1. Chapter 4 Cough or difficult breathing Case III

2. Case study:
Mary is an 8 year old girl with cough and weight loss for some weeks

3. What are the stages in the management in Mary’s case?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Plan discharge
Follow-up

5. Have you noticed any emergency (danger) or priority (important) signs?
Temperature: C, pulse: 136/min, RR: 50/min with mild chest indrawing and use of accessory muscles to breathe, thin looking. Speaks in short sentences, but with a quiet voice

6. Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing
Severe respiratory distress
Central cyanosis
Signs of shock
Coma
Convulsions
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable,
lethargic
Referral
Malnutrition
Oedema of both feet
Burns

7. History
Mary has had cough for months. She has difficult breathing on exertion, and her mother said she had not been playing as much as before, and had not attended school for 3 weeks. She had received 2 courses of medicine, the last one 2 weeks ago, but the cough persisted. She sometimes felt hot and perspired a lot according to her mother. Mary’s appetite had been poor in recent weeks, and she had lost weight.
Mary’s grandmother had been treated for TB when Mary was 4 years of age. Mary’s parents and younger brother (age 4) and sister (age 2) are well .

8. Examination
Mary had mild chest indrawing, but moderate use of accessory muscles, which increased when she moved to sit up on the bed. She had no cyanosis, but had finger clubbing.
MUAC: 12.5 cm, Weight 20 kg
Chest: dullness to percussion and increased breath sounds over right chest at the back, crackles throughout
Cardiovascular: two heart sounds were heard, but chest very crackly
Abdomen: palpable liver 4 cm below the RCM
Neurology: tired but alert; responds with a quiet voice

9. Differential diagnoses
List possible causes of the illness
Main diagnosis
Secondary diagnoses
Use references to confirm (Ref. p )

10. Differential diagnoses (continued)TB
Asthma
Foreign body
Pertussus
HIV
Bronchiectasis
Lung abscess
(Ref. p. 110)

11. Additional questions on history
Night sweats?
Purulent sputum?
Wheeze?
Personal or family history of asthma?
Paroxysms of cough?
Other symptoms of HIV (e.g. persistent diarrhoea, mouth sores)
Vaccinations (? BCG, ? DTP)
(Ref. p. 110)

12. What investigations would you like to do to make your diagnosis ?

13. Investigations
Pulse oximetry (SpO2 : 93% at rest, falls to 88% on exertion)
Chest x-ray:
(Ref. p. 116)

14. Investigations Mantoux test Sputum smear for acid fast bacilli
In younger children, gastric aspirate or induced sputum
smear microscopy for acid-fast bacilli
GeneXpert MTB/Rif if available and if MDR suspected
HIV testing should be offered
(Ref. p )

15. Diagnosis Summary of findings:
Cough for months, unresponsive to antibiotics
Family history of TB
Chest crackles
Clubbing
Pulmonary Tuberculosis (Ref , p. 115)

16. How would you treat Mary?

17. Treatment
How many drugs in Intensive Phase for Mary’s PTB, and what does this depend on? (check p. 117)
Intensive Phase: Four drugs for 2 months if: high HIV prevalence or high H resistance, or severe lung disease
Rifampicin (R), Isoniazid (H), Pyrazinamide (Z), Ethambutol (E) – now dispensed as Fixed Dose Combination Therapy (see Standard Treatment Manual for exact doses)
Maintenance Phase: RH for 4 months

18. What supportive care and monitoring are required?

19. Supportive Care Oxygen Nutritional support
Ready-to-use-therapeutic feeds (Plumpy-nut), balanced diet
Schooling, entertainment and privacy while in hospital
Mary must stay in hospital for the full 2 months of the Intensive Phase
Many children relapse if sent home before completing IP, and develop worse forms of TB
Staff protection: wear N95 mask until sputum smear negative (check weekly)

20. Monitoring treatment and complications
Adherence: Direct observation of each dose
Temperature
SpO2
Weight gain
(Ref. p. 117)

21. Public health measures
Register every TB patient with National TB Program and Disease Control Office
Check all household contacts, and school contacts if appropriate, for undetected TB
Who should receive Isoniazid preventative therapy? (Ref. p. 118)
<5 years of age, household or close contacts
No active TB
6 months Isoniazid preventative therapy
(Ref. p. 117)

22. When to suspect MDR
History of previous treatment for TB within the past 6-12 months
Close contact with MDR-TB
Close contact with a person who has died from TB, or failed TB treatment
Failure to improve clinically after 2-3 months of 1st-line TB treatment, including:
Persistence of +ve smears or cultures
Persistence of symptoms
Failure to gain weight
(xray changes often are slower to improve)
(Ref. p. 117)

23. Contact screening
On further questioning Mary’s mother had cough, and sputum smear was heavily positive for TB
Mary’s sister and brother were clear of symptoms, and were well nourished and active
Mary’s father was well, normal chest xray
Contact screening can be “symptom-based screening” if x-ray and sputum microscopy not available
If no symptoms and child <5 years, start IPT
If symptoms refer for CXR, Mantoux.
(Ref. p. 117)

24. Follow-up When can Mary be discharged?
Completed Intensive Phase (2 months)
Nutrition improved
Not hypoxic, with good exercise tolerance
Family screening done
Reliable and committed community treatment supervisor identified
A program of “active follow-up”, where a TB outreach nurse visits Mary and her family at their home, can reduce defaulting from TB treatment. During follow-up at home or in the hospital, TB outreach nurse can do the following things… (Ref. p. 118)

25. Summary
Mary, 4 year old girl with weight loss and chronic cough. Pulmonary TB. Severe lung disease (so 4 drugs in intensive phase), HIV negative.
Can only be properly treated by 2 full months of hospital care during the IP – so make hospitals child friendly and safe.
While in hospital identify a reliable and committed community treatment supervisor
Regular follow-up in the home by a TB outreach nurse

26. Summary
A missed opportunity for prevention, as Mary did not have screening and IPT when her grandmother was treated for TB
Active case finding and follow-up needed for Mary’s family. TB treatment for mother, also HIV negative. ITP for sister and brother (both <5 years and no evidence of active TB)