DEPARTMENT OF PEDIATRICS

Pediatric case presentation

Pulmonary Tuberculosis
BY PGI ARWAH FEROZE
➔ Name : AF
➔ Age 2years old
➔ Gender : Female Patient information
➔ Address Panacan Davao city
➔ DOB :
➔ Informant : mother
➔ Reliability:90 %
Chief Complaints Cough
 History of present illness

➔ 12 DAYS PTA
➔ onset of non productive cough
➔ associated with generalized. Abdominal pain. And intermittent fever
( T max :39 )
➔ No meds given no consultation done
➔ 10 days PTA

➔ PERSISTENCE OF SYMPTOMS, led to consultation

➔ Chest X-ray revealed pneumonia

➔ Pt was given

◆ Simethecone syrup 1ml 4 times a day

◆ Amoxicillin 250/5 , 2 ml 2times a day completed ,(30mkd)
◆ Paracetamol 250/5every 4 Hours as needed for fever
➔ 9 day PTA ,

➔ Opted fro admission at a private hospital

➔ Managed as a case of PCAP MODERATE RISK

➔ Fllowing antibiotics were given :

● Ceftraxone 1g vial 100mkd

● Pepracillin tazobactum 4.5g vial
● Azitheromycin 200/5 1 suspension
 LABORATORY WORK UPS

Hemoglobin 95
➔ U/A ➔ Chest X-ray
◆ Yellow
HCT 29.8
◆ Pnemonia with
Slightly hazy
consolidated right
◆
WBC 16.5
Specific Gravity =1,025
PLT
N
411
54
◆
upper lobe with
L 32
◆ PH= 6.0 suspecious
M 11 ◆ Albumin= negative pneumatocele
E 2
B 1 ◆ Sugar = negative
• Patient was discharged against medical advice then referred to our
institution for further management
 Maternal and birth history
➔ G3P2 (3002) 32year old mother
➔ Full term
➔ Birth weight 3.1kg
➔ Good cry, good activity
➔ Via natural spontaneous vaginal delivery
➔ Good prenatal check-up
➔ No complications during delivery
➔ No medical comorbidities like gestational diabetes or hypertension or maternal infections
➔ No exposure to drugs or radiation
➔ No history of smoking and alcohol intake
 Neonatal history
➔ Routine newborn care given
➔ No feeding difficulties
➔ No history of jaundice
➔ Newborn screening test normal
➔ Hearing screening test normal
 Nutritional and feeding history

➔ Was exclusively breastfed for 8 months

➔ Started complementary feeding at 1 year of age
➔ Formula Fed with formulation 1:1 dilution

11
 Growth and development

• Gross Motor:

• Language:

• Social:

• Fine Motor:

• Toilet training:

• Bladder and bowel training:

Immunization
 Past medical history

• No previous illness

• No previous hospitalization

• No previous surgery

• No known food and drug allergies

 Personal and social history

No hypertension
No cardiovascular diseases
No other heredofamilial diseases
 Family history

• She has 2 older sister and one younger sibling

• Lives her siblings and her parents in the house.

• Grandfather has Tuberculosis ongoing treatment for past 6 months

 Environment History

Garbage collection 2 times a week

No pets in the house
Water is from the Davao City water district
 Review of System
• General: (+) Weight loss, (-) fever, (-) change in appetite

• Skin: (-) rashes, (-) abnormal pigmentation, (-)redness, (-) bruises

• Head: (-) headache, (-) dizziness

• Eyes: (-) puffiness, (-) conjunctivitis, (-) redness, (-)lacrimation

• Ears: (-) pain,(-) discharge

• Nose: (-) bleeding, (-) discharge

• Throat: (-) soreness

• Mouth: (-) bleeding, (-) dysphagia, (-) toothache

• Neck: (-) swelling, (-) pain

• Cardiovascular: (-) chest pain, (-) cyanosis, (-) fainting spells

• Gastrointestinal: (-) vomiting, (-) nausea, (-) rectal bleeding, (-) diarrhea, (-) constipation, (-) passage of worms, (-)
abdominal pain, (-) jaundice, (-) food intolerance, (-) pica

• Genitourinary: (-) hematuria, (-) oliguria, (-) pain, (-) itchiness, (-) discharge, (-)

• Endocrine :(+) night sweats

• Muskuloskeletal: (-) joint pain, (-) stiffness,(-) weakness, (-) paralysis

• Neurologic: (-) seizure, (-) night terrors,

• Hematologic: (-) easy bruising, (-) bleeding, (-) pallor

 Physical examination

• General: patient is awake, alert, not in respiratory distress

• Vital signs:

• Temp: 36.7 C

• BP: 90/60 mmHg

• PR: 128 BPM

• RR: 31 cpm
• O2 saturation: 98% at room air

• Anthropometrics Measurements:

• Wt: 10kgs

• Ht: 90cms

• HC :43 cms

• BMI: 12.3 kg/m2

• Cardiovascular System
• Inspection: Adynamic precordium
• Auscultation: Regular rhythm, no murmur, distinct heart sounds
• Palpatio: No heaves, no thrills
• Abdomen
• Inspection: Globular, distended, no caput medusa, no distended veins
• Auscultation: normoactive bowel sounds
• Percussion: resonance to dullness present
• Palpation: No tenderness on abdomen, no hepatomegaly, no splenomegaly
• Skin: No pallor, no cyanosis,
• HEENT: Anicteric sclerae, pink palpebral conjunctiva, no eye discharges, no ear discharge, no nose discharge,
moist lips and oral mucosa, Grade 2 tonsills non exudative
• Chest and Lungs
• Inspection:
• Palpation:
• Percussion: dullness on the right side 4th- 5th inter-coastal space
• Auscultation: fine bibasalar crackles
• Cardiovascular System
• Inspection: Adynamic precordium
• Palpation: No heaves, no thrills
• Auscultation: Regular rhythm, no murmur, distinct heart sounds
• Abdomen
• Inspection: Flat, non distended
• Auscultation: normoactive bowel sounds
• Percussion: Tympanic on percussion
• Palpation: Soft ,No tenderness on abdomen, no hepatomegaly, no splenomegaly
• Extremities: the is a noted erythematous patch with non distinct borders on the anterior thigh

• warm to touch on right thigh; CRT<2 sec; with full pulse

• Neurologic Exam:

• GCS 15

• all cranial nerves are intact

 Salient features

• non productive cough

• Abdominal pain

• Intermittent fever

•
Night sweats

Weight loss
Pertinent positives
• TB exposure

• BCG GIVEN

• GRADE 2 tonsillis non exudative

• Fine bibasialr crackles

• Dullness on percussion at right 4th -5th ICS middles no egophony

• Chest X-ray shows pnematocele

 Salient features

• non productive cough

• Abdominal pain

• Intermittent fever

• Night sweats Pertinent Negative

• Weight loss

• TB exposure

• BCG GIVEN

• GRADE 2 tonsillis non exudative

• Fine bibasialr crackles

• Dullness on percussion at right 4th -5th ICS middles no egophony

• Chest X-ray shows pnematocele

 Differential Diagnosis

• Asthma

• Asthma is a condition in which your airways narrow and swell and may produce extra mucus.
This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when
you breathe out and shortness of breath.
• Pediatric Community Acquired pneumonia C with impression
consolidations right upper lobe , resolving

• Presumptive Tuberculosis, right upper lobe

 Management
Diagnostics
Diet: Diet as tolerated with strict
CBC
aspiration precaution
Monitoring blood clurture
urinalysis Medications:
Vital Signs q 4hrs
I&O q shift gastric lavage - gene expert paracetamol 250mg/5 ml 9ml
IVF: D5 0.45NaCl 500ml @ 70 cc/hr Chest x-ray APL every 4 hous as needed for fever
(MR) RT-PCR
PPD watch out for tachapnea rr of
ore than 40 cpm and po2 of less
than 94 %
 SUBJECTIVE OBJECTIVE ASSESMENT PLAN

PRODUCTIVE OCUGH
FEVER

HOPITAL DAY 0
 SUBJECTIVE OBJECTIVE ASSESMENT PLAN
(MR) NON
PRODUCTIVE COUGH
FEBRILE
SUBJECTIVE OBJECTIVE ASSESMENT PLAN
SUBJECTIVE OBJECTIVE ASSESMENT PLAN
SUBJECTIVE OBJECTIVE ASSESMENT PLAN
SUBJECTIVE OBJECTIVE ASSESMENT PLAN
DISCUSSION
 ETIOLOGY

Mycobacterium tuberculosis bacilli

Pleomorphic
Weakly gram-positive curved rods
Acid fast,
Has capacity to form stable mycolate complexes with arylmethane dyes.
 EPIDEMIOLOGY

One third of the world’s population is infected with tuberculosis (TB).

9 million new cases of tuberculosis occur each year worldwide, including 1 million children.
One to 2 million deaths are attributed to the disease annually.
 Transmission

Person to Person
Usually by respiratory droplets that become airborne when a symptomatic individual coughs,
sneezes, laughs, or even breathes.
Infected droplets dry and become droplet nuclei, which may remain suspended in the air for hours,
long after the infectious person has left the environment.
 Clinical Manifestations
Latent tuberculosis
asymptomatic stage of infection with M. tuberculosis.
tuberculin skin test (TST) or interferon-gamma release assay (IGRA) is positive
chest radiograph is normal or shows healed infection (calcification)

Tuberculosis disease
Clinical signs and symptoms and/or an abnormal chest radiograph or other extrapulmonary
manifestation.

*Interval between latent tuberculosis and the onset of disease may be or many decades in
adults.several weeks in children
In young children:
Usually develops as an immediate complication of the primary infection
Distinction between infection and disease may be less obvious.
Positive TST or IGRA with mild abnormalities on the chest radiograph
CXR:
atelectasis
infiltrate
hilar or other adenopathy (Ghon complex)
Malaise, low-grade fever, erythema nodosum, or symptoms resulting from lymph node
enlargement (after the development of delayed hypersensitivity)