Transcript Adolescent with chronic Illness

Pramono, MD
2nd year PCMC Resident
General data
• D.A.
• 14 years old, female
• Upper Bicutan Taguig City
• Consulted last August 22nd 2013
Chief Complaint
Cough x 2 months duration
History of present illness
2 months
1 month
•
•
•
•
(+) non productive cough
Decrease in appetite
Undocumented low grade fever
Self medicated with paracetamol 11mkdose and
amoxicillin clavulanic acid 22mkday x 7days
• (+) productive cough with greenish phlegm
• Colds, undocumented low grade fever by touch,
frequent throat clearing
• Consulted with Private MD.
• Chest Xray done with normal result. A> URTI
• Home Meds : Clarithromycin 22mkday x 7days,
acetylcysteine
History of present illness
3 weeks
4 days
• Progression of cough
• Chest pain, on right axillary line, tolerable, aggravated
during cough
• No consultation nor medication were taken
•
•
•
•
Still with cough
Fever undocumented
Post-tussive vomiting
Took Paracetamol with afforded slight relief of fever
History of present illness
DOC
• Progression of cough
• Increase frequency of post- tussive
vomiting
• Chest pain
Review of systems
 (+) weight loss
 (-) headache
 (-) palpitation
 (-) hemoptysis
 (-) diarrhea
 (-) dysuria
 (-) swelling of joints
 (-) bleeding
 (-)rashes
(+) body malaise
(-) sore throat
(-) dyspnea
(-) abdominal pain
(-) constipation
(-) edema
(-) numbness
(-) pallor
Past Medical History
• January 2013 - cough x 1week
• no consult done; no medications taken.
• 2011- Bronchitis,
• consultation was done at private doctor, diagnosis said but no
explained, given unrecalled medications for 7 days. Which
resolved after intake of medications for 5 days.
• 2009- Pneumonia,
• consultation was done, at local health center, given unrecalled
antibiotic for 1 week with improved condition after.
 No history of allergy to food nor medication
 No history of operation or admission at hospital before
Family History
41, janitor
(+) PTB
34, HW
11
(-)diabetes
(-)asthma
(-)hypertension
(-)cancer, blood dyscrasias
(-)seizure disorder
(-)neuromuscular, skeletal disorders
Family History
 Father was a diagnosed case of Pulmonary TB, January 1999,
 Presented with 1 year recurrent cough, hemoptysis, and weight





loss
Chest Xray : pulmonary tuberculosis
Three-regimen Isoniazid, Rifampicin, Pirazinamide for two
months, continued with INH and rifampicin for four months
Good compliance and improving condition during medication
Currently, father is having recurrent dry cough for one year,
starting January 2013, with weight loss.
No check up was done, no medication was taken.
Family History
 Patient’s Uncle , paternal side, was having infection on the




lungs, with pleural effusion, it was said by father that his
brother was admitted January 2013, due to “may tubig sa
baga”.
Patient’s father visited his brother last January 2013, when
his brother was sick, and was with him for 2 days.
Patient’s father does not fully understand what was his
brother’s illness.
Patient had no direct contact to her uncle.
Patient’s grandmother passed away about 15 years ago, it
was said by father that she had pulmonary tuberculosis.
Patient’s father
Birth and Maternal History
• Born to a 19 year old G1P1 (1001) mother
• Non-smoker, non-alcoholic beverage drinker
• Regular check-up at local health center
• Normal Ultrasound at 7 months
• Regular intake of multivitamins, ferrous sulfate
• No exposure to radiation,no intake of toxic substances nor
•
•
•
•
viral exanthems.
Delivered fullterm via NSD at hospital assisted by obgyne
With good cry and activity, no fetomaternal complications
Birth weight of 2.5 kg
No history of neonatal convulsion, cyanosis
Nutritional History
• Patient was purely breastfed up to 1 year of age.
• Complimentary feeding started at 6 months old.
• She is a non- picky eater.
• Consumes ½ cup of rice per meal with viand, with 2
snacks in between
Immunization History:
C/O Local Health Center
• BCG
• DPT 3
• Hepa B3
• OPV3
• Measles
• MR 1
• No boosters given
Socioeconomic
• Lives in a 1-storey house, well lit, fairly ventilated with 2
•
•
•
•
•
windows, 1 bedroom
4 household members
Tap water not boiled as drinking source
Garbage collected daily
No nearby industries, crowded area
No Exposure to smoke
Gynecologic History
 Menarche at 12 years old
 Regular menstruation lasting 7 days, mild-moderate flow,
no dysmenorrhea
 Last Menstrual Period: August 5, 2013
 Breast budding at 11 years old
 Pubic hair appearance at 12 years old
HEADSSS
 H - eldest of two children; lives with parents and younger
brother, closest to mother, no sibling rivalry
 E - currently a 4th year high school student at a public
school in Taguig; her favorite subject is English, wants
to be a teacher, average grade 80%, has a good
relationship with teachers and classmates, no
bullying, no truancy , no failing grades
HEADSSS
 E - no food preference; favorite dish is adobo, has
decreased appetite since the illness; no eating
disorders no body image issues
 A - likes to listen to music, watches TV 4 hrs/day, no
involvement in sports
HEADSSS
 D - has never tried smoking cigarettes, alcohol drinking or
prohibited drugs
 S-
heterogenous sexual orientation; has never had a
boyfriend but has a crush on a male classmate; had 1
suitor when she was 13 years old but refused to be
courted;(-) sexual contact
HEADSSS
 S-
no depression or suicidal ideation. She knows and
understands her illness, she is optimistic that she will
get well from her illness.
 S-
believes in One supreme being, prays often, goes to
church every Sunday with family
Physical Examination
 Gen. Survey
 Weight
 Height
 BMI
 SMR
: awake, ambulatory, not in respiratory
distress
: 44.2 kg
(Percentiles 25-50)
: 152cm
(percentiles 5-10)
: 19
(Z score 0)
: Breast 3 ; Genitalia 3
Vital Signs :
 Temp
: 36.7 oC
 RR
: 19
CR
BP
: 88 bpm
: 90/60mmHg
Physical Examination
 Skin: brown, warm, moist, no active dermatoses
 HEENT: pink palpebral conjunctiva, anicteric sclerae,
symmetrical auricles, no tenderness, patent ear canals,
pink tympanic membrane, visible cone of light, no nasal
deformity, septum midline, (+) green nasal discharge, no
tonsillopharyngeal congestion, (+) CLADS, size 0.8-1.1 cm ,
bilateral, multiple
 Chest and Lungs: symmetrical chest expansion, good air
entry, no retractions, equal stem fremiti at both lung
fields, (+) rhonchi on bilateral lower lung fields, no rales,
no wheezing
Physical Examination
 Cardiovascular: adynamic precordium, apex beat at 4th ICS
left mid clavicular line, normal rate, regular rhythm, no
murmur
 Abdomen: flat, no visible veins, no bruit, normoactive
bowel sounds, tympanitic , soft, no tenderness, no
organomegaly, no masses
 Genitals: grossly female; SMR 3
 Extremities: full pulses, no edema, no cyanosis
Neurologic Examination
• Conscious, coherent
• Oriented to time, place and
•
•
•
•
•
•
•
•
person
Cranial nerves:
CN I: can smell
CN II: pupils 2-3mm EBRTL
CN III,IV,VI: full extraocular
muscles
CN V: good masseter tone
CN VII: no facial asymmetry
CN VIII: gross hearing intact
CN IX,X: good gag
 CN XI: can shrug shoulders
 CN XII: tongue midline
 Good muscle tone, no
fasciculation or atrophy, no
involuntary movements
 Motor: 5/5 all extremities
 Sensory: 100% all extremities
 DTR: ++
 No Brudzinski, Kernigs,
Babinski, Clonus
Working Impression
Pneumonia
t/c Pulmonary TB
Middle Adolescent with Psychosocial issue
(Chronic Illness)
No stunting, no wasting
Approach To Chronic Cough in
Children
Acute vs Chronic cough in children
 Definition of chronic cough : daily cough more than 4
weeks
 Chronic Cough :
 Specific cough

Associated with other signs and symptoms (suggestive of an
associated or underlying problem)
 Non Specific cough

Dry cough in the absence of an identifiable respiratory disease
of known etiology
Guidelines for evaluating Chronic Cough in Pediatric :ACCP Evidence-Based Clinical Practice Guidelines, Anne B. Chang et al, Chest
2006;129
Approach To Chronic Cough in
Children
F
I
G
U
R
E
1
Guidelines for evaluating Chronic Cough in Pediatric :ACCP Evidence-Based Clinical Practice Guidelines, Anne B. Chang et al, Chest
2006;129
Approach To Chronic Cough in
Children
F
I
G
U
R
E
1
Guidelines for evaluating Chronic Cough in Pediatric :ACCP Evidence-Based Clinical Practice Guidelines, Anne B. Chang et al, Chest
2006;129
Approach To Chronic Cough in
Children
F
I
G
U
R
E
3
Guidelines for evaluating Chronic Cough in Pediatric :ACCP Evidence-Based Clinical Practice Guidelines, Anne B. Chang et al, Chest
2006;129
PND
Inhalation
of foreign
body
GERD
Chronic cough
Asthma
Tuberculosis
Pneumonia
+cough
(-) snorting to
clear mucus
from nasal
passage
(-) Halitosis
(-) Rhinorrhea
PND
(+) nasal
discharge
(-) Mucus
feeling in the
back of the
throat
(-) Congestion
in Nasal
(-) Chronic
Sore Throat
+cough (dry)
(-) sensation
of a lump in
the throat
(+) chest pain
GERD
(-)
Regurgitation
of food or sour
liquid
(-)difficulty
swallowing
(-)
Hoarseness,
Sore Throat
(-) shortness
of breath
+cough (dry)
(-)wheezing
(-) night
symptom
Asthma
(-) family
history of
atopy
CXR findings
of Asthma
Lung function
test
FEP
∆Pulmonology
(-) shortness
of breath
+cough (dry)
(-)wheezing,
crackles
Chest
retraction
Normal RR
Pneumonia
(-) family
member with
pneumonia
CXR findings
of
pneumonia
Fever low
grade,
currently
afebrile
No history
of
inhalation
Patient is
not in
distress
Inhalation
of foreign
body
CXR
No one of
the family
is a smoker
Normal
RR
No
wheezing,
no stridor
CLINICAL
EPIDEMIOLOGIC
IMMUNOLOGIC
Childhood
TB
GOLD
STANDARD
RADIOLOGIC
Culture
LABORATORY
DSSM
Pneumonia
Chronic
cough
Tuberculosis
Management
• Diagnostic :



CBC : Hgb 136, hct 40, wbc 14.1, seg 77, lym 14, apc 297
Chest Xray
Sputum AFB
• Started Cefuroxime 500 mg/tab 3x a day for 7 days
• Follow up after 1 week
On Follow Up, OPD
August 30, 2013
S = No fever, + cough, (-) cold, improving chest pain, fair appetite.
Father (+) cough, (-)hemoptysis, noted with weight loss.
O = awake ambulatory, not in distress
T= 36.7oC , CR = 90, RR = 20, BP = 90/60
No rashes, no scrofuloderma
Pink palpebral conjunctivae, anicteric sclerae, - CLADs, non
congested tonsil, no ear discharge.
Adynamic precordium, no murmur
Symmetrical chest expansion, no chest retraction , clear breath
sound.
Soft abdomen, flat, no organomegallywarm equal full pulse, CRT
< 2 seconds.
On Follow Up, OPD
August 30, 2013
Sputum AFB negative day 1, day 2, day 3
Chest xray official result :
compared with study done outside (date could not be
discerned, from the available Chest xray film) there are now
increased reticular infiltrates in both lower lobes with
interspersed peribronchial cuffings and cystic lucencies
with honeycomb appearance. There are few fibroids in the
left lung apex. The rest of the lung are clear, the heart is
normal in size, diaphragm and sulci are intact. Thoracic
dextroscoliosis is evident. No other remarkable findings.
Impression : Pneumonia with bronchiectatic and or
bronchitis changes. Minimal left lung apical fibroids.
Radiologic Findings for TB in
Children
 A presumptive diagnosis of Pulmonary TB is acceptable in




symptomatic patients with suggestive findings on Chest Xray
This maybe sufficient to initiate treatment after due
consideration of benefits and risk to the individual
Radiographic terms will be used to describe structural or
anatomic extent of the disease, and not to imply activity status of
the disease
The term “minimal” or “extensive” should be used to describe the
advance of disease
The use of mobile CXR facilities with miniature film should not
be used for interpretation and commitment to a diagnosis of PTB
Clinical practice guidelines for Tuberculosis 2006 Update
Radiologic findings for TB in
Children
Some commonly used terms in radiographic findings
 Cavity : a focus of increased density whose central
portion has been replaced by air, may or may not
contain air fluid level. Surrounded by a wall usually of
variable thickness
 Ciccatricial changes/atelectasis : refers to volume loss
found in patients with local or general pulmonary
fibrosis, secondary to fibrotic contraction, compliance is
decreased
 Fibrosis : scarring of lung parenchyma
Clinical practice guidelines for Tuberculosis 2006 Update
Radiologic findings in TB in
Children
Some commonly used terms in radiographic findings
 Cavity : a focus of increased density whose central
portion has been replaced by air, may or may not
contain air fluid level. Surrounded by a wall usually of
variable thickness
 Ciccatricial changes/atelectasis : refers to volume loss
found in patients with local or general pulmonary
fibrosis, secondary to fibrotic contraction, compliance is
decreased
 Fibrosis : scarring of lung parenchyma
Clinical practice guidelines for Tuberculosis 2006 Update
Radiologic findings in TB in
Children
Some commonly used terms in radiographic findings
 Infiltrates : single or multiple irregular shadows ;
shadows of parenchymal abnormalities characterized
histologically by cellular infiltration, wheter interstitial,
alveolar
 Nodules : well defines regions of dense confluent
cellularity which is < 3 cm
 Masses : well defines regions of dense confluent
cellularity which is < 3 cm
Clinical practice guidelines for Tuberculosis 2006 Update
Approach to Diagnosis of
Tuberculosis in Children
 History , including history of TB contact and






symptoms consistent with TB (Epidemiologic)
Clinical examination, including growth assesment
Tuberculin Skin testing (Immunologic)
Chest Xray (Radiologic)
Bacteriological confirmation if possible (DSSM,
PCR, Culture)
Investigation of suspected source of infection
HIV testing
WHO 2006 Guidance for NTP on Management of TB in children
CLINICAL MANIFESTATION
“TB symptomatic” is defined as a child with any 3
or more of the following signs and symptoms:
 Cough/ wheezing of two weeks or more
 Unexplained fever of two weeks or more
 Either loss of appetite , loss of weight, failure to gain
weight, or weight faltering
 Failure to respond to two weeks of appropriate antibiotic
therapy for lower respiratory tract infection
 Failure to regain previous state of health after two weeks
of a viral infection or exanthem
 Fatigue, reduced playfulness, or lethargy
Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013
CLINICAL MANIFESTATION
“TB symptomatic” is defined as a child with any 3
or more of the following signs and symptoms:
 Cough/ wheezing of two weeks or more
 Unexplained fever of two weeks or more
 Either loss of appetite , loss of weight, failure to gain
weight, or weight faltering
 Failure to respond to two weeks of appropriate antibiotic
therapy for lower respiratory tract infection
 Failure to regain previous state of health after two weeks
of a viral infection or exanthem
 Fatigue, reduced playfulness, or lethargy
Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013
Algorythm WHO - DOH
Summary of Casefinding : PTB
1
Walk in Referrals
All Children 0-14 yo with
ANY symptom
presumptive of TB
2
Contact screening
All children 0-14 yo close
contacts of registered TB
All 0-4 yo
TB symptomatic
10-14 yo
TB symptomatic
0-9 yo
TST
Flow Chart 1 to 3
TB symptomatic 59 yo
TB
symptomatic
10-14 yo
DSSM
DSSM
TB infection
TB exposure
0-4 yo
TB Disease
TB Treatment
IPT
Register treatment card
& ID card
Quarterly Reports
Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013
Summary of Casefinding : PTB
1
Walk in Referrals
All Children 0-14 yo with
ANY symptom
presumptive of TB
2
Contact screening
All children 0-14 yo close
contacts of registered TB
All 0-4 yo
TB symptomatic
10-14 yo
TB symptomatic
0-9 yo
TST
Flow Chart 1 to 3
TB symptomatic 59 yo
TB
symptomatic
10-14 yo
DSSM
DSSM
TB infection
TB exposure
0-4 yo
TB Disease
TB Treatment
IPT
Register treatment card
& ID card
Quarterly Reports
Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013
Flowchart A Child
With Possible Sxs of
TB and a Close
Contact of a Source
+ SXS of TB
+ TB symptomatic
unknown
Yes
Close contact of a source
case
0-4 yo
5-9 yo
See Flowchart 2
Can produce sputum
No
Yes
TST
DSSM
TST
Negative
Negative
Positive
DSSM results of
source case
Negative
Positive
Positive
CXR
TB disease
Suggestive TB
Positive
Treat as TB
disease
Negative
Repeat TST after 3
months
No
Evaluate for other
disease or refer
Yes
TB disease
Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013
Flowchart A Child
With Possible Sxs of
TB and a Close
Contact of a Source
+ SXS of TB
+ TB symptomatic
unknown
Yes
Close contact of a source
case
0-4 yo
5-9 yo
See Flowchart 2
Can produce sputum
No
Yes
TST
DSSM
TST
Negative
Negative
Positive
DSSM results of
source case
Negative
Positive
Positive
CXR
TB disease
Suggestive TB
Positive
Treat as TB
disease
Negative
Repeat TST after 3
months
No
Evaluate for other
disease or refer
Yes
TB disease
Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013
On Follow Up, OPD
September 16, 2013
House hold
member
CXR
Father
Normal
Mother
Normal
Patient
clearing
Sibling
Normal
Sputum
day 1
Sputum
day 2
Sputum
Day 3
negative
negative
negative
negative
negative
negative
PPD
11mm
On Follow Up, OPD
September 16, 2013
House hold
member
CXR
Father
Normal
Mother
Normal
Patient
clearing
Sibling
Normal
Sputum
day 1
Sputum
day 2
Sputum
Day 3
negative
negative
negative
negative
negative
negative
PPD
11
11mm
mm
IMMUNOLOGIC
Tuberculin skin test : regarded as positive
5TU-PPD-S
PPD
≥ 5mm
(+) close contact
(+) chest xray
(+) clinical evidence HIV & other immunosuppresive
condition
≥ 10 mm
< 4 years old
Other medical conditions : chronic renal failure,
Hodgkin’s, lymphoma, DM, malnutrition
Other risk factors : exposure to adult with HIV,
homeless, drug abuse etc
≥ 5mm
< 5years
(+) house hold contact
Severe malnutrition
≥ 10 mm
Others
Regardless of BCG status
WHO 2006
Guidance for National TB programmes
≥ 15 mm
>4 years without risk factor
Regardless of BCG
CDC & AAP 2006
DOH NTCP
≥ 10 mm
Flowchart A Child
With Possible Sxs of
TB and a Close
Contact of a Source
+ SXS of TB
+ TB symptomatic
unknown
Yes
Close contact of a source
case
0-4 yo
5-9 yo
See Flowchart 2
Can produce sputum
No
Yes
TST
DSSM
TST
Negative
Negative
Positive
DSSM results of
source case
Negative
Positive
Positive
CXR
TB disease
Suggestive TB
Positive
Treat as TB
disease
Negative
Repeat TST after 3
months
No
Evaluate for other
disease or refer
Yes
TB disease
Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013
Salient Feature
 14 years old female
 Cough for two months
 Weight loss (3-4 kg in a




month)
Body Malaise
Decrease appetite
Low grade, recurrent
undocumented fever for >3
weeks
With strong history of
contact to a source of
tuberculosis
 No stunting no wasting
 3 sputum AFB negative
 CXR :
 Bronchiectatic and or
bronchitis changes
 Minimal left lung apical
fibroid
 No response to a course of
antibiotics
 TST 11 mm
Impression
Pulmonary TB III
Dextroscoliosis
Middle adolescent with Psychosocial issue
(Chronic Illness)
No stunting, no wasting
Management
Tuberculosis
Classification
Classification of TB Disease
 Pulmonary
 Sputum positive
 Sputum negative
 Extra-pulmonary TB (EPTB)
 Severe
 Less severe
Integrated DOTS Training for Hospitals Modules, National TB Control Program, National Center for Disease Prevention and Control, Department of Health, 2013
Pulmonary TB
Pulmonary TB, sputum smear (+)
2 or more initial sputum (+)smears for AFB
or
1 sputum (+) smear + CXR consistent w/ PTB
or
1 sputum (+) smear + sputum (+) TB culture
WHO Guidance for National TB Program on the Management of TB in Chiildren 2006
Available at whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf
Pulmonary TB
Pulmonary TB, sputum smear (-), for children 0- 9 years
old; negative DSSM, cannot expectorate, DSSM was not
performed, but other diagnostic tests were done
Fulfill ; at least 3 of 5

TB symptomatic

Exposure
Positive TST



Abnormal Chest Xray suggestive of TB
Laboratory findings
WHO Guidance for National TB Program on the Management of TB in Chiildren 2006
Available at
whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf
Pulmonary TB
Pulmonary TB, sputum smear (-), for children 10-14 yrs old
3 sputum(-) AFB smears
AND
(+) CXR consistent with active Pulmonary TB
AND
(+) signs and symptoms, no response to a course of broad
spectrum of antibiotics
AND
Decision by a physician and/or TB DOTS Clinic to treat the patient with a full course of
anti TB chemotherapy
WHO Guidance for National TB Program on the Management of TB in Chiildren 2006
Available at whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf
Pulmonary TB
Pulmonary TB, sputum smear (-), for children 10-14 yrs old
3 sputum(-) AFB smears
AND
(+) CXR consistent with active Pulmonary TB
AND
(+) signs and symptoms, no response to a course of broad
spectrum of antibiotics
AND
Decision by a physician and/or TB DOTS Clinic to treat the
patient with a full course of anti TB chemotherapy
WHO Guidance for National TB Program on the Management of TB in Chiildren 2006
Available at whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf
Extrapulmonary TB (EPTB)
 Severe forms
Disseminated (miliary) TB
TB meningitis, abscess, tuberculoma
Pleural and Pericardial TB
TB of bones/joints
GIT TB
GUT TB
 Less severe forms
TB of cervical lymph nodes, skin ,etc
WHO Guidance for National TB Program on the Management of TB in Chiildren 2006
Available at whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf
Characteristics of TB Stages in Children
Exposure
Infection
Disease
(at least 3)*
I
II
III
Exposure to adult /
adolescent with active
disease
+
+/-
+/-
Positive Mantoux tuberculin
test
-
+
+/-
Signs and symptoms
suggestive of TB *
-
-
+/-
Abnormal chest radiograph
suggestive of TB
-
-
+/-
Laboratory findings
suggestive of TB
-
-
+/-
Classification
* Child should have at least 3 out of 5 criteria to satisfy a diagnosis of TB disease
Modified from: Feigin & Cherry. Textbook of Pediatric Infectious Diseases 4th ed.
PPS / PIDSP / PhilCAT. 1997. National Consensus on Childhood Tuberculosis
Characteristics of TB Stages in Children
Exposure
Infection
Disease
(at least 3)*
I
II
III
Exposure to adult /
adolescent with active
disease
+
+/-
+
Positive Mantoux tuberculin
test
-
+
+
Signs and symptoms
suggestive of TB *
-
-
+
Abnormal chest radiograph
suggestive of TB
-
-
+
Laboratory findings
suggestive of TB
-
-
+/-
Classification
* Child should have at least 3 out of 5 criteria to satisfy a diagnosis of TB disease
Modified from: Feigin & Cherry. Textbook of Pediatric Infectious Diseases 4th ed.
PPS / PIDSP / PhilCAT. 1997. National Consensus on Childhood Tuberculosis
WHO TB DIAGNOSTIC CATEGORY
Category I
 New smear (+) PTB
 New smear (-) PTB with extensive parenchymal involvement
 Severe forms of EPTB other than TBM
Category Ia
 Tb meningitis
Category II
 Previously treated smear (+) PTB
relapse, treatment failure, treatment after interruption
Category III
 New , smear (-) PTB
 Less severe forms of EPTB
Category IV
 Chronic and MDRTB


WHO Guidance for National TB Program on the Management of TB in Chiildren 2006
Available at whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf
WHO TB DIAGNOSTIC CATEGORY
Category I
 New smear (+) PTB
 New smear (-) PTB with extensive parenchymal involvement
 Severe forms of EPTB other than TBM
Category Ia
 Tb meningitis
Category II
 Previously treated smear (+) PTB
relapse, treatment failure, treatment after interruption
Category III
 New , smear (-) PTB
 Less severe forms of EPTB
Category IV
 Chronic and MDRTB
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WHO Guidance for National TB Program on the Management of TB in Chiildren 2006
Available at whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.371_eng.pdf
Treatment
WHO Recommended Doses of First-line Anti TB drugs
DRUG
Dose
Isoniazid (H)
10 mg/kg (10-15mg/kg) max 300 mg/day
Rifampicin (R)
15 mg/kg (10-20 mg/kg) max 600 mg/day
Pyrazinamide (Z)
30 (20-40 mg/kg) max 2gm
Ethambutol (E)
20 mg/kg (15-25 mg/kg) max 1.2 gm
PPS-DOH/NTP Joint Statement on WHO Rapid Advice on Therapy of TB in Children 2011
Recommended Category of Treatment Regimen
Category
TB cases
Regimen
Intensive
Continuation
2HRZE
4 HR
Severe concomitant HIV disease
Severe forms EPTB (bone & joints)
2HRZE
10HR
Ia
TB Meningitis
2HRZE
10HR
II
Treatment interruptions
Relapse
Treatment Failure
2HRZES/
1HRZE
5HRE
New Smear (-)PTB (other than in cat I )
Less severe forms of EPTB
if high H resistance
2HRZ
4 HR
2HRZE
4 HR
Chronic (still smear (+) after
supervised re-treatment) &MDR-TB
Refer to MDR TB
Treatment Center
I
New Smear (+)PTB
New Smear (-) PTB with extensive
parenchymal lesions on CXR
III
IV
PPS-DOH/NTP Joint Statement on WHO Rapid Advice on TX of TB in Children 2011
Treatment
 Children living in settings where resistance to Isoniazid is
high, with suspected or confirmed pulmonary tuberculosis
or peripheral lymphadenitis, or children with extensive
pulmonary disease even in settings of low isoniazid
resistance, should be treated with four-drug regimen
(HRZE for two months, followed by a two drug
regimen (HR) for four months.
Join statement on treatment of tuberculosis (TB) in children, PhilCAT, Department of
Health-National TB Control Program and the Philippine Pediatric Society, Inc, May 10
2011
Isoniazid Preventive Therapy (IPT)
 6 months course of INH 5 mkday
 IPT should be given to children 0-4 yo, no sign and
symptom presumptive of TB, but the child is :
 Positive TST (TB infection)
 Negative TST, but close contact of a smear positive TB
(TB exposure)
 Close contact to smear positive but TST was not done
because it was not available
Scoliosis
 It affects 2-3% of adolescent
 Lateral curvature spine ≥ 11 degree
 Clinical manifestation : Asymptomatic, body image
problem ; cardiopulmonary compromize ; decrease
lung fuction or cor pulmonale (severe curve)
 Screening to adolescent 10-14 yo
 AAP recommendation : to screen regularly for
adolescent 10, 12, 14 , and 16 yo(forward bending test)
physical examination , radiograph (Cobb method)
Neinstein-Adolescent Health Care- A Practical Guide
Scoliosis
 Therapy : observation, physical therapy, occupational
therapy, casting, bracing, surgical
 Prognosis : If curvature (Cobb method) > 20%  20 %
cases progressing. Curvature > 50 %  90% case
progressing
Neinstein-Adolescent Health Care- A Practical Guide
Chronic Illness
 Definitional concepts :
 Disorder on biological, psychological, or cognitive basis
 Duration or expected duration of at least 12 months
 Consequences of the disorder :



Functional limitation compared with healthy peers in the
same age group
Reliance on compensatory mechanism or assistance, such as
medication, special diet, medical technology, assistive device,
personal assistance
Need for medical care or related service, psychological,
educational services over and above the usual for the child’s
age
Neinstein-Adolescent Health Care- A Practical Guide
Chronic Illness
 Management :
 Education
 Respond to emotion
 Involve the family and patient for reassurance
 Provide continuity care
 Referral to peer or disease support group
 Self help training
 Provide comphrehensive ambulatory service
Neinstein-Adolescent Health Care- A Practical Guide
Chronic illness and emotional distress in adolescence
M.D., M.P.H. Joan-Carles Surís, M.D. Nuria Parera, M.D. Conxita Puig
• Chronic illnesses were associated with substantive
emotional distress and suicide ideation in females but
not in males.
• Females with chronic conditions did not, however,
seek mental health services more often than their
non-chronically ill counterparts. This suggests serious
shortcomings in identification of “at-risk” youth and
effective outreach to this population
Updates
 Patient is currently on 2nd week of anti tuberculosis,
good compliance
 Patient has a better appetite, improving cough
 TB culture was done
 Patient will do follow up regularly at our OPD, still for
referral to Ortho
 Father is referred to TB DOTS Clinic near their house
for further management
 Mother and patient’s sibling is now under close
observation
Learning Points
 Approach of children with chronic cough
 Approach in diagnosis of Pulmonary tuberculosis
 Monitoring of compliance and response to therapy is
important
 Scoliosis and chronic illness in adolescent
Thankyou