* Corresponding Author
Challenge in diagnosing tuberculosis on a boy with severely wasted in limited resource area
https://doi.org/10.19106/JMedSci005402202208 Marini Siagian(1*), Norman Tanyadji(2)
(1) Oksibil District General Hospital, Pegunungan Bintang, Papua
(2) Department of Pediatric, Oksibil District General Hospital, Pegunungan Bintang, Papua
(*) Corresponding Author
Abstract
Hunger and malnutrition are still the leading cause of morbidity and mortality among children around the world. Undernutrition increases the risk of tuberculosis (TB) which in turn could worsen undernutrition. Indonesia is currently the second highest newly diagnosed TB in the world after India. TB in children with severely wasted is difficult to diagnose. This is a case report about a 35-month-old boy with severely wasted complicated with hypoglycemia, severe dehydration, and pneumonia. After proper nutritional management without the expected outcome, patient was then worked up for TB resulting negative result of tuberculin skin test (TST). Nevertheless, he was still treated with antituberculosis and had significant improvement, hence continuation to complete 6 mo period of therapy. This case report describes the challenge of diagnosing TB in children with severely wasted in limited resource areas. The reduced immune responses, due to severely wasted, caused subtle clinical signs of TB and decreased sensitivity to tuberculin testing. The unavailability of radiologic examination added further problem in diagnosis. The diagnosis of TB should be considered among children in areas with a high prevalence of TB, presenting with severely wasted refractory to proper nutritional management.
Keywords
Full Text:
PDFReferences
1.Kementerian Perencanaan Pembangunan Nasional (Bappenas)/UNICEF. Laporan baseline SDG tentang anak-anak di Indonesia. Jakarta: BAPPENAS dan UNICEF, 2017.
Available from: https://www.unicef.org/indonesia/sites/unicef.org.indonesia/-files/201906/SDG_Baseline_report%20Indonesian.pdf
2.UNICEF/WHO/World Bank Group. Levels and trends in child malnutrition: UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates: Keys Findings of the 2020 edition. Geneva (Switzerland): UNICEF/WHO/World Bank, 2020 [cited 2020 Dec 02]. Available from: https://apps.who.int/iris/rest/bitstreams/1273507/retrieve
3.Kementrian Kesehatan Republik Indonesia. Pedoman pencegahan dan tatalaksana gizi buruk pada balita. Jakarta: Kementrian Kesehatan Republik Indonesia, 2019. Available from: Pedoman pencegahan dan tatalaksanan gibur pada balita.pdf. [cited 2020 Dec 05].
4.Kementrian Kesehatan Republik Indonesia. Riset kesehatan dasar 2018. Jakarta: Kementerian Kesehatan Republik Indonesia 2019. Available from: http://www.depkes.go.id/resources/download/info-terkini/. [cited 2020 Dec 07].
5.Badan Pusat Statistik Provinsi Papua. Papua dalam angka 2020. Irian Jaya: Badan Pusat Statistik Provinsi Papua; 2020. Available from: https://papua.bps.go.id/publication/download. [cited 2020 Dec 10].
6.UNICEF. Regional report on nutrition security in ASEAN, Vol 2. Bangkok: UNICEF, 2016 Available from: https://www.asean.org/storage/2016/03/Regional-Report-on-Nutrition-Security-in-ASEAN-Volume-2.pdf. [cited 2020 Dec 12].
7.Kementrian Kesehatan Republik Indonesia. Pedoman pelayanan gizi pada masa tanggap darurat Covid-19. Kementerian Kesehatan Republik Indonesia; 2020. Available from: https://covid19.go.id/storage/app/media/Materi%20Edukasi/pedoman-pelayanan-gizi pada-masa-tanggap-darurat-pandemi-covid-19-13-05-2020.pdf. [cited 2020 Dec 12].
8.Patel LN & Detjen AK. Integration of childhood TB into guidelines for the management of acute malnutrition in high burden countries. Public Health Action 2017; 7(2):110-5.
https://doi.org/10.5588/pha.17.0018
9.Kementerian Kesehatan Republik Indonesia. Pedoman Nasional Pelayanan Kedokteran Tatalaksana Tuberkulosis. Kementerian Kesehatan Republik Indonesia; 2019. Available from: https://rsparudungus.jatimprov.go.id/wp-content/uploads/2020/03/KMK-No.-HK.01.07-MENKES-755-2019-ttg-Pedoman-Nasional-Pelayanan-Kedokteran-Tata-Laksana-Tuberkolosis-1.pdf
10.WHO. Global tuberculosis report 2020. Geneva: World Health Organization, 2020. Available from: https://apps.who.int/iris/rest/bitstreams/1312164/retrieve
11.Roya-Pabon CL, Perez-Velez CM. Tuberculosis exposure, infection and disease in children: a systematic diagnostic approach. Pneumonia 2016; 8:23
https://doi.org/10.1186/s41479-016-0023-9
12.Chisti MJ, Salam MA, Shahid ASMSB, Shahunja KM, Das SK, Faruque ASG, et al. Diagnosis of tuberculosis following world health organization-recommended criteria in severely malnourished children presenting with pneumonia. Global Pediatric Health 2017; 4:2333794X16686871.
https://doi.org/10.1177/2333794X16686871
13.Maqbool A, Parks EP, Shaikhkhalil A, Panganiban J, Mitchell JA, Stallings VA. Nutritional requirements. In: Kliegman RM, ST Geme JW, Shah SS, Tasker RC & Wilson KM, editors. Nelson textbook of pediatrics. 21 ed. Philadelphia: Elsevier Inc, 2020; 55:303-21
14.Worku BN, Abessa TG, Wondafrash M, Vanvuchelen M, Bruckers L, Kolsteren P, et al. The relationship of undernutrition/psychosocial factors and developmental outcome of children in extreme poverty in Ethiopia. BMC Pediatrics 2018; 18(1):45.
https://doi.org/10.1186/s12887-018-1009-y
15.Blaney S, Menasria L, Main B, Chhorvann C, Vong L, Chiasson L, et al. Determinants of undernutrition among young children living in South Nikum District, Siem Reap, Cambodia. Nutrients 2019; 11(3):685.
https://doi.org/10.3390/nu11030685
16.Ngo J, Serra-Majem L. Hunger and Malnutrition. In: Ferranti P, Berry EM, Anderson JR, editors. Encyclopedia of Food Security and Sustainability. Philadelphia: Elsevier Inc. 2019:315-35.
17.Matarese G. Leptin and the immune system: how nutritional status influences the immune response. Eur Cytokine Netw 2000; 11(1):7-14.
18.Maurya R, Bhattacharya P, Dey R, Nakhasi H. Leptin function in infectious disease. Front Immunol 2018; 9:2741.
https://doi.org/10.3389/fimmu.2018.02741
19.Rodríguez L, Cervantes E, Ortiz R. Malnutrition and gastrointestinal and respiratory infections in children: a public health problem. Int J Environ Res Public Health 2011; 8(4):1174-205.
https://doi.org/10.3390/ijerph8041174
20.Valeria D, Ugo C, Claudio R. Acute malnutrition in children: Pathophysiology, clinical effects and treatment. Nutrients 2020; 12(8):2413.
https://doi.org/10.3390/nu12082413
21.WHO. Revised WHO classification and treatment of childhood pneumonia at health facilities: Implications for policy and implementation. Geneva: World Health Organization, 2014. Available from: https://apps.who.int/iris/bitstream/handle/. [cited 2021 May 22].
22.Chisti MJ, Tebruegge M, Vincente SL, Graham SM, Duke T. Pneumonia in severely malnourished children in developing countries-mortality risk, aetiology and validity of WHO clinical signs: a systematic review. Trop Med Int Health 2009; 14(10):1173-89.
https://doi.org/10.1111/j.1365-3156.2009.02364.x
23.Arpitha G, Rehman MA, Ashwitha G. Effect of severity of malnutrition on pneumonia in children aged 2M-5Y at a tertiary care center in Khammam, Andhra Pradesh: a clinical study. Sch J App Med Sci 2014; 2:3199-203
24.Artawan, Purniti PS, Sidiartha IGL. The relationship between nutritional status with pneumonia severity in children at Sanglah Hospital, Bali, Indonesia. Sari Pediatri 2016; 17(6):418-22.
25.Lloyd AV. Tuberculin test in children with malnutrition. Br Med J 1968; 3(5617):529-31.
https://doi.org/10.1136/bmj.3.5617.529
26.Kumbhojkar SM, Sarawade S, Khalate S. A study of mantoux test reaction in protein energy malnutrition. IJHSR 2016; 6(2):78-83.
27.Mandal N, Anand PK, Gautam S, Das S, Hussain T. Diagnosis and treatment of peadiatric tuberculosis: an insight review. Crit Rev Microbiol 2017; 43(4):466-80.
https://doi.org/10.1080/1040841X.2016.1262813
28.NTP & WHO Bangladesh. National guidelines for the management of tuberculosis in children. Second edition. Bangladesh; NTP and WHO Bangladesh, 2016 Avaible from: https://www.who.int/docs/default-source/searo/bangladesh/pdf-reports/year-2016-2018/national-guidelines-for-the-management-of-tuberculosis-in-child.pdf?sfvrsn=fa4456b8_2 . [cited 2021 May 23].
29.WHO. Guidance for national tuberculosis programmes on the treatment of tuberculosis in children. Second edition. Geneva: World Health Organization, 2014. Avaible from; https://apps.who.int/iris/bitstream/handle/10665/112360/ 9789241548748 eng.pdf?sequen. [cited 2021 May 23].
30.Global Laboratory Initiative. GLI model TB diagnostic algorithms. Global Laboratory Initiative, 2018. Avaible from;http://www.stoptb.org/wg/gli/assets/documents/ gli_algorithms.pdf. [cited 2021 May 27].
31.Oshikoya KA, Senbanjo IO. Cation when treating tuberculosis in malnourished children. Arch Dis Child 2018;103(12):1101-3.
https://doi.org/10.1136/archdischild-2018-314972
32.Oshikoya KA, Sammons HM, Choonara I. A systematic review of pharmacokinetics studies in children with protein-energy malnutrition. Eur J Clin Pharmacol 2010; 66(10):1025-35.
https://doi.org/10.1007/s00228-010-0851-0
33.Roy V, Gupta D, Gupta P, Sethi GR, Mishra TK. Pharmacokinetics of isoniazid in moderately malnourished children with tuberculosis. Int J Tuberc Lung Dis 2010; 14(3):374-6.
34.Graham SM, Bell DJ, Nyirongo S, Hartkoorn R, Ward SA, Molynuex EM. Low levels of pyrazinamide and ethambutol in children with tuberculosis and impact of age, nutritional status, and human immunodeficiency virus infection. Antimicrob Agents Chemother 2006; 50(2):407-13.
https://doi.org/10.1128/AAC.50.2.407-413.2006
35.Mukherjee A, Velpandian T, Singla M, Kanhiya K, Kabra SK, Lodha R. Pharmacokinetics of isoniazid, rifampicin, pyrazinamide and ethambutol in Indian children. BMC Infect Dis 2015; 15:126.
https://doi.org/10.1186/s12879-015-0862-7
DOI: https://doi.org/10.19106/JMedSci005402202208
Article Metrics
Abstract views : 1389
| 
views : 1622
Copyright (c) 2022 Marini Siagian, Norman Tanyadji
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.