Case report pp

CASE REPORT:
TUBERCULOSIS WITH SEVERE MALNUTRITION

Presenter:
Dinesha Paniselvam
Tay Chiu Mei

Supervisor:
dr. H.Hakimi, Sp.A(K)

Definition
Tuberculosis is a disease due to Mycobacterium
tuberculosis infection with systemic spread thus can
affect almost all organs, and the most frequent site is
in the lung, which usually as the site of primary
infection

Etiology:
Mycobacterium
tuberculosis

Host Exposure Doses /
immune duration numbers Virulence
Concentration
state in the air

Fac
acq tors
uir in
inf ing
ect Tb
ion

Pathogenesis of primary tuberculosis
Ingestion by PAM’S
Droplet nuclei
Alveoli
inhalation Intracellular replication
of bacilli
Destruction
Destruction of PAM’S of bacilli

Tubercle formation Lymphogenic spread Hilar lymph nodes
primary focus lymphangitis lymphadenitis

Hematogenic spread
Primary
complex Acute hematogenic Occult hematogenic
spread spread

CMI Disseminated primary TB Multiple organs
remote foci
12/18/12 7

Systemic Specific
Manifestation Manifestation

IDAI Pediatric TB scoring system

10

Notes for IDAI scoring system
Diagnosis: total score ≥6 (by doctor)
BW at present
Fever & cough no respons to standard tx
CXR is NOT a main diagnostic tool
Accelerated BCG reaction: evaluated
<5 y.o: Score 5 or strong suspicion refer
INH prophylaxis: score <6 with contact (+)

11

Mantoux 0.1 ml PPD
intermediate strength
- Location : volar lower
arm
- Reading time: 48-72 h
post injection
-Induration diameter :
 0 - 5 mm : negative
 5 - 9 mm : doubt
 > 10 mm : positive

Rapid
reduction of
the number
of bacilli

Objectives
of
treatment
Sterilization Preventing
to prevent acquired
relapses drug
resistance

Treatment principles
• Drug combination, not single drug
• Two phases :
 Initial phase (2 months) – intensive,
bactericidal effect
 Maintenance phase (4 months / more) –
‘sterilizing’ effect, prevent relaps

12/18/12 14

Dosage of antituberculosis drug
2 Time/week
Daily dose
Drugs (mg/Kg/day)
dose Adverse reactions
(mg/Kg/dose))
Isoniazid 5-15 15-40 Hepatitis, peripheral neuritis,
(INH) (300 mg)) (900 mg)) hypersensitivity
Gastrointestinal upset,skin reaction,
Rifampicin 10-15 10-20 hepatitis, thrombocytopenia,
(RIF) (600 mg)) (600 mg) hepatic enzymes, including orange
discolouraution of secretions

Pyrazinamide 15 - 40 50-70 Hepatotoxicity, hyperuricamia,
(PZA) (2 g) (4 g) arthralgia, gastrointestinal upset

Optic neuritis, decreased visual
Ethambutol 15-25 50 acuity, decreased red-green colour
(EMB) (1,5 g) (1,5 g) discrimination, hypersensitivity,
gastrointestinal upset

Streptomycin 15 - 40 25-40
Ototoxicity nephrotoxicity
(SM) (1 g) (1,5 g)

When INH and RIF are used concurrently, the daily doses of the drugs are reduced
12/18/12 15
National consensus of tuberculosis in children, 2001

Systems for assessing the severity of
malnutrition in underweight children
Method Mild Moderate Severe

Weight for age ≥90 % 75 to 89 % 60 to 74 % <60 %

Weight for height ≥90 % 80 to 89 % 70 to 79 % <70 %

Height for age ≥95 % 90 to 94 % 85 to 89 % <85 %

Weight/height for age ≥90 % 85 to 89 % 75 to 84 % <75 %

18

Marasmus Kwashiorkor
Absence of edema Presence of edema
Inadequate intake of protein Fair-to-normal calorie intake
and calories with inadequate protein
intake

Marasmus-Kwashiorkor
A combination of both, kwashiorkor and marasmus. Signs and symptomps of
marasmus could be found coincidently with kwashiorkor. The child look very thin with
bones and ribs could be inspected very prominently, with mild edema found
minimally, particularly in the lower extremities. 19

MANAGEMENT OF SEVERE MALNUTRITION
Stabilization Transition Rehabilitation Follow Up
No Treatment Day Day Week Week
Week 2
1-2 3-7 3-6 7-26
1 Hypoglycemia ̸
2 Hypothermia ̸
3 Dehydration ̸
4 Electrolyte Correction ̸ ̸ ̸
5 Treatment of Infection ̸ ̸ ̸
6 Micronutrition Defficiency Without Without Iron With Iron
Iron With Iron
Correction Supplementa- Without Iron Supplement-
Supple- Supplementation
Supplementation
tion ation
menta-
tion
7 Formula Formula 75
Initial Refeeding 75 Formula 75 to 100

8 Correctional Refeeding Formula 100 Formula
100
(Catch Up Growth)
9 Stimulation ̸ ̸ ̸ ̸ ̸
10 Prepare for Discharge ̸ ̸ 20

TB AND MALNUTRITION
TB

Energy intakes Metabolic rate / Presence of
are decreased resting rate increased pro-inflammatory
cytokines

Utilization of amino
Increased energy needs acids & protein synthesis
to meet the basic
The cell mediated demands for body function
immunity response
is impaired

MALNUTRITON

12/18/12 21

Loss of body weight since 1 year ago. According to her
parents, the patient’s highest body weight was 25kg
(October 2010) and it’s decreasing for the past 1 year
with drastic weight loss (± 10kg) for the past 4 months.

Decreased of appetite was found since 6 months ago.

Fever was found since 2 year ago. The characteristic of the
fever : intermittent and low grade fever; decrease temporarily
with consumption of paracetamol. History of intermittent
fever was found since the patient was 9 years old.

The patient was coughing for the past 2 years, Phlegm (+),
white in color, bloody(-). History of contact with a tubercular
patient/prolonged coughing adult was found.

Lesions were found on patients right neck which was noted by
the patient’s family 1 year ago. 2 small noduls with ᴓ 1,5cm,
Initially, the lesion started as papules that progressed to
nodules and pustules. 2 months ago, there was discharge from
the lesion. The discharge from the lesion was serous, bloody(-)
and its painless.
Distention of the patients’s stomach was realized by patient’s mother since 6
months ago.
History of diarrhea (+), vomiting(-), loss of concentration for the past 2 days.
Normal mictuation and defecation.

History of feeding :
0 to 4 mth : Breast milk
4 mths- 1 year: Breast milk + Porridge
1 year till now : Normal meals

• Face: old man face (+)
• Eyes: Light reflex +/+, isochoric pupil,conjunctiva palpebra inferior
Head pale (+/+)
• Nose: Nasal flare (-) Mouth: Paleness of mucous (-), cyanosis (-) Ears :
Secrete (-)

• Lymph node enlargement (-), Scrofuloderma (+) on regio colli dextra,(
Neck 2 noduls with serous discharge ᴓ ± 1.5cm), JVP: R-2 cm H2O

• Symmetrical fusiform, retraction (-), intercostal ribs can be seen clearly.
Thorax HR: 96 bpm regular, murmur (-) RR: 20 tpm regular, rales (-)

• Ascites (+),Shifting dullness (+),Double sound(+), Normal peristaltic
Abdomen
• Liver and spleen was not palpable

• Pulse 96 bpm regular, adequate pressure and volume, warm acral,
CRT < 3’, BP: 100/60 mmHg, clubbing fingers (-), cyanotic (-),
Extremities pale(+) Baggy pants (+), hypotrophy muscle (+), thin subcutaneous
fats(+)
• Normal physiology reflex, Pathologic reflexes (-)
Genitalia • Female, within normal limit

Old man face

Intercostal ribs can
be seen clearly

Dried scrofuloderma
lesions

Stomach distended

Thin subcutaneous
fats

Hypotrophy muscle

Laboratory Findings: (Adam Malik General Hospital: 31/10/2011)
Complete Blood Count Results Normal Value
Hemoglobin (Hb) 6,50 g% 11.3-14.1g %

Erytrocyte (RBC) 3,18 x106/mm3 4.40– 4,48 x106/mm3

Leukocyte (WBC) 8.31 x 103/mm3 4.5-13.5x103/mm3

Hematocrite 23,280 % 37 – 41 %

Trombocyte (PLT) 236 103/mm3 150 – 450 x103/mm3

MCV 73,10 fl 81 – 95 fL

MCH 20,40 pg 25 – 29 pg

GLUCOSE Ad Random
Blood glucose 89 mg/dl <200 mg/dl
ELECTROLITE
Natrium 131 135 - 155
Kalium 3,5mEq/L 3,6 - 5,5
Klorida 10 mEq/L 96 - 106 28

Working Diagnosis:
Pulmonary Tuberculosis +
Scrofuloderma with Severe
malnuturion marasmic-
kwashiorkor type

RADIOLOGY

Interpretation of the chest X-Ray:
CTR < 50%, Aorta and pulmonal segment is Interpretation of the abdominal photo :
not elongated. Infiltration can be seen on
Homogenous consolidation can be seen on
whole lung field.
the abdominal space which enforces air
Results: Bronchopneumonia, from intestines towards central. Results:
DD: - active specific process Ascites

Date 1 November 2011
S Fever (-), Abdomen distended (+)
O Sens :Alert, T:37,30C, BW:15kg, BL: 130 cm, BW/BL: 55.55% LLT:57cm LLD:54cm

Head Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness of conjunctiva inferior palpebra (+/+),
icteric sclera(-/-). Ear/Nose/Mouth : within normal limit

Lymph nodes enlargement(-)Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O
Neck

Thorax Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be
seen clearly.
Abdomen Distented(+), Ascites(+), Shifting dullness(+),Double sound(+), normal peristaltic. Liver and spleen: not palpated.

Extremities Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy
pants (+), hypotrophy muscle (+), thin subcutaneous fats(+),Normal physiology reflex: APR/KPR (+) ,Pathologic reflexes (-)
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnuturion marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed)
- IVFD D5% NaCl 0.45% 4gtt/min
-Isoniazid 1 x 150 mg
- Rifampicin 1 x 300 mg
- Pyrazinamid 1 x 450 mg
- Ethambutol 1 x 300 mg
- Zinc tablet 1 x 20mg D1
- Folic Acid 1x5 mg 1 x1 mg
- Multivitamin without Ferum 1 x Cth II
- F75 diet 200cc/2hrs/oral
Further - Consult to Metabolic & Nutrition Division
evaluation - Consult to Pediatric Respirology :
•Mantoux test (at 1400 WIB, Interpretation on 3/11/2011)
- Gaster lavage
- BTA culture ( 3 days continuously)
- Scrofuloderma lesion culture

Date 2 November 2011
S Fever (-), Abdomen distended (+)
O Sens :Alert, T:37,30C, BW:15kg, BL: 130 cm, BW/BL: 55.55% LLT:57cm LLD:52cm
Face: Old man face (+) Eye: Light reflexes (+),isochoric pupil (R=L), paleness of conjunctiva inferior palpebra (+/+), icteric
Head sclera(-/-) Ear/Nose/Mouth : within normal limit
Neck
Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O
Thorax Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-)
RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Abdomen
Distented(+), Ascites(+), Shifting dullness (+),Double sound(+),normal peristaltic Liver and spleen: not palpated.
Extremities
Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants

(+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+), Pathologic reflexes (-)
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnuturion marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed)
- IVFD D5% NaCl 0.45% 4gtt/min
-Isoniazid 1 x 150 mg
- Pyrazinamid 1 x 450 mg D2
- Ethambutol 1 x 300 mg Consultation from Dermatology:
- Zinc tablet 1 x 20mg Lesions were found on patients dextra colli region which was
- Folic Acid 1x1 mg
- Multivitamin without Ferum 1 x Cth II noted by the patient’s family 1 year ago. 2 small noduls with ᴓ
- F75 diet 200cc/2hrs/oral 1,5cm, Initially, the lesion started as papules that progressed to
nodules and pustules. 2 months ago, there was discharge from
Further - Gaster lavage the lesion. The discharge from the lesion was serous, bloody(-)
evaluation - BTA culture ( 3 days continuously)
- Scrofuloderma lesion culture and its painless.
Diagnose: Scrofuloderma
Therapy: Compress with Nacl 0,9% for 15 menits every 4
hours and apply Gentamicin cream 2x/day.

ate 3 November 2011 4 November 2011
S Fever (-), Abdomen distended (+) Fever (-), Abdomen distended (+)
O Sens :Alert, T:37,30C, BW:16kg, BL: 130 cm, BW/BL: 55.57% Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.57%
d
Face: Old man face (+) Eye: Light reflex (+), isochoric pupil (Right=Left), Face: Old man face (+) Eye: Light reflex (+), isochoric pupil (R=L),
paleness of conj. inf. palpebra (+/+), icteric sclera(-). Ear/Nose/Mouth:within paleness of conj. inf. palpebra (+/+), icteric sclera(-). Ear/Nose/Mouth:
normal limit within normal limit
Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2 noduls Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli dextra,(2
k with serous discharge ± 1.5cm), JVP: R-2 cm H2O noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O
ax Symmetrical fusiform, retraction (-) HR: 106 bpm, regular, murmur (-) Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-)
RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
men
Distented(+),normal peristaltic,Ascites(+), Shifting dullness (+),Double sound(+) Distented(+),normal peristaltic, Ascites(+), Shifting dullness (+),Double
mities Liver and spleen: not palpated. sound(+), Liver and spleen: not palpated.
Pulse: 106 bpm, regular, adequate pressure and volume, warm acral, oedema (-), Pulse: 92 bpm, regular, adequate pressure and volume, warm acral,
pale(+) CRT: < 3’, BP: 100/60mmHg, Baggy pants (+), hypotrophy muscle oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+),
(+), thin subcutaneous fats(+), Normal physiology reflex:APR/KPR(+ ) hypotrophy muscle (+), thin subcutaneous fats(+), Normal physiology
reflex:APR/KPR(+)
A Pulmonary Tuberculosis + Scrofuloderma with severe malnutrition marasmic- Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition
kwashiorkor type marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed) - O2 1-2L per minute (if needed)
- IVFD D5% NaCl 0.45% 4gtt/min aff - Isoniazid 1x 150 mg
- Isoniazid 1x 150 mg - Rifampicin 1 x 300 mg
- Rifampicin 1 x 300 mg - Pyrazinamid 1 x 450 mg D4
- Pyrazinamid 1 x 450 mg D3 - Ethambutol 1 x 300 mg
-Ethambutol 1 x 300 mg - Zinc tablet 1 x 20mg
- Zinc tablet 1 x 20mg - Folic Acid 1 x1 mg
- Folic Acid 1 x1 mg - Multivitamin without Ferum 1 x Cth II
- Vitamin A 1 x 200.000 IU - F75 diet 200cc/2hrs/oral
BW:16 kg BW/BH: 55.57%
- Compress the lesion with NaCl 0,9% for 15 menits every 4 hours.
- Gentamicin cream 2x/day

Treatment:
- Compress the lesion with NaCl 0,9% for 15 menits every 4 hours. Consultation from Gastroenterology:
- IVFD D5% NaCl 0.45% 4gtt/min aff - Albumin correction and re-check
- Vitamin albumin level after correction
Laboratorium Result: A 1 x 200.000 IU (1 day)
r Mantoux test Results : Negative - Gaster lavage
ion - BTA culture ( 3 days continuously)
- Albumin Correction:150cc of
Liver: - Total Bilirubin : 0,93mg/dL - Scrofuloderma lesion culture
- Direct Bilirubin : 0,78mg/dL Plasbumin 20%
Mantoux test Results : Negative
- Alkaline Phosphate(ALP) : 142U/L
- AST/SGOT : 28 U/L
Laboratorium Result: Albumin 1,0 g/dL
- ALT/SGPT
- Albumin
: 15 U/L
: 1,0 g/dL
Albumin needed=(3,5-1,0) x 16x 0,8=32g
Plasbumin 25% = 32/25x 100 = 128 cc
Plasbumin 20% = 32/20x 100 = 160 cc

Date 5-6 November 2011 7 November 2011
S Abdomen distended (+) Abdomen distended(+)
O Sens :Alert, T:36,80C, BW:16kg, BL: 130 cm, BW/BL: 55.57% Sens :Alert, T:37,50C, BW:16,5kg, BL: 130 cm, BW/BL: 55.6%
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil
Head (R=L), paleness of conj.inferior palpebra (+/+),icteric sclera(-/-). (Right=Left), paleness of conj.inferior palpebra(+/+),icteric sclera
Ear/Nose/Mouth :within normal limit (-/-) Ear/Nose/Mouth : within normal limit
Lymph nodes enlargement(-) Scrofuloderma (+) on regio colli Lymph nodes enlargement(-) Dried lesion can be seen on the right
Neck dextra,(2 noduls with serous discharge ± 1.5cm), JVP: R-2 cm H2O neck, JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 120 bpm, regular, murmur Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-)
Thorax (-) RR: 24 tpm, regular, rales (-/-), Intercostal ribs can be seen RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
clearly.
Abdomen Distented(+), Ascites(+), Shifting dullness (+),Double sound(+),
normal peristaltic. Liver and spleen: not palpated.
-BW:16,5kg, BL: 130 cm,
Distented(+), Ascites(+), Shifting dullness (+),Double sound(+),
normal peristaltic. Liver and spleen: not palpated.
Pulse:120bpm, regular, adequate pressure and volume, warm acral, BW/BL: 55.6%
Pulse: 92 bpm, regular, adequate pressure and volume, warm acral,
Extremity oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants oedema (-), pale(+) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+),
(+), hypotrophy muscle (+), thin subcutaneous fats(+), Normal - Dried lesion can be seen on the
hypotrophy muscle (+), thin subcutaneous fats(+), Normal
physiology reflex:APR/KPR(+) Pathologic reflexes( -) physiology reflex:APR/ KPR (+) Pathologic reflexes (-)
right neck,
A -Albumin Correction: 50 cc of
Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition
marasmic-kwashiorkor type - F100 diet 240cc/3hrs/oral
marasmic-kwashiorkor type
P Plasbumin 20%
- O2 1-2L per minute (if needed) - O2 1-2L per minute (if needed)
- Albumin Correction: 50 cc of
-Isoniazid 1x 150 mg -Isoniazid 1x 150 mg
Laboratorium Result:
- Rifampicin 1 x 300 mg Plasbumin 20%
- Albumin : 2,0 g/dL
- Ethambutol 1 x 300 mg D5,6
-Pyrazinamid 1 x 450 mg
- Ethambutol 1 x 300 mg D7
- Zinc tablet 1 x 20mg - Vitamin B6 1 x 20 mg
- Folic Acid 1 x1 mg - Albumin : 2,0 g/dL
- Zinc tablet 1 x 20mg
- Multivitamin without Ferum 1 x Cth II - Folic Acid 1 x1 mg
- F100 diet 240cc/3hrs/oral (D1),(D2) Albumin Correction: 100cc of
- Gentamicin cream 2x/day Plasbumin 20%
- F100 diet 240cc/3hrs/oral (D3)

Further -Albumin Correction: 50 cc of Plasbumin 0% (05/11/2011; 1750 - Waiting for the results of gaster lavage,
evaluation WIB) BTA culture and Scrofuloderma lesion
-Waiting for the results of gaster lavage, BTA culture and culture
Scrofuloderma lesion culture Albumin Correction:100cc of Plasbumin 20%
- Albumin : 2,0 g/dL
Albumin needed=(3,5-2) x 16x 0,8 ≈20g
Plasbumin 25% = 20/25 x 100 = 80 cc
Plasbumin 20% = 20/20 x 100 = 100 cc

Date 8-10 November 2011 11 November 2011
S Abdomen distended (reduced) Fever (-), Diarrhea (6x/day)
O Sens :Alert, T:36,80C, BW:18kg, BL: 130 cm, BW/BL: 55.57% LLT:55cm LLD:52cm Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.55%
Face: Old man face (+) Eye: Light reflexes (+),isochoric pupil (R=L) paleness of Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), paleness
Head
conjunctiva inferior palpebra (+/+), Ear/Nose/Mouth : within normal limit of conjunctiva inferior palpebra (+/+). Ear/Nose/Mouth : within normal limit

S:Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R-2 cm H O nodes enlargement(-) Dried lesion can be seen on the right neck, JVP: R-2 cm
H O Abdomen distended (reduced)
2 2
Lymph

Neck
BW:18kg, BW/BL: 55.57% LLT:55cm LLD:52cm fusiform, retraction (-) HR: 92 bpm, regular, murmur (-)
Symmetrical fusiform, retraction (-) HR: 136 bpm, regular, murmur (-) Symmetrical
RR: 32 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. RR: 28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Thorax
P:Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and spleen: not 09/11)
Meropenem Inj. 300 mg/8hr/iv (Starting on Distension(+),ascites(+), shifting dullness (+) normal peristaltic, Liver and spleen: not
palpated. palpated S: Diarrhea (6x/day)
Abdomen
Pulse: 136 regular, adequate pressure and volume, warm acral, oedema
CRT: < of gaster lavage: (08/11/2011)
BP:
Pulse:
3’, BP:
BW:16kg, BW/BL: 55.55%
Results3’,bpm, 100/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin (-), pale(+) CRT: <92 bpm, 110/70mmHg, Baggy pants (+), hypotrophy muscle (+), thin (-), pale(+)
regular, adequate pressure and volume, warm acral, oedema
Extremities
Day 1 No fats(+), Normal physiology reflex:APR/KPR(+). Pathologicjamur,yeast cell(+) - Normal physiology reflex:APR/KPR(+).Pathologic reflexes (-)
subcutaneous bacteriaes were found.Growth of reflexes (-) subcutaneous fats(+), Lacto B 3 x 1 sachet
P:
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic-
Epitel: 0-2
kwashiorkor type Leucocytes: 1-2 BTA: 2/100 LP
kwashiorkor type
P Day 2&3: minute bacteriaes were found. Growth of jamur, yeast minute (if needed)
- O 1-2L per No (if needed)
2 - O 1-2L per
2 -Resomal 100cc/xdiarrhea
- Isoniazid 1x 150 mg - Isoniazid 1x 150 mg
- Rifampicin cell(+)
1 x 300 mg - Rifampicin 1 x 300 mg
- Pyrazinamid 1 x 450 mg - Pyrazinamid 1 x 450 mg
Results of1lesion culture: (09/11/2011) Aerob bacteriEthambutol 1 xresult: Albumin: 2,3g/dL
- Ethambutol x 300 mg - wasLab 300 mg
- Vitamin B6 1 x 20 mg - Vitamin B6 1 x 20 mg
found;tablet 1 x 20mg
- Zinc Enterobacter Clocal - Zinc tablet 1 x 20mg
- Folic Acid 1 x1 mg - Folic Acid 1 x1 mg
- Multivitamin without Ferum 1 x Cth II - Multivitamin without Ferum 1 x Cth II
- F100 diet 240cc/3hrs/oral - F100 diet 240cc/3hrs/oral
Lab result: Hb = 4,4
- Gentamicin cream 2x/day Albumin: 2,0g/dL - Gentamicin cream 2x/day
- Meropenem Inj. 300 mg/8hr/iv (D 3)
Transfusion Inj. 300 mg/8hr/iv (starting on 09/11/2011)
Meropenem of PRC: -Lacto B 3 x 1 sachet
Transfusion of PRC 100cc I (08/11) -Resomal 100cc/xdiarrhea

Transfusion of PRC 100cc II (09/11)
Further Laboratorium Result (08/11/2011):
Albumin of PRC:
evaluation Hb/Ht/L/PltCorrection :
= 4,4/ 15,2/7990/348000 Plasbumin 20% = 22/20x 100 = 110 cc
Albumin: 2,0g/dL
Transfusion Laboratorium Result:
(12-4,4) x 19 x 4 = 570 cc ≈ 600 cc
Availability : 5 x 19= 95cc ≈ 100 cc
Albumin : 2,3 g/dL
Transfusion of PRC 100cc I (08/11) Transfusion of PRC 100cc II (09/11)
Albumin Correction :
Albumin needed=(3,5-2,0) x 18x 0,8=22g Albumin Correction :
Plasbumin 25% = 22/25x 100 = 88 cc Plasbumin 20% = 22/20x 100 = 110 cc
Albumin needed= 10g
Plasbumin 25% = 50cc
Plasbumin 20% = 40cc

Date 12-13 November 2011 14-16 November 2011
S Diarrhea(+)Abdomen distended(reduced) Diarrhea(-) Abdomen distended
O Sens :Alert, T:36,8 C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:54cm
0
Sens :Alert, T:37,50C, BW:16kg, BL: 130 cm, BW/BL: 55.55%
LLD:52cm
Head Face: Old man face (+) Face: Old man face (+)
Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inf. palp.(+/ Eye: Light reflexes (+), isochoric pupil (R=L), paleness of conj.inf. palp -/-
+),icteric sclera(-/-). Ear/Nose/Mouth : within normal limit
Ear/Nose/Mouth : within normal limit
Neck Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R- S: Eye: paleness of Conj.Inf.Palp (-)
Lymph nodes enlargement(-) Dried lesion can be seen on the right neck,
Thorax
2 cm H2O
Extremities: pale(-)
JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 90 bpm, regular, murmur (-) RR: 28 Symmetrical fusiform, retraction (-) HR: 92 bpm, regular, murmur (-) RR:
Abdomen tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
S: Diarrhea (+) P: - Lacto B 3 x 1 sachet
28 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Distension(+),ascites(+), shifting dullness (+) normal peristaltic, Distension(+),ascites(+), shifting dullness (+) normal peristaltic.
BW:17kg, BW/BL: 55.57%
Extremities Liver and spleen: not palpated. Liver and spleen: not palpated.
P: - Lacto B 3 x 1 sachet
Pulse: 90 bpm, regular, adequate pressure and volume, warm acral, oedema (-), -Resomal 100cc/xdiarrhea
Pulse: 92 bpm, regular, adequate pressure and volume, warm acral, oedema
pale(+) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle
(+), thin subcutaneous fats(+), Normal physiology reflex: APR/KPR(+)
- Repeat Chest X-Ray
(-), pale(-) CRT: < 3’, BP: 110/70mmHg, Baggy pants (+), hypotrophy
muscle (+), thin subcutaneous fats(+) Normal physiology reflex
A -Resomal 100cc/xdiarrhea
Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- Pulmonary Tuberculosis + Scrofuloderma with test malnutrition
- Blood culture, sensitivity Severe
kwashiorkor type marasmic-kwashiorkor type Antibiotics with
-Combination of
P - O2 1-2L per minute (if needed) O2 1-2L per minute (if needed)
Lab Result (12/11/2011):
- Meropenem Inj. 300 mg/8hr/iv - Meropenem Inj. 300 mg/8hr/iv
- Isoniazid 1x 150 mg
Hb : 12,8 Albumin: 2,9 g/dL Amikasin (16/11/2011):
- Isoniazid 1x 150 mg
- Rifampicin 1 x 300 mg - Rifampicin 1 x 300 mg
-Nasograstric tube (NGT) was inserted
- Pyrazinamid 1 x 450 mg Day 1: 20 mg/kgBW – 320 mg/day/iv
on 13/11/2011 because the patient did
Day 2: 15 mg/kgBW – 240 mg/day/iv
- Folic Acid 1 x1 mg - Folic Acid 1 x1 mg
not eat for the whole day
- Multivitamin without Ferum 1 x Cth II - Multivitamin without Ferum 1 x Cth II
- F100 diet 240cc/3hrs/oral - F100 diet 240cc/3hrs/oral or NGT
- Gentamicin cream 2x/day - Gentamicin cream 2x/day
- Lacto B 3 x 1 sachet - Lacto B 3 x 1 sachet
- Resomal 100-200 cc/x diarrhea - Resomal 100-200 cc/x diarrhea

Further - Laboratorium Result (12/11/2011): - Repeat Chest X-Ray
evaluation Hb/Ht/L/Plt : 12,8/ 38,9/17410/305000 - Blood culture, sensitivity test
Albumin : 2,9 g/dL -Combination of Antibiotics with
Na / K / Cl : 128/ 2,8/ 92 Amikasin (16/11/2011):
-Nasograstric tube (NGT) was inserted on 13/11/2011 because the patient did not Day 1: 20 mg/kgBW – 320 mg/day/iv
eat for the whole day Day 2: 15 mg/kgBW – 240 mg/day/iv

Date 17-20 November 2011 21-26 November 2011
S Diarrhea(-) Abdomen distended Diarrhea(-) Abdomen distended
O Sens :Alert, T:36,8 C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:52cm
0
Sens :Alert, T:36,80C, BW:17kg, BL: 130 cm, BW/BL: 55.57% LLT:52cm
LLD:50cm LLD:50cm
Head
Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil (Right=Left), Face: Old man face (+) Eye: Light reflexes (+), isochoric pupil
paleness of conjunctiva inferior palpebra (-/-), icteric sclera(-/-). (R=L), paleness of conjunctiva inferior palpebra (-/-), icteric sclera(-/-).
Neck
Lymph nodes enlargement(-), Dried lesion can be seen on the right neck, JVP: R- Lymph nodes enlargement(-), Dried lesion can be seen on the right neck,
Thorax 2 cm H2O JVP: R-2 cm H2O
Symmetrical fusiform, retraction (-) HR: 96 bpm, regular, murmur (-) RR: Symmetrical fusiform, retraction (-) HR: 96 bpm, regular, murmur (-)
Abdomen 26 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly. RR: 26 tpm, regular, rales (-/-), Intercostal ribs can be seen clearly.
Extremities Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and Distension(+),ascites(+), shifting dullness (+),normal peristaltic, Liver and
spleen: not palpated. spleen: not palpated.
Pulse: 96 bpm, regular, adequate pressure and volume, warm acral, oedema (-), Pulse: 96 bpm, regular, adequate pressure and volume, warm acral, oedema
pale(-) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy muscle (+),
thin subcutaneous fats(+), Normal physiology reflex :APR/ KPR (+),Pathologic (-), pale(-) CRT: < 3’, BP: 100/70mmHg, Baggy pants (+), hypotrophy
reflexes (-) muscle (+), thin subcutaneous fats(+), Normal physiology reflex : APR/KPR
(+), Pathologic reflexes(-)
A Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition marasmic- Pulmonary Tuberculosis + Scrofuloderma with Severe malnutrition
kwashiorkor type marasmic-kwashiorkor type
P - O2 1-2L per minute (if needed) - O2 1-2L per minute (if needed)
- Meropenem Inj. 300 mg/8hr/iv - Meropenem Inj. 300 mg/8hr/iv
- Isoniazid 1x 150 mg - Isoniazid 1x 150 mg
- Rifampicin 1 x 300 mg - Rifampicin 1 x 300 mg
- Pyrazinamid 1 x 450 mg The patient was discharged from Adam - Pyrazinamid 1 x 450 mg
- Ethambutol 1 x 300 mg - Ethambutol 1 x 300 mg
- Folic Acid 1 x1 mg
Malik Hospital on her own request on 26 - Zinc tablet 1 x 20mg
- Folic Acid 1 x1 mg
th

of November 2011 - Multivitamin without Ferum 1 x Cth II
- Gentamicin cream 2x/day - Gentamicin cream 2x/day
- Lacto B 3 x 1 sachet - Lacto B 3 x 1 sachet
- Resomal 100-200 cc/x diarrhea aff(17/11) - Amikasin 250 mg/day/iv
- Amikasin 350 mg/day/iv (D1:17/11/11)

Further Re-check lab
evaluation

THEORY CASE
Children are most vulnerable to the effects of S, 11 years old girl, with 15 kg body weight and
undernutrition in infancy and early childhood and 130 cm body height originated from
globally the most important risk factor for illness Indonesia(developing country).
and death, contributing to more than half of deaths
in children worldwide. In developing countries,
more than 50% of the 10 million deaths each year
are either directly or indirectly secondary to
malnutrition

The diagnosis of TB in children relies on The diagnosis of tuberculosis in this patient was
careful and thorough assessment of all the evidence made based on history taking where a low grade
derived from a careful history, clinical fever and mild cough was experienced by the
examination and relevant investigations, e.g. patient since 2 years ago and weight loss since 1
Tuberculin Skin Test(TST), chest X-ray year ago. History of contact with a tubercular
and sputum smear microscopy. patient/prolonged coughing adult was also
found.
Chest X-Ray shows a result of an active
specific process and mantoux test was
also done.

Most children who develop tuberculosis disease Patient has lesions on her right neck with serous
experience pulmonary manifestations, but 25-35 discharge and the dermatologist diagnosed it as
percent of children have an extrapulmonary scrofuloderma(cutaneous tuberculosis)
presentation.

THEORY DISCUSSION
The diagnosis of malnutrition can be made from The patient experienced weight loss since 1
history taking, physical examination, year ago , decreased of appetite was also
antropometrical measurement and laboratory found since 6 months ago. According to physical
finding. In physical examination, we look for findings in this case, it was found that the patient
sign of dehydration, fever, skin changes, muscle has an old man face, pale conjunctiva
hypotrophy, and oedema.The antropometrical palpebra inferior, intercostal ribs can be
measurement will show the growth failure of the seen clearly, ascites, baggy pants,
child. The child’s weight for her height under 70%. hypotrophy muscle and thin
subcutaneous fats. In antropometrical
measurement. the child's weight for her
height is 55,55 % which indicates of severe
malnutrition.

Management of severe malnutrition are by doing This patient was firstly treated in the stabilization
10 essential steps in line with the guideline of phase in which dehydration were assesed and
malnutrition management from Department treated subsequently. IVFD D5% NaCl 0.45% was
of Health Republic of Indonesia . given for electrolyte balance. To treat or prevent
dehydration, this patient is given ReSoMal 100 cc
each time diarrhea occurrs . To correct
micronutrients deficiencies, this patient was
given Zinc, vitamin A 100.000 IU, and
multivitamin without ferum. Feeding started by
giving milk-based formula F-75 containing 75
kcal/100 cc and in the rehabilitation phase,
milk-based F-100 contains 100 kcal is given to
achieve very high intakes and rapid weight gain.

Case report pp

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