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PENDAHULUANWHO:1,3 juta anak menderita TB/tahun 11% seluruh kasus TB

Indonesia:Peringkat ke-3 tertinggi di dunia

TB pada anak kurang diperhitungkan:Anak mendapat infeksi M.tuberkulosis dari dewasaTidak berperan dalam penyebaran penyakit

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PENDAHULUANKegagalan dlm mengidentifikasi dan terapi TB pada anak meningkatkan angka kematian pada anak usia < 3 tahun.

Infeksi TB pada anak:Asimptomatis >>Konfirmasi bakteriologis jarang sulitnya pengumpulan spesimenDiagnosis kombinasi dari px klinis, X-thorax foto, tes tuberkulin yg , riwayat kontak dng penderita TB aktif dewasa, computed tomografi & bronkoskopi (>> negara-negara industri).*

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PENDAHULUANInterpretasi tes Tuberkulin pada anak dipengaruhi :Vaksinasi BCGMalnutrisiSupresi imunPemeriksaan radiologis pd anak bervariasi

Pemeriksaan serodiagnostik infeksi M.tuberkulosis:Sensitivitas & spesivisitas rendah terutama pd anakData seroreaktivitas TB pd anak juga rendahPenelitian terbaru evaluasi multiple antigen menggunakan ELISA, multiantigen print immunoassay pd manusia (-)*

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Figure. Pathogenesis of primary tuberculosisdroplet nuclei inhalationalveoliingestion by PAMSintracellular replicationof bacillidestruction of bacillidestruction of PAMSTubercle formationHilar lymph nodeshematogenic spreadmultiple organs remote foci Lymphogenic spreaddisseminated primary TBacute hematogenic spread occult hematogenic spread primary focuslymphangitislymphadenitisprimary complexCMIPATOGENESIS

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PATOGENESISM tuberculosis inoculationphagocytocis by PAMM tb destroyedM tb survive, replicate primary focus formationlymphogenic spreadhematogenous spread primary complexCMI (+) complication of: (1)primary complex, (2)lymphogenic and (3)hematogenous spreadoptimal immunityTB diseaseTB infectiondeathcuredTB diseasetuberculin test (+)primary TBpost primary TBreactivation / reinfectionincubation period 2-12weeks

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Miller FJW. Tuberculosis in children, 1982A minority of childrenexperience :1. Febrile illness2. Erythema Nodosum3. Phlyctenular ConjunctivitisComplications of focus1. Effusion2. Cavitation3. Coin shadowComplications of nodes1. Extension to bronchus2. Consolidation3. HyperinflationMENINGITIS OR MILIARYin 4% of children infectedunder 5 years of ageLATE COMPLICATIONSRenal & SkinMost after 5 years123456BONE LESIONMost within3 years24 monthsResistance reduced :1. Early infection (esp. in first year)2. Malnutrition3. Repeated infections :measles, whooping coughstreptococcal infections4. Steroid therapyinfectionBRONCHIAL EROSIONMost childrenbecome tuberculinsensitive12 monthsDIMINISHING RISKBut still possible90% in first 2 yearsGREATEST RISK OF LOCAL & DISEMINATED LESIONSDevelopment Of Complex4-8 weeks3-4 weeks fever of onsetPRIMARY COMPLEXProgressive HealingMost casesUncommon under 5 years of age25% of cases within 3 months75% of cases within 6 months3-9 monthsIncidence decreasesAs age increased

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TB Extra Paru Pada Anak*

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DIAGNOSIS*

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Langkah Diagnosis TB Pada Anak*

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Sugestif TB ?*

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Faktor Resiko*

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Sumber penularan:SulitPenting : Untuk dxBerhasil/tidaknya txAx : Febris lama Batuk lama Bb Lesu Aktifitas

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Tbc primer : sering asymptomatikGx. Paru/r : ~ INFEKSI LAINConjunctivitis phlyctenularisTbc extrathoracalScrofulodermaPembesaran kelenjarMen-serCold abscesTbc tulang/SendiCariPEMERIKSAAN FISIK

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Mantoux TestSangat penting untuk diagnostikDipakai : Ot 0,9 mg Ppd 5 tuR :Tidak spesifikFoto bersih : tidak menyangkal ada prosesDx. TBC TIDAK DAPAT DIBUAT ATAS DASAR rPersangkaan kuat tbc : Gbr miliair Pembesaran kelenjar paratracheal

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INTERPRETASI MANTOUX 0-4 mm NEGATIF5-9 ragu> 10 mm POSITIFKlinis : infeksi Klinis : sedang/pernah terinfeksiTidak perlu diulang, kecuali ada dugaan keras tbcKlinis :Teknik salahAda infeksiCross reaksiPsot bcg/crpAktif, bila :< 6 thTx Bcg Konverse : Dlm 1 thTx Bcg InfeksiCross reaksi post bcgMUNGKIN 5x TBCKet : konversi :I. 0 2 mm II. BERTAMBAH > 10 mm> 10 mm TetapTetap tanda-tanda lainDiulang dgn dosis sama

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Interpretasi Tes Mantoux*

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DIAGNOSISNegara-negara berkembang:Diagnosis TB pd anak sistem skoring

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*A score of 7 or more indicates a high likelihood of TB, treatmentis justified

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Skor Keith Edwards*A score of 7 or more is indicative of tuberculosis

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*According to this scoring system, 7 or more points indicateunquestionable TB; 5-6 points indicate probable TB, therapymay be justified; 3-4 points indicate that further investigationsare needed

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DIAGNOSIS*

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DIAGNOSIS*

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DIAGNOSIS*

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DIAGNOSIS*

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Catatan Sistem Skoring TB IDAI 2008 Diagnosis dengan sistem skoring ditegakkan oleh dokterJika dijumpai skrofuloderma, langsung didiagnosis tuberkulosisBerat badan dinilai saat pasien datang (moment opname)Demam dan batuk tidak ada respons terhadap terapi sesuai baku puskesmas.Foto rontgen toraks bukan alat diagnostik utama pada Tb anakSemua anak dengan reaksi cepat BCG harus dievaluasi dengan sistem skoring Tb anakDidiagnosis Tb jika skor 6 (skor maksimal 13). Pasien usia balita yang mendapat skor 5, dirujuk ke RS untuk evaluasi lebih lanjut.Gambaran sugestif TB : pembesaran kelenjar hilus atau paratrakeal dengan/tanpa infiltrat;konsolidasi segmental/lobar;milier;kalsifikasi dengan infiltrat;atelektasis;tuberkuloma.

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DIAGNOSIS*

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Batuk akut dengan kesembuhan yang lamaBatuk akut berulangPersisten, non- remitting cough

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Objectives of TB therapyRapid reduction of the bacilli number, to cure the patientSterilization to prevent relapsesto achieve two phases:Initial phase (2 months) intensive, bacilli eradicationMaintenance phase (4 months / more) sterilizing effect, prevent relaps

Prevention of acquired drug resistance,to achieve: principles of therapy

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Ped TB therapy principles Multi drug, NOT single drug (monotherapy)to prevent drug resistancerisk of fall and rise phenomenoneach TB drug has specific action to certain TB bacilli populationLong term, continue, uninterrupted problem of adherence (compliance)The drug is taken daily and regularly

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DrugsDaily dose(mg/Kg/day)Adverse reactions2 Time/weekdose(mg/Kg/dose))Isoniazid(INH)5-15(300 mg))Hepatitis, peripheral neuritis,hypersensitivity15-40(900 mg))Rifampicin(RIF)10-15(600 mg))Gastrointestinal upset,skin reaction, hepatitis, thrombocytopenia,hepatic enzymes, including orangediscolouraution of secretions10-20(600 mg)Pyrazinamide(PZA)15 - 40(2 g)Hepatotoxicity, hyperuricamia,arthralgia, gastrointestinal upset50-70(4 g)Ethambutol(EMB)15-25(2,5 g)Optic neuritis, decreased visualacuity, decreased red-green colourdiscrimination, hypersensitivity,gastrointestinal upset50(2,5 g)Streptomycin(SM)15 - 40(1 g)Ototoxicity nephrotoxicity25-40(1,5 g)When INH and RIF are used concurrently, the daily doses of the drugs are reducedNational consensus of tuberculosis in children, 2001Dosage of antituberculosis drug

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TB therapy regimen 2 mo 6 mo 9 mo 12mo

INHRIFPZA

ETBSM

PREDDOT.S !

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KORTIKOSTEROIDAnti inflamasiPrednison : oral, 1-2mg/kgBW/day, tid 2-4 weeks, tap offIndikasi :TB MiliarMeningitis TBPleuritis TB dengan efusi

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TB drugs & pharmaceutical formulationIsoniazid (H)Rifampicin (R)Pyrazinamide (Z)Ethambutol (E)monosubstancecombi-packsfixed dose comb

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KOMBIPAK 2 macam obat terpisah dalam satu kemasan

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FDC with IDAI formulation

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FDC tablet formulationWHOH: 30 mgR: 60 mgZ: 150 mgIDAIH: 50 mgR: 75 mgZ: 150 mg

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Anti-tuberculosis Lini Kedua*

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PENUTUP*

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