Case Report:

Pulmonary
Tuberculosis with
Bronchiectasis
Supervised by: dr. Nurifah, Sp.A
Presented by: Akbar Fatahillah
 Patient Identity

01 03
An. SA 01265296 Female

02 04
Entry date: May, 12
15 years old 2023
Examination date:
May, 12 2023
 Anamnesis
Anamnesis was done by autoanamnesis and alloanamnesis with the patient’s mother
on Friday, 12nd Mei 2023 at Anggrek 2 Ward, Bhayangkara TK. I Pusdokkes Polri
Hospital
0 0
1 2
ADDITIONA
CHIEF
L
COMPLAINT
COMPLIANT
Cough with phlegm
Fever, weight loss,
since 1 month of
night sweats,
SMRS, has been heavy
decreased appetite
for the last 2 weeks
 History of Presenting Illness
The patient comes to the ER at Bhayangkara TK Hospital. Ir. Said
Sukanto on Friday, May 12 2023 with complaints of coughing up
phlegm since 1 month of SMRS, the cough initially came and
went but was getting worse for the last 2 weeks continuously
with yellow-green phlegm, blood and pain when coughing was
denied. Complaints accompanied by, the mother said that when
the fever was never measured, the fever fluctuating throughout
the day since 1 week of SMRSfever was accompanied by chills
every night. Other complaints include weight loss of 5 kg within
two weeks, night sweats, decreased appetite and weakness. Two
weeks after coughing, the patient went to the 24-hour clinic and
was given cough syrup (mother forgot the name of the medicine),
but the complaint still hasn't improved. Then, on 09/05/23 the
mother brought Puskesmas Kel. Penggilingan Elok, was given
two types of tablet medication (the mother did not know which
drug) and underwent a Molecular Rapid Test (TCM) examination.
Complaints of tightness, chest pain, sore throat, hoarseness,
nausea & vomiting, heartburn, bloody bowel movements, black
bowel movements, bleeding urination were denied.
 Past Medical History
Similar complaints were previously denied.
History of drug and food allergies was denied.
History of TB and treatment of pulmonary TB
was denied. History of asthma was denied.
Family Medical History
Complaints similar to Grandfather's coughing up
phlegm have been coming and going since 2
months ago. Grandfather's history of pulmonary TB
in 2021, complete treatment for 6 months and
declared cured. History of asthma and malignancy
was denied

Habits and Environment

The patient is a student, similar complaints at school are
denied. Smoking history was denied. Irregular and
meager diet, high in carbohydrates, high in fat, and low in
protein. Father is an active smoker. The patient lives in a
densely populated environment, ventilation and lighting
in the house are lacking, and the house is inhabited by 7
people
 Pragnancy and Birth
History
• The first child of three siblings
• Sectio caesarea, UK 39 weeks, BBL 2800 gram, PB
48 cm. The patient immediately cried out loud,
there was no cyanosis and jaundice. Immediately Brestfeeding
get an injection of vitamin K and Hepatitis B after
birth
Exclusive breastfeeding until 24 months of age,
formula milk from 2 years of age, complementary
food for ASI (MPASI) from 6 months of age

Growth & Developmental

History
Patients started to be able to lie down at 3 months, sit at
6 months, stand at 1 year, walk at 1 year, and talk at 1
year
Immunization history
Basic immunization BCG 1x, Hepatitis B 4x,
Polio 4x, DPT 3x, HiB 3x, Measles 1x

Menstrual history
Menstruation age 12 years, regular with menstrual
cycles 7-9 days, changing pads 2x a day,
dysmenorrhea is denied
 Physical Examination
General
Status
General State : Moderately ill
Level of conciousness : E4M6V5
Vital Signs :
• Blood Pressure : 99/58 mmHg
• Pulse Frequency : 134x/minute
• Respiratory rate : 32x/minute
• Temperature : 37,7 ºC
• Saturation: 86%
Anthropometry
Data (CDC Curve)
Body weight : 30 kg
Body height : 150 cm
BMI : 13,3 kg/m2
W/A : 57,6% (BB sangat kurang)
H/A : 92,5% (Baik)
BW/BH: 73,1% (Gizi kurang)
 Physical Examination
Head Ear
01 Normocephal, hair Normotia, 04
is not easy to pull secretions -/-, blood
out, black color -/-, cerumen -/-

Eye Nose
02 Eyelids not sunken, Secretions -/-, 05
conjunctiva anemic -/-, deformity -, nostril
icteric sclera -/-, breathing -
isochoric round pupils,
RCL +/+, RCTL +/+

Neck Mouth
03 Enlargement of the KGB -, Normoglossia,
moist oral mucosa
06
use of the accessory
muscles of breathing and lips, coated
m.sternocleidomastoideus + tongue -, tremor
tongue -, cyanosis
of lips -
 Physical Examination
Esktremities
Cor
01 and Skin Ictus cordis not 03
Warm acral, CRT <2
sec, edema -/-, visible, palpable at
cyanosis of fingers ICS V Left
and toes -/- midclavicle, normal
heart borders, BJ
1/II regular,
murmurs and
gallops -

Pulmo
02 normal skin color,
Abdomen
symmetrical, retraction
between ribs -/-, use of Flat, sociable, 04
accessory muscles for normal BU (+),
breathing -/-, VF right = tympani, tenderness
left, sonor +/+, vesicular -, liver and spleen
+/+, rhonki +/+ all lung enlargement -, good
fields, wheezing -/- turgor
 Laboratory Evaluation
Puskesmas Kel. Penggilingan Elok (10/05/23)

Checking type Results Reference Value

Genexpert MTB detected RIF sensitive -

 RS POLRI (11/05/23)
Checking type Results Reference Value

Hemoglobin 9,8g/dL 13-16 gr/dL

Leukocytes 17.930 uL 5.000 -10.000 µL

Hematocrit 33% 40-48 %

Trombosit 528.000 uL 150.000 – 400.000 µL

SGOT 78 U/L <31 U/L

SGPT 40 U/L <31 U/L

 RS POLRI (12/05/23)
Checking type Results Reference Value

LED 61 mm

GDS 82 mg/dL

Natrium 125 mmol/L

Kalium 3.8 mmol/L

Chlorida 96 mmol/L

Widal Negatif
 RS POLRI (12/05/23)

Checking type Results Reference Value

Protein total 6.8 gr/dL

Albumin 2.9 gr/dL

Globulin 3.9 gr/dL

 RS POLRI (12/05/23)
Checking type Results Reference Value

pH 7,54

pCO2 22 mmHg

pO2 160 mmHg

HCO3 23 mmol/L

Base Excess 4.3 mmol/L

Total CO2 19 mmol/L

O2 Saturasi 99,3%
 Chest X-Ray (11/05/23)
Chest photo taken at the POLRI Hospital on May 11, 2023 on
behalf of An. SA is 15 years old.
• PA projections
• Sufficient violence
• Symmetrical
• Maximum inspiration
• Between the ribs are not widened
• Skeletal and tissue within normal limits
• Costophrenicus and cardiophrenicus sharp right and left
angles
• Normal diaphragm
• Inhomogeneous consolidation & infiltrates in the upper-
basal fields bilaterally with multiple cavities in the upper
fields of both lungs, as well as multiple ecstatic rings
• Cor does not enlarge, CTR <50%

Impression: Active pulmonary tuberculosis with multiple

cavities and bronchiectasis
 Resume
Pediatric patient on behalf of An. SA, aged 15, was brought by her
parents to the emergency room at Bhayangkara TK Hospital. IR. Said
Sukanto on Friday, May 12 2023 with complaints of coughing with
yellowish green phlegm since 1 month of SMRS and has been heavy
for the last 2 weeks. Complaints accompanied by fever fluctuating
throughout the day since 1 week of SMRS and chills every night.
Other complaints include weight loss of 5 kg within two weeks, night
sweats, decreased appetite and weakness. On general status and vital
signs, the general condition looked moderately ill, blood pressure
99/58 mmHg, pulse 134x/minute, breathing 32x/minute, temperature
37.7°C, and saturation 86%. The patient's nutritional status was
undernourished and on physical examination found the use of the
accessory muscles for breathing M. Sternocleidomastoideus +,
rhonki +/+ all lung fields. Investigations showed increased SGOT
(78U/L) and SGPT (40 U/L), anemia (Hb: 9.8 g/dL), leukocytosis
(Leukocytes: 17,930 uL), thrombocytosis (Platelets: 528,000 uL),
hyponatremia (Na : 125 mmol/L), hypoalbuminemia (Albumin:
2.9g/dl), respiratory alkalosis (pH 7.54, PCO2 22, HCO3 23), TCM MTB
results detected sensitive RIF, chest X-ray impressions of active
pulmonary TB with multiple cavities and bronchiectasis
Working Diagnosis and Problems

0 0
1 2

- Anemia
1. Bacteriological - Electrolyte
Pulmonary TB imbalance
New Case with - Hypoalbuminem
HIV (-) - Respiratory
2. Bronchiectasis Alkalosis
3. Malnutrition - Leukocytosis
- Thrombocytosis
- Difficult intake
Pediatrician
Non-Medikamentosa
-
Medikamentosa
 IVFD RL 500 cc 14 tpm
 NaCl 3% 300 cc/8 jam
 Ceftriaxone 2x750 mg IV
 Dexametason 3x5 mg IV
 Paracetamol 3x300 mg PO
 Ambroxol 3x15 mg PO
 Curcuma Syr 2x5 ml PO
 Rifampisin 1x450 mg PO
 Isoniazid 1x300 mg PO
 Pirazinamid 2x500 mg PO
 Streptomisin 1x30 mg IM
 Vit. B6 1x1 tab PO
Co-Assistant
Non-Medikamentosa
 Wear a mask when talking to other people;
Treatment
 Educate cough and sneeze properly;
 Education about disease, risk factors, prevention, transmission,
and the importance of treatment to completion;
 Education about the side effects of OAT drugs
 Education on high-calorie, high-protein, and high-fat diets
Medikamentosa
 IVFD RL 500 cc 14 tpm
 NaCl 3% 300 cc
 Ceftriaxone 2x1.5 gr IV
 Paracetamol 3x300 mg PO
 Ambroxol 3x15 mg PO
 Curcuma Syr 2x5 ml PO
 Apialys Syr 1x5 ml PO
 VIP Albumin 2x1 caps PO
 Vit. B6 1x1 tab PO
 Rifampisin 1x450 mg PO
 Isoniazid 1x300 mg PO
 Pirazinamid 1x1000 mg PO
 Prognosis

Ad Vitam: Bonam
Ad Sanationam: Dubia ad
bonam
Ad Functionam: Dubia ad
malam
 Follow Up
12nd May 2023 13th May 2023 14th May 2023

Day of hospitalization : 1 Day of hospitalization : 2 Day of hospitalization : 3

Day of sick : 30 Day of sick : 31 Day of sick : 32

S/ Continuous cough with phlegm, yellow- S/ Continuous cough with phlegm, yellow- S/ Continuous cough with phlegm, greenish yellow
green color, blood (-), fever (+), weakness (+), green color, blood (-), fever (-), weakness (-), color, blood (-), fever (-), weakness (-), shortness of
shortness of breath (+) when lying down, shortness of breath (+) when lying down, breath (-), appetite has not improved
decreased appetite (+) appetite has not improved
O/ Looks moderately ill O/ Looks moderately ill O/Looks moderately ill
Case: Compos Mentis Case: Compos Mentis Case: Compos Mentis
BP: 100/78 mmHg BP: 100/70 mm Hg BP: 98/60 mm Hg
Pulse: 128x/minute Pulse: 110x/minute Pulse: 101x/minute
Breath: 28x/minute Breath: 24x/minute Breath: 24x/minute
Temperature: 37.8°C Temperature: 36.6°C Temperature: 36.4°C
Saturation 97% on NRM 8 lpm Saturation 99% on NRM 8 lpm Saturation 99% on NK 3 lpm
O/ O/ O/
Neck: Use of accessory muscles for breathing Neck: Use of accessory muscles for Lungs: rhonchi +/+ throughout field
(+) breathing (+)
Lungs: rhonchi +/+ throughout field Lungs: rhonchi +/+ throughout field

Hb: 9.8 g/dL Na/K/Cl: 140/4.0/108 mmol/L

Leu: 17,930 µL HIV: Non-reactive
HT: 33% Hepatitis B: Non-reactive

Troms: 528,000 µL
OT/PT: 78/40 U/L
Na/K/Cl: 125/3.8/96 mmol/L
A/ A/ A/
Pulmonary TB Pulmonary TB Pulmonary TB
Malnutrition Malnutrition Malnutrition
Hyponatremia Hyponatremia repair Hyponatremia repair
Anemia Anemia
P/ P/ P/
IVFD RL 14 tpm IVFD RL 14 tpm IVFD RL 14 tpm
Check LED, widal, albumin, globulin, GDS, HIV Ceftriaxone 2x750 mg IV (H2 Ceftriaxone 2x750 mg IV (H3)
NaCl 3% 300 cc/8 hours )Dexamethasone 3x5 mg IV Dexamethasone 3x5 mg IV
Ceftriaxone 2x750 mg IV Paracetamol 3x300 mg PO Paracetamol 3x300 mg PO
Dexamethasone 3x5 mg IV Ambroxol 3x15 mg PO Ambroxol 3x15 mg PO
Rifampicin 1x450 mg PO Curcuma 2 x 5 ml PO Curcuma 2 x 5 ml PO
Isoniazid 1x300 mg PO Rifampicin 1x450 mg PO Rifampicin 1x450 mg PO
Pyrazinamide 2x500 mg PO Isoniazid 1x300 mg PO Isoniazid 1x300 mg PO
Streptomycin 1x30 mg IM Pyrazinamide 2x500 mg PO Pyrazinamide 2x500 mg PO
15nd May 2023 16th May 2023

Day of hospitalization : 4 Day of hospitalization : 5

Day of sick : 33 Day of sick : 34

S/ cough with phlegm intermittent, slightly better, S/ No complaints
fever (-), shortness of breath (-), weakness (-),
appetite is starting to improve

O/ O/
General condition is good General condition is good
Cons: Compos Mentis Cons: Compos Mentis
BP: 110/89 mmHg BP: 90/70 mm Hg
Pulse: 105x/minute Pulse: 90x/minute
Breath: 22x/minute Breath: 24x/minute
Temperature: 36.7°C Temperature: 36.2°C
Saturation 98% on NK 3 lpm Saturation 98%
Lungs: rhonchi +/+ throughout field Lungs: rhonchi +/+ throughout field
Thorax X -ray: Active pulmonary TB with multiple
cavity and bronchiectasis
A/
Pulmonary TB
Bronchiectasis
Malnutrition
Hyponatremia repair
Anemia
P/
IVFD RL 14 TPM
Ceftriaxone 2x750 mg IV (H4)
Dexametasone 3x5 mg IV
Paracetamol 3x300 mg PO
Ambroxol 3x15 mg PO
Curcuma 2x5 ml PO
Rifampicin 1x450 mg PO
Isoniazid 1x300 mg PO
Pirazinamid 2x500 mg PO
Streptomycin 1x30 mg IM
A/
Pulmonary TB
Bronchiectasis
Malnutrition
Hyponatremia repair
Anemia
P/
IVFD RL 14 TPM
Ceftriaxone 2x750 mg IV (H5)
Dexametasone 3x5 mg IV
Paracetamol 3x300 mg PO
Ambroxol 3x15 mg PO
Curcuma 2x5 ml PO
Rifampicin 1x450 mg PO
Isoniazid 1x300 mg PO
Pirazinamid 2x500 mg PO
Vit. B6 1x1 Tab PO
 01
Tuberculosis
Infectious diseases caused by
infection Mycobacterium
tuberculosis complex
 Epidemiology Tuberculosis

About 95% of TB
45
cases occur in
%
developing countries
In Indonesia it is
estimated that in 2019
30
there were 845,000
% new cases of
pulmonary TB
Pulmonary TB in
25 developing countries
% occurs at the age of 15-29
years
Case Definition

Presumed TB

Someone who shows the main

symptoms and signs of TB

Case of TB
TB patients with bacteria from
clinical specimens and culture or
who have been diagnosed with
doctors
 Classification

Location of Drug Treatment

Main HIV status
Infection sensitivity test History

● TB with HIV
● TB confirmed positive ● New case of TB
● Pulmonary TB
bacteriological ● TB with HIV ● TB - SO
negative ● Cases that have
● Extrapulmonary
● TB clinical ● TB - RO been treated by
TB
diagnosed ● TB with unknown TB
HIV status
 TB Confirmed Bacteriological
Found evidence of MTB infection based on bacteriological
examination
01 04
Patients with active Pulmonary TB
pulmonary TB patients the results
of the positive mtb
test
02
TB children diagnosed
with bacteriological 05
examination
Extrapulmonary TB patients are
03 bacteriologically confirmed, both
Patient pulmonary with BTA, culture and TCM from
TB results of the exposed tissue test sample
positive MTB
culture
 TB Confirmed Clinical
Does not meet bacteriological criteria, but diagnosis and
management as TB by a doctor
01 04
BTA pulmonary TB patients TB Children who are
(-) with TB x-rays diagnosed with a
scoring system

02
BTA pulmonary TB patients (-)
there is no clinical NOTE:
improvement from non-OAT 05
antibiotics and there are risk
factors TB clinically  confirmed
03
bacteriological  TB confirmed
TB extrapulmonary patients are bacteriological
diagnosed with clinical, laboratory,
and histopathological without
bacteriological confirmation
Patogenesis & Patofisiologi
 Diagnosis
Anamnesis

Cough with
Shortness of Subfebrile
phlegm ≥ 2 Weight Loss Night Sweats
Breathing Fever
weeks
 Diagnosis: Pemeriksaan Fisik
01 02
Pulmonary TB Pleuritis TB
- Bronchial breath
- Dull or deafening
sounds
- Breath sounds are percussion
weak
- Auscultate diminished 3
- Coarse/fine wet breath sounds on the
rhonchi side where there is fluid 1
- Retraction signs of
lung, diaphragm, and
mediastinum 2

03
Limfadenitis TB
KGB enlargement of the
neck
Diagnosis: Supporting investigation

Bacteriological Radiological
examination Examination
- Microscopy Thorax PA
- Bacterial Culture
- TCM
- Other Molecular
Examination
 Materials: sputum, pleural fluid, CSF,
bronchial washings, gastric washings,
Bacterial bronchoalveolar drainage, urine, feces,
tissue biopsies
Examination How to take: sputum as much as 2x
(minimum in the morning). For
GeneXpert, 1x sputum examination
material is sufficient.
Mikroskopis : Pewaarnaan Ziehl Nielsen
Fluoresens: pewarnaan auramin rhodamin

SKALA IUATLD

Negatif Tidak ditemukan BTA dalam 100 lapang pandang

Scanty Ditemukan 1-9 BTA dalam 100 lapang pandang, ditulis

jumlah basil yang ditemukan
1+ Ditemukan 10-99 BTA dalam 100 lapang pandang

2+ Ditemukan 1-10 BTA dalam 1 lapang pandang

3+ Ditemukan >10 BTA dalam 1 lapang pandang

 TB Bacterial Culture
Is a gold standard
Bacteriologis Bacterial Culture > Microscopic (Sensitive)
Culture
Examination Medium : Liquid (MGIT [Mycobacteria Growth Indicator Tube)
Time : 21.2 days (range 4-53 days)
Solid (Lowenstein-Jensen)
Time : 40.4 days (range 30-56 days)

TCM (Tes Cepat

Molekuler)
• The most commonly used TCM is GeneXpert
MTB/RIF
• At the same time, a drug sensitivity test can be
carried out
• Results came out within 120 minutes
• Screening susp cases. TB-RO
• Sensitivity and specificity about 100%
 Standar : Thorax radiograph in postero
anterior (PA) projection
Radiologic Other examinations for clinical
Examination indications such as lateral, top-lordotic,
oblique chest radiographs and CT scans
Foto Thorax PA Foto Thorax lateral
Active TB Lesion:
- Cloudy/nodular shadows on the
apical, posterior upper lobe of the lung
and superior segment of the lower
lobe
- Cavity > 1 surrounded by
cloudy/nodular opaque shadow
- Miliary spotting shadows
- Uni or bilateral pleural effusion
 Radiological features that are suspected as active TB lesions
are:

Tampak infiltrat Tampak kavitas Terdapat nodul

Milier Efusi pleura bilateral Efusi pleura unilateral

 Radiological features that are suspected of being an inactive
TB lesion are:

Fibrosis Penebalan pleura Kalsifikasi

Other Supporting Examination

Histopatologic
Examination
a. KGB fine needle aspiration biopsy (BJH).
b. Pleural biopsy (thoracoscopy or with an Abrams,
Cope and Silverman vein)
c. Lung tissue biopsy by bronchoscopy, TTNA
(trans thorachal needle aspiration), open biopsy
d. Biopsy or aspiration of extrapulmonary organ
lesions suspected of TB
e. Autopsy

This examination will show a picture of a granuloma

with caseous necrosis (caseosa) in the middle and
can find a picture of Datia Langhans cells and or TB
germs.
 Other Supporting Examination
Uji Tuberkulin
- Establish the diagnosis of TB in children,
especially if there is a history of contact
with TB patients is not clear

Swelling (induration): Swelling (induration): 5-9 mm, Sweeling (induration): ≥10

0 – 4 mm, negative Mantoux Mantoux Test Doubts this can be due mm, mantoux test positive;
test clinical meaning: no to technical errors, cross reactions linical meaning: currently or
Mycobacterium tuberculosis with mycobacterium atypical or post have been infected with
infection, vaccination BCG Mycobacterium tuberculosis
Diagnosis
Algorithm
 Scoring TB

• If the total score ≥ 6: TB

diagnosis and treat with OAT
• If the total score is <6, with a
positive tuberculin test or there
are close contacts: diagnose TB
and treat with OAT
• If the total score is <6, and the
tuberculin test is negative or there
are no close contacts: observe
the symptoms for 2-4 weeks, if
they persist, re-evaluate the
possibility of a TB diagnosis or
refer to a higher health care
facility.
 TB Treatment
TB-SO Treatment Stages

Early/Intensive Stage (2 months)

• OAT is given every day
• Giving OAT at an early stage aims to reduce the number
of TB germs and minimize the risk of transmission
• The risk of transmission is reduced after the first two
weeks of the initial stage of treatment, if taken regularly

Advanced Stage (4-6 months)

Aims to kill remaining TB germs that do not die at an early
stage to prevent recurrence

NOTE!
TB-RO  Rujuk pusat rujukan TB-RO
 TB-SO Regimen in Indonesia
Release Medication

Intensive Phase  Combination of 4

drugs Rifamycin (R), Isoniazid (H),
Pyrazinamide (Z), Ethambutol (E) for 2
months

Advanced Phase  Isoniazid (H) and

Rifamycin (R) for 4 months

NOTE!
Panduan OAT untuk pengobatan TB-SO di Indonesia adalah
2RHZE/4RH
TB-SO Regimen in Indonesia
KDT/FDC

The number of KDT is given based on BB

• To support drug adherence
• One capsule of KDT RHZE Children for the intensive
phase contains 75 mg of rifampicin, 50 mg of isoniazid,
and 150 mg of pyrazinamide, Continuation phase 
RH KDT contains 75 mg of rifampicin + 50 mg of
isoniazid given daily
 OAT Classes and Mechanisms

Rifampisin Pirazinamid
Group: Bactericidal R Z Group: Bactericidal
Mechanism: Inhibition of Mechanism: Inhibition of
RNA synthesis cell membrane synthesis

Isoniazid Etambutol
Group: Bactericidal
H E Group: Bacteriostatic
Mechanism: Inhibition of
Mechanism: Inhibition of
Mycobacterium Arabinosyl
mycolic acid synthesis in
Transferase in the cell
the cell wall
membrane
 OAT Side Effects
Rifampisin
Minor: Flu syndrome,
dyspepsia syndrome
Major: Hepatitis, Pirazinamid
jaundice, purpura, acute
Minor: joint pain,
hemolytic anemia,
gouty arthritis, fever,
shock, renal failure,
nausea, flushing
respiratory syndrome
(skin reaction)
Minor: tingling, Major: drug-induced
burning hepatitis
sensation in
limbs and
muscle pain,
pellagra Visual impairment and
syndrome color blindness green
Major: drug-
induced hepatitis Etambutol
Isoniazid
 Efek samping
OAT
Streptomisin
Minor : tingling around
the mouth, tinnitus..
Major : Damage to the
balance and hearing nerves
with symptoms of tinnitus,
dizziness, and loss of
balance. Hypersensitivity
reactions: headache, vomiting,
skin erythema.

Should not be given to

pregnant women because it
can damage the hearing
function of the fetus.

Minor side effects  OAT was continued and given symptomatic

medication
Major side effects  OAT was stopped and referred
 Tatalaksana reaksi kutaneus dan
alergi
• Apabila terjadi reaksi gatal TANPA kemerahan dan
tidak ada penyebab lain, maka pengobatan yang
direkomendasikan adalah obat simptomatis seperti
menggunakan antihistamin.

• Apabila terjadi kemerahan pada kulit maka OAT

harus dihentikan. Jika reaksi tersebut sudah
berkurang dan sembuh maka OAT dapat dicoba
satu per satu, dimulai dengan OAT yang jarang
menimbulkan reaksi alergi
 Reintroduksi OAT → Obat Penyebab Alergi (+) → Proses
Desensitisasi.

• Jika reaksi alergi berat, mulai dengan dosis yang jauh • Jika reaksi alergi ringan, maka dapat dilakukan
lebih kecil dan dinaikkan bertahap beberapa kali dalam desensitisasi dengan peningkatan dosis per hari
satu hari (multi-step daily dose escalation). (single step daily dose escalation).
 Drug-Induced Hepatitis
Treatment
Important Information
1. Alcoholic consume history
2. Previous live disease history
3. Laboratory tests to rule out presence hepatitis
A, B, and C
4. Ultrasound of the abdomen to rule out a
disturbance in the biliary system

Criteria for Drug-Induced

Hepatitis
- OT/PT increased 3x + Clinical Complaints
- OT/PT increased 5x NO Complaints Total
Bilirubin increases 2x

• TB treatment was discontinued until liver function
returned to normal (SGPT < 2x upper limit of
normal value) and clinical symptoms (nausea or
abdominal pain) disappeared.
• If it is not possible to perform liver function tests,
then it is best to wait 2 weeks after the jaundice
and abdominal pain/tension disappear before
being given OAT again.
OAT Reintroduction Recommendation of the American
Thoracic Society
1. Start with Rifampicin with or without ethambutol.
2. After 3-7 days and it is proven that there is no increase in
SGPT, then Isoniazid can be given.
3. If during the reintroduction process there is an increase in
SGPT, then the last drug reintroduced is the cause of
drug-induced hepatitis and must be discontinued.
4. In patients with a history of severe drug-induced hepatitis
and who can tolerate Rifampicin and Isoniazid,
pyrazinamide should not be attempted for reintroduction.
 Treatment
Evaluation
0 02
0
1 4
03
Bakteriological
Clincal Radiological The patient
• Periodically evaluated • Detect whether there is
conversion of sputum Performed before
recovers
every month
treatment, after 2
• Evaluation of treatment • Microscopic months, and at the • Evaluated the 3rd,
response, side effects, examination before end of treatment 6th, and 12th months
complications treatment, after 2
after the treatment
months, 3rd month if
• Clinical evaluation: was finished.
the 2nd month result is
complaints, • To know recurrence
positive, at the end of
increase/decrease in • Things evaluated:
treatment
weight, physical clinical condition,
examination • Culture and sensitivity smear microscopy
tests were carried out sputum and chest X-
ray
Tuberkulosis dan
HIV
Jumlah CD4 menurun  imunitas tubuh
turun 16-27 x risiko terinfeksi TB

1,2 juta kematian akibat TB dengan HIV

negatif dan tambahan sebanyak 208.000
kematian akibat TB dengan HIV-positif di
tahun 2019 (Global Tuberculosis Report
WHO, 2020)
 Prevention
Indication
Prevention and Treatment with INH is
given to contact children who are
proven not to be sick with TB with the
following criteria:
1. Age less than 5 years
2. Children with HIV positive
3. Children with other
immunocompromised conditions
(eg malnutrition, diabetes mellitus,
malignancy, receiving long-term
systemic steroids.
Dosage
• The dose of INH is 10 mg/kg
BW/day (maximum 300 mg/day)
• The medicine is taken once daily,
preferably at the same time
(morning, afternoon, evening or
night) on an empty stomach (1 hour
before eating or 2 hours after
eating).
• The duration of giving PP INH is 6
months (1 month - 30 days of
treatment), provided that the child's
clinical condition is good. If TB
symptoms appear during follow-up,
do an examination to prevent TB
diagnosis. If the child is proven to
be sick with TB, PP INH is stopped
and OAT is given.
 02
Bronchiectasis
Illustration by Smart-Servier Medical Art

Definition
Bronchial dilatation (ecstasy) is chronic and
persistent, accompanied by an inflammatory
process in the bronchial wall and surrounding
lung parenchyma.
Epidemiology

 Prevalence 1-18 sufferers

per 1000 population
 2/3 of patients are women
 The frequency of BE is
higher in developing
countries where many
reports of measles, TB and
HIV infection occur
 Classification
Normal
Varikosa
Features such as varicose
veins, the presence of areas
of focal constriction due to
bronchial wall defects
Silindris
Respiratory tract dilatation
Kistik
Progressively dilated, large
cysts filled with mucus
(grape-like clusters) form.
Heavy BE sign
 Etiology
Changes in BE in localized areas of
the lung caused by extrinsic & intrinsic
airway obstruction
Obstruction
• Intrinsic: tumor, foreign body
aspiration, bronchial atresia due to
imperfect development (conginetal
abnormalities)
• Extrinsic: lung parenchymal tumor,
lymphadenopathy
Changes in BE with
characteristics that spread in the
lungs
• Infection
• Immunodeficiency:
hypogammaglobulinemia,
HIVGenetic: cystic fibrosis, a1
antitrypsin deficiency
• Autoimmune or rheumatological:
rheumatoid arthritisIdiopathic
 Cole’s Vicious Circle Pathogenesis

Impaired mucociliary clearance

Involves neutrophils, causes increased mucus secretion
lymphocytes, and  mucus stasis
macrophages
There was intense The bronchial walls lose
inflammation their muscularity and
elasticity

Bacterial colonization of
the sino bronchial tree
Cole’s Vicious Circle Pathogenesis
 Diagnosis (Anamnesis)

Productive cough Shortness off Hemoptisis

Breathing

Sputum that smells

Pleuritic Chest Pain of pus or rot Looking thin
 Dahak 3 Lapis

● Layer A: Slightly cloudy froth/foam

● Layer B: Saliva / clear fluid
● Layer C: Pus/sediment
 Physical Examination

Pulmonary Extremity
Keadaan Umum Examination Examination
- The patient looked - Chest wall retraction - Image of clubbing
moderately ill - Palpate the chest for finger or clubbing
- The patient looks thin, vibration near the finger
malnourished and hilum
anemic - On auscultation there
are crackles, moderate
to coarse para-hiller
and/or paracardial
crackles
 Supporting investigation

Sputum BTA/gram Laboratorium

Determines whether BE TB - Decreased Hb
or Non-TB - Polycythemia
- Leukocytosis
- CRP increase
Rontgen Thorax

A. Bronchiectasis kistik
with Ring Shadow 
Honeycomb appearance
B. Bronchiectasis silindrik
with tram track opacities
HRCT

Gold Standar: HRCT (High-

Resolution Computed
Tomography)
Signet Ring Sign illustration
Pemeriksaan Penunjang:
HRCT
Lung Function Examination

Spirometri
Examination
- Gambaran keterbatasan aliran napas
- Penurunan FEV1
- Penurunan rasio FEV1/FVC
 FACED Variable Values Points
Bronchiectasis FEV1 >50% 0

Severity <50% 2

Evaluation Score Age <70 tahun 0

>70 tahun 2

Chronic colonization by No 0
PA

Yes 1

Extension 1-2 lobes 0

>2 lobes 1

Dyspnea 0-II 0

III-IV 1
Bronchiectasis
Severity Index
(BSI)
Acute Exacerbation of Bronchiectasis

Increase shortness of breathing Decreased lung function

Increase cough New radiological changes consistent

with pulmonary infiltration

Fever >38°C Changes in breath sounds

Changes in sputum production

Malaise, fatigue, lethargy, or reduced

tolerance for physical activity
Treatment
 1 2
Purpose Goal
Prevent exacerbations, reduce Cutting cole's vicious circle  airway
complaints, improve patient quality of inflammation, decreased mucus
life, stop disease worsening clearance, damage to airway structures,
and bacterial colonization
 Treatmnet

Surgery

Conservative
Medicine
- General Management
- Special Management
- Symptomatic
Management
 Pengelolaan Umum

1. Creating a good and

appropriate environment for
patients
2. Bronchial secretion drainage
• Postural drainage
• Liquefies sputum
• Control respiratory tract
infections
 Special Management
Antibiotik
- Control of bronchial infections and/or treatment of acute
exacerbations
- Empiric antibiotics and according to sensitivity test
- Short course of antibiotics given 14 days alone or in combination
(amoxicillin 500 mg orally every 8 hours/ciprofloxacin orally 750 mg
twice daily in high risk of P. aeruginosa)
- Long-term antibiotics administered for 12 months (oral
erythromycin 400 mg twice per week)

Anti-inflamasi
Kortikosteroid inhalation

Secretion Drainage with Bronkoskop

- Determine the origin of the secretions
- Identify the location of the stenosis or obstruction
- Removing obstruction with suction drainage
 Symptomatic Managemet
- Treatment of obstruction with bronchodilators
- Administration of oxygen in hypoxia
- Treatment of hemoptysis using hemodynamic drugs or operative
measures in massive cases
- Giving antipyretics to treat fever

Mukoactive Theraphy
- Therapy can be used either orally, inhalation, or nebulization
- Reduce the thickness of phlegm and help expel phlegm
 Surgery

- Performed on patients with localized disorders who fail medical

therapy and suffer from clinical symptoms that worsen the patient's
quality of life
- Basic concept: remove damaged areas of lung parenchyma
 03
Case Analysis
Definition Tuberculosis is a chronic infectious disease Patients come with complaints of
caused by the bacterium Mycobacterium coughing up phlegm since 1
tuberculosis month, fever since 1 week, weight
loss, night sweats, decreased
Bronchiectasis is a chronic disorder
appetite, and weakness. Similar
characterized by permanent bronchial
complaints were found in
dilatation, accompanied by an inflammatory
grandfathers who had been
process in the bronchial wall and
coughing up phlegm since 2
surrounding lung parenchyma. The sequelae
months.
that occur are chronic cough, chronic airway
obstruction, and progressive breathing
problems
Epidemiology In Indonesia it is estimated that in 2019 Patients included in the prevalence
there will be 845,000 new cases of of TB sufferers for ages 15-29
pulmonary TB, with the DKI Jakarta province years (patients aged 15 years)
having the highest rate of TB sufferers. Data
from the World Health Organization (WHO)
show that pulmonary tuberculosis in
developing countries occurs at the age of
15-29 years

Reported frequency of this disease is higher

in developing countries where there are
many reported cases of measles, TB and
HIV infection
Risk Factor a) Ages over 45 years (69.8%) and ages a) Patient is 15 years old
between 15-45 (37.7%) have the
b) The patient's nutritional status
potential to be affected by pulmonary
was found to be
TB with positive smears.
undernourished
b) Malnutrition will affect the immune
c) The patient lives in a densely
system and will indirectly cause the
populated environment,
child's immune system to be more
ventilation and lighting in the
susceptible to infectious diseases than
house are lacking, and the
healthy children. This can increase TB
house is inhabited by 7 people
cases because of low body resistance.

c) Density of occupancy is a risk factor for

TB infection which is more commonly
found in groups of subjects who have a
source of transmission of more than
one person. If the occupancy is getting
denser, the transfer of infectious
diseases through the air will be easier
and faster, especially in one house
there are members.
TB with BE Diagnose a) Bacteriological confirmation of TB a) 1. The results of the Molecular Rapid Test
dated 10/05/2023 in the patient found MTB
b) Clinical symptoms are typical of TB
Detected RIF sensitive

c) Evidence of TB infection (positive tuberculin test result or

b) Patient complaints include coughing up
close contact with a TB patient)
phlegm since 1 month and getting worse since
2 weeks, fever fluctuating since 1 week, weight
d) Chest radiograph suggestive of TB
loss of 5 kg within 2 weeks, night sweats,
decreased appetite, and weakness.

c) Similar complaints were found in grandfathers

who have been coughing up phlegm since 2
months and have a history of pulmonary TB
treatment in 2021

• Chest X-ray shows inhomogeneous

consolidation & infiltrates in the upper-basal
fields bilaterally with multiple cavities in the
upper fields of both lungs, as well as multiple
ectatic rings. Impression: Active pulmonary
tuberculosis with multiple cavities and
Treatment Recommendations for giving 4 types of OAT in the
intensive phase are only given to children with
positive smears, whereas in the intensive phase
2HRZE is given.
Antibiotics have a crucial role in the management of
bronchiectasis, antibiotics can inhibit the vicious
cycle of infection, inflammation, and damage to the
airway epithelium.
The patient while in the hospital received
HRZ + S therapy and antibiotics•
Ceftriaxone 2x750 mg IV• Rifampicin
1x450 mg PO• Isoniazid 1x300 mg PO•
Pyrazinamide 2x500 mg PO•
Streptomycin 1x30 mg IM
TERIMA KASIH