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A Case Report
Presented by:
Kadek Ayu Atrie Swarita, dr.
Consultants:
Figure 4. Chest X-ray of patient's on 5th day of admission after got five days antibiotic reveal lobar
pneumonia right lobe superior
After optimal pneumonia treatment, she still had fever with temperature 38.5 oC.
Blood culture revealed no bacteria. Due to lack of improvement on patient’s condition, a
decision was taken to do an evaluation of probable other infection such as tuberculosis.
Mantoux test revealed 10 mm induration, and first AFB smear was negative. Second AFB
smear microscopy was positive one and Xpert MTB/RIF assay result was positive with
rifampicin suseptibility detected. Four-drug antituberculous therapy (rifampicin,
isoniazid, pyrazinamide, and ethambutol) was started. After 2 days four-drug
antituberculous therapy, her fever decreased, and after afebrile for 48 hours, she was
discharge. Antituberculous treatment was continued for intensive phase using 4-drug
fixed-dose combination (FDC) and sent the patient to respirology outpatient clinic for
next evaluation.
DISCUSSION
Patients 2-year-and-2-month-old girl. Patient came with chief complaint
dyspnea in the last 10 days before admission, cough in the last 5 days before
admission, and fever until 390 C. Physical examination on admission revealed a
weak child and fine moist rales in upper region of both lungs. According to the
anamnesis and physical examination this patient was diagnosed pneumonia.
In pneumonia, the symptomps were cough or difficult breathing of less
than 14 days, and fever. Absence of fever makes pneumonia less likely. 15,16
Auscultation of all lung fields should be performed, listening for crackles (rales)
or crepitations, the presence of which correlates with pneumonia.15
Children aged 2–24 months are at increased risk for infections. 17 The
etiologic agents of pneumonia depend on the patient’s age. In children ages 3
months to 5 years, 50% to 60% of cases are associated with viral respiratory
infections. In school-aged children (>5 years), atypical organisms. 6,7,15
Predispositions to pneumonia such as acquired immunodeficiency have been
reported in 40–92% of the children.16,18,19
Children with pneumonia have body temperature ≥38.0oC, leukocytosis
(WBC count ≥ 10,500/mL) and infiltrate on chest radiograph.15 Laboratory
examination from this patient revealed leukocytosis (white blood count
25.360/cm3) and neutrophil dominant (67%), increased CRP level (258.99 mg/dl)
and chest x-ray in AP position revealed uniform opacity with air-bronchogram on
right upper lobe consistent with lobar pneumonia. In our cases, this patient was
aged 2 years 2 months old, so it could be included to the risk of viral infection.
But from laboratory examination this patient revealed bacterial infection.
Pneumonia can be caused by many pathogens, mainly bacterial and
viruses. 15 Bacteria are the most common cause of pneumonia. Streptococcus
pneumoniae are the most common cause of bacterial pneumonia in the United
States.20,21 Streptococcus pneumoniae, classically associated with a cough
productive of rust-colored sputum. Staphylococcus aureus is known to be an
important cause of pneumonia. There is no doubt that the organism can cause
pneumoniae, often very severe pneumoniae with abscesses and pneumatocoeles
within the lung. 16 Mycoplasma pneumoniae is a major etiologic agent behind
community-acquired pneumonia.21 Clinical manifestation of atypical pneumonia
shows gradual symptoms from days to weeks, dominated by constitutional
symptoms such as myalgia, malaise, severe headache, non-productive cough, and
low-grade fever. 20 The bacterial pneumonia score (BPS) is a clinical assessment
comprised of several investigations: age, assessment of axillary temperature,
absolute neutrophil count, band neutrophil percentage, and interpretation of
radiological examination. The score will use to differentiate the etiology of
pneumonia.21,22
Initial treatment antibiotic empirically was recommended to all patient
with pneumonia. All patients with pneumonia are at risk to be infected by typical
or atypical pathogens.23 In our case, initial treatment pneumonia evaluation did
not respond well.
Clinical improvement should be evaluated as early respond to initial
treatment. The clinical picture should show decrease of respiratory rate, decrease
of fever, and better appetite. Evaluation done within 48-72 hours after empirical
treatment started. Children with unresponsive to initial treatment should be
considered of other cause of pneumonia including differential diagnosis such as
heart defect or foreign substance aspiration. History taking, physical examination,
and chest x-ray should be reevaluated, and do other diagnostic test based on
indication. Other possible etiologies of unresponsive to initial treatment of
pneumonia are viral, atypical pneumonia, tuberculosis. 16 In our cases, we
suggested this patient suffered atypical pneumonia.
On average, a virus can be found in 40-50% of acute lower respiratory
tract infections (ALRI) cases seen at clinics or hospitals. Respiratory syncytial
virus (RSV) is the leading cause of viral ALRI, followed by parainfluenza virus,
influenza virus, adenovirus. In earlier years’ measles also played a major role in
childhood pneumonia. Where measles control activities have broken down this
can be expected to return as a major cause of pneumoniae. 16
Atypical pneumonia is pneumonia caused by atypical organism that are
not detectable by standard diagnostic of pneumonia and generally do not respond
to beta-lactam antibiotics. Atypical pneumonia can be diagnosed from history,
physical, laboratory, and radiologic examination. Radiologic examination in
atypical pneumonia does not show a specific sign. Infection caused by M.
pneumonia usually only affect one lobe of lung, radiology examination show
reticular consolidation.23 On laboratory examination, atypical pneumonia does
not show a specific sign.24 In our cases, according to the laboratory and
radiological examination this patient was diagnoses atypical pneumonia.
Atypical pneumonia incidence quite high and not all center has facilities
to diagnose atypical pathogen. Experts consider starting antibiotic treatment
empirically to all patients with pneumonia who still able to be treated as atypical
pneumonia. There are 3 classes of empirical antibiotic for atypical pneumonia;
they are macrolide, quinolone, and tetracycline.23 In this case we give macrolide,
but the antibiotic therapy did not respond well. So we suggested probably other
disease such as pulmonary tuberculosis.
Tuberculosis (TB) is a global health concern for both developing and
developed countries and has recently become more complex due to persistence in
aging populations and the rise of drug-resistant strains. In clinical practice, rapid
TB diagnosis can be difficult, and early pulmonary TB detection continues to be
challenging for clinicians. Prompt diagnosis of active pulmonary TB is a priority
for TB control, both for treating the individual and for public health intervention
to reduce further spread in the community.25
Table 1. Sign and Symptom Tuberculosis.6
Clinical Feature or Disease Type Infants Children Adolescents
Symptom
Fever Common Uncommon Common
Night sweats Rare Rare Uncommon
Cough Common Common Common
Productive cough Hemoptysis Rare Rare Common
Dyspnea Never Rare Rare
Common Rare Rare
Sign
Rales Common Uncommon Rare
Wheezing Common Uncommon Uncommon
Decreased breath sounds Common Rare Uncommon
Location of Disease
Pulmonary Common Common Common
Pulmonary + Extrapulmonary Common Uncommon Uncommon
Gejala sistemik yang didapatkan pada TB yaitu berat badan turun atau
tidak naik dalam 2 bulan sebelumnya atau gagal tumbuh (failure to thrive)
meskipun telah diberikan upaya perbaikan gizi yang baik dala waktu 1-2 bulan,
demam lebih dari 2 minggu dan atau berulang tanpa sebab yang jelas, batuk lama
lebih dari 2 minggu dan bersifat non remitting dan sebab lain batuk telah dapat
disingkirkan, batuk tidak membaik dengan pemberian antibiotika atau obat asma,
malaise, anak kurang aktif bermain. Gejala TB ekstraparu dapat dijumpai gejala
dan tanda klinis yang khas pada organ yang terkena. Tuberkulosis kelenjar
biasanya di daerah leher (regio colli), pembesaran PKG tidak nyeri, konsistensi
kenyal, multiple, dan kadang saling melekat (konfluens), ukuran besar terlihat
jelas bukan hanya teraba, tidak berespon terhadap pemberian antibiotika, bisa
terbentuk rongga dan discharge. Tuberkulosis sistem saraf pusat seperti gejala
pada pasien meningitis. Tuberkulosis sistem skeletal, spondilitis didapatkan
gibbus, koksitis tanda peradangan di daerah panggul, gonitis bengkak pada lutut
tanpa sebab yang jelas. TB kulit (skrofuloderma) ditandai adanya ulkus dengan
jembatan kulit antar tepi ulkus (skin bridge). 14 Pada kasus ini didapatkan anak
demam lebih dari 14 hari termasuk selama perawatan di RS, batuk lebih dari 14
hari termasuk selama perawatan di RS, dan penurunan berat badan 1.5 kg dalam 2
minggu sehingga dugaan kearah pulmonary TB.
The diagnosis of TB in children relies on history physical examination as
well as any relevant investigations tuberculin skin test (TST) or Mantoux test,
acid-fast-bacilli (AFB), Xpert MTB/RIF assay and chest x-ray. Even though
microbiological diagnosis is not always feasible, all efforts should be made to do
sputum microscopy where possible in children with suspected pulmonary
tuberculosis. A trial treatment with anti-TB drugs is not recommended as a
method of diagnosing TB in children.26 In this case, mantoux test revealed 10
mm induration, and AFB smear I was negative. Second AFB smear microscopy
was positive one and X-pert MTB/RIF assay result was positive with rifampicin
susceptibility detected. So we assessment the patient as pulmonary tuberculosis.
10–99/100 fields 1+
1–10/field 2+
>10/field 3+