TUBERKULOSIS pada

ANAK
Pendahuluan
Penyakit yang sudah sangat lama
Ditemukan oleh Robert Koch thn 1882
Jumlah kasus TB meningkat di seluruh dunia
TB pada anak meliputi masalah diagnosis,
pengobatannya, pencegahannya, serta TB
pada infeksi HIV
Underdiagnosis / undertreatment
overdiagnosis / overtreatment
Pendahuluan
Morbiditas dan mortalitas penyakit TB masih
cukup tinggi.
Tahun 1998-2002 jumlah kasus TB sebanyak
1086 anak dengan angka kematian berkisar
0-14,1%, terbanyak usia balita
Faktor risiko infeksi TB : anak kontak TB
dewasa, daerah endemis, penggunaan obat
IV, kemiskinan, lingkungan tidak sehat dll
Pendahuluan
Risiko Penyakit TB ; anak balita, konversi tes
tuberkulin dalam 1-2 tahun terakhir,
malnutrisi, immunokompromais ( infeksi HIV,
keganasan, transplantasi organ dll). Diabetes
melitus, gagal ginjal kronik dll
 PATOGENESIS
Port dentre : paru paru 98%
Percik renik (droplet) terhirup dan mencapai
alveolus
Mekanisme imunologis nonspesifik
merupakan pertahanan awal
Pada sebagian kecil kasus makrofag alveol
tidak dapat menghancurkan kuman TB
sehingga bereplikasi
Makrofag hancur terbentuk fokus primer
 Patogenesis
Kuman TB menyebar melalui saluran limfe ke
KGB regional terjadi inflamasi saluran limfe
(limfangitis) dan kelenjar limfe (limfadenitis)
Kompleks primer : fokus primer, limfangitis
dan limfadenitis
Masa inkubasi : waktu yang dibutuhkan
kuman TB sejak masuk ke tubuh sampai
terbentuk kompleks primer (2-12 minggu)
 Infeksi Mycobacterium tuberculosis

Kuman mati Fagositosis oleh makrofag

alveolus paru
Masa inkubasi
2-12 minggu
Kuman hidup
berkembang biak

Pembentukan fokus primer

Uji tuberkulin (+) Penyebaran limfogen -hematogen

Kompleks primer
terbentuk imunitas spesifik seluler

Sakit TB Infeksi TB
Komplikasi kompleks primer Imunitas optimal
Komplikasi penyebaran hematogen/limfogen

Meninggal Sembuh Reaktivasi/infeksi Sakit TB

 Inhalation Alveoli Ingestion by PAMS

Intracellular multiplication Destruction of bacilli

of bacilli

Destruction of PAMS

Resolution Tubercle formation Hilar lymph nodes

Calcification

Caseation Hematogenous spread

Ghon Complex

Liquefaction

Lesions in liver, spleen, kidneys,

Secondary lung lesions bone, brain, other organs

Pathogenesis of tuberculosis. PAMS, pulmonary alveolar macrophages

Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20
 Complications of nodes
EVOLUTION AND TIMETABLE OF Complications of focus 1. Extension into bronchus
UNTREATED PRIMARY TUBERCULOSIS 1. Effusion 2. Consolidation
IN CHILDREN 2. Cavitation 3. Hyperinflation
3. Coin shadow

MENINGITIS OR MILIARY
in 4% of children infected
under 5 years of age
LATE COMPLICATIONS
Renal & Skin
Most children Most after 5 years
become tuberculin BRONCHIAL EROSION
sensitive
3-9 months
Uncommon under 5 years of age Incidence decreases
PRIMARY COMPLEX 25% of cases within 3 months As age increased
A minority of children 75% of cases within 6 months
Progressive Healing
experience :
Most cases
1. Febrile illness
BONE LESION
2. Erythema Nodosum Most within
3. Phlyctenular Conjunctivitis
1 2 3 4 3 years
5 6

infection Resistance reduced :

1. Early infection
(esp. in first year)
2. Malnutrition
3. Repeated infections :
measles,wwhooping cough
streptococcal infections
24 months
4-8 weeks 3-4 weeks fever of onset 12 months 4. Steroid therapy

Development
Of Complex DIMINISHING RISK

But still possible

GREATEST RISK OF LOCAL & DISEMINATED LESIONS 90% in first 2 years Miller FJW. Tuberculosis in children, 1982
Lokasi fokus primer pada 114 kasus , 1909-1928
Location %
Lung 95.93
Intestine 1.14
Skin 0.14
Nose 0.09
Tonsil 0.09
Middle ear (Eustachian tube) 0.09
Parotid 0.05
Conjungtiva 0.05
Undetermined 2.41

Source: Adapted from Ghon and Kudlich, in Engel and Pirquet (eds.),
Handbuch de Kindertuberkulose, Georg Thieme Verlag, Stuttgart, 1930, Vol 1
Clinical types of tuberculosis in children
Infection
Positive tuberculin skin test reaction without clinical, radiographic, or laboratory evidence of disease
Disease
Pulmonary
Primary pulmonary tuberculosis (hilar adenopathy with or without primary parenchymal disease
Progressive primary pulmonary tuberculosis (pneumonia, endobronchial disease)
Chronic pulmonary tuberculosis (cavitary, fibrotic, tuberculoma)
Miliary tuberculosis
Tuberculous pleural effusion
Extrapulmonary
Lymph nodes
Brain and meninges
Skeleton (bone and joint)
Gastrointestinal tract, including liver, gall bladder, and pancreas
Genitourinary tract, including kidneys
Skin
Eyes
Ears and mastoids
Heart
Serous membranes (peritoneum, percardium)
Endocrine glands (adrenal)
Upper respiratory tract (tonsil, larynx, salivary glands)
Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20
Positive Mantoux tuberculin test reactions as
determined by risk categories for exposure and size of
induration of skin test

Risk category Size of induration

None > 15 mm
Moderate > 10 mm
High > 5 mm
Received BCG immunization > 15 mm

Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20

 Causes of false-positive and false-negative Mantoux
tuberculin skin test reaction
False-positive
Incorrect application of tuberculin
Incorrect interpretation
Cross-reactivity with nontuberculous mycobacteria
False-negative
Incubation period
Incorrect storage and application of tuberculosis
Incorrect interpretation
Widespread tuberculous disease
Coexistence of viral infections (measles, rubella, varicella, influenza, human immunodeficiency)
Cellular immunoincompetence, including use of corticosteroids
Complement depletion
Fever
Leukocytosis
Malnutrition
Sacoidosis
Psoriasis
Jejunoileal bypass
Ultraviolet light exposure (sun, solaria)
Zinc deficiency
Pernicious anemia
Uremia Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20
 Chemotherapy for tuberculosis in children
6-month regimen
INH + RIF + PZA daily for 2 months

For hilar adenopathy without drug resistance : use INH + RIF for 6 months
9-month regimen
INH + RIF daily for 9 months

Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20

Chemotherapy for tuberculosis in children in special
situations
Tuberculosis meningitis, miliary tuberculosis, bone and joint tuberculosis, and
congenital tuberculosis
INH + RIF + PZA + SM daily for 2 months
plus
INH + RIF daily or 2 times/week with DOT for 10 months
Mutiple drug-resistant tuberculosis
INH + RIF + PZA + SM
(or high-dose EMB) with DOT for 12-18 months
HIV infection
INH + RIF + PZA for 9 months
May add SM or EMB for initial 2 months

Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20

 Prophylaxis of tuberculosis infection in children
Isoniazid-suspectible organisms
INH for 9 months
10 mg/kg/day, max 300 mg/day, daily
or
10 mg/kg/day, max 300 mg/day, daily 1 month
plus
20-30 mg/kg/dose, max 900 mg/dose, 2 times/week with DOT for 8 months
Isoniazid-resistant organisms
RIF + INH for 9 months
RIF 10 mg/kg/day, max 600 mg/day, daily
+ INH 10 mg/kg/day, max 300 mg/day, daily
HIV infection
INH for 12 months
INH 10 mg/kg/day, max 300 mg/day, daily

Inselman LS. Tuberculosis in children : An Update. Pediatr Pulmonol 1996; 21:101-20

 2 Time/week 3 Time/week
Daily dose
Drugs (mg/Kg/day)
dose dose Adverse reactions
(mg/Kg/dose) (mg/Kg/dose)
Isoniazide * 5-15 15-40 15-40 Hepatitis, peripheral neuritis,
(INH) (300 mg) (900 mg) (900 mg) hypersensitivity
Gastrointestinal upset,skin reaction,
Rifampicin 10-15 10-20 10-20 hepatitis, thrombocytopenia,
(RIF) (600 mg) (600 mg) (600 mg) hepatic enzymes, inducing orange
discolouration of secretions

Pyrazinamide 15 - 40 50-70 50-70 Hepatotoxicity, hyperuricaemia,

(PZA) (2 g) (4 g) (3 g) arthralgia, gastrointestinal upset

Optic neuritis, decreased visual

Ethambutol 15-25 50 50 acuity, decreased red-green colour
(EMB) (2,5 g) (2,5 g) (2,5 g) discrimination, hypersensitivity,
gastrointestinal upset

Streptomycin 15 - 40 25-40 25-40

Ototoxicity nephrotoxicity
(SM) (1 g) (1,5 g) (1,5 g)
Values in parentheses are maximum doses
* In combination with rifampicin, doses < 10 mg/kg/day
When INH and RIF are used concurrently, the daily doses of the drugs are reduced
National Concensus of tuberculosis in children, 2001
 Regimen OAT
2 bl 6 bl 9 bl 12bl

INH
RIF
PZA

EMB
STREP

PRED

Directly Observed Treatment Short course (DOTS)

DOTS with a SMILE
S : Supervised
M : Medication
I : In
L : a Loving
E: Environment

(Grange JM. Int J Tuberc Lung Dis 1999; 3:360-362)

 A. Focus and complication

Primary complex Rupture of focus intro pleura space

Focus and Reg. glands with effusion; serous occ. purulen

Rupture of focus into Enlarged focus sometime

bronchus cavitation laminated round or coin shadow
 B. Mediastinal (regional) nodes and complication

Incomplete bronchial Collapsed right lower lobe after Collapsed after partial
Obstruction (Ball-valve) Complete bronchial obstruction Consolidation segmental
inflation of Middle & lower lobus Without consolidation lesion

Erosion into bronchus, inhalarion

And areas of Tub. Pericardial effusion post rupture
Bronchopneumonia of node through percardium
 C. Sequelae of bronchial complication

Cylindrical bronchiectasis in area

Stricture of bronchus Of old collapse

Wedge shadow with fibrosis and

bronchiectasis following contracture Linear scar of fibrosis following
of segmental lesion segmental lesion