TUBERCULOSIS

Indonesia is third of the world largest cases of tuberculosis, every year theres a new infection cases for about 500.000. Tuberculosa criteria for country are one case for one million people. Incidence of tuberculosis is increasing in modern country because of HIV/AIDS. TB is one of the most serious problems in Indonesia that can cause mortality to 140,000 people every year. But the incidence and the prevalence of TB among the children is difficult to be observe1. Table 1. Estimation cases of tuberculosis in three country1. Country BTA + Incidents in all Prevalence cases India 805.000 1.799.000 2.182.000 China 630.000 1.402.000 1.132.000 Indonesia 262.000 583.000 715.000 Prevalent in all cases 4.854.000 2.721.000 1.606.000

The tuberculosis among the children can cause a systemic infection and they also spread to many organs especially on lung. This disease is systemic because their spreading in lymphogen and hematogen type1. Definition Mycobacterium Tuberculosis is the organism that is the causative agent for tuberculosis, aerobe, live especially on lung and other organs which have high partial pressure of oxygen. Mycobacterium Tuberculosis consist lipid layer as the surface membrane so their can protect them from acid and made them grow slowly. These bacteria couldnt take a lot of an ultraviolet, so they may spread better on night2. Transmission TB is spread when people who have active untreated TB germs in their lungs or throat cough, sneeze or speak and send their germs in to air. People who breathe these germs into their lungs can become infected. People who breathe in TB germs usually have had very close, day to day, contact with someone who has the disease. Thats why most people get TB germs from someone they spend a lot of time with, like a family member, friend or close worker. People are not likely to get TB from someone coughing in the subway, or at the restaurant. It is not spread by dishes, drinking glasses, sheets or clothing. Transmission usually came from adult to the children, not the opposite1,3.

Picture1. TB germs spread through the air/droplet infections3. Pathogenesis After the TB germs enter the body, they will pass through the mucocilliary system so they can get and live in bronchioles or alveolus, later Mycobacterium tuberculosis will be phagocytes by the alveolar macrophage then destroyed, but if the TB germs that had breathe is more virulent nor the alveolar macrophage is weak, TB germs will multiplicates then destroyed the macrophage. Monocytes and macrophages from blood move chemotaxicly to TB germs to phagocytes them. Non specific inflammation reaction occurred in alveoli. Macrophages inside alveoli cant destroy them they only can eat them, so the TB germ can still live and multiplicates without any difficulty. Macrophage and TB germ become tubercles which contains epitheloid cells (destroyed macrophage), united macrophage (datia Langerhans cell) and T lymphocytes. The tubercles can resolute either being calcified as Ghon complex. Necrotic tissue also can occur with caseous mass made from macrophage, if the caseous mass so the TB germs could multiplicates extracelullar and widespread all over the lung (pneumonia, milliary TB, endobronchial lesions, pleuritic also made lesion in other organs). From the lymph nodes, TB germs spread lo lymphatic system and blood vessel and reach many organs which have high oxygen partial pressure such as lungs, brain, spleen, liver and kidney. TB germs could directly cause disease or live dormant inside tissue macrophage when defenses are weakened and inactive TB germs become active, the germs then break out and cause damage the lungs and other organs1,2,3,4 .

Picture2. Tubercles contains epitheloid cells and datia Langhans cell3 .

Picture3. Mycobacterium Tuberculosis spreads in many organs3. Inactive TB When Mycobacterium Tuberculosis enters the body, body defense control the germs by building a wall. Around TB germs the way a scab forms over a cut. The germs can stay alive inside these walls for years in an inactive state. While TB germs are inactive, they cant do damage, and they cant spread to other people. The person is infected, but not sick. He/she probably wont even know that he/she been infected TB3.

Picture4. TB germs are inactive3. It is possible to get TB disease shortly after the germs enter the body if body defense are weak. It is also possible, even after many years for inactive TB germs to become active when body defense are weakened. This may be due to aging, a serious illness, drugs, or alcohol, or HIV infections. When defenses are weakened and inactive TB germs become active, the germs can break out the walls and begin multiplying spreading lymphogen and hematogen so they can damage lungs and other organs3.

Picture5. TB germs become active and break out3 . Clinical manifestations I. Unspecific 1. Weight loss or malnutrition without any causes. Stabile body weight after 1 month nutritional intervention. 2. Anorexia or loss of appetite , failure to thrive 3. Unexplained continuous fever or intermittent fever, could accompanied by night sweat 4. Enlargement of superficial Lymph nodes, multiple, especially on neck, axilla and inguinal 5. Respiratory symptoms Unlikely adult people, on children with tuberculosis, cough is not as a main symptoms, cough occur because enlargement of lymph node irritate and push the bronchus. But in older children tuberculosis symptoms happened as same as adult. They could have cough, sputum or hemopthysis. 6. Gastro intestine symptoms Persistent diarrhea unresponds with medication, abdominal mass, or fluid in abdominal1. II. Specific 1. Skin tuberculosis /scrofuloderma 2. Bone and joint tuberculosis Back bone (spondylitis): gibus hip bone (coxitis) : Patella bones : swelling Leg and arm bones 3. Brain tuberculosis, meningitis tuberculosis with symptoms: irritable, vomits and decreasing of alertness. 4. Eye symptoms 1. Conjunctivitis flictenularis 2. Tubercle choroids1. Diagnosis 1. Specific and unspecific symptoms 2. Tuberculin test (mantoux) Tuberculin skin test can show if the person has ever been infected by TB germs, there are several kinds of tuberculin skin test. There is 2 type of tuberculin: OT (Old Tuberculin) and tuberculin PPD (purified protein derivative). Also 2 type of 4

Tuberculin PPD that we used to have in Indonesia, which is PPD-S and PPDRT23. Standard doses is PPD-S5TU or as same as PPD RT23TU 2TU1,5 . Procedures: A small of a harmless substance called PPD tuberculin 0,1 ml is place just under the top layer of the skin on a persons arms with a very small needle and syringe. The needle will only feel like a slight pin prick. Two or tree days later the skin test reactions must be read by trained health workers, and determine if the reactions positive or negative3 .

Picture6. The Tuberculin test3 .

Picture7. The Tuberculin test procedures5.

Picture8. The Tuberculin Test Result5 . 5

Results: indurations over 10 mm : positive indurations 5-9 mm : confused indurations less than5 mm : negative. Although the BCG vaccine can also made the tuberculin test result is positive, but it not as strong as when we are truly infected by TB germs. After the BCG vaccine given and tuberculin test show indurations over 10 mm it shows that super infection occur on this person, so another test for TB germs needed1. Mycobacterium atypical also made the tuberculin test positive in small reaction1. 3. Fast reactions of BCG vaccine After BCG vaccine given we also see an area of red indurations over > 5 mm on 3-7 days, indurations, we also suspect this person is being infected1. 4. X-Ray examination Position: PA and lateral. X-Ray is positive when the radiologist find enlargement of hillier lymph node, or Para tracheal lymph node. It also appears as milliary TB, atelektasis, infiltrate pleural reactions, and pleural effusion, calcification, brochiectasis, cavity, destroyed lung and other1. 5. Microbiologist and serologist examination Fix diagnosis as made if Mycobacterium tuberculosis found from sputum or gastric secret which contains sputum. But it is difficult to have such a sample. TB germ culture on Lowenstein Jensen media takes a long time for about 6-8 weeks, BACTEC system can detect in 1-3 weeks1 .

Picture9. Acid Fast Staining5 .

Picture9. Mycobacterium Tuberculosis germs5 . 6. Biopsy

Biopsy usually made from superficial lymph node an neck, or lung biopsy1 .

Picture10. Caseous necrosis5.

Picture11. Milliary Tuberculosis5 . Treatment Treatment is given to person with suspect of tuberculosis. Things that suggestive to tuberculosis infection, such as: 1. Person who have close contacts with people who have active untreated TB germs (BTA +) 2. Fast reaction of BCG vaccine 3. Weight loss or malnutrition without any causes. Stabile body weight after 1 month nutritional intervention, failure to thrive. 4. Unexplained continuous fever or intermittent fever, could accompanied by night sweat 5. Unspecific enlargement of superficial lymph nodes, multiple, especially on neck, axilla and inguinal 6. a coughs that hangs on more than 3 weeks 7. scrofuloderma 8. conjunctivitis flictenularis 9. Positive Tuberculin test indurations over > 20 mm 10. X-Ray examination suggestive TB1 . Medication for TB Most of people who have TB will begin treatment by taking at least four different types of pills. After several months, the doctor may give fewer types of medicines. These drugs can cure TB if taken everyday for at least 6 months. Sometimes, TB germs are resistant. This means that the TB medicines that are most often use do not kill the TB

germs, when this happens, combinations of other medicines are given. Even after the patient fell well, do not stop taking the pills, because there still many active TB germs3. 1. Isoniazid (INH) Bactericide, it can kill 90 % germs population on the first few days. Highly effective for TB germs in active metabolic states. Doses: 5-15 mg/KgBb/day Side effect is: hepatitis 0, 5 %, if icterus happens the doctor will reduce the doses/stopped until the person get better, paresthesia, muscle spasm, pruritus1. 2. Rifampisin (R) Bactericide, kill semi dormant TB germs which can not kill by INH Doses: 10-15 mg/KgBb/day. It must be given before meal. Side effect is: hepatitis, give color to urine from orange to red, nausea, trombocytopenia. 3. Pirazinamid (Z) Bactericides kill germs on acid surroundings Doses: 25-25 mg/KgBb/day divided in 2 doses Side effect is: hepatits, joint pain, arthritis gout 4. Etambutol (E) Bacteriostatic Doses: 15-20 mg/KgBb/day Side effect is: neuritis optics, 5. Streptomycin (S) Bactericides Doses: 15-30 mg/KgBb/day Side Effect is: N.VIII damaged, related with balance and hear ness, nefrotoxic. The sign are: tinnitus, headache. 6. Steroids/prednisone Used on several cases. Steroid is given in order to reduce the inflammation, edema on meningitis tuberculosis, it also helps to absorb fluid if pleural effusion happened, and reducing any occlusion on alveoli capillary on milliary TB, and helps reduces obstruction and atelektasis on TB. Doses: 1-2 mg/KgBb/day, 4 weeks, tapering off on 4 week after. Prophylaxis 1. Primary Prophylaxis Children who had close contacts to person with BTA + 2. Secondary prophylaxis Is given for 1 year, to children who are infected by TB, which is indicates by positive tuberculin test and good health status Under 5 years Normal X-Ray Having viral infection (morbili, varisela) Having immunosuppressive medicines Puberty Infected by TB for less than 12 months

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1. Good health status for 2 months after having medication, person should continue his/her medication 2. Decreasing health status for 2 months after having medication, she/he should go back to doctor and ask for evaluating the diagnosis 3. For people who dont take their pills regularly, doctor should put extra medication etambutol to prevent the resistance. Stopping the medication 1. After 6 months treatment, doctor will evaluate the patients: Cough have had disappears Good health status Increasing body weight 2. If after 6 months there is no changing in health status, it probably : MDR (Multi Drugs Resistance) Doctor should put an extra medication or change the medication It is not TB BRONCHOPNEUMONIA Bronchopneumonia is an inflammation of the lungs and the bronchi, which are the larger air passages conveying air to and within the lungs. Bronchopneumonia is usually related to a bacterial infection and may be caused by many different kinds. Bacterial pneumonia is an important cause of illness and death in dogs, especially in hospitalized animals. The route of infection is typically inhalation, and bacteria that is spread by blood is less common and can be very difficult to treat. Pneumonia can occur in dogs and cats, but is more common in dogs. Sporting dogs, hounds, working dogs and mixed breed dogs over 25 pounds may be predisposed. Most affected pets are under one year of age. However, the age range varies from two months to 15 years. Prompt recognition and treatment of bronchopneumonia is important. Doctor should alert if there is any sign of: 1.Respiratory distress 2.Fever 3.Productive cough 4.Tachypneu 5.Depression 6.Mucopurulent nasal exudates Anorexia Diagnosis Diagnostic tests are needed to recognize bronchopneumonia and exclude other diseases. Your veterinarian should perform a complete medical history and physical examination, including careful auscultation of the heart and lungs. Lung sounds are often abnormal with a crackle upon auscultation when your dog takes a deep breath. Medical history may include questions regarding your pets previous illness or illnesses, therapy

and response to therapy, appetite, weight loss, activity or exercise intolerance, cough and environmental exposure to dusts, smoke and vapors. Other tests may include:

Chest X-rays Complete blood count (CBC) Airway cytology Culture (tracheal wash cytology and culture and sensitivity)

Other tests may include:

Heartworm test Bronchoscopy

Therapy Pneumonia causes difficulty breathing and can be a severe and progressive condition. Severely ill pets may require hospitalization with oxygen, intravenous fluids, antibiotics and supportive care. Mildly affected pets that are well hydrated and eating properly may be treated as outpatients, but would require frequent follow-ups to monitor the progression of the infection. Treatments for bronchopneumonia may include one or more of the following:

Antibiotics for at least three weeks or longer pending clinical results and radiographs Humidified oxygen for animals that have trouble breathing Plenty of fluids and warmth Airway humidification to assist in expectoration of secretions Percussion of the thorax (coupage) to help loosen and remove secretions
Home Care and Prevention Keep your pet warm, dry and indoors, if possible, and encourage him to eat and drink. Avoid cough suppressants. Follow-up with your veterinarian for examinations, laboratory tests and radiographs. Administer any veterinary-prescribed antibiotics. Do not over-exercise your pet; allow only what your pet can tolerate. Do not allow your pet to get short of breath during exercise/activity. Use a harness instead of a collar; this is less restricting to the neck, and will allow your pet to breathe easier. There arent any specific recommendations for prevention of pneumonia other than eliminating the predisposing causes. If your pet is exposed to smoke, dusts, fumes, barns or crop dust, these should be eliminated. Provide routine vaccinations as recommended by your veterinarian and vaccinate dogs for kennel cough (Bordetella bronchiseptica) if boarding or if there is much exposure to other dogs.

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