95% CI 0,5–1,6).17(Level of evidence 1a) TB is a contributor to
mortality among hospitalised children with severe acute malnutrition. Chisti et al.
32
reported no in-hospital mortality in Bangladesh but high post-discharge mortality in
severely malnourished children with TB.18(Level of evidence 3b)
33
REFERENCES
1. Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of
Hemoptysis. Dtsch Arztebl Int. 2017;114(21):371-381.
doi:10.3238/arztebl.2017.0371
2. Rahajoe NN, Supriyatno B, Setyanto DB. Buku Ajar Respirologi Anak Edisi
Pertama. Jakarta: Badan Penerbit IDAI. 2018.
3. Martinez L, Cords O, Horsburgh CR, Andrews JR; Pediatric TB Contact
Studies Consortium. The risk of tuberculosis in children after close exposure:
a systematic review and individual-participant meta-analysis. Lancet.
2020;395(10228):973-984. doi:10.1016/S0140-6736(20)30166-5
4. Reddy D, Ma Y, Lakshminarayanan S, et al. Severe undernutrition in
children affects tuberculin skin test performance in Southern India. PLoS
One. 2021;16(7):e0250304. Published 2021 Jul 16.
doi:10.1371/journal.pone.0250304
5. Chisti MJ, Salam MA, Shahid AS, et al. Diagnosis of Tuberculosis Following
World Health Organization-Recommended Criteria in Severely Malnourished
Children Presenting With Pneumonia. Glob Pediatr Health.
2017;4:2333794X16686871. Published 2017 Jan 19.
doi:10.1177/2333794X16686871
6. Kunkel, A., Abel zur Wiesch, P., Nathavitharana, R.R. et al. Smear positivity
in paediatric and adult tuberculosis: systematic review and meta-
analysis. BMC Infect Dis 16, 282 (2016). https://doi.org/10.1186/s12879-016-
1617-9
7. Atashi S, Izadi B, Jalilian S, Madani SH, Farahani A, Mohajeri P. Evaluation
of GeneXpert MTB/RIF for determination of rifampicin resistance among new
tuberculosis cases in west and northwest Iran. New Microbes New Infect.
2017;19:117-120. Published 2017 Jul 13. doi:10.1016/j.nmni.2017.07.002
8. Reither, Klaus & Manyama, Christina & Clowes, Petra & Rachow, Andrea &
Mapamba, Daniel & Steiner, Andreas & Ross, Amanda & Mfinanga,
Elirehema & Sasamalo, Mohamed & Nsubuga, Martin & Aloi, Francesco &
Cirillo, Daniela & Jugheli, Levan & Lwilla, Fred. (2014). Xpert MTB/RIF assay
for diagnosis of pulmonary tuberculosis in children: A prospective, multi-
centre evaluation. The Journal of infection. 70. 10.1016/j.jinf.2014.10.003.
9. Guidance for National Tuberculosis Programmes on the Management of
Tuberculosis in Children. 2nd edition. Geneva: World Health Organization;
2014. 4, Treatment of TB in children. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK214449/
10. Laghari, Madeeha & Sulaiman, Syed & Khan, Amer & Memon, Naheed.
(2018). Epidemiology of tuberculosis and treatment outcomes among
children in Pakistan: A 5 year retrospective study. PeerJ. 6. e5253.
10.7717/peerj.5253.
11. Chabala, Chishala et al. “Shorter treatment for minimal tuberculosis (TB) in
children (SHINE): a study protocol for a randomised controlled
trial.” Trials vol. 19,1 237. 19 Apr. 2018, doi:10.1186/s13063-018-2608-5
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12. Feleke BE, Feleke TE, Biadglegne F. Nutritional status of tuberculosis
patients, a comparative cross-sectional study. BMC Pulm Med.
2019;19(1):182. Published 2019 Oct 21. doi:10.1186/s12890-019-0953-0
13. Santana LG, Cruz LAB, Arriaga MB, Miranda PFC, et al. Tuberculosis-
associated anemia is linked to a distinct inflammatory profile that persists
after initiation of antitubercular therapy. Salvador: Springer Nature. 2018.
14. Windiastuti E, Nency YM, Mulatsih S, Sudarmanto B, et al. Buku Ajar
Hematologi Onkologi Anak. Jakarta: Badan Penerbit IDAI. 2018.
15. Chegondi M, Sasaki J, Raszynski A, Totapally B, R: Hemoglobin Threshold
for Blood Transfusion in a Pediatric Intensive Care Unit. Transfus Med
Hemother 2016;43:297-301. doi: 10.1159/000446253
16. Kementerian Kesehatan Republik Indonesia. Bagan Tatalaksana Anak Gizi
Buruk Buku I. Jakarta: Direktorat Jenderal Bina Gizi dan Kesehatan Ibu dan
Anak. 2011.
17. Kementerian Kesehatan Republik Indonesia. Petunjuk Teknis Tatalaksana
Anak Gizi Buruk Buku II. Jakarta: Direktorat Jenderal Bina Gizi dan
Kesehatan Ibu dan Anak. 2011.
18. Lenters L, Wazny K, Bhutta ZA. Management of Severe and Moderate Acute
Malnutrition in Children. In: Black RE, Laxminarayan R, Temmerman M, et
al., editors. Reproductive, Maternal, Newborn, and Child Health: Disease
Control Priorities, Third Edition (Volume 2). Washington (DC): The
International Bank for Reconstruction and Development / The World Bank;
2016 Apr 5. Chapter 11. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK361900/ doi: 10.1596/978-1-4648-
0348-2_ch11
19. Williams PCM, Berkley JA. Guidelines for the treatment of severe acute
malnutrition: a systematic review of the evidence for antimicrobial
therapy. Paediatr Int Child Health. 2018;38(sup1):S32-S49.
doi:10.1080/20469047.2017.1409453
20. Jenkins, Helen E; Yuen, Courtney M; Rodriguez, Carly A; Nathavitharana,
Ruvandhi R; McLaughlin, Megan M; Donald, Peter; Marais, Ben J; Becerra,
Mercedes C (2017). Mortality in children diagnosed with tuberculosis: a
systematic review and meta-analysis. The Lancet Infectious Diseases, 17(3),
285–295. doi:10.1016/S1473-3099(16)30474-1
21. Munthali, T., Chabala, C., Chama, E. et al. Tuberculosis caseload in children
with severe acute malnutrition related with high hospital based mortality in
Lusaka, Zambia. BMC Res Notes 10, 206 (2017).
https://doi.org/10.1186/s13104-017-2529-5
35
Appendix 1. List of Abbreviations
- AC : abdominal circumference
- BCG : bacillus calmette-guerin
- BH : body height
- BW : body weight
- CA : chronological age
- CBC : complete blood count
- CDC : center of disease control
- CMS : centimeters
- DPT : diphtheriapertussis tetanus
- GCS : Glasgow coma scale
- Grms : grams
- HA : height age
- Hb : hemoglobin
- Hib : Hemophilus influenza type b
- IV : Intravenous
- mEq : milli Equivalent
- mg : milligram
- mg/dl : milligram per desiliter
- mg/kg : milligram per kilogram of body weigh
- mmHg : millimetres of mercury
- mmol/L : millimoles per liter
- Posyandu : Pospelayanan terpadu
- Puskesmas : Pusat Kesehatan Masyarakat
- PSC : Pediatric Symptoms Checklist
- U : Unit
36
Appendix 2. Head circumference
Examination date : October 23th 2021

Name :I
Age : 14 years 7 month
Head circumferences 53 cm (normal: 52 cm – 58 cm)
37
Appendix 3. Growth Examination date : October, 23th 2021
BH HA
IBW
BW
Chart
• Body weight (BW): 53 kgs

• Ideal body weight (IBW): 68 kgs
• Body Height (BH): 177 cms
• Weight-for-height: 53/68 x 100% = 77,9%
• Height-for-age (H/A): 177/168 x 100% = 105,3%
• Weight-for-age : 53/55 x 100% = 96,3%
• Father’s height = 175 cms
38
• Mother’s height = 160 cms
Genetic potential height: 165,5 – 182,5 cms (<P3 – P25); Mid parenteral height = 174 cms
Appendix 4.Pediatric Symptom Checklist
Emotional and physical health go together in children. Because parents are often the first to
notice a problem with their child’s behavior, emotions or learning, you may help your child
get the best care possible by answering these questions. Please mark under the heading
that best fits your child.
Never Sometimes Often

child’s behavior (0) (1) (2)
1. Complains of aches/pains √
2. Spends more time alone √
3. Tires easily, has little energy √
4. Fidgety, unable to sit still √
5. Has trouble with a teacher √
6. Less interested in school √
7. Acts as if driven by a motor √
8 Daydreams too much √
9. Distracted easily √
10. Is afraid of new situations √
11. Feels sad, unhappy √
12. Is irritable, angry √
13. Feels hopeless √
14. Has trouble concentrating √
15. Less interest in friends √
16. Fights with others √
17. Absent from school √
18. School grades dropping √
19. Is down on him or herself √
20. Visits doctor with doctor finding nothing √
wrong
21. Has trouble sleeping √
22. Worries a lot √
23. Wants to be with you more than before √
24. Feels he or she is bad √

25. Takes unnecessary risks √
26. Gets hurt frequently √ √
27. Seems to be having less fun
28. Acts younger than children his or her age √
29. Does not listen to rules √

30. Does not show feelings √
31. Does not understand other people’s √
feelings
32. Teases others √
33. Blames others for his or her troubles √
34. Takes things that do not belong to him or √
her
35. Refuses to share √
Examination date
ociety) : October, 10th 2021
Name :I
Age : 14 years 7 months
Total Score :9
39
APPENDIX 5. PedsQL Version 4.0
1. Parent Report
Dalam SATU bulan terakhir, seberapa seringkah hal ini menjadi masalah bagi anak anda
40
Parent report score Teen report score
Physical function 84,3 Physical function 84,3
Emotion function 80 Emotion function 85
Social function 100 Social function 100
School function 70 School function 70
41
APPENDIX 6. Chest X-Ray Examination date : October, 23th 2021
Name :I
Age : 14 years 7 months
42

Nurul Sylvana Long Case Baru-1 (1) - 1

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TIMELINE DIAGRAM

Patient was Patient was Final

PATIENT’S HISTORY (Anamnesis and alloanamnesis from both parents)

History of illness in the family

Patient’s personal and social history

e) Growth and developmental history

Mental stimulation needs

h) Family socio-economy history/environment/ housing

PATIENT’S HOSPITAL ADMISSION SUMMARY

3. Anemia of Chronic Disease differential diagnosis Iron Deficiency

October 27th 2021 (5th day of hospitalization)

First symptoms of “W” Hospital at

• Reccuren fever (2 months) • Hemoptysis, decreased appetite, reduced body weight.

Diagnosis: Pulmonary Tuberculosis

Children with suspected or confirmed pulmonary TB or tuberculosis peripheral

Evaluation of treatment is done after 2 months. For children with culture-

Tuberculosis caused nearly a quarter of a million deaths in children younger

Examination date : October 23th 2021

• Body weight (BW): 53 kgs

Never Sometimes Often

24. Feels he or she is bad √

29. Does not listen to rules √

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