Chapter 4 Cough or difficult breathing Case III

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Chapter 4Cough or difficult breathingCase III
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Case study
Mary is an 8 year old girl with cough and weight
loss for some weeks
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• What are the stages in the management in Marys
  case?

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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

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Have you noticed any emergency (danger) or
priority (important) signs?
Temperature 37.8 0C, 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
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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

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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. Marys appetite had been poor in
  recent weeks, and she had lost weight.
• Marys grandmother had been treated for TB when
  Mary was 4 years of age. Marys parents and
  younger brother (age 4) and sister (age 2) are
  well
• .

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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
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Differential diagnoses

• List possible causes of the illness
• Main diagnosis
• Secondary diagnoses
• Use references to confirm (Ref. p. 109-111)

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Differential diagnoses (continued)

• TB
• Asthma
• Foreign body
• Pertussus
• HIV
• Bronchiectasis
• Lung abscess

(Ref. p. 110)
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Additional questions on history

• Night sweats?
• Purulent sputum?
• History of choking or sudden onset of symptoms?
• Wheeze?
• Personal or family history of asthma?
• Paroxysms of cough?
• Any other symptoms of HIV (e.g. persistent
  diarrhoea, mouth sores)
• Vaccinations (? BCG, ? DTP)

(Ref. p. 110)
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What investigations would you like to do to make
your diagnosis ?
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Investigations

• Pulse oximetry (SpO2 93 at rest, falls to 88
  on exertion)
• Chest x-ray

(Ref. p. 116)
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Investigations

• Mantoux test
• Sputum smear for acid fast bacilli
• In younger children, gastric aspirate or Induced
  sputum
• for smear microscopy
• Xpert MTB / Rif if available and if MDR suspected
• HIV testing should be offered

(Ref. p. 115-116)
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Diagnosis

• Summary of findings
• Cough for months, unresponsive to antibiotics
• Family history of TB
• Chest crackles
• Clubbing
• Pulmonary Tuberculosis (Ref. 4.7.2, p. 115)

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How would you treat Mary?
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Treatment

• How many drugs in intensive phase for Marys
  PTB, and what does this depend on?(check p. 117)
• Four if high HIV prevalence or high H
  resistance, or severe lung disease
• Rifampicin (R), Isoniazid (H), Pyrazinamide (Z),
  Ethambutol (E)
• For 2 months, followed by RH for 4 months

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What supportive care and monitoring are required?

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Supportive Care

• Oxygen
• Nutritional support
• Ready-to-use-therapeutic feeds (Plumpy-nut)
• Schooling, entertainment and privacy while in
  hospital
• Staff protection p50 mask until sputum smear
  negative (check weekly)

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Monitoring treatment and complications

• Adherence Direct observation of each dose
• Temperature
• SpO2
• Weight gain

(Ref. p. 117)
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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)
• lt5 years of age, household or close contacts
• No active TB
• 6 months Isoniazid preventative therapy

(Ref. p. 117)
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Contact screening

• On further questioning Marys mother had cough,
  and sputum smear was heavily positive for TB
• Marys sister and brother were clear of symptoms,
  and were well nourished and active
• Marys 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 lt5 years, start IPT
• If symptoms refer for CXR, Mantoux.

(Ref. p. 117)
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Follow-up

• When can Mary be discharged?
• Completed Intensive Phase (2 months)
• Nutrition improved
• Not hypoxic, with good exercise tolerance
• Family screening done
• Education
• A program of active follow-up, where a health
  worker visits Mary and her family at their home,
  can reduce defaulting from TB treatment. During
  follow-up at home or in the hospital, health
  workers can do the following things(Ref. p. 118)

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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.
• A missed opportunity for prevention, as Mary did
  not have screening and IPT when her grandmother
  was treated for TB
• Directly Observed Therapy. Registration with
  NTP
• Active case finding and follow-up needed for
  child and family
• TB treatment for mother, also HIV negative
• ITP for sister and brother(both lt5 years and no
  evidence of active TB)