Chapter 4

Cough or difficult breathingCase III

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

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

Stages in the management of a sick child (Ref. Chart 1, p. xxii)

1. Triage

2. Emergency treatment

3. History and examination

4. Laboratory investigations, if required

5. Main diagnosis and other diagnoses

6. Treatment

7. Supportive care

8. Monitoring

9. Plan discharge

10. Follow-up

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

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

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

.

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 kgChest: dullness to percussion and increased breath sounds over right chest at the back, crackles throughoutCardiovascular: two heart sounds were heard, but chest very cracklyAbdomen: palpable liver 4 cm below the RCMNeurology: tired but alert; responds with a quiet voice

Examination

• List possible causes of the illness

• Main diagnosis

• Secondary diagnoses

• Use references to confirm (Ref. p. 109-111)

Differential diagnoses

Differential diagnoses (continued)

• TB

• Asthma

• Foreign body

• Pertussus

• HIV

• Bronchiectasis

• Lung abscess

(Ref. p. 110)

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)

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

Investigations • Pulse oximetry (SpO2 : 93% at rest, falls to

88% on exertion)

• Chest x-ray:

(Ref. p. 116)

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)

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)

How would you treat Mary?

Treatment

• How many drugs in intensive phase for Mary’s 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

What supportive care and monitoring are required?

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)

Monitoring treatment and complications

• Adherence: Direct observation of each dose

• Temperature

• SpO2

• Weight gain

(Ref. p. 117)

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)

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)

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)

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 <5 years and no evidence of active TB)