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PLEURAL EFFUSION EC PULMONARY TUBERCULOSIS
Presenters: Erwin Siahaan (060100090) Yunny Safitri (060100158)
Supervisor: Dr.Tina Christina L.Tobing, SpA
TUBERCULOUS PLEURAL EFFUSION
Pleural effusion is the abnormal accumulation of fluid in the pleural space. A pleural effusion is always abnormal and indicates the presence of an underlying disease.
Pleural effusion that caused by tuberculosis infection is called tuberculosis pleural effusion.
ETIOLOGY
Mycobacterium tuberculosis causes tuberculosis and is a very important pathogen of humans
EPIDEMIOLOGY Infection occurs at an earlier age in urban than in
rural populations This risk is proportionate to the rate of active
infection in the population, crowding, socioeconomic disadvantage, and inadequacy of medical care
It is influenced by age (high risk in infancy and in the elderly), by undernutrition, and by immunologic status, coexisting diseases, and other individual host resistance factors.
PATHOGENESIS Pleural effusion occurs in 2-38% of all
cases of pulmonary tuberculosis in children Can be either primary or results of
reactivation disease Results from direct hematogenous invasion
of the pleural space The rupture of subpleural foci into the
pleural space 6 to 12 weeks after primary infection then promotes a delayed hypersensitivity response to the mycobacterial proteins, resulting in a pleural effusion
SIGN AND SYMPTOMS
Many children with tuberculosis do not have significant cough
pleuritic pain Night sweats low-grade fever weight loss easy fatigability
DIAGNOSIS detailed history and physical examination chest x-ray complete blood count and cell differential acid-fast stain and culture Adenosine deaminase Tuberculin test Thoracentesis Ultrasonography
DIAGNOSIS
Children were categorized as bacteriologically confirmed tuberculosis, radiologically certain tuberculosis, probable tuberculosis or not tuberculosis.
DIFFERENTIAL DIAGNOSIS
bacterial pneumonia
TREATMENT The same general principles that apply to the
treatment of tuberculosis in adults also apply to children
COMPLICATION
Possible complications include respiratory failure caused by massive fluid accumulation, septicemia, bronchopleural fistula, pneumothorax, or pleural thickening
PREVENTION
method available to prevent tuberculosis in children is administration of a bacille Calmett-Guérin (BCG) vaccine
interrupting transmission through a community-based contact investigation with appropriate chemotherapy, and the treatment of tuberculosis infection to prevent the development of disease.
PROGNOSIS
The prognosis of pleural diseases depends on the underlying cause
Most tuberculosis effusions completely resolve with the use of proper antituberculosis agents.
Residual pleural thickening can occur in 50% of patients
CASE REPORT
OBJECTIVE
The aim of doing this paper is to report a case of tuberculosis pleural effusion in a 7 years old boy that was admitted to Infection Unit of Pediatrics Departement in Haji Adam Malik General Hospital
CASE Y, 7 years old boy, body weight 21 kg, and
125 cm of height, was admitted to infection unit of pediatrics departement, Haji Adam Malik General Hospital on December 3rd 2010 at 10.45 am with chief complain breathlessness. Breathlessness occurs since 1 week ago and subsided when the patient lie down on right side. This complain was followed by cough. The cough occurs since 1 month ago with yellow phlegm and no bloody streak. These chief complain also followed by night hyperperspiration, decreased of body weight and lessen of appetite. Night hyperperspiration occurs since 1 week ago. Decreased of body weight and lessen of appetite occurs since 1 month ago.
The patient also complained having fever since 1 month ago, the fever is subfebrile, the temperature falls with the adminstration of paracetamol. Fever always occur at night and subsided in the morning. History of having contact to tuberculosis patient was not found. History of immunization is complete (according to his mother) and a BCG scar was found.
He had history to be inpatient in RB4 with diagnoses dengue fever 2 weeks later before his chief complain for his medical problem now.
PHYSICAL EXAMINATION
Presence StatusSens: Compos MentisTemp : 37,60CBW : 21 kg BL : 125 cm
Anemic (-) Cyanosis (-)Dypsnoe (-) Oedema (-) Icteric (-)
LOCALIZED STATUS
Head: - Eye: light reflexes (+/+), isochoric pupil, conjunctiva palpebra inferior pale (-/-). Ear/Mouth/Nose: within normal limit
Neck : lymph node enlargement (+) at sinistra and dextra colli regio, size + 1 cm, multiple, soft, mobile and without pain pressure
Thorax : asymmetric, seems like right dominant, retraction (+) epigastrial. HR 112 bpm, regular, without murmur. RR 32 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion
Abdomen: symmetric, soepel, peristaltic (+). With no palpable of liver and spleen
Extremities: pulse 122 bpm, regular,adequate pressure and volume, warm acral, BP 100/60 mmHg. Physiological reflexes: within normal limit, pathological reflexes (-) and meningeal reflexes (-)
DIFFERENTIAL DIAGNOSE:
Pneumonia Sinistra pleural effusion ec tuberculosis
Working Diagnose: Pneumonia
Management: IVFD D5% NaCl 0,225% 10 gtt/I micro
FUTHER EXAMINATION:
CBC Chest X-Ray LFT RFT 3 times Direct Smear Sputum Tuberculin Skin Test
FOLLOW UPFollow Up December 3 rd 2010 S: Breathless (+), fever (+), cough (+) O: Sens: CM, T: 39,2, BL= 125 cm, BW= 22 kg, BW/ BL=
89, 79% Head: Eye: pupil reflex (+/+), isochoric pupil (+), pale
palpebra inferior conjunctiva (+) E/N/T: within normal limit Neck: Lymph node enlargement (+) bilateral, size ± 1
cm, multiple, consistency soft, mobile (+), tenderness (+).
Chest: asymmetric, seems like right dominant, retraction (+) epigastrial. HR: 110 bpm, regular, without murmur. RR: 38 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.
Abdominal: Soepel, normal peristaltic, liver/ spleen: unpalpable.
Extremities: Pols: 120 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities. BP: 100/70 mmHg.
A: Left pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition
2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV - Inj. Chloramphenicol 600 mg/ 8 hours/ IV - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever) R: - Consult to respirology department Sputum analysis AFB direct smear Pleural tapping
LABORATORY FINDING (DECEMBER 3RD 2010) – EMERGENCY UNITTestTest ResultResult Normal ValueNormal Value
Complete Blood CountComplete Blood CountHemoglobin (Hb)Hemoglobin (Hb)Erytrocytes (RBC)Erytrocytes (RBC)Leucoytes (WBC)Leucoytes (WBC)Hematocrite (Ht)Hematocrite (Ht)Trombocytes (Plt)Trombocytes (Plt)MCVMCVMCHMCHMCHCMCHCRDWRDWMPVMPVPCTPCTPDWPDW
10,7010,704,37x104,37x10 6 6
9,75x109,75x1033,0033,00503x10³503x10³75,5075,5024,5024,5032,4032,4014,1014,107,907,900,400,407,87,8
11,3-14,111,3-14,14,40-4,484,40-4,484,5-13,54,5-13,537-4137-41150-450150-45081-9581-9525-2925-2929-3129-3111,6-14,811,6-14,87,0-10,27,0-10,2
Chest X-Ray finding: Massive pleura effusion on the left
hemithorax. CTR < 50%
Follow Up December 4 th 2010 S: Breathless (+), fever (-), cough(+) O: Sens: CM, T: 37,3, BL= 125 cm BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+), pale
palpebra inferior conjunctiva (+). E/N/T: within normal limit
Neck: Lymph node enlargement (+) bilateral, size ± 1 cm, multiple, consistency soft, mobile (+), tenderness (+).
Chest: asymmetric, seems like right dominant, retraction (+) epigastrial. HR : 98 bpm, regular, without murmur. RR: 30 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.
Abdominal: Soepel, normal peristaltic, liver/ spleen: unpalpable.
Extremities: Pols: 98 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities. BP: 100/50 mmHg.
A: Left pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition
2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225%10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 1) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV (Day
1) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever) R: - Consult to respirology department Sputum analysis AFB direct smear Montoux Test Pleural tapping Pleural fluid analysis
Follow Up December 5 th 2010 S: Breathless (+), fever (-),cough(+) O: Sens: CM, T: 36,8, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+),
pale palpebra inferior conjunctiva (+). E/N/T: within normal limit
Neck: Lymph node enlargement (+) bilateral, size ± 1 cm, multiple, consistency soft, mobile (+), tenderness (+).
Chest: asymmetric, seems like right dominant, retraction (+) epigastrial. HR: 98 bpm, regular, without murmur. RR: 38 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.
Abdominal: Soepel, normal peristaltic, liver/ spleen: unpalpable.
Extremities: Pols: 120 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities.
BP: 100/60 mmHg.
A: Left pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition
2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute
micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 2) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV
(Day 2) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)
Follow Up December 6 th 2010 S: Breathless (+), fever (-), cough (+) O: Sens: CM, T: 36,7, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+),
pale palpebra inferior conjunctiva (+). E/N/T: within normal limit
Neck: Lymph node enlargement (+) bilateral, size ± 1 cm, multiple, consistency soft, mobile (+), tenderness (+).
Chest: Asimetric, seems like right dominant with minimal epigastrial retraction (+) epigastrial. HR: 100 bpm, regular, without murmur. RR: 26 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.
Abdominal: Soepel, normal peristaltic, liver/ spleen: unpalpable.
Extremities: Pols: 100 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities. BP: 100/60 mmHg.
A: Left pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition
2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 3) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV (Day
3) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg R: - Consult to respirology department Sputum analysis AFB direct smear Pleural tapping Pleural fluid analysis
Montoux Test Result: - Positive - Undulation (+) hyperemis, size 12 mm
Follow Up December 7 th 2010 S: Breathless (+), fever (-), cough (+) O: Sens: CM, T: 36,8, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+), pale
palpebra inferior conjunctiva (+). E/N/T: within normal limit
Neck: Lymph node enlargement (+) bilateral, size ± 1 cm, multiple, consistency soft, mobile (+), tenderness (+).
Chest: asymmetric, seems like right dominant, retraction (+) epigastrial. HR: 108 bpm, regular, without murmur. RR: 38 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.
Abdominal: Soepel, normal peristaltic, liver/ spleen: unpalpable.
Extremities: Pols: 108 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities. BP: 100/60 mmHg.
A: Pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition
2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute
micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV
(Day 4) - Inj. Chloramphenicol 600 mg/ 8 hours/
IV (Day 4) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)
Advice from Pediatric Pulmonology Departement:
- Pleural tapping- Pleural fluid analysis
Follow Up December 8 th 2010 S: Breathless (+), fever (+), cough (+) O: Sens: CM, T: 39,2, BL= 125 cm , BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+),
pale palpebra inferior conjunctiva (+). E/N/T: within normal limit
Neck: Lymph node enlargement (+) bilateral, size ± 1 cm, multiple, consistency soft, mobile (+), tenderness (+).
Chest: asymmetric, seems like right dominant, retraction (+) epigastrial. HR: 100 bpm, regular, without murmur. RR: 40 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.
Abdominal: Soepel, normal peristaltic, liver/ spleen: unpalpable.
Extremities: Pols: 100 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities. BP: 100/70 mmHg.
A: Let pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition
2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 5) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV (Day
5) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)
Until 22.00 WIB AFB direct smear result is negative
Follow Up December 9 th 2010 S: Breathless (+), fever (-), cough (+) O: Sens: CM, T: 36,2, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+), pale
palpebra inferior conjunctiva (+). E/N/T: within normal limit
Neck: Lymph node enlargement (+) bilateral, size ± 1 cm, multiple, consistency soft, mobile (+), tenderness (+).
Chest: asymmetric, seems like right dominant, retraction (+) epigastrial. HR: 110 bpm, regular, without murmur. RR: 38 tpm, regular, weakness breathing soundwas found at left side pulmonary regio and dull in percussion.
Abdominal: Soepel, normal peristaltic, liver/ spleen: unpalpable.
Extremities: Pols: 120 bpm, regular, pressure and volume was adequate, cyanotic (-), with warm extremities. BP: 100/70 mmHg.
A: Left pleural effusion ec: DD: 1. Pneumonia + Mild malnutrition
2. Pulmonary TB P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute
micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day
6) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV
(Day 6) - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)
Follow Up December 10 th 2010 S: Breathless (+), fever (-), cough (-) O: Sens: CM, T: 39,2, BL= 125 cm, BW= 22 kg Head: Eye: pupil reflex (+/+), isochoric pupil (+),
pale palpebra inferior conjunctiva (+). E/N/T: within normal limit
Neck: Lymph node enlargement (+) bilateral, size ± 1 cm, multiple, consistency soft, mobile (+), tenderness (+).
Chest: Asimetric with minimal epigastical retraction.
HR: 100 bpm, regular, mur-mur (-) RR: 48 rpm, regular Abdominal: Soepel, normal peristaltic, liver/
spleen: unpalpable. Extremities: Pols: 100 bpm, regular, pressure and
volume was adequate, cyanotic (-), with warm extremities. BP: 100/70 mmHg..
A: Left pleural effusion ec: DD: 1. Pulmonary TB + Mild malnutrition
2. Pneumonia P: - Oxygen 1 L/ minutewith nasal canule - IVFD D5% NaCl 0,225% 10 gtt/minute micro - Reguler diet 1540 kkal with 44gr protein - Inj. Cefotaxime 600 mg/ 8 hours/ IV (Day 7) - Inj. Chloramphenicol 600 mg/ 8 hours/ IV (Day
7) - Rifampicin 1 x 240 mg - INH 1 x 240 mg - Pirazinamid 2 x 40 mg - Ambroxol syrup 3 x Cth1 - Paracetamol 3 x 250 mg (if fever)December, 11 th 2010 Patient discharge from
RSUP HAM
Discussion
Teory Case
Pleural effusion most common complication of bacterial pneumonia in child
Epidemiology of tuberculosis pleural effusion is influenced by age, undernutrition,immunologic status,coexisting disease and other individual host factors.
In this case report, the patient was firstly diagnosed as pneumonia pleural effusion based on epidemiologic study
This patient is young boy with undernutrition and immunodepressed status caused by dengue fever
Teory Case
In pleural effusion, the radiographic finding show a homogenous density that obscured the underlying lung.
Treatment decicion in children wih pleural effusionare dictated based on the likely etiology of he infectous organism from the pleural fluid analysis and and the clinical status of the patient.
In this case, the chest x ray show homogenous consolidation in left side thorax
In this case we give Inj. Cefotaxime 600 mg/ 8 hours
- Inj. Chloramphenicol 600 mg/ 8 hours
- Rifampicin 1 x 240 mg - INH 1 x 240 mg - Pirazinamid 2 x 40 mg because the pleural tapping didn’t do.
SUMMARY
It has been reported a case of an 7 years old boy with pleural effusion. Who was suspected as pleural effusion caused by M. tuberculosis infection. The diagnosis was established based on history taking, clinical manifestation, radiology finding and laboratory findings. Treatment for this patient was based on underlying disease, symptomatic and supportive treatment