Syntax Literate: Jurnal Ilmiah Indonesia p–ISSN: 2541-0849 e-ISSN:
2548-1398
Vol. 9, No. 4, April2024
CASE REPORT: MILLIARY TB IN
ADOLESCENCE DIAGNOSED IN TAPIN, SOUTH KALIMANTAN, A CALL FOR TB AWERENESS
Rony Trilaksono1, Karina Mayang Sari2
Universitas Gadjah Mada,
Yogyakarta, Indonesia1
RSUD Datu Sanggul, Kab
Tapin, South Kalimantan, Indonesia2
Email:
[email protected]1, [email protected]2
Abstract
This case report presents the
clinical scenario of a 15-year-old adolescent admitted to the emergency room
with complaints of shortness of breath and a persistent productive cough for
the past 3 weeks, despite over-the-counter medication. The cough did not improve
with over-the-counter medication. He also sometimes noticed blood stains in his
phlegm. During the physical examination, a BCG scar was found on the right
upper arm. The results showed that positive HIV status and the absence of BCG
scars were significantly associated with miliary TB and extrapulmonary TB.
However, in this case, both factors were not detected. The treatment regimen
for miliary TB requires therapy for a minimum of 12 months, but teenagers
experience difficulties in undergoing therapy due to the consumption of illegal
drugs every day for a long period of time. Apart from that, social isolation
and disrupted daily activities are also challenges for teenagers. The death
rate from miliary TB in children reaches 15-20%, highlighting the importance of
awareness of this disease. Therefore, handling and treating TB in adolescents
requires special attention and further efforts to reduce the risk of treatment
failure. Awareness of TB, especially in adolescents with chronic respiratory
symptoms, must be increased to overcome this challenge in the future.
Keywords: TB, Billion TB, Teenagers
Introduction
Tuberculosis (TB), or what is often
called TB, is one of the main causes of death due to lung infections. Indonesia
is ranked second for the highest number of TB cases in the world after India (Baliasa et al., 2021; Santjoko et al., 2024). In 2022, more than 724,000 new TB cases were reported, and
this figure increased to 809,000 cases in 2023. This number is much higher
compared to cases before the pandemic, where the average discovery was below
600,000 per year. The TB detection procedure is similar to Covid-19 detection,
where if testing, detection and reporting are not carried out properly, the
number of recorded cases will be low, causing a lack of actual data reporting
and resulting in TB sufferers not receiving appropriate treatment, which in the
end at risk of transmitting the disease because it is not treated (Rokom, 2024).
Miliary tuberculosis (Milier TB) is a pathological condition characterized by the presence of small granulomas the size of millet seeds, which are yellowish in color, and can be found scattered in various organs of the body. This is caused by the spread of Mycobacterium tuberculosis through blood vessels and lymph nodes. The term "milier TB" was first used by John Jacob Manget in the 18th century, derived from the Latin "milierius" meaning related to millet seeds. Miliary TB is often fatal and can attack organs that have many phagocytic cells in the sinusoid walls (Pratiwi & Ramadhani, 2024).
The cause of miliary TB is the spread of Mycobacterium tuberculosis complex bacilli. This bacillus is rod-shaped or slightly curved, has a length of around 2-5 µm, and a thickness of around 0.2-0.3 µm (Azizah, 2018). Mycobacterium tuberculosis is aerobic, does not move, does not form spores, and does not have a protective layer. Miliary TB that occurs due to primary infection usually has an acute and progressive start, while miliary TB that occurs due to reactivation can cause episodic or chronic symptoms. Symptoms tend to be non-specific and generally include fever, weight loss, loss of appetite, and weakness. Other symptoms can vary depending on the organ infected by TB (Pratiwi & Ramadhani, 2024).
Children have a higher risk of
experiencing Miliary Tuberculosis (Milier TB) (Utami et al., 2021). Although national TB programs in almost all countries do
not prioritize childhood TB, because they are not the main cause of TB
transmission in the community, this view is not entirely accurate. Handling TB
in children has an important role in the TB control program for several
reasons. Children have a high risk of being infected with TB, especially
infants and toddlers. Children infected with TB have the potential to
experience severe TB disease and have fatal consequences or long-term
disability. Apart from that, teenagers (aged 10-19 years) are also susceptible
to TB disease, generally in an infectious form and can transmit this disease to
people around them (Kementerian Kesehatan, 2023).
Based on the above, a case report
was carried out regarding Miliary TB in teenagers diagnosed in Tapin, South
Kalimantan to increase awareness of the importance of tuberculosis (TB) in
society. Through this case, it is hoped that it can clarify the condition of
Miliary TB in adolescents as well as the challenges faced in the diagnosis,
treatment and management of this disease in this area. Another aim is to
provide better information to the public regarding the symptoms, spread and
treatment of Miliary TB, as well as to encourage appropriate preventive
measures and treatment. Moreover, this research aims to present a case of TB in
an adolescent, discussing the clinical presentation, diagnosis, treatment
challenges, and implications for management.
Case Report
History
M.A.G, a 15-year-old boy presented to the emergency room
with a chief complaint of shortness of breath. He had been suffering productive
cough in the last 3 weeks. The cough was not improved by over-the-counter
medication. He also witnessed stains of blood in the sputum sometimes. He lost
almost 10 kgs despite his normal appetite. He also complained of fatigue easily
after doing light daily activities. He lives with his parents and a
nine-year-old brother. He was previously a healthy child with no history of
hospitalization. The other family member in the house did not show any symptoms. The parents denied any history of
allergic disease in the family. His basic immunization record was not available
upon admission but the mother recalls a complete immunization based on national
immunization program. He also received 2 doses of COVID-19 immunization this
year. He is a normal 10th grader without any trouble in terms of
following subjects in school. He is a passive cigarette smoker in his peer
group. He denied any close contact with either a tuberculosis patient or a
confirmed covid-19 patient. He was sexually inactive. He never received any
blood component transfusion.
Physical examination
Upon admission, he seemed breathless but still able to talk
in full phrases. His vital sign showed tachycardia (heart rate 135
times/minute), tachypnea (respiratory rate 25 times/minute), decrease oxygen
saturation at room air (91-92%), normal axilla temperature (36.8°C), and normal
blood pressure (96/66 mmHg). His current
body weight was 41 kg and his height was 172cm. Based
on the CDC growth chart, his ideal body weight based on his actual height was
58 kg. His BMI was 13.8 kg/m² which was less than the 5th percentile
on the BMI/age of CDC curve. The chest movement was symmetrical with mild
intercostal retraction. No palpable mass on the chest wall. The ronchi can be
heard in all lung fields. No heart murmur on auscultation. A BCG scar was noted
on the right upper arm. Neither lymph node enlargement nor joint inflammation was
present. His fingers were normal, no organomegaly, and there was no jugular
vein pressure increment. The other systemic examination was normal.
Working Diagnosis and Investigations
1.
Working diagnosis:
a.
Pulmonary tuberculosis
b.
Pneumonia
c.
COVID-19 infection
d.
Lung carcinoma
2.
Investigations:
a.
Blood test
Table 1. Blood test result
|
Parameter |
Result |
Normal
range |
|
Hemoglobin
(g/dl) |
12.2 |
12.8-16.8 |
|
Leukocyte
(10³/ul) |
21.5 |
4.5-12.5 |
|
Lymphocyte
(%) |
13 |
|
|
Granulocyte
(%) |
69 |
|
|
Mid
(%) |
18 |
|
|
Erythrocyte
(10⁶/ul) |
4.44 |
3.8-5.8 |
|
Hematocrit
(%) |
35 |
33-45 |
|
Thrombocyte
(10³/ul) |
385 |
140-392 |
|
SGOT
(U/l) |
49 |
<50 |
|
SGPT
(U/l) |
51 |
<50 |
|
Urea
(mg/dl) |
24 |
8-24 |
|
Creatinine
(mg/dl) |
0.6 |
0.62-1.1 |
|
Rapid
HIV test |
Non
reactive |
Non
reactive |
b.
SARS-Cov-2 Antigen swab test:
Negative
c.
SARS-Cov-2 PCR swab test: Not
available
d.
Sputum smear microscopy test:
Positive for acid-fast bacill
e.
Rapid molecular test (Xpert MTB/RIF
with sputum specimen): MTB detected high. Rifampicin resistance not detected
f.
Thorax X-ray: miliary TB appearance,
no pleural effusion.
Figure 1. Thorax X-ray
Final diagnosis, management, and progress
The patient was admitted to an isolation room due to
suspicion of pulmonary infectious diseases. He was initially treated with
supportive care and antibiotics for pneumonia which were intravenous
Ceftriaxone (50mg/kg body weight/12 hours) and Azithromycin (15mg/kg body
weight/24 hours in day 1 then 7.5 mg/kg body weight/24 hours) orally for 5
days. The final diagnosis was miliary Tuberculosis (TB) based on the
investigation panels. The TB drugs were started on day 3 of hospitalization
with the regimen of 2RHZE / 10RH. He takes 3 tablets of fixed-dose combination
TB drugs daily. The patient was discharged on day 7. We report the case to the district health
officer and local primary health care to plan close contact investigations and
observe TB drug compliance.
Results and
Discussion
In the case of a 15-year-old boy and still a 10th grade
student, data to the emergency room because he had complaints of shortness of
breath. Although shortness of breath his vital signs showed tachycardia (heart
rate 135 times/minute), tachypnea (respiratory rate 25 times/minute), decreased
oxygen saturation in room air (91-92%), normal axillary temperature (36.8°C),
and normal blood pressure. Based on the diagnosis, it was found that the boy
had lung tuberculosis, pneumonia, covid-19 infection, and lung carcinoma. So the patient was put into isolation due to suspected
pulmonary infectious diseases. Then, the final diagnosis based on the
investigation panel was miliary tuberculosis (TB).
Tuberculosis (TB) remains a health problem globally with
more than 5 million people are newly diagnosed with TB. Our country, Indonesia,
ranks 2nd in the world for TB incidence with 312 per 100,000
population. TB may have a broad spectrum of symptoms which may similar to other
infectious diseases. In our case, the patient showed respiratory symptoms which
lasted for around 3 weeks accompanied by significant loss of weight. A
particular x-ray appearance can highly suggest miliary TB. A study conducted in
Sanglah Hospital Bali concluded that positive HIV status and no BCG scar were
associated significantly with miliary TB and extrapulmonary TB (Utami et al., 2021). However, in our case both factors were absent.
Tuberculosis (TB) is a major cause of morbidity and
mortality worldwide. TB is a disease caused by the pathogenic germ
mycobacterium tuberculosis (Diantara et al., 2022). Miliary TB occurs when the bacteria spread through the
bloodstream, affecting multiple organs throughout the body. Miliary TB may
present as overt adrenal insufficiency (Addison's disease) at first onset or
during antitubercular treatment. Manifestations include skin hyperpigmentation,
hypotension, hypoglycemia, and electrolyte imbalance (Vohra & Dhaliwal, 2024).
Miliary tuberculosis is a form of tuberculosis characterized by widespread spread into the human body with small size lesions (1-5 mm), the name comes from the characteristic pattern seen on chest x-ray of many small spots distributed throughout the lung fields with an appearance similar to millet seeds, thus called 'miliaria' TB. Miliary tuberculosis is a type of tuberculosis that varies from slowly progressive infection to acute fulminant disease, it is caused by hematogenous or lymphogenous spread of infected vessels into the bloodstream and affects multiple organs (Arsyad & Fauzar, 2018).
TB treatment is the most efficient way to cure, reduce the
spread of TB-causing bacteria, prevent death and drug resistance. TB treatment
requires a relatively long period of time with two stages of treatment, namely
the intensive stage and the advanced stage to avoid relapse. Treatment must be
adequate and generally drugs are given in the form of an OAT blend containing
at least 4 types of drugs to prevent resistance. Treatment with a combination
of drugs can prevent resistance but can increase the possibility of drug side
effects. Side effects will affect the patient's adherence to taking medication.
Most patients who complain of mild and severe side effects often choose to
discontinue treatment for fear that if the treatment is continued it will get
worse and they cannot bear to continue (Ningsih et al., 2022).
The DOTS (Directly Observed Treatment Short Course) strategy
is a direct supervision of short-term treatment with the obligation of every
tuberculosis program manager to focus attention (direct attention) in an effort
to find patients with microscope examination. Then each patient must be
observed in swallowing the medicine, every medicine swallowed by the patient
must be in front of a supervisor. Patients must also receive treatment that is
organized in the management system, distribution with sufficient supply of
drugs, then each patient must receive good drugs, meaning standard short-term
treatment (short course) that has been clinically proven to be effective.
Finally, there is an absolute need for government support to make TB control
programs a high priority in health services (Inayah & Wahyono, 2019).
TB management is all health efforts that prioritize
promotive and preventive aspects, without neglecting curative and
rehabilitative aspects aimed at protecting public health, reducing morbidity,
disability or death, breaking transmission, preventing drug resistance and
reducing the negative impact caused by Tuberculosis.
Multidrug-resistant tuberculosis is treated with second-line treatment. This treatment is less effective than first-line drugs and has far more side effects. The treatment phases in this case were intensive phase and continuation phase. The intensive phase is carried out for at least 6 months with a drug combination of pyrazinamide, ethambutol, kanamycin, levofloxacin, ethionamide, and cycloserine and 18 months of follow-up phase with a drug combination of pyrazinamide, ethambutol, levofloxacin, ethionamide, and cycloserine (Sari, 2021).
The treatment regimen for miliary TB requires at least 12
months of therapy. This long period of daily drug consumption is a challenge
for adolescents. They may lose follow-up or have poor compliance during 12
months of therapy. Furthermore, isolation from peer groups, school activities, and
other daily activities can also be frustrating for some adolescents (Snow et al., 2020). The mortality rate of miliary TB in children is 15-20%.
Hence, proper monitoring and good compliance are essential.
The incidence of tuberculosis is influenced by several
factors. The first factor of tuberculosis is age because the highest incidence
of tuberculosis is in young adulthood. In Indonesia, it is estimated that 75%
of tuberculosis patients are in the productive age group. The second factor is
gender which affects more men than women, because most have smoking habits. The
third factor is the habit of smoking, which can reduce the body's resistance,
making it easy to get sick, especially in men who have a smoking habit. The
fourth factor is the density of occupancy, which is an environmental factor,
especially in people with tuberculosis, namely M. tuberculosis germs can enter
houses that have dark buildings and no sunlight entering. The fifth factor is
occupation, which is a risk factor for direct contact with patients. The sixth
factor is economic status, which is the main factor in the family, as low
income can infect people with tuberculosis because small income makes people
unable to fulfill health requirements (Sejati & Sofiana, 2015).
The diagnosis of tuberculosis (TB) in adolescents with
numbers reaching billions in Tapin, South Kalimantan, highlights the escalation
of a public health problem that requires serious attention. This phenomenon
underscores the urgency to raise awareness of TB, both in terms of prevention,
detection and treatment. This reflects complex challenges within the health
system, including access to appropriate health services, appropriate
information about TB, and adequate support for treatment and monitoring. The
call for TB awareness is becoming increasingly urgent in an effort to reduce
the spread of the disease in the community, as well as to ensure that infected
individuals receive appropriate and timely care. Collaboration between
governments, health institutions, communities, and non-governmental
organizations is needed to develop a holistic and sustainable strategy to
tackle TB, strengthen public health systems, and achieve the global goal of
eliminating TB.
Conclusion
A study conducted at Sanglah Hospital in Bali found that
positive HIV status and the absence of BCG scars were significantly associated
with miliary TB and extrapulmonary TB. However, in our case, both factors were
not detected. The treatment regimen for miliary TB requires therapy for a
minimum of 12 months. Daily use of illegal drugs over long periods of time is
challenging for adolescents, who may have difficulty engaging in therapy over
long periods. Apart from that, isolation from peer groups, school activities,
and other daily routines can also cause feelings of frustration in some
teenagers. The death rate due to miliary TB in children reaches 15-20%.
Therefore, TB is a critical disease and must be paid attention to, especially
in children with chronic respiratory symptoms, especially in Indonesia. To
reduce the risk of treatment failure, more efforts are needed in the management
and treatment of adolescents suffering from TB.
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Copyright holder: Rony Trilaksono, Karina Mayang Sari (2024) |
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