Long Case Report

PULMONARY TUBERCULOSIS WITH HYDROPNEUMOTHORAX SINISTRA, SEVERE MALNUTRITION, AND

ANEMIA OF CHRONIC DISEASE

Name of candidate

ROSALIA SRI WAHYUNI NURDIN

Local Board Examination

Makassar, April 26th 2022

INDONESIAN COLLEGE OF PEDIATRIC

 TIMELINE DIAGRAM

PATIENT’S RECORD FOR NATIONAL BOARD EXAMINATION

I. PATIENT’S IDENTITY

Name : RN Father : Mr. A

Gender : Female Father’s age : 26-years old
Age : 3-years 3-month Education : Senior High School
Date of birth : November 3rd, 2018 Occupation : Entrepreneur
MR : 968xxx Mother : Mrs. N
Address : MataNori, Kendari Mother’s age : 22-years old
Admission date : March 2nd 2022 Education : Senior High School
Length of stay : 37 days Occupation : House wife

Initial observation by candidate began on April 3th 2022

II. HISTORY TAKING (Anamnesis and alloanamnesis from mother)

Chief complaint
Shortness of the breath

History of present illness

Shortness of the breath since one months before being admitted to the hospital. Cough had
occurred since 3 months before admitted to “W” Hospital, with productive cough without blood. The
patient complained of left chest pain since 2 months. There was no fever nor seizure. There was no
vomiting. She had decreased appetite since two months. There was weight loss since two months ago
with a reduction of 2 kg body weight. She did not complain about urination and defecation. There was
history of frequent fever since two months. There was no history of decrease of consciousness, sweating
at night, frequent diarrhea, recurrent white patches in mouth, discharge from the ear, pale, bleeding, and
transfusion.

History of previous illness

There is a history of contact with confirmed tuberculosis patients, namely the patient's mother
and has undergone treatment in 2020, when the patient was 1 years old (2 years ago), now the patient is
3 years old.
 A history of being treated at B hospital with diagnosed pulmonary tuberculosis and massive
hydropnemothorax sinistra with the results of examination of pleural fluid chronic inflammation of a
specific process, mantoux test negative, gastric lavage negative and chest X-ray result sign of active
tuberculosis and massive efussion pleura sinistra in February 2022 was then given therapy with
ceftriaxone, gentamicin, metronidazole, anti-tuberculosis drugs and has been installed Water Seal
Drainage (WSD). During treatment at B hospital the patient did not improve so she was admitted to the
W hospital. When he first came to W hospital, the patient was put on WSD and given therapy with
ceftriaxone, gentamicin, metronidazole, anti-tuberculosis drug and improved after 5 days of treatment.

History of family illness.

The mother said that there was family history of the same illness with the patient (patient’s
mother) 1 year ago when the patient was 1-year-old. Patient’s mothers was diagnosed with tuberculosis
with confirmed bacteriologic. Her mother was treated with anti-tuberculosis drugs 2 year ago and taking
medication for 6 months. The patient's father is not an active smoker.
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 routine control at the midwives, and given vitamin and iron
supplementation, she never had any herbal nor drugs other than prescribed from a medical professional.
She felt healthy with aterm pregnancy and never experienced any trauma or other problems during her
pregnancy. Conclusion: A mother had a normal prenatal history
b) History of delivery
The patient was born at a hospital. It was aterm. The baby cried immediately with no cyanosis.
Birth weight was 2800 grams; birth length was 50 cm. Head circumference was forgotten. Conclusion:
Patient was born aterm, normal birth weight, with normal history of delivery.
c) Postnatal history
The patient received vitamin K1 injection. Hepatitis B vaccination was given the first day and oral
polio at the discharge time. No history of cyanosis, jaundice, seizure nor bleeding. The mother stayed at the
hospital for two more days after delivery. Conclusion: post-natal history was unremarkable
a) Feeding history
The patient was exclusively breastfed since born up to 6 months old. Complementary food
introduced at 6 months of age in form of milk porridge, followed by steamed rice by the age of 9 months
old and had family meal since 1-year-old. Before two month ago, patient consumed rice, fish,
chicken/meat, eggs, tofu/tempeh, vegetables and fruits. Since 2 months ago the patient has decreased
appetite by only eating 2 times per day and the patient only eats 2 times a day with half the adult portion
Conclusion: patient had adequate quality and quantity of intake

b) Growth and developmental history

Growth
 Until the patient was 1-year-old, the mother routinely took him to posyandu, and based on Kartu
Menuju Sehat (KMS), the patient’s growth was always above the green line, hence normal growth.

Developmental
The patient was able to show responsive smile at the age of 2 months old, rollover at 4 months old, sat
without support at 7 months old, stand alone at 12 months old, was able to walk by the age of 14 months
old and was able to speak at 12 months old.
Conclusion: Growth and developmental history were within normal limit.

c) History of immunization
The immunization that has been obtained were hepatitis B 4 times (age 0 day, 2, 3, 4 months), oral
polio 4 times (age 2 days, 2, 4, 6 months), BCG at 1 month, DPT 3 times (at 2,3,4 months), measles 1 time
(at 9-months-old). A booster vaccination has been given at 18 months of age. Conclusion: basic
vaccination was complete and booster has been given.

d) Basic need
Physical-bio medic needs
Patient’s main caregiver was her mother. The patient got adequately breastfed. Complimentary food
was introduced after 6 months old, and since the age of 1 year, she had a family meal. Clothing needs were
also fulfilled. The patient had received complete basic vaccination. Conclusion: Patient’s parent is able to
fulfill all of the patients physical-bio medic needs adequately.

Emotional needs
Parents child relationship seems close and lovingly. Both the mother and father love the patient very
much. The mother is patient enough and tries to give more attention to her child illness. Conclusion:
Adequate emotional needs from both parents

Mental stimulation needs

Early stimulation was given by both parents and siblings since early age that includes touch and
hug, playing together and talking. Conclusion: Mental stimulation needs are fulfilled

e) Family Socio-economy/environmental/housing
The father is a 26 years old, his daily activity is as a farmer. He does not have any fixed income
(ranged from IDR 2.000.000 to 3.000.000). The mother is a 22 years old housewife. Both are from Kendari
and both are Moslem. The patient lives with both his parent, brother in a permanent house 6x10 m 2 with 1
living room, 1 kitchen, 1 bathroom, 2 bedrooms.
Drinking water source is from refill water product water for daily activities such as for washing and
bath is from boreholes. Electricity sources is coming from the national electricity company (PLN).
Ventilation and light at the house is sufficient. The nearest health facility from the patient’s house are
primary health center (Puskesmas) ± 1 km away. The hospital bill is covered by national health insurance.
Conclusion: patient comes from a low middle economic class. Health facility is easily accessible and
health care fees are covered by government.
III. PHYSICAL EXAMINATION (pediatric ward, April 3rd, 2022)
General examination
General appearance : Severely illness
Level of consciousness : Glasgow coma scale (GCS) E4M6V5
Blood pressure (BP) : 90/60 mmHg
Heart rate (HR) : 110 bpm, regular, adequate pulsation
Respiratory rate : 34 times per minute, regular, spontaneously
Temperature (Axilla) : 36,5 o C
Pain score : 0 FLACC

Anthropometry measurement and nutritional status

Chronological age : 2 years 8 months
Body weight : 10 kg
Body length : 92 cm
Head circumferences : 50 cm (-2 <HC < 0, nellhaus)
Mid upper arm circumference: 10 cm
Weight for Height : z-score < -3 SD (Malnutrition/Severely wasted, WHO Curve)
Weight for Age : -2 SD < z-score < -3 SD (Underweight, WHO Curve)
Height for Age : -2 SD < z-score < 0 SD (Normo height, WHO Curve)
Midparental height : 153,5 cm (father’s body height 165 cm, mother’s body height 155 cm)
Genetic potential height : 145– 162 cm (<P3 – P25), CDC NCHS 2000 chart)
Conclusion: Malnutrition, normal stature and normocephaly.

Physical examination

System Description
Skin BCG Scar positive on right deltoid, no erythema marginatum or subcutaneous nodule, no
purpura.
Head Normocephal, mesocephal, closed fontanelle, no deformities.
Black, evenly distributed, not easily plucked.
Face No oldman face, no dysmorphic, no cranial nerves palsy, no erythema on the cheeks.
Eyes There was edema palpebral, no anemic conjunctiva, no icteric sclera. Eye movement was
normal, no strabismus, pupil round, isochoric, diameter 3mm/3mm, 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.
Teeth No carries dentis.
Throat Pharynges not hyperemic, no tonsillar enlargement.
Neck No nuchal rigidity. Normal jugular vein pressure (+2 cmH2O).
Chest Shape and movement were asymmetric with piano chest. There was chest indrawing
and no deformities.
Lung Vocal fremitus asymmetrical and decreased in left lung, percussion sonor on the right
lung and dim percussion on the left lung, vesicular breath sound, no additional breath
sound (rhales) and no wheezing both lung.
Heart Ictus cordis was not visible and palpable, heart sound I-II normal, no murmur.
Abdominal Supple, there was normal bowel sound, liver and spleen not palpable. No ascites.
 Genitalia Female, pubertal status A1M1P1
Lymph nodes No enlarged lymph nodes.
Spine No gibbous
Extremities There was wasting. No Baggy pants. No edema. Warm extremities, capillary refill
timeless than 2 seconds, no edema. No swollen joints. Motoric: muscle strength and tonus
are within normal limit, normal physiological reflexes, no pathologic reflexes.

Tuberculosis score: 8 (Contact: 3, Nutritional Status: 2, Fever: 1, Cough: 1, Chest X-Ray: 1)

Laboratory examination on April 2th 2022

Blood test result showed
Complete blood count revealed Hemoglobin 9.3 gr/dl, MCV 80 fL, MCH 26 pg, MCHC 30 g/dL,
Leucocytes 9.300/mm3, Neutrophil 63%, Lymphocyte 25%, Monocyte 10.8%, eosinophil 0.4%, Platelet
164.000/mm3, Blood Sugar 81 mg/dL, Creatinine 0,4 mg/dL, Ureum 16 mg/dL, SGOT 14 U/L, SGPT
36 U/L, Albumin 4,1 g/dL, Natrium 139 mmol/l, Potassium 4,4 mmol/L, Chloride 106 mmol/L.
Blood smear: Anemia normocytic normochromic due to infection.
Reticulocyte 3,76 %, Ferritin 933,31 ng/ml

Radiology examination on April 3th 2022

Chest X-ray examination revealed Hydropneumotorax sinistra.
SUMMARY
A girl, 3 years and 3 months old, hospitalized with complaints of shortness of the breath since
one months before being admitted to the hospital. Cough had occurred since 3 months before admitted
to “W” Hospital, with productive cough without blood. The patient complained of left chest pain since 2
months. There was no fever nor seizure. There was no vomiting. She had decreased appetite since two
months. There was weight loss since two months ago with a reduction of 2 kg body weight. She did not
complain about urination and defecation. There was history of frequent fever since two months. There is
a history of contact with confirmed tuberculosis patients, namely the patient's mother and has undergone
treatment in 2020, when the patient was 1 years old (2 years ago), now the patient is 3 years old. A
history of being treated at B hospital with diagnosed pulmonary tuberculosis and massive
hydropnemothorax sinistra in February 2022 was then given therapy with ceftriaxone, gentamicin,
metronidazole, anti-tuberculosis drugs and has been installed Water Seal Drainage (WSD). During
treatment at B hospital the patient did not improve so she was admitted to the W hospital. When he first
came to W hospital, the patient was put on WSD and given therapy with ceftriaxone, gentamicin,
metronidazole, anti-tuberculosis drug and improved after 5 days of treatment.
Physical examination revealed a severely ill, with severe wasted, GCS 15, vital signs within
normal limit except respiratory rate was increased. There was a BCG scar on right deltoid. There were
piano chest and wasting. There was no crazy pavement dermatosis, old man face, baggy pants,
stomatitis, nuchal rigidity, and edema. There are no lymphadenopathies. There was no pale, no icteric,
no bleeding manifestation. There was decreased breath sounds in the left hemi thorax. There was chest
retraction, no rhales, no wheezing.
Laboratory examination revealed anemia with erythrocyte normocytic normochromic and
hyperferitinemia. Chest X-ray examination revealed Hydropneumotorax sinistra. Tuberculosis score 8.
IV. LIST OF PROBLEM

1. Pulmonary Tuberculosis
2. Hydropneumothorax
3. Severe Malnutrition
 4. Anemia of Chronic Disease

V. DIAGNOSIS
1. Pulmonary Tuberculosis [A15.0]
2. Hydropneumothorax [J94.8]
3. Severe Malnutrition [E43]
4. Anemia of Chronic Disease [D63]

VI. MANAGEMENT PLANING

1. Pulmonary tuberculosis and hydropneumothorax.
 Diagnosis: History taking and Physical examination, laboratory: Acid-fast Bacilli test, culture of
hydropneumothorax fluid, chest X-Ray, tuberculin test, tuberculosis score ≥ 6.
 Treatment: Oxygenation via nasal cannula 1 liter/minute, Anti-tuberculosis Drugs 2 (R/H/Z) + 4
(R/H) Intensive phase 2nd month 15th day (Rifampicin (R) (10-20) mg/kg BW/day = 150 mg/24
hours/oral, Isoniazid (H) (7-15) mg/kg BW/day = 100 mg/24 hours/oral, Pyrazinamide (Z) (30-40)
mg/kg BW/day = 350 mg/24 hours/oral), Pro WSD treatment
 Education: Parents were informed about the patient’s current condition, drugs schedule, possible
adverse effects due to treatment, blood pressure, weight, appetite follow up/monitoring. Therapy
given is not for short time and depends on patient’s adherence. Red/orange color urinary is normal
and consume drugs on an empty stomach. Adherence and routine checkup after being discharge are
influencing prognosis. Routine control every 2 weeks on intensive phase (first 2 months) and every
month on advanced phase (next 4 months).
 Monitoring: General condition, consciousness, vital signs, make sure the medicine is taken, drugs
tolerance and adverse effect of drugs.
2. Anemia of chronic disease
 Diagnosis: Ferritin, reticulocytes, blood smear, complete blood count, MCV, MCH.
 Treatment: Treat basic disease
 Education: Inform the parents that their child’s hemoglobin level below standard from the age of
the child. Transfusion only needed if the patient gets tissue anoxia
 Monitoring: Vital sign, pale, signs of tissue anoxia
3. Malnutrition management
 Diagnosis: History taking, Physical Examination and anthropometry: Weight for Height based on
WHO curve chart
 Treatment: Management of severe malnutrition
 Rehabilitation phase days 1. Energy 150 x BW = 1.500 K Cal/day with protein 40 grams (milk 300
ml/8 hours/oral, rice 400 kcal/8 hours/oral, snack 100kcal/24 hours/oral), folic Acid 1 mg/24
hours/oral, Vitamin B Complex 1 tablet/12 hours/oral and vitamin C 50 mg/12 hours/oral
 Education: Personal and environmental hygienic lifestyle and monitoring: acceptability, tolerance,
and effectivity
 Monitoring: General condition, vital sign, body weight and feeding acceptability and tolerance.
4. Psychosocial
 Education to family about disease and long-term therapy
 Emotional support to patient and family
5. Developmental screening and planning
 Education to family for control in pediatric policlinic to assess patient progress.
VII. FOLLOW UP (4th –10st April, 2022)

On the second and third day of observation (April, 5-6 th 2022), the patient still had shortness of the
breath (decreasing). Vital signs within normal limit except respiratory rate was increased. BW 10 kg. There
were piano chest and wasting. There was decreased breath sounds in the left hemi thorax. There was chest
retraction decreased, no rhales, no wheezing. Planning with WSD treatment and other therapies were continued.
On the fourth and fifth day of observation (April, 7-8th 2022), the patient still had shortness of the breath. Vital
signs within normal limit except respiratory rate was increased. BW 10 kg. There were piano chest and wasting.
There was decreased breath sounds in the left hemi thorax. There was chest retraction, no rhales, no wheezing.
Planning with WSD treatment and other therapies were continued.
On observation sixth-seventh day the condition of the patient still had shortness of the breath
(decreasing). Vital signs within normal limit except respiratory rate was increased. BW 10.1 kg. There were
piano chest and wasting. There was decreased breath sounds in the left hemi thorax. There was chest retraction
decreased, no rhales, no wheezing. Laboratory examination revealed Hemoglobin 10.1 gr/dl, MCV 80 fL, MCH
25 pg, MCHC 31 g/dL, Leucocytes 8.400/mm3, Platelet 383.000/mm3, Blood Sugar 71 mg/dL, Creatinine 0,3
mg/dL, Ureum 26 mg/dL, SGOT 39 U/L, SGPT 36 U/L, Albumin 4,1 g/dL, Natrium 138 mmol/l, Potassium 4,2
mmol/L, Chloride 108 mmol/L Patient got WSD instalation and other therapies were continued.

PROGNOSIS
Quo ad vitam : dubious ad bonam
Quo ad sanationam : dubious ad bonam
Qua ad functionam : dubious ad bonam

SUMMARY OF HISTORY OF ILLNESS AND HOSPITALIZATION

During observation by candidate

First symptom of shortness of “W” Hospital at Paediatric Ward

the breath (November 2021) April 4th-10st 2022

 Cough, shortness of the breath and decreased of appetite. The patient

Reccuren fever (2 months)
Shortness of the breath (2 months)
Cough (3 months)
Decreased appetite (2 months)
Chest pain (2 months)
Reduced body weight about 2 kg
last 2 months
Close contact patients
tuberculosis treatment.
has been taking anti-tuberculosis drugs for 1 months
 There were piano chest and wasting. There was decreased
breath sounds in the left hemi thorax and chest indrawing.
 Hb 9.3 gr/dl, Reticulocyte 3,76 %, Ferritin 933,31 ng/ml, MCV
79 fL, MCH 24 pg.
on  Blood smear: Anemia normocytic normochromic due to
infection.
 Chest X-ray examination revealed Hydropneumotorax sinistra.

Management Diagnosis: Pulmonary

Anti-tuberculosis drugs
WSD installation tuberculosis,
Management of severe nutrition hydropneumothorax,
Monitoring severe malnutrition,
Education
anemia of chronic disease
 CASE ANALYSIS
A 3-year-3-months old girls
Tuberculosis exposure Decreased appetite and reduced body
P
weight
R Recurrent cough Shortness of the breath
O Martinez L et al, Pediatric TB Contact Studies
Consortium. The risk of tuberculosis in children
B after close exposure: a systematic review and
L individual-participant meta-analysis. 2020 (LoE
E 2a)
M
Tuberculosis score 8 History taking Weight-for-Height: < 3 SD
Chest X-ray: hydropneumothorax and Physical examination Piano chest, wasting
active
D tuerculosis Laboratory findingHb 9,3 g/dL, MCV 80 fL, MCH 26 pg.
Radiology findingBloodsmear : Normocytic normochrome
I
Anemia due to infection, Ferritin 933,31 ng/ml
A
G
N
O
S Pulmonary Tuberculosis Hidropneumotoraks
Severe Malnutrition Anemia of Chronic Disease
I
S Kunkel, A., et al. Smear positivity in paediatric and adult
tuberculosis: systematic review and meta-analysis. 2016. Feleke BE et al. Nutritional Santana LG, Cruz LAB, Arriaga MB,
(LoE 1a) status of tuberculosis Miranda PFC, et al. Tuberculosis-
Reddy D, et al. Severe undernutrition in children affects
T patients, a comparative cross- associated anemia is linked to a
tuberculin skin test performance in Southern India. 2021.
sectional study.  2019. (Loe distinct inflammatory profile that
H (Loe 3a)
3b)
E persists after initiation of
antitubercular therapy. Salvador:
R
A Anti TB drugs WSD Management severe Springer Nature. 2018.(LoE 2a)
P malnutrition
Y Laghari, et al. Epidemiology
Williams PCM, Berkley JA.
of tuberculosis and treatment Guidelines for the treatment of severe
P outcomes among children in acute malnutrition: a systematic
R Pakistan: A 5 year review of the evidence for
O retrospective study. 2018 antimicrobial therapy. 2018 (LoE 1a) Quo ad vitam : dubious ad bonam
G Quo ad sanationem : dubious ad bonam
N Quo ad functionam :dubious ad bonam
O
S Jenkins, et al. Mortality in children diagnosed with tuberculosis:
a systematic review and meta-analysis. 2017(LoE 1a)
I
Munthali, Tet al. Tuberculosis caseload in children with severe
S
acute malnutrition related with high hospital based mortality in
Lusaka, Zambia. 2017 (LoE 3b)
DISCUSSION

This patient was diagnosed with Pulmonary Tuberculosis (clinical) based on clinical
presentation and supported by laboratory and radiology findings. Clinical findings showed cough
and shortness of breath since three weeks and decreased appetite with reduced of body weight in
past 2 months. He also had history of fever since 2 months before hospitalization. There was
history of close contact of adult tuberculosis with treatment in 2020. Tuberculin test was
negative, with acid-fast bacilli smear test was negative. Tuberculosis score was 8.
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 happens in adolescent, rare in children less than 5 years old. Lymph nodes may caseate
or necrose, erupting into the airway leading to bronchopneumonia and manifesting with cough,
dyspnea, malaise and fever. Hypersensitivity reactions may also occur, including pleural
effusions which may provoke symptoms of chest pain, fever and reduced endurance. 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 negative. 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 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 negative. 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 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 pleural fluid analysis result with rivalta test positive for this patient is positive and
culture negative. Tuberculous pleural effusion (TPE) is one of the most common forms of
extrapulmonary tuberculosis. Identification of M.Tb in pleural fluid is made by identifying the
presence of tubercle bacilli in sputum, pleural fluid, pleural biopsy specimens, or by the presence
of granulomas on histopathological examination. It is necessary to obtain sputum in addition to
pleural fluid for the acid-fast bacilli smear and Mycobacteria tuberculosis culture in patients with
suspected TPE, even in the absence of parenchymal involvement. In a series of 254 patients with
TPE, 93 patients (36.6%) had positive of pleural fluid cultures for Mycobacteria tuberculosis in
the Löwenstein-Jensen medium. Rivalta's test is a conventional examination that is still often
done today to differentiate transudate pleural effusion (negative Rivalta's test) and exudate
(positive Rivalta's test). A positive rival test can be caused by the inflammatory process and
changes in membrane permeability on the pleural surface, which among other things can be
caused by pulmonary TB infection. Positive Rivalta tests were found in 46.7% of positive PCR
tests and 36% of negative PCR tests. The results of this study indicate the weakness of the
Rivalta test in differentiating fluid exudate caused by TB and non-TB infections. 7,8 (Level of
evidence 3a)
Chest X-ray in this patient is left hydropneumotorax. Imaging has an important role in the
initial evaluation of patients suspected of having active tuberculosis. Chest X-ray is useful to
look for any evidence of pulmonary tuberculosis as well as to identify other abnormalities
responsible for the symptoms. CT chest is an important tool in the detection of radiographically
occult disease, differential diagnosis of parenchymal lesions, evaluation of mediastinal lymph
nodes, assessing disease activity, and evaluating complications. It not only enables earlier and
more accurate diagnosis of pulmonary lesions, but also can be used to differentiate the etiologies
of pneumonia. The value of CT lies in the fact that it enables one to suggest a diagnosis of TB in
patients with negative sputum examination and those without sputum production. CT findings
may permit empirical initiation of anti-tuberculosis therapy until the time culture results are
obtained. 9
Table 1. Tuberculosis Score.2

This patient was treated with 3 regimens of anti-tuberculosis drugs and installation of
WSD for pleural effusion. The goals of the treatment of TPE includes: (I) to prevent the
subsequent occurrence of active tuberculosis; (II) to relieve the symptoms of TPE; and (III) to
avoid the presence of a fibrothorax. Anti-tuberculosis chemotherapy of TPE should be the same
as that used for pulmonary tuberculosis. The patients with TPE should be treated with isoniazid,
rifampin, and pyrazinamide for 2 months followed by 4 months of two drugs, isoniazid and
rifampin (2HRZ/4HR). Tuberculous empyema represents an uncommon chronic, active infection
of the pleural space, which is characterized by the presence of thick pus and the visceral pleura is
usually calcified. Penetration of anti-tuberculosis drugs is impaired, and surgical drainage is
often needed to control the situation. If the patient has dyspnea because of a large pleural
effusion, a therapeutical thoracentesis is recommended.8,10
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 2. Regimens of treatment tuberculosis in children.11

Local Board Examination, April 24th 2022 11

 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.12
Patient was diagnosed anemia of chronic disease. The prevalence of anemia among TB
patients was 88.52%.12 Tuberculosis can cause anemia of inflammatory cytokines. Chronic
inflammation caused this condition. Laboratory finding for this patient revealed hemoglobin
level 9,3 g/dl, MCV 80 fl, MCH 26 pg, blood smear normocytic normochromic anemia due to
infection, reticulocyte 3,76%, and ferritin 933,31 ng/ml.14 (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.15
This patient hemoglobin level 7.7 gr/dl with signs of tissue anoxia and 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.16 (Level of evidence 2b)
This patient has been diagnosed severe malnutrition. Based on CDC-NCHS 2000 chart
weight for height 59% (<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 underweight and 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.13 (Level of evidence 3b)
Management of severe malnutrition is based on 10 step malnutrition treatment and care.
The patient was given diet gradually, 2 days stabilization phase (50% total calories), then 5 days
transition phase (75% total calories).17,18 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. 19 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.20 (Level of evidence 1a)
Table 4. 10 steps to manage severe malnutrition.17

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).21(Level of evidence
1a) TB is a contributor to mortality among hospitalized children with severe acute malnutrition.
Chisti et al. reported no in-hospital mortality in Bangladesh but high post-discharge mortality in
severely malnourished children with TB.22(Level of evidence 3b) 
 

Local Board Examination, April 24th 2022 13

 REFERENCES
1. Thomas TA. Tuberculosis in Children. Pediatr Clin North Am. 2017;64(4):893-909.
doi:10.1016/j.pcl.2017.03.010
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. Salmah S, Culla AS. Identification of mycobacterium tuberculosis by polymerase chain
reaction (pcr) test and its relationship to mgg staining of pleural fluid in patients with
suspected tuberculous pleural effusion. DOI: 10.20956/nmsj.v3i2.5778
8. Zhai K, Lu Y, Shi HZ. Tuberculous pleural effusion. J Thorac Dis. 2016;8(7):E486-E494.
doi:10.21037/jtd.2016.05.87.
9. Bhalla AS, Goyal A, Guleria R, Gupta AK. Chest tuberculosis: Radiological review and
imaging recommendations. Indian J Radiol Imaging. 2015;25(3):213-225.
doi:10.4103/0971-3026.161431
10. Marais BJ, Schaaf HS. Tuberculosis in children. Cold Spring Harb Perspect Med.
2014;4(9):a017855. Published 2014 Jul 18. doi:10.1101/cshperspect.a017855
11. 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.
12. 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
13. 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
14. 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.
15. Windiastuti E, Nency YM, Mulatsih S, Sudarmanto B, et al. Buku Ajar Hematologi
Onkologi Anak. Jakarta: Badan Penerbit IDAI. 2018.
 16. 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
17. Kementerian Kesehatan Republik Indonesia. Bagan Tatalaksana Anak Gizi Buruk Buku
I. Jakarta: Direktorat Jenderal Bina Gizi dan Kesehatan Ibu dan Anak. 2011.
18. Kementerian Kesehatan Republik Indonesia. Petunjuk Teknis Tatalaksana Anak Gizi
Buruk Buku II. Jakarta: Direktorat Jenderal Bina Gizi dan Kesehatan Ibu dan Anak.
2011.
19. 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
20. 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
21. 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
22. 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

Local Board Examination, April 24th 2022 15

Appendix 1
Rontgen thoraks 05/04/2022 :

Impression :
- Left Hydropneumothorax ( compared to photo thorax 24-03-2022,Impression:progresif )
- Right Pneumonia (compared to photo thorax 24-03-2022,impression: St.QA )

Rontgen Thorax PA/AP + Lateral 11/04/2022

Impression:

Applied chest tube tip impression pad ICS IV anterior

- Applied gastric tube with tip impression to gaster
- Left Hydropneumothorax (compared to photo thorax 5 April 2022, Impression:
improvement)
- Right Pneumonia (compared to photo thorax 5 April 2022, Impression: improvement )
Rontgen Thorax PA/AP + Lateral 14/04/2022

Impression:
- Applied chest tube with tip impression pad ICS IV anterior
- Applied gastric tube with tip impression to gaster
- Left Hydropneumothorax (compared to photo thorax 11 April 2022,
Impression: Improvement)
- Pneumoniae dextra (compared to photo thorax 11 April 2022, Impression:
Progresif )

Local Board Examination, April 24th 2022 17

Appendix 2
Head Circumference (HC)

Examination date : April 3rd 2022

Name : RN
Age : 2 years 8 months
Head circumferences : 50 cm (-2 <HC < 0, nellhaus)

Appendix 3
Growth Chart

Name :RN
Age : 2 years 8 months
Weight : 10 kg
Height : 92 cm
Weight for height : z-score < -3 SD (Malnutrition/Severely wasted, WHO Curve)
Height for age : -2 SD < z-score < 0 SD (Normo height, WHO Curve)
Weight for age : -2 SD < z-score < -3 SD (Underweight, WHO Curve)
Midparental height : 153,5 cm (father’s body height 165 cm, mother’s body height 155
cm)
Genetic potential height : 145– 162 cm (<P3 – P25), CDC NCHS 2000 chart)

1. Weigtht for Lenght chart

2. Weight for Age Chart

3. Lenght for Age Chart

Local Board Examination, April 24th 2022 19