Primary Complex Thread 3

[leletmd]

@lez101:
I suggest you have the xray plates reviewed by a pulmonologist to make sure that you really have no TB. Please tell the plumonologist that your child was recently diagnosed as having PC so you are trying to find the source of her exposure.

@mariefranchesca_soberano@:
Please bring your son to the pedia for a follow up check up. Your pedia is the best person to determine whether or not your child is having an adverse reaction/side effect to the PC meds or having a gastrointestinal infection.

@purplepink888:
Did he have problems gaining weight before he turned 1 year old? How is his appetite? Is he a picky eater? Did he take all these multivitamins at the same time or papalit palit?
How is his length? At par ba daw with age? What is his ideal weight per length? Mas accurate kasi to look at the weight based on the length/height and not based on the age.
Starting at 1 year of age, kids only gain about 2 kilos/year so mas mabagal talaga ang weight gain compared to the first year of life.

[rhylie10]

good pm doc leletmd;-) sorry kung out of topic po ako hindi po ako sure, worried lang kasi baka mahawa daughter ko, inuubo po kasi ako more than 2 weeks na po nilalagnat po sa gabi hirap huminga, then nagpacheck up po ako, nagpa x-ray, sabi po sa result ng x-ray ko may PTB daw po, pero pagdating naman po sa doctor ko kung siya daw tatanungin wala naman daw po di ko daw need magtake ng gamut, para daw sure pa CT Scan daw po, so nagpa CT scan nga po ako, ito po result: 1. Multiple  axial images reveal a generally well-aerated lung fields with no evidence of active infiltrate or mass. 2. There are few linear densities or fibrosis in the left interior lingual and interior left lower lobe. 3. there is no focal bronchiectasis or bulla formation. No bronchial wall thickening is noted. 4. the mediastinal lymph nodes, heart and great vessels are not enlarged. There is no pleural effusion.
the ribs and thoracic spine are intact.
IMPRESSION:
1. NO ACTIVE LUNG INFILTRATE AND MASS
2. MINIMAL PULMONARY FIBROSIS..

sa x-ray po kasi PTB

[leletmd]

^ Fibrosis is most commonly due to scarring in the tissue, usually due to old infection. Wala naman kasing active infiltrates na nakita which would indicate a new infection. Best to bring the CT scan and the chest xray to the pulmo para ma-correlate with your history and physical examination.

[rhylie10]

thanks for the reply dra lelet. old infections po ba? hindi ko po pala nasbai na, January nagpa x0ray din po ako sa work po kasi, clear naman po.. then May 2014 po ulit clear, minsan po kasi yung phlegm ko may blood stain, minsan lang naman po yun, so x-ray po ulit ako ng September 2014 clear din po yun, pero nitong October lang nagtagal ubo ko kaya po x-ray ulit requested by pulmo, may PTB then C scan naman po mild fibrosis, kung old infections po bakit po kaya hindi nadetect sa mga naunang x-ray ko? sorry po

[leletmd]

^ It takes a while for fibrosis to take place so it is really possible na clear ang previous chest xrays.
Pwede ka rin magpacheck ng sputum AFB smear mo to see if may live acid fast bacilli or TB. Ask mo na lang sa Pulmo mo if kailangan pa ito.

[sky_butterfly17]

Hi doc, considered po ba na qualification ng PTB ang monthly cough and colds from aug-nov? His pedia suggested to have a clinical trial of PTB Meds sa knya, kasi he is not gaining weight still 15kg at 3 yr and 10 months. Pero hindi po bumababa weight nya

[leletmd]

^ Gaano katagal na siyang 15 kgs?
Starting at 1 year of age kasi, kids gain only 2 kgs/year compared to the first year of life wherein mabilis talaga ang growth spurt. At his age, pasok pa sa ideal weight for age ang 15 kgs.
What is his height? Ano daw ang ideal weight for height niya? Better gauge of growth kasi ang weight for height compared to weight for age.
May mga tests bang ginawa like chest xray or ppd? Or based lang sa monthly cough from august to november? Wala ba siyang allergic rhinitis or asthma?

@rhylie10:
It takes a while for fibrosis to develop. Sometimes years, sometimes months kaya yung initial xrays can really be clear. Just the same, I suggest you have the plates and the ct scan evaluated by the pulmo kasi iba pa rin talaga ang one on one consultation. Your doctor is the best person to discuss the radiologic findings with you kasi dapat nacocorrelate with clinical findings and hindi basta basa lang ng labs or xray. Sabi nga, we treat the patient/person, not the labs.

[m_lim]

nagpa 3rd opinion na ako kasi kontra ang sinasabi ng Pulmo and Pedia ni baby.

suggest ni Pulmo, ipa Quantiferon test kasi invalid daw ipa PPD si baby dahil sa BCG vaccine. si Pedia naman, enough na daw ang PPD.

since 13mm nga ang PPD ni baby, positive nga daw. she only gave Comprilex kasi negative anG Xray, positive PPD.

lalo lang ako na confuse sa 3rd opinion (Pedia-Pulmo) kahapon. although na confirm niya na no need for Quantiferon, pinapa dagdagan naman ang gamot ni baby. Kids Kit na tinatawag, basta 3 ang gamot sa kit.

kinontra rin niya ang suggestion ng Orig Pedia na magpa Xray sa Feb. kasi hindi naman daw dapat magbase sa Xray kung lumaki or lumiit ang mga kulani. parang bunch of grapes daw kasi yon, impossible daw makuha mo ang size ng 1grape sa black & white film.

sinabi rin niya na usually daw na oovertreat ang mga bata pag nagbbase sa Xray.  basta daw tapusin ang 6months treatment, ok na daw yun.

hindi klaro ang explanation niya sa question ko na paano malalaman kung magaling na si baby after the 6month treatment? (or baka hilo na rin ako kaya hindi klaro saken)

she also mentioned na up to 10years magiging positive pag nagpa PPD ulit once nagka primary complex or TB kaya no use rin magpa PPD ulit.

kanya kanya daw kasing approach ang doctors sa pag treat ng primary complex or Tb. wala daw standard procedure kumbaga.

kampante na sana ako dito kay Pedia-Pulmo since specialization nga niya yun, pero bigla niya sinabi na After meals ang Comprilex. eh sabi ko baket prescribed ni Pedia, before breakfast??? tinawag pa niya sa pharmacy or whatsoever para itanong ang tamang pag inom ng gamot. kaloka.

sino ba talagang tama sa kanila?

[gharz412]

Doc,
 
Yung baby ko din po may sipon siya this month for almost 2 weeks at the same time yung weight niya lang is 7.8 1 year and 1 month siya. Before medyo kampante ako pag sinasabi ng pedia niya na okay pa yung weight niya kase according sa birth weight niya 2.2kgs lang siya 37 weeks ko siya nilabas. Is it possible ba talaga na dahil maliit ko siya nilabas kaya ganyan lang weight niya and pwede din daw sa genes kase hindi kame parehong katangkaran ng papa niya. Hindi din kase palakain baby ko, nido junior milk niya now tapos pinadagdagan niya ng pediasure once a day with heraclene. After 2 months pag hindi padin siya naggain papa skin test na siya. Medyo kinakabahan ako about this.

[leletmd]

@gharz412:
If her birth weight is 2.2 kgs, she should at least be 8.8 kgs by 1 year of age, that is if she is able to meet the expected weight gain per month which is 6oo grams per month for the 1st 6 months and 500 grams per month from 6 months to 12 months of age. After the 1st year of life, a child is expected to gain at least 2 kgs/year. Try to check her baby book if she is able to meet the expected weight gain per month.
Ano ang length niya?
I suggest to encourage her to eat properly kasi baka kailangan lang ayusin ang eating habits niya for her to gain weight.

@m_lim:
Did the pedia pulmo offer any explanation as to why she wanted to treat as active disease? Did your baby manifest with any symptoms suggestive of PC such as poor weight gain, poor appetite, easily gets sick, has enlarged neck lymph nodes, etc.
I agree na hindi talaga routine na magpa-ulit ng chest xray at 6 months of treatment. Better kasi to check if nawala or nag-improve ang initial symptoms (the ones that made us suspect PC in the first place). Example, did the baby gain weight during treatment? Did her appetite and well being improve? Did she become less sickly compared to prior to treatment? If yes, then based on that alone, pwede na magmake ng decision to stop treatment after 6 months. No need for repeat chest xray kasi may mga times na hindi basta basta nawawala ang initial findings (radiologic lag) sa xray.
With regards to PPD, we don't usually repeat it because of the risk of booster response (having a greater induration to previous PPD exposure/injection) but if negative ang initial finding, may times na inuulit (2 step process) just to be sure na hindi false negative. The fact na 13mm ang PPD size and may maga pa rin ito a week after injection is a sign na it is a true positive.
There is a Phil TB consensus with guidelines on how to treat PC or TB.
Comprilex or Isoniazid is given at least 30 minutes before breakfast for good absorption. It may also be given at least 2 hours after a meal. The only time it may be taken with food is if it produces gastric discomfort or an upset stomach.
Better siguro to stick to your original pedia since she knows your baby better than the other 2 doctors you went to.

[m_lim]

^hi doc! hindi sakitin si baby pero underweight daw according to Dr. Lily Lao (pedia pulmo) 24lbs lang kasi siya at 2yrs old. 7.9lb birth weight niya. mahirap rin pakainin, kailangan matyaga magsubo habang inaaliw para lang kumain.

since negative Xray, positive PPD siya, infected siya but no disease yet. tama po ba?

eto po kasi ang summary ng sabi ng mga docs:

comprilex only- Pedia
kids kit3- pedia pulmo and family friend pulmo

baket po kaya both si pedia pulmo and family friend pulmo, active disease ang approach nila?

[m_lim]

got your PM po doc. so clear na po na ang treatment po dapat ay kids kit3 dahil meron siyang clinical signs.

medyo hindi po kasi ako kampante sa pedia niya dahil :

bakit hindi na binanggit na may mga kulani si baby?

bakit hindi niya tinreat as disease kahit na may clinical signs

[leletmd]

^ During her previous check ups with the pedia, wala bang binabanggit tungkol sa lymph nodes or tungkol sa weight niya? Medyo mababa kasi talaga ang weight niya as a 2 year old if her birth weight is 7.9 lbs. She should at least be 12 kgs by now. 10 kgs ang target weight at 1 year old. Did she just start to manifest weight lag at 2 years old or she really had poor weight gain even before?

[m_lim]

^totally walang nabanggit about lymph nodes

kaya nga po naging kampante ako dahil every month nasa kanya kami for vaccine. wala naman sinasabi saken.

ako pa nagtanong about baby's weight. ok naman daw kasi girl. kaya akala ko hindi underweight.

gulat na gulat nga ako nung sinabi ni pedia pulmo Dr. Lily Lao na madaming kulani si baby.

nagpa 3rd opinion naman po kami kanina kay Dr. Alex Koa Lee. gusto ko ang pag explain niya. klaro sa akin.

negative ang reading ng Xray pero nung tiningnan niya, hindi daw pasado sa kanya kasi dami nga lymph nodes. and kahit na mag negative Xray at PPD positive lang, kailangan daw i-treat as disease kasi:

sa age ni baby (super liit pa daw)
sa weight
3 adults siya na exposed. the yaya and 2 drivers na lahat stay in. 1.5yrs pa exposed kay yaya na direct contact at diabetic and overweight rin kaya mas madami daw bacteria ang na ccarry.

so Kids Kit 3 ang gamit namin starting tom. praying gumaling na si baby at mag gain ng weight kasi papayat ng papayat

[leletmd]

^ It's good that you were able to find a good pedia pulmo who was able to address your concerns.
Based on what you have shared so far, she was able to fulfill 3 out of the 5 criteria

1. history of symptoms related to PC or TB -poor weight gain, exposure to TB patients
2. physical examination suggestive of PC or TB - presence of lymph nodes, low weight compared to age or height
3. positive PPD

Tama din na dinala niyo ang xray plates or CD kasi dapat binabasa pa rin ito and hindi nagbabase sa findings ng radiologist. There are times na doctors do not agree with the radiologist findings. Depends din kasi sa xray plates or cd na ginamit and expertise ng bumasa ng plates. Dyan pumapasok ang importance ng clinical correlation.
If your yaya has diabetes, then her immune system is down if hindi controlled ang blood sugar niya. Pwede kasing mag cause ng secondary immunodeficiency ang diabetes and that would make her prone to getting infected. I hope you can facilitate the sputum collection for your yaya and drivers, too, to monitor their treatment response.
I hope your baby responds well to treatment.

[m_lim]

^thank you po doc!!

the yaya po, wala na po ako balak pabalikin kasi may edad na rin (she's 53) and diabetic pa. but im willing to help her with her meds and labs. kawawa rin kasi.

but the 2 drivers, medyo mahirap paalisin kasi kailangan sila sa office.

eto po questions ko:

sa sputum test po ba makikita kung anong level or gaano na kalala ang TB?

2weeks lang ba talaga sila nakakahawa or depende kung mas malala na ang TB , mas matagal sila dapat i-isolate?

sa January po kasi ang scheduled balik ng 2drivers. based po sa recommendation ng pulmo na 2-week isolation period. but im worried since hindi pa sila na sputum test, baka malala na ang TB nila at hindi enough ang 2weeks.

[leletmd]

^ You're welcome.
There is a grading system used in the AFB sputum smear which shows the load of TB bacilli found in the sputum collection. Ideally, though, this should have been done prior to starting treatment. Pwede kasi itong gamitin to monitor treatment (kung nabawasan na ba ang load ng bacilli from time of treatment to repeat sputum collection). Ideally meron din AFB culture para makita kung sensitive ba sila sa meds na binigay. Matagal nga lang lumabas ang culture results since it may 2 months for TB to grow in a culture as opposed to AFB smear na mabilis lang ang results.
Ilan ang meds na binigay sa kanila ng pulmo? 3 or 4 meds?
Yung 2 weeks na hindi na infectious or contagious ay for those with uncomplicated infection. With those with more TB bacilli load, it would depend on how well their immune system takes care of the infection. Dapat may follow up sila sa pulmo nila before you have them report back to work.

[m_lim]

^isang gamot lang po yung binigay. but sa pagkakaintindi ko, 4 na gamot yun na pinagsasama sa 1tablet. Quad-something yung brand.

since nakauwi na po sila, January ko nalang sila ipapa-sputum test.

sana enough na ang 2weeks isolation nila.

thanks again Doc and Merry Christmas!

[guiding star]

Hi Doc Lelet.

My son had a bad cough last January so her pedia requested for a X-ray test. This was the result; there are interstitial densities seen in the retro cardiac region, nodular densities are seen along the tracheobronchial region. Impression: bilateral interstitial pneumonia, nonspecific mediastinal lymphadenopathis.The pedia said he is positive with PC both in X-ray and PPD. He was prescribed to take pedia kit 3, he has been taking this for 4 weeks. But now I am concerned since he have cold & cough again for a week. He have history din of atopic dermatitis and allergic rhinitis so I'm confused if allergy unit ito.
And also, why he was not treated with pneumonia when the X-ray says he had it? Same na po ba Ito with PC?

His pedia is out of the country so I'm planning to tAke him to another pedia. Hope you can enlighten me with my concerns.

[smile22]

Thank God. my 4yo daughter's xray after 6mos of medication is now normal. inuubos nalang yung kidz kit 2 and in a matter of 3 days siguro ubos na yung gamot. God is good!