Chapter 4 Cough or difficult breathing Case III

1. Chapter 4Cough or difficult breathingCase 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: 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

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. 109-111)

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. 115-116)

15. 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)

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)