CASE

Objective The aim of this paper is to report a case of Miliary Tuberculosis in a 15 years 3 month old girl. Case F, 15 years 3 month old girl, was admitted to Haji Adam Malik Hospital at May 8 2012 with a main complaint was breathlessness. Breathlessness had been occurring 1 months ago, become worse 1 week ago and often occur when the patient at rest There was cough since 3 months ago. Sputum was found with volume about half of spoon, the color is yellowish green, and slab. Coughing up blood occurred twice about 1 months ago. Fever had been found since 1 months ago and it is not high enough. Fever up and down and recovered with a febrifuge. The decrease of weight and appetite were found since 2 months ago. Experienced of chest pain was not found and history of contact with an infected person (TB) coughs was found, that is her father who has take medication completely for 6 months. History of previous illness : He was referred from RSU Langsa with differential diagnosis is Lung Tuberculosis. History of previous medication : Not clear.
th

Physical Examination Presence Status : Sensorium : Compos Mentis , temperature: 36,5C, anemic (), dyspnea (+), cyanotic (-), edema (-) icteric (-).

Weight: 28 kg Length: 147 cm BW/BL: 72.5%

Head

: Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (+/+) Ear and Mouth: within normal limit; Nose: nasal flare (+)

Neck Thorax

: Lymph node enlargement (-) : Symmetrical fusiform , retraction suprasternal (+) HR: 104 bpm, regular, murmur (-) RR : 50 bpm, regular, ronchi (+/+), the left lung sounds is wane

Abdomen Genitalia Extremities

: Soepel, peristaltic (+) N, Hepar/Lien: non palpable : Female, within normal limit : Pulse : 104 bpm, regular, adequate pressure/volume, CRT<3, warm, oedem (-),

Photo Rontgen

Conclusion of the radiological 1.There is fluid level from anterior until posterior at the left hemithorax 2.There is infiltrate at the left hemithorax 3.The size of heart is normal with CTR <50% 4.Trakea at the midline 5.Bones and soft tissue is normal Conclusion : Active TB + hydropneumothorax sinistra

Laboratory Result (May 8th 2012) : Test Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) MCV MCH MCHC RDW MPV PCT PDW Neutrofil Limfosit Monosit Eosinophil Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute Results Normal Value

12.70 g % 4.20 x 106/mm3 10.86 x 103/mm3 37.20 % 254 x 103/mm3 88.60 fL 30.20 pg 34.10 g % 13.50 % 8.70 fL 0.22 % 9.0 fL 77.40 % 11.10 % 7.60 % 3.80 % 0.100 % 8.40x103/L 1.21x103/L 0.83x103/L 0.41x103/L 0.01x103/L

11.7 15.5 g % 4.20 4.87 x106/mm3 4.5 11.0 x103/mm3 38 - 44 % 150 450 x103/mm3 85 - 95 fL 28 - 32 pg 33 35 g % 11.6 14.8 % 7.0 10.2 fL

37 80 % 20 40 % 28% 16% 01% 2.7 76.5 x103/L 1.5 53.7 x103/L 0.2 0.4 x103/L 0.00 0.10 x103/L 0 0.1 x103/L

Parameters AGDA pH pCO2 pO2 Bicarbonat(HCO3) Total CO2 Base Excess (BE) Saturation O2 Liver Function Test AST/SGOT ALT/SGPT Carbohydrate Metabolism Blood Glucose ad Random Renal Ureum Creatinin Electrolite Sodium Pottasium Chlorida

Value

Normal Value

7.442 32.3 101.1 21.5 22.5 -1.9 99.4

7.35-7.45 38-42 85-100 19-25 19-25 (-2)-(+2) 95-100

26 8

<32 <31

153.30

< 200

12.10 0.71

<50 0.50-0.90

139 3.8 107

135-155 3.6-5.5 96-106

Differential Diagnosis : - Miliary TB - Pneumonia

Working Diagnosis : - Miliary TB

5

Treatment : - O2 1/2-1 L/minute - IVFD D5% NaCl 0,45% 15 microdrips/minute - Inj. Ceftriaxone 1 g/12 hour IV - Paracetamol 3x300 mg - Diet MB 1700 kcal with 60 gram protein

Planning: - Waiting for an answer of consultation from respirology division - Reading the results of Mantoux test on 10/5/2012

FOLLOW UP May 9th, 2012 Cough (+), breathlessness (+) S O Sens: CM , Temp: 38.1oC. Body weight: 28 kg Length :147 cm Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (+/+) Ear and Mouth: within normal limit; Nose: nasal flare (+) Neck Lymph node enlargement (-) Thorax Symmetrical fusiform , retraction (+) suprasternal HR: 115 bpm, regular, murmur (-) RR : 22 bpm, regular, ronchi (+/+)the left lung sounds is wane Abdomen Genital Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Female, within normal limit.

Extremities Pols : 115 bpm, regular, adequate pressure/volume, CRT<3, warm, subcutaneous fat decrease.

DD : - Miliary TB - Pneumonia Management : - O2 1/2-1 L/minute - IVFD D5% NaCl 0,45% 15 microdrip/minute - Inj. Ceftriaxone 1 gr/12 hour IV - Paracetamol 3x300 mg - Diet MB 1700 kcal with 60 gram protein

May 10th, 2012 Cough (+), breathlessness (+) S O Sens: CM , Temp: 36 oC. Body weight: 28 kg BW/BL : 72.5 % Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (+/+) Ear and Mouth: lips is pale; Nose: nasal flare (+) Lymph node enlargement (-) Symmetrical fusiform , retraction (+) suprasternal HR: 100 bpm, regular, murmur (-) RR : 28 bpm, regular, ronchi (+/+)the left lung sounds is wane Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Female, within normal limit.

Neck Thorax

Abdomen Genital

Extremities Pols : 100 bpm, regular, adequate pressure/volume, CRT<3, warm, subcutaneous fat decrease.

DD : - Miliary TB - Pneumonia Management : - O2 1/2-1 L/minute - IVFD D5% NaCl 0,45% 15 microdrips/minute - Inj. Ceftriaxone 1 gr/12 hour IV - Paracetamol 3x300 mg - Vitamin A 200.000 IU - Folat Acid 1 x 5 mg continue with 1x1mg - Multivitamin without Fe 1 x cth - Diet MB 1700 kcal with 60 gram protein

Reading of mantoux test result: 0 mm induration BTA sputum: +2 Waiting for the result of blood culture Photothorax lateral Consultation for hematology oncology

May 11st, 2012 Cough (+) , breathlessness (+) decrease S O Sens: CM , Temp: 36.5 oC. Body weight: 28 kg BW/BL : 72.5 % Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (+/+) Ear and Mouth: lips is pale; Nose: nasal flare (+) Lymph node enlargement (-) Symmetrical fusiform , retraction (+) suprasternal HR: 102 bpm, regular, murmur (-) RR : 28 bpm, regular, ronchi (+/+)the left lung sounds is wane Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Female, within normal limit.

Neck Thorax

Abdomen

Genital

Extremities Pols : 102 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi A P Diagnose : - Miliary TB Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 15 microdrip/minute - Inj. Ceftriaxone 1 g/12 hour IV - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Folat Acid 1 x 1 mg - Multivitamin without Fe 1 x cth - Nebul Nacl 0.9% 2.5 cc +ventolin / 8 hours - Diet F 75 300 cc/3 hours orally + mineral mix 7.2 cc/ 3 hours

10

Waiting for the result of culture Waiting for result of photothorax lateral

11

May 12nd, 2012 S O Breathlessness (+), fever(+) Sens: CM , Temp: 37.9oC. Body weight: 28 kg BW/BL : 72.5 % Head Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (+/+) Ear and Mouth: lips is pale; Nose: nasal flare (+) Lymph node enlargement (-) Symmetrical fusiform , retraction (+) suprasternal HR: 110 bpm, regular, murmur (-) RR : 42 bpm, regular, ronchi (+/+) both lung sounds is wane at basal area. Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Female, within normal limit.

Neck Thorax

Abdomen Genital

Extremities Pols : 110 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi A P Diagnose : - Miliary TB + hidropneumothorax + malnutrition Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 15 gtt/minute micro - Inj. Ceftriaxone 1 gr/12 hour IV - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Paracetamol 3x300 mg - Folat Acid 1 x 1 mg - Multivitamin without Fe 1 x cth - Nebul Nacl 0.9% 2.5 cc +ventolin / 8 hours - Diet F 75 300 cc/3 hours orally + mineral mix 7.2 cc/ 3 hours

12

Waiting for the result of culture Reconsultation to the thorax Surgeon.

13

May 13rd 14th 2012 Breathlessness (+) decrease, fever (+) S O Sens: CM , Temp: 37,9oC. Body weight: 28 kg Length :147 cm Head

BW/BL : 72.5 %

Neck Thorax

Abdomen

Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear, mouth, nose: within normal limit Lymph node enlargement (-) WSD attached : blood (+), drainange (+) undulation (-) HR: 110 bpm, regular, murmur (-) RR : 40 bpm, regular, ronchi (+/+) Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement Female, within normal limit.

Genital

A P

Extremities Pols : 110 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi. Diagnose : - Miliary TB + hidropneumothorax + malnutrition Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 20 microdrip/minute - Inj. Ceftriaxone 1 gr/12 hour IV - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Paracetamol 3x300 mg - Etambutol 1x750 mg - Folat Acid 1 x 1 mg - Multivitamin without Fe 1 x cth - Nebul Nacl 0.9% 2.5 cc +ventolin / 8 hours - Inj. Ketorolac 5.4 mg/ 8 hours/ IV - Diet F 75 300 cc/3 hours orally + mineral mix 7.2 cc/ 3 hours

14

Waiting for the result of culture Reconsultation to the thorax Surgeon.

15

May 15th 18th 2012 Breathlessness (+) decrease S O Sens: CM , Temp: 37oC. Body weight: 28 kg Length :147 cm Head

BW/BL : 72.5 %

Neck Thorax

Abdomen

Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear, mouth, nose: within normal limit Lymph node enlargement (-) Stem fremitus, retraction (-) WSD attached : serouse liquid(+) 1cc, undulation (+) HR: 104 bpm, regular, murmur (-) RR : 32 bpm, regular, ronchi (-/-) Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement

Genital

Female, within normal limit.

Extremities Pols : 104 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi.

A P

Diagnose : - Miliary TB + hidropneumothorax + malnutrition Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 20 gtt/minute micro - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Inj. Ceftriaxone 1 gr/12 hour IV - Folat Acid 1 x 1 mg - Multivitamin without Fe 1 x cth - Nebul Nacl 0.9% 2.5 cc +ventolin / 8 hours - Inj. Ketorolac 5.4 mg/ 8 hours/ IV - Diet F 75 300 cc/3 hours orally + mineral mix 7.2 cc/ 3 hours

16

Sensitivity: Vancomycin, Doxicycline, tetracycline, Lidezolid Waiting for the result of culture Reconsultation to the thorax Surgeon.

17

May 19th - 20th 2012 Breathlessness (+) decrease S O Sens: CM , Temp: 37oC. Body weight: 28 kg Length :147 cm Head

BW/BL : 72.5 %

Neck Thorax

Abdomen

Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear, mouth, nose: within normal limit Lymph node enlargement (-) Stem fremitus, retraction (-) WSD attached : serouse liquid(+) 10 cc, undulation (+) HR: 138 bpm, regular, murmur (-) RR : 34 bpm, regular, ronchi (-/-) Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement

Genital

Female, within normal limit.

A P

Extremities Pols : 138 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi. Diagnose : - Miliary TB + hidropneumothorax + malnutrition Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 20 gtt/minute micro - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Vitamin B6 1x1 - Inj.Vancomycin 10 mg/KgBB/6jam - Folat Acid 1 x 1 mg - Multivitamin without Fe 1 x cth - Nebule Nacl 0.9% 2,5 cc +ventolin / 8 hours - Inj. Ketorolac 5.4 mg/ 8 hours/ IV - Diet F100 460 cc/4 hours orally + mineral mix 9.2 cc/ 4 hours

18

Waiting for the result of culture Reconsultation to the thorax Surgeon.

19

May 20th - 25th 2012 Breathlessness (+) decrease S O Sens: CM , Temp: 37oC. Body weight: 25 kg Length :147 cm Head

BW/BL : 63.8%

Neck Thorax

Abdomen

Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear, mouth, nose: within normal limit Lymph node enlargement (-) Stem fremitus, retraction (-) WSD attached : serouse liquid(-), undulation (-) HR: 110 bpm, regular, murmur (-) RR : 34 bpm, regular, ronchi (-/-) Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement

Genital

Female, within normal limit.

Extremities Pols : 110 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi. A P Diagnose : - Miliary TB + hidropneumothorax + malnutrition Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 20 gtt/minute micro - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Vitamin B6 1x1 - Inj.Vancomycin 10 mg/KgBB/6jam - Folat Acid 1 x 1 mg - Multivitamin without Fe 1 x cth - Nebul Nacl 0.9% 2.5 cc +ventolin / 8 hours - Inj. Ketorolac 5.4 mg/ 8 hours/ IV - Diet F100 460 cc/4 hours orally + mineral mix 9.2 cc/ 4 hours

20

Waiting for the result of culture Reconsultation to the thorax Surgeon.

21

May 26th - 31st 2012 Breathlessness (+) decrease S O Sens: CM , Temp: 37oC. Body weight: 25 kg Length :147 cm Head

BW/BL : 63.8%

Neck Thorax

Abdomen

Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear, mouth, nose: within normal limit Lymph node enlargement (-) Stem fremitus, retraction (-) WSD attached : serouse liquid(-), undulation (+) HR: 110 bpm, regular, murmur (-) RR : 34 bpm, regular, ronchi (-/-) Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement

Genital

Female, within normal limit.

Extremities Pols : 110 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi.

A P

Diagnose : - Miliary TB + hidropneumothorax + malnutrition Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 20 gtt/minute micro - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Vitamin B6 1x1 - Inj.Vancomycin 10 mg/KgBB/6jam - Prednison 25 mg/kg 2-2-1 - Folat Acid 1 x 1 mg - Multivitamin with Fe 1 x cth

22

- Nebul Nacl 0.9% 2,5 cc +ventolin / 8 hours - Inj. Ketorolac 5.4 mg/ 8 hours/ IV - Diet F100 460 cc/4 hours orally + mineral mix 9.2 cc/ 4 hours

Photothorax Waiting confirmation from Thorax Surgeon for take WSD off.

Conclusion of Radiology 1.CTR < 50% , size of heart is normal 2.Aorta normal, superior mediastinum normal 3.Trakea at medial line , both hilus not dilated 4. Infiltrat positive in both lung 5. Consolidation opaque at hemithorax bilateral 6. Drain fixed at ICS II-III anterior sinistra

23

7.Left costophrenicus sinus and diaphragma is cloudy,the right side is normal 8.Costae intact Conclusion :Compared with previous thorax x-ray : Active Lung TB with left pleural effusion. Left pneumothorax is not found

24

June 1st 2012 Breathlessness (+) decrease S O Sens: CM , Temp: 37oC. Body weight: 26 kg Length :147 cm Head

BW/BL : 65%

Neck Thorax

Abdomen

Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear, mouth, nose: within normal limit Lymph node enlargement (-) Stem fremitus, retraction (-) WSD off HR: 110 bpm, regular, murmur (-) RR : 34 bpm, regular, ronchi (-/-) Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement

Genital

Female, within normal limit.

Extremities Pols : 110 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi. A Diagnose : - Miliary TB + malnutrition Post WSD a/i hydropneumothorax Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 20 gtt/minute micro - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Vitamin B6 1x1 - Prednison 25 mg/kg 2-2-1 - Folat Acid 1 x 1 mg - Multivitamin with Fe 1 x cth - Inj. Ketorolac 5.4 mg/ 8 hours/ IV - Diet F100 460 cc/4 hours orally + mineral mix 9.2 cc/ 4 hours

25

Waiting for the result of culture Reconsultation to the thorax Surgeon.

26

June 2nd 4th 2012 Breathlessness (+) decrease S O Sens: CM , Temp: 37oC. Body weight: 26 kg Length :147 cm Head

BW/BL : 65%

Neck Thorax

Abdomen

Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear, mouth, nose: within normal limit Lymph node enlargement (-) Stem fremitus, retraction (-) HR: 100 bpm, regular, murmur (-) RR : 28 bpm, regular, ronchi (-/-) Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement

Genital

Female, within normal limit.

Extremities Pols : 100 bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi. A P Diagnose : - Miliary TB + malnutrition Management : - O2 1-2 L/minute - IVFD D5% NaCl 0,45% 20 gtt/minute micro - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Vitamin B6 1x1 - Prednison 25 mg/kg 2-2-1 - Folat Acid 1 x 1 mg - Multivitamin with Fe 1 x cth - Inj. Ketorolac 5.4 mg/ 8 hours/ IV - Diet F100 650 cc/4 hours orally + mineral mix 13cc/ 4 hours

27

June 5th 6th 2012 Breathlessness (+) decrease S O Sens: CM , Temp: 37oC. Body weight: 26 kg Length :147 cm Head

BW/BL : 65%

Neck Thorax

Abdomen

Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-) Ear, mouth, nose: within normal limit Lymph node enlargement (-) Stem fremitus, retraction (-) HR: 88 bpm, regular, murmur (-) RR : 28 bpm, regular, ronchi (-/-) Soepel, peristaltic (+) N, Hepar/Lien: non palpable enlargement

Genital

Female, within normal limit.

Extremities Pols : 88bpm, regular, adequate pressure/volume, CRT<3, warm, muscle is hipotrofi. A P Diagnose : - Miliary TB + malnutrition Management : - INH 1x250 mg - Rifampycin 1x300 mg - Pyrazinamide 2x250 mg - Etambutol 1x750 mg - Vitamin B6 1x1 - Prednison 25 mg/kg 2-2-1 - Multivitamin with Fe 1 x cth - Diet F100 650 cc/4 hours orally + mineral mix 13cc/ 4 hours - Diet MB 1800 kkal dgn 50 grprotein

28

29

REFERENCES

1.

Behrman, Richard E., Kliegman, Robert M., Arvin, Ann M. Nelson Textbook of Pediatrics 17th Edition. United States of America: Elsevier Science, 2004, Section 2; Central Nervous System Infection. 2. Razonable, R. R., 2011. Meningitis. Available from : http://emedicine.medscape.com/article/232915-overview [Accessed on March 18th, 2012) 3. Soetomenggolo, T.S., Ismael,S., Bab 13 : Meningitis Bakterial dalam Buku Ajar Neurologi Anak. Jakarta : Ikatan Dokter Anak Indonesia 2000; 339-353. 4. Pusponegoro, H,D., et al.. Neurologi : Meningitis Bakterial pada Anak dalam Standar Pelayanan Medis Kesehatan Anak Ed.1. Ikatan Dokter Anak Indonesia 2000; 204-206. 5. Gershon, Anne., Hotez, Peter J., Katz, Samuel L. Krugmans Textbook Infectious Diseases of Children 17th Edition. Philadelphia: Mosby, 2004; Meningitis. 6. Nudelman, Y. & Tunkel, A. R. Bacterial Meningitis, Epidemiology, Pathogenesis and Management Update. Drugs 2009; 69 (18): 2577-2596 7. Kim, K. S. Acute Bacterial Meningitis in Infants and Children. Lancet Infect Dis 2010; 10: 3242. 8. Jaeger, F. Et al.. Validation of a Diagnosis Model for Differentiating Bacterial from Viral Meningitis in Infants and Children under 3.5 Years of Age. Eur J Clin Microbiol Infect Dis (2000) 19 :418421 9. Chaudhuri, A et al. EFNS guideline on the management of community acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. European Journal of Neurology 2008, 15: 649659 10. M. Bamberger, D. M. Diagnosis, Initial Management, and Prevention of Meningitis. Am Fam Physician. 2010;82(12):1491-1498 11. Scarborough, M. & Thwaites, G. E. The diagnosis and Management of Acute Bacterial Meningitis in Resource-poor Settings. Lancet Neurol 2008; 7: 637 48

30