SHANZ – PEDIA II 2.

05

FUO TB TYPHOID FEVER MALARIA SCRUB TYPHUS

ETIOPATHO • Infectious • 95% tubercle bacilli via • Incubation period 10-12 days • • Orientia tsutsugamushi
• CT disease (JVA, inhalation • S.typhi à mouth à GIT à Peyer’s • (-) LPS and Peptidoglycan in cell wall
SLE,, vasculitis) • Upper lung: well oxygenated patches àperfusion à Bacteremia • Infects endothelial cell, cardiac myocytes,
• Malignancy à gallbladder à peyer’s patches macrophages
(leukemia, à fever in stepladder pattern • Rural area
lymphoma) • Common in rainy months
• Boys > girls
• Via bite of chigger (larval stage) of
leptotrombidium (trombiculid mite)
CLINICAL • Axillary temp 38.3 • Incubation 2-10 weeks • fever, chills, headache, abdominal • paroxysm of fever alternating with • vasculitis
FEATURE for > 8days • Hypersensitivity in wallgren’s tenderness, splenomegaly fatigue • fever 9-11 days
• Fever: timetable • high fever ,sweat, headache • regional/generalized lymphadenopathy
intermittent/ • Military TB & TB meningitis • myalgia, back pain • hepatomegaly and splenomegaly
remittent/ within 3 months (significant LN • abdominal pain, N/V, diarrhea, pallor, • abdominal pain, vomiting, diarrhea
persistent/ involvement) jaundice • single painless eschar with erythematous
relapsing • TB pleural effusion within 1 yr • lack typical paroxysms, non specific rim at chigger bite site
• Eyes: fundoscopy • TB of bones & joints (within 1- symptoms • maculopapular rash
(petechiae, Hge) 3 years) • splenomegaly, hepatomegaly • end organ injury in brain and lungs
• Progressive pulmonary TB
(within 5 years)
• Urogenital TB : after 5 years
DX • CBC • • blood C/S: highest yield in 1st week • •
• UA of illness
• ESR/CRP • stool C/S: (+) in 2nd-3rd week
• Procalcitonin • urine C/S: (+) in 2nd-3rd week
• PPD/CXR • PCR: useful, expensive
• Blood culture • Rapid typhoid assay: detect
• Urine culture IgM/IgG for S.typhi (typhirapid,
• LFT typhiliza)
• RFT
• 2D ECHO
• Biopsy: BM, LN,
liver
• Exploratory
laparotomy
TX • Antimicrobial • • Chloramphenicol 75-100 • • DOXYCYCLINE 4mg/kg/day PO or IV BID ,
mg/kg/day in 4 doses x 14 days max 200 mg/day
• Amoxicillin 100 mg/kg/day in 3 • Alt: tetracycline, chloramphenicol
doses x 14 days
• Cotrimoxazole 8 mg/kg/day
• TMP: 40 mg/kg/day in 2 doses
PROGNOSIS • Good in children • • • • Avoid chiggers
• Protective clothing
• No vaccine
 TB: PULMONARY/INTRATHORACIC
PRIMARY COMPLEX
• Upper part of lower lobe
• 4 components
o Primary parenchymal lesion
o Regional LN enlargement
o Lymphatic connection
o Concomitant pleural effusion
• Pleurisy
MILIARY TB
• Millet seeding appearance
• 2-6 months from initial infection
• Hematogenous primary TB
• Common constitutional symptoms
• May develop leukemoid reaction or aplastic anemia
• Typhoidal: tender abdomen, spleno/hepatomegaly, toxic
• Pulmonary/meningeal
• Meningitis: do spinal tap

TB: EXTRAPULMONARY/ EXTRATHORACIC

SCROFULODERMA TB MENINGITIS POTT’S DISEASE TB ENTERITIS
• TB of superficial LN (scrofula) • Most serious and fatal complication • PEAK during 1st 5 years of life • Hematogenous
• with skin involvement • Children 4 mo-6 yo • Within 6 mo after initial dissemination
• Most common • Brainstem: CN 3,6,7 dysfunction infection • Swallowing of tubercle
• Occur within 6-9 mo of initial infection • Basilar cisterns exudate = communicating hydrocephalus • Gibbous deformity, kyphosis bacilli
• Enlargement, cold abscess formation, LN • Slow progression • Erosion of vertebral body, • Jejunum & ileum and
breakdown, cervical chain, extension to overlying • 1st stage: 1-2 week with non specific symptoms (early stage of irritability) caseation necrosis appendix
skin • 2nd stage: abrupt (most common: lethargy, nuchal rigidity, seizures, + kernig’s , • Lumbosacral/thoracic spines • Enlarged nodes à intestinal
• Cervical LN caseate and matted +brudzinki, hypertonia, vomiting, CN palsy, focal neuro sign) obstruction/ erosion
• Linear or serpiginous ulcer, dissecting fistula, PRESSURE/CONVULSIVE STAGE • Constriction (similar to
subcutaneous tracts, soft nodules • 3rd stage: coma, hemiplegia, paraplegia, HTN, decerebrate posturing (PARALYTIC/ colon CA)
• (+) tuberculin induration 10 mm TERMINAL STAGE)
• LJ medium

TB DIAGNOSIS IN CHILDREN
CLASS I : TB EXPOSURE CLASS II: TB INFECTION CLASS III: TB DISEASE CLASS IV: TB INACTIVE
• (-) Tuberculin test • (+) Exposure • (+) exposure • With/without exposure
• No S/S • (+) Tuberculin test • (+) Mantoux/tuberculin test • With/without previous treatment
• (-) CXR • No S/S • S/S • CXR: healed or calcified TB
• (-) CXR • (+) CXR • (+) Mantoux test
• Caseation necrosis • No S/S
• (-) Smear or culture

DOH PROGRAM
EARLY DX & CURE OF SMEAR (+) ADULTS = DECREASE TB INFECTION AMONG CHILDREN
BCG IMMUNIZATION IN INFANTS = DECREASE EXTRAPULMONARY TB
BCG PPD
• Produce innocuous primary infection due to bacillus of Calmette and • Screening tool
Guerin • Negative: may be in state of anergy
• Prevents dissemination of disease • False negative: malnourished (negative nitrogen balance), fever,
• Doesn’t prevent infection of MTB dehydration
• 0.05 mL for newborn & neonate
• 0.1mL for infants
• Intradermal R deltoid / buttock
• Multiple doses NOT recommended

AntiTB side effects
• Ethambutol: optic neuritis (>15-
20 mg)
• Isoniazid (pyridoxine def)
• Streptomycin (ototoxic, CN 8
dysfunction)
• Rifampicin (orange urine)
ISONIAZID PREVENTIVE THERAPY
• Children < 5 yo
• Asymptomatic people living with HIV
• Isoniazid 10 mg/kg/day x 6 mo (max
300 mg/day)
TB TREATMENT IN CHILDREN
LATENT TB INFECTION
• HIGH BURDEN: low to middle
income (6 mo of INH)
• INH + RFT weekly x 3 mo
• Low incidence: 6 H vs 9H:
Resource requirements
Feasibility
Acceptability by patients
TREATMENT RESPONSE
EVALUATION
• CXR infiltrate clear in 2-9 mo
• Hilar adenopathy disappear 2-3 yr
• Complete resorption 6-12 weeks
DOTS
• Microscopes: confirmation
• Medicine: anti TB drug
• Observer: community health workers
see swallowing
• Reporting books: documentation until
cure
• Funding: political support

THYPHOID FEVER: COURSE

WEEK 1 WEEK 2 WEEK 3 WEEK 4 SEQUELAE
• Hyperemic and swollen peyer’s patches = abdominal pain • Necrosis • Very high and raging fever • recovery • typhoid meningitis
• Slow, soft, dicretic prostration diarrhea, constipation, abdominal • Eventual sloughing of peyer’s patches • SI: ulcer, hemorrhage, perforation • salmonella
distension, bronchitis, epistaxis • Toxemia, delirium, pea soup stools and typhoid • Hepatosplenomegaly pericarditis
• WBC 4000-5000 tongue • Typhoid state • salmonella
• Rose spots • Rose spots: maculopapular rash on trunk • Stupor, delirium, muscle twitching, myocarditis
• (+) blood culture • (+) stool culture meningism • salmonella
• (-) widal test • Pea soup stools (patient looks toxic) • Palpable spleen at 1-2 fingerbreadth below cholecystitis
LCM • salmonella
• WBC > 10k nephritis