兒科學(xué)教學(xué)課件：Cases Presentation

CasesPresentationCaseHistoryCase1:2y8mboy,fever,can’twalk,abdominalpain×15ds,andprogress×3dsBornandgrownupinGuizhouprovince.

Dateofadmittance:Mar23th,2012Historyofpresentillness15dsago,hecouldn’twalk,developedabdominalpain,mildfeverandcough.?obvioussweat,?seizure/personalitychangeTreatedaslowerlimbspainofunknownwithAbxbyoutpatientdoctorw/oimprovement.PastmedicalhistoryHealthyBCGimmunization?closecontactactiveTBBirthHistory:normalSocialhistory

livingconditionispoorSocioeconomicstatusislowerPhysicalExaminationHepatosplenomegaly,Babinskisign(+),decreasedmuscletoneandstrength(3/6)oflowerlimbsChest:goodairentrybilaterally,?crackle/wheeze

Familymedicalhistory:Parents:

HisfartherhadpulmonaryTBin2009andbeencured.Motherishealthy.NosiblingWhat’syourpossiblediagnosis?LowerlimbspalsyofunknownIntracranialinfection?Guillain-BarreSyndrome?Intracranialspace-occupying?Transversemyelitis?InvestigationCBC:Hb96,WBC10.2N69%,Plt420PPD:pendingBiochemistry:normalSerologyforCP,MPandLegionella:all+veTBAntibodies:(-)CSFanalysis:cell2/μl,protein:1364.2(),AFB(-).Mar24th,2012CTscan:NormalAnovalsheetopacitiesatprecordium,suggestingCTscanMar24th,2012Maybeatumor?Neuroblastoma?MediastinalmultiplelymphnodecalcificationMar24th,2012ThoracicvertebratuberculosisMar24th,2012ColdabscessformationColdabscessformationMar24th,2012Whatisyourdiagnosis?PulmonaryTBThoracicvertebraTBColdabscessformationCase2CaseHistory:10yearsgirl,vomitingx6dBornandgrownupinSuburbanofJinhuaCity,ZhejiangProvince,parentsarehealthy.

Dateofadmittance:Jun8,2011Historyofpresentillness6dago,Shedevelopedvominting,1-2times/d,nofeverandcough.?obvioussweat,?seizure/personalitychange,lostweighforlast4wks(BW:19.5kg)TreatedasVomitingofunknown,possibleacutegastritiswithAbxandLosecbyoutpatientdoctorw/oimprovement.PastmedicalhistoryHealthy?BCGimmunizationNoclosecontactactiveTBBirthHistory:normalFamilymedicalhistory:Parents

Healthy

Socialhistory

livingconditionispoorSocioeconomicstatusislowerPhysicalExaminationNospecifichintChest:goodairentrybilaterally,?crackle/wheeze

CNS:NormalWhat’syourdiagnosis?Acutegastritis?Intracranialspace-occupying?Pancreatitis?Investigation3CBC:Hb120,WBC

11.7N89.6,Plt540PPD:8mmAmylaseanalysis:normalinserumandurine

Biochemistry:Normal

MiliaryTBTenthThoracicvertebraedestructionwithparavertebralabscessJun8,2011BrainCTScanRighthemispheremultiplesheethypodenseJun8,2011CTscanQ1:

Whatisyourdiagnosis?MiliaryTBTuberculosisMeningitisThoracicvertebraTBparavertebralabscessCase3CaseHistory:11monthsgirl,Feverandcoughx4wksBorninCanada,parentsandgrandparentsimmigratedtoCanadafromChina10yrsago.

Dateofadmittance:Sep15th,2008PastmedicalhistoryHealthy?BCGimmunizationClosecontactactiveTB(sputum+ve)betweenJunandAug2008BirthHistory:normalHistoryofpresentillness4wksago,Shedevelopedmildfeverandnonproductivecough,1wklater,highfever,almosteveryday.?obvioussweat,?seizure/personalitychangeTreatedasapossibleUTI(urineWBC10-20/HPF,UCx:NG)withAbxontwocoursesbyBCCHandGPdoctorw/oimprovement.GrowthcurverFamilymedicalhistory:Parents

MomPPD+,onINHprophylaxis

DadPPD-,hasasthmaand?“hepatitis”MaternalgrandfatherjustdiagnosedactiveTB(sputumsmear+ve),hedidn’ttakeanti-TBmedicinebefore.3yrsbrother,healthy,onINHprophylaxis.Socialhistory

livingconditionispoorSocioeconomicstatusislowerPhysicalExaminationNospecifichintChest:goodairentrybilaterally,?crackle/wheeze

InvestigationCBC:Hb112,WBC

14.7N6.59,Plt551PPD:3mmUrineanalysis:normal

Urineacidfastnessbacillistain:-veUrineCx:NGLFT:ALT12,AST44,alkphos161,GGT16LDH1185,bilirubin<2SerologyforHBV,HCV,HIV:all-vethepatchyareaaboveandlateraltotherighthilum

wouldbeconsistentwithTB

Sep12Q1:

Whatisyourdiagnosis?PulmonaryTBQ2:FurtherinvestigationGastricwashsmear:AFB2+,2+,3+TBculture:pendingTBPCR:pendingFinalDiagnosisTuberculosis,clinicallyactive.NeverreceivetherapyPulmonaryPositivebacteriologicstatusbyMicroscopy(Sep17,18,19/08)ChestX-lay:abnormal,non-cavityPPDnegative(3mm)Q2PPD(-),why?DXofTBinChildrenisChallengingClinicalsymptomandsignaremorevariable.PPD(-)doesnotdefinitelyruleoutTBinfection,about10-20%ofchildrenwithTBdevelop-vePPDreaction.Difficulttogettheorganism,forchildrenrarelyproducesputum.PPDfalsenegativefactorsFalsepositiveBCGNontuberculousmycobacteriaTellthedifference:basedsolelyonthesizeofPPD,epidemiologicandclinicalfeaturesmustbeweight.DiagnosisLevelPresumableDX:Exposurehistory,PPD,SymptomsandsignClinicalDX:Images+presumableevidencesConfirmedDX:Smear,orculture,orhistologyQ6:

WheredidthemgetTB?Oftenfromadult,byhouseholdcontactsEducationparentsTreatabledisease,6-9months,Takemedicineregularly,DOTNutritionSideeffectsRecurrenceDrug-resistance(chromosomalanddrugselectiveresistant)FollowupRecommendeddosagesandadverseeffectsof

first-lineDrugsinchildrenandadolescentsWHO2006KeycontentsforreviewThecommonclinicalmanifestationsofprimarypulmonarytuberculosis.Thecommonclinicalmanifestationsanddiagnosticimagingofpulmonarytuberculosis.Howtodefinitethepositivetuberculinskintestresults.Pleasedescribetheclinicalmanifestationsofreactivationpulmonarytuberculosis.1.Pleasedescribethecommonclinicalmanifestationsofprimarypulmonarytuberculosis

①I(mǎi)t’susuallyanasymptomaticinfectioninolderinfantsandchildren;②OftenthediseaseismanifestedbyapositiveTSTwithminimalabnormalitiesonthechestradiograph,suchasaninfiltratewithhilarlymphadenopathyorGhoncomplex.;③Malaise,low-gradefever,erythemanodosum,orsymptomsresultingfromlymphnodeenlargementmayoccurafterthedevelopmentofdelayedhypersensitivity.2.Pleaselistthecommonclinicalmanifestationsanddiagnosticimagingofpulmonarytuberculosis

①Thecommonclinicalmanifestations:malaise,cough,low-gradefever,erythemanodosum,weightloss,nightsweat,lymphadenopathy,orsymptomsresultingfromlymphnodeenlargement.②Specificimagechanges:Ghoncomplex(aninfiltratewithlymphadenopathy),hilarlymphadenopathy,bilateralmilitaryinfiltrates,partialbronchialobstructioncausedbylymphadenopathy,cavitation,calcification,andpleuraleffusion.3.Howtoidentifythepositivetuberculinskintestresultsininfants,children,andadolescents.Dependsontwofactors:diameteroftheindurationandperson’sriskofbeinginfected.

①I(mǎi)nduration≥5mmispositiveinhighestriskperson,suchasrecentcontactwithTBdisease,immunosuppressiveconditionsandsuspectedtohaveTBdisease;Whichmeanstheinfectionprogressingtodisease;②Induration≥10mmispositiveinchildrenwithincreasedexposuretoTBdisease.Inchildren<4yearsofageorimmunosuppressiveconditions,Induration≥10mmmeanshighr