Dr Usama Zafar- Child Specialist, Azad Kashmir Mirpur (2026)

11/04/2026

*ڈاکٹر اسامہ ظفر — میرپور آزاد کشمیر کے معروف چائلڈ اسپیشلسٹ*

*ڈاکٹر اسامہ ظفر* میرپور، آزاد جموں و کشمیر کے ایک نامور کنسلٹنٹ چائلڈ اسپیشلسٹ ہیں، جو اپنے شائستہ اخلاق، عاجزانہ رویے اور مریضوں سے دلی لگاؤ کی وجہ سے پورے علاقے میں عزت و احترام کی نگاہ سے دیکھے جاتے ہیں۔ ان کا تعلق پونچھ کے معز *سردار خاندان* سے ہے۔ یہ ایک علمی و سماجی گھرانہ ہے جس میں *35 سے زائد ڈاکٹرز* خدمات انجام دے رہے ہیں۔ ڈاکٹر اسامہ کے والد اور والدہ دونوں سینئر ڈاکٹرز ہیں اور *ڈی ایچ کیو ہسپتال میرپور* میں طویل عرصے تک اپنی خدمات سر انجام دے چکے ہیں۔

*تعلیم و تربیت*
- *ایم بی بی ایس:* شہید ذوالفقار علی بھٹو میڈیکل یونیورسٹی، پمز اسلام آباد – 2017
- *ہاؤس جاب:* پمز ہسپتال اسلام آباد – 2018
- *ایف سی پی ایس پارٹ-1:* میڈیسن اینڈ الائیڈ – کامیابی سے پاس کیا
- *پوسٹ گریجویٹ ٹریننگ:* ایف سی پی ایس پیڈیاٹرکس، ڈویژنل ہیڈکوارٹر ٹیچنگ ہسپتال میرپور، 2021 تا 2025۔ یہ ٹریننگ میرٹ پر سلیکشن کے بعد *پروفیسر ڈاکٹر صبا حیدر تارڑ* کی نگرانی میں مکمل کی۔

*پیشہ ورانہ تجربہ*
- *میڈیکل آفیسر، رفاہ انٹرنیشنل ہسپتال اسلام آباد* – 3 سال
- *رفاہ سوشل ویلفیئر ڈیپارٹمنٹ* کے ساتھ مل کر پنجاب اور پوٹھوہار کے پسماندہ علاقوں میں *200 سے زائد فری میڈیکل کیمپس* کا انعقاد کیا۔
- *کووڈ-19 فرنٹ لائن رضاکار:* ڈاکٹر اسامہ ان چند کشمیری ڈاکٹرز میں سے ہیں جنہوں نے *کووڈ آئی سی یو* میں ڈیوٹی کے ساتھ ساتھ *ڈی ایچ او اسلام آباد* کی ٹیم کے ہمراہ سیمپلنگ اور کانٹیکٹ ٹریسنگ میں بھی رضاکارانہ خدمات انجام دیں۔

*اعزازات و اعتراف*
کورونا وبا کے دوران بے لوث خدمات کے اعتراف میں ڈاکٹر اسامہ ظفر کو مندرجہ ذیل شخصیات سے ایوارڈز سے نوازا گیا:
- *سردار مسعود خان*، صدر آزاد جموں و کشمیر
- *علی محمد خان*، وفاقی وزیر
- *شہریار خان آفریدی*، سابق وفاقی وزیر

*سماجی و فلاحی خدمات*
- *کشمیری کارکن:* مقبوضہ کشمیر میں انسانی حقوق کی خلاف ورزیوں کے خلاف بھرپور آواز بلند کرتے ہیں اور بھارتی مظالم کے خلاف ریلیاں اور احتجاج منظم کرتے ہیں۔
- پوسٹ گریجویشن کے دوران *تھیلیسیمیا کے مریض بچوں* کے لیے خصوصی کام کیا اور ڈی ایچ کیو میرپور کے چلڈرن وارڈ کی بہتری کے لیے رضاکارانہ مہم کی قیادت کی، جس میں *انکیوبیٹرز اور وینٹی لیٹرز کا عطیہ* بھی شامل ہے۔
- میرپور بھر میں اس حوالے سے جانے جاتے ہیں کہ یہ وہ *واحد چائلڈ اسپیشلسٹ* ہیں جو غریب اور مستحق مریضوں کے لیے *24/7 دستیاب* رہتے ہیں اور اکثر مفت مشاورت بھی فراہم کرتے ہیں۔

*موجودہ پریکٹس*
ڈاکٹر اسامہ ظفر اس وقت *مغل فاؤنڈیشن ہسپتال، میرپور* میں ہر شام *4 بجے سے 7 بجے* تک پرائیویٹ پریکٹس کر رہے ہیں

11/04/2026

*Dr. Usama Zafar – Renowned Child Specialist, Mirpur, Azad Kashmir*

*Dr. Usama Zafar* is a well-known Consultant Child Specialist based in *Mirpur, Azad Jammu & Kashmir*, widely respected for his polite, humble nature and dedication to patient care. He hails from the distinguished *Sardar family of Poonch* and comes from a strong social and medical background — with over *35 doctors in his family*. Both his parents are senior doctors who have served at *DHQ Hospital Mirpur*.

*Education & Training*
- *MBBS:* Shaheed Zulfiqar Ali Bhutto Medical University, PIMS Islamabad – 2017
- *House Job:* PIMS Hospital Islamabad – 2018
- *FCPS Part-1:* Medicine & Allied – Passed
- *Postgraduate Training:* FCPS Pediatrics at Divisional Headquarters Teaching Hospital Mirpur, 2021–2025, under the supervision of *Prof. Dr. Saba Haider Tarar*. Selected on merit.

*Professional Experience*
- *Medical Officer, Riphah International Hospital Islamabad* – 3 Years
- Worked extensively with *Riphah Social Welfare Department*, organizing *200+ free medical camps* across rural Punjab and the Potohar region.
- *COVID-19 Frontline Volunteer:* One of the only Kashmir-based doctors to serve in both *COVID ICU* and *COVID-19 sampling & contact tracing* with the DHO Islamabad team.

*Awards & Recognition*
For his selfless volunteer services during the COVID-19 pandemic, Dr. Usama received awards from:
- *Sardar Masood Khan*, President AJK
- *Ali Muhammad Khan*, Federal Minister
- *Shehryar Khan Afridi*, Former Federal Minister

*Social & Humanitarian Work*
- Active *Kashmir Activist* who raises voice against human rights violations in IOK. Organizes rallies and protests against Indian brutality in occupied Kashmir.
- During his postgraduate training, he worked for *Thalassemia patients* and led volunteer efforts to improve the Children’s Ward at DHQ Mirpur, including *donation of incubators and ventilators*.
- Known across Mirpur as the *only child specialist available 24/7* for poor and needy patients, often providing free consultations.

*Current Practice*
Dr. Usama Zafar is currently doing private practice at *Mughal Foundation Hospital, Mirpur* every evening from *4 PM to 7 PM*.

22/01/2026

Cardiology High Yield Points

CYANOTIC CONGENITAL HEART DISEASES

Tetralogy of Fallot (TOF)

Key/triad: VSD + RVOT obstruction + overriding aorta (+ RVH)

ECG: RVH, RAD

Murmur: Harsh ejection systolic at LUSB

S2: Single / narrow (soft or absent P2)

Pulmonary flow: Oligemic

CXR: Boot-shaped heart, ↓ lung markings

---

Transposition of Great Arteries (TGA)

Key: Aorta from RV, PA from LV (parallel circulation)

ECG: RVH (physiologic neonatal RV dominance)

Murmur: Often absent (unless VSD/PDA)

S2: Single loud S2

Pulmonary flow: Plethoric

CXR: Egg-on-side, narrow mediastinum

---

Tricuspid Atresia

Key: Absent tricuspid valve, hypoplastic RV, ASD ± VSD

ECG: LAD, LVH

Murmur: Pansystolic (VSD)

S2: Single S2

Pulmonary flow: Oligemic

CXR: ↓ pulmonary vascularity

---

TAPVR (Total anomalous pulmonary venous return)

Key: Pulmonary veins drain to RA/systemic veins

ECG: RVH

Murmur: Ejection systolic at LUSB

S2: Wide split

Pulmonary flow: Plethoric

CXR: Snowman sign (supracardiac type)

---

Pulmonary Atresia

Key: Atretic pulmonary valve

ECG: RVH or hypoplastic RV

Murmur: Often absent

S2: Single S2

Pulmonary flow: Oligemic

CXR: Markedly ↓ lung markings

---------------------------

ACYANOTIC CONGENITAL HEART DISEASES

Ventricular Septal Defect (VSD)

Key: LV → RV shunt

ECG: LVH ± RVH (large VSD)

Murmur: Pansystolic at LLSB

S2: Normal (or loud P2 if large shunt)

Pulmonary flow: Plethoric

CXR: Cardiomegaly + ↑ pulmonary markings

---

Atrial Septal Defect (ASD – secundum)

Key: LA → RA shunt

ECG: RAD, incomplete RBBB

Murmur: Ejection systolic at LUSB

S2: FIXED wide split S2

Pulmonary flow: Plethoric

CXR: Cardiomegaly + ↑ pulmonary vascularity

---

Patent Ductus Arteriosus (PDA)

Key: Aorta → PA shunt

ECG: LVH

Murmur: Continuous machinery (left infraclavicular)

S2: Single / obscured by murmur

Pulmonary flow: Plethoric

CXR: Cardiomegaly + ↑ lung markings

---

Pulmonary Stenosis (intact septum)

Key: RVOT obstruction

ECG: RVH

Murmur: Ejection systolic at LUSB

S2: WIDE split S2 (delayed P2)

Pulmonary flow: Normal or ↓

CXR: Post-stenotic dilatation of PA

---

Coarctation of Aorta

Key: Juxtaductal narrowing

ECG: LVH

Murmur: Systolic at left infrascapular area

S2: Normal

Pulmonary flow: Normal

CXR: Figure-3 sign, rib notching (older child)

---

Ultra-high-yield S2 splitting shortcuts

Fixed split S2 → ASD

Wide split S2 → Pulmonary stenosis

Single / narrow S2 → TOF, TGA, Tricuspid atresia

Single loud S2 → TGA

Normal S2 → VSD, CoA

07/11/2025

HD- Heberden’s - Distal
BP- Bouchard’s - Proximal

20/09/2025

> *Update in the Treatment of Tuberculosis*

¶ How Will you treat *Drug Susceptible* Tuberculosis?

In 2025 TB *management module*, we have three treatment regimens for Drug susceptible Tuberculosis ie
¬ *6 months Regimen* ( the Classic one)
¬ *4 months regimen* ( this is New one and has received strong recommendations in recent guidelines. It's applicable for 3 months age onwards)
¬ *4 months new regimen* ( added in 2025 guidelines, and is applicable for age 12 years and above)

¶ Who should recieve *4 months* and who should receive *6 months* regimen ❓
¬ Nonsevere drug-susceptible TB » Prefer 4months regimen ie 2HRZE/2HR
¬ Those who do not meet the criteria for non-severe TB, should recieve *standard 6* months regimen. 2HRZE/4HR.

¶ What is *non-severe TB* according to 2025 guidelines ❓
Non-severe TB is defined as: Peripheral *lymph node* TB; intrathoracic lymph node TB without airway obstruction; *uncomplicated* TB pleural effusion or paucibacillary, non-cavitary disease, confined to one lobe of the lungs, and *without* a miliary pattern.

¶ What is *new 4 months* regimen ❓
Patient age 12 years or older, with drug susceptible Tuberculosis may recieve 4 drugs regimen of, Isoniazide, *Rifapentin*, Moxifloxacin and Pyrazinamide ie (2 HPMZ/2HPM)

¶ What should be the *duration* of treatment for *Severe Acute Malnutrition* with TB disease ❓
As *SAM* is defined as *danger sign*, children with SAM and non-severe TB should preferably receive *6 months* of TB treatment.

¶ How will you treat patient of *Congenital TB* ❓
Infants aged 0–3 months with suspected or confirmed Pul TB or tuberculous peripheral lymphadenitis should be treated with the *six-month* treatment regimen (2HRZE/4HR),

¶ How will you treat patient of *HIV having* Tuberculosis ❓
Those patients having *HIV and concomitant TB disease*, should recieve same duration of TB treatment as HIV negative patients.
ART should be started as soon as possible, within *2 weeks* of initiating ATT regardless of CD4 count.
Remeber that;
In case of *TBM*, delay ART initiation for at least *4 to 8 weeks* after starting ATT.

¶ How will you treat *Extra pulmonary* TB?
( Note: in new guidelines, there's no separate chapter dedicated to severe forms of TB disease like meningitis, arthritis etc, so we are going to keep the old durations, untill and unless we recieve updates)
First we will divide it into two groups.
¬ Ext Pulmonary TB (most forms, including cervical lymphadenopaghy) treated exactly the way we treat Pulmonary TB ie. 6 months regimen 2HRZE/4HR
¬ Ext Pul TB that's treated with 09 to 12 months regimen (2HRZE/10HR) . We memorize it with Mnemonic *ABCD*
*A*» Articular TB (Joint)
*B*» Bones TB
*C*» CNS TB
*D*» Disseminated TB.
So *ABCD = 09-12* months treatment

¶ How will you treat *Drug Resistant* TB?
We have multiple regimens tailored according to patient status. Let's discuss each......

¬ Isolated *Isoniazid resistant* «»
In patients with confirmed *rifampicin-susceptible, isoniazid-resistant* tuberculosis , treatment with rifampicin, ethambutol, pyrazinamide and levofloxacin is recommended for a *duration of 6 months*.
*Key notes*: Just replace Isonizide with Levoflxacin

¬ *Rifampin Resistant or Multi drug resistant ie MDR/RR-TB*
In children with MDR/RR-TB who's age is below 6 years, an *all-oral treatment regimen containing bedaquiline* may be used.
All *Oral 09-months Regimen* «» WHO suggests the use of the *9-month all-oral regimen* in patients with *MDR/RR-TB* and in whom resistance to *fluoroquinolones* has been excludeded.
The regimen can be Memorized with Mnemonic
*Close BELIEP*

*C* lofazimine (just for *4* months)
*B* edaquiline (just for *6* months )
*E* thambutol
*L* evoflxacin
*I* sonizide
*E* thionamide
*P* yranzenamide (for *5* months)

¶ How will you start *antiretroviral therapy* in patients on MDR/ RR-TB regimens ❓

Antiretroviral therapy is recommended for all patients with *HIV and drug-resistant* tuberculosis requiring second-line antituberculosis drugs, irrespective of CD4 cell count, as early as possible (within the *first 8 weeks*) following initiation of antituberculosis treatment.

¶ How will you treat *Hepatitis C* positive patient having concomitant Drug resistant TB disease ❓
In patients with MDR/RR-TB and HCV co-infection, WHO suggests the co-administration of HCV and TB treatment.

¶ How will you manage *MDR* with additional Floroquinolones resistannce ❓
¬ MDR with Additional *Floroquinolone resistance* «»
WHO suggests the use of a 6-month treatment regimen composed of bedaquiline, delamanid, linezolid, levofloxacin, and clofazimine in MDR/RR-TB patients *with or without fluoroquinolone* resistance.

¶ What is BPaLM Regimen ❓ *BPaLM* regimen ie *B* edaquilin,
*P* retomanid and
*L* inezolid,
*M* oxifloxacin used for 6 months in case of drug resistant TB. If Floroquinolones resistance is identified. Drop moxifloacin and continue the *BPaL* regimen.
(BPaLM is recommended for >14yrz old patients)

¶ what's duration of treatment for a *longer* regimen ❓

MDR/RR-TB patient on longer regimen, a total duration of *18 to 20* months is suggested. This regimen mainly applies to TBM and severe extra pulmonary TB disease.

¶ How to *make a regimen for longer duration* ❓
Combine the drugs to make *a regimen of at least 4* drugs, for example.......
*Regimen one* : all 3 group A drugs plus one group B drug so
4 drug regimen = 3A + 1B
*Regimen two* : if only 2 group A drugs used then add 2 drugs from group B, so our regimen = 2A+2B
*If Group A or Group B* drugs can't complete regimen, add drugs from group C e.g
*4 drug Regimen* = 1A+1B+2C

¶ What are *drug groups* for MDR TB?
¬ Group A (*LLB*, Linezolid, Levofloxacin, Bedaquiline : U Can replace Levoflxacin with Moxifloxacin) b
¬ Group B (*CC*, Clofazimine, Cycloserine)
¬ Group C (All the remaining drugs) .

¶ What is *WHO definition* of severe MDR TB?
Severe MDR-TB = cavities or bilateral parenchymal disease on chest radiography or extrapulmonary forms of disease other than Lymphadenopathy.

¶ Who should receive *steroids* ?
*PETS* should receive steroids (Initial adjuvant corticosteroid therapy with dexamethasone or prednisolone tapered over 6–8 weeks should be used. Remember that In new 2025 guidelines there's emphasis specifically on TBM & Pericarditis.)
1.*P* Pericarditis
2.*E* ndobronchial tuberculosis
3.*T* BM
4.*S* evere miliary tuberculosis

> *Regards. Dr Tanveer*

16/09/2025

Separation anxiety Disorder ✅
_________________

One key difference in separation anxiety disorder and specific phobia ( like phobia of animal/Cat, Place/School, Situation/Darkness and blood/injection) is that

> Specific Phobias have no Physical Symptoms

*while*

> Separation Anxiety disorder will have Physical symptoms and even Nightmares.

Median age of onset for Separation anxiety is 6 years while Specific phobia is around 08 years. Schizophrenia ✅

_______________
Not a common pediatrics disorder, but it keeps showing up there again n again
___________________

> *DSM-5 criteria for Schizophrenia*

*A*. Delusion, Hallucination, abnormal speech
*B*. Duration more than *6 months*
*C*. Not explained by other medical or psychological conditions Brief Psychotic Disorder ✅
__________________
> *DSM-5 crtiera for Brief Psychotic Disorder*
_______________
This one is a COMMON pediatrics disorder and most of the time related to stress.
_________________
Schizophrenia has incomplete recovery and prognosis isn't good. While BPD has good recovery chances and prognosis.
________________

Here's is DSM-V criteria

*A*. Delusion, Hallucinations or abnormal speech
*B*. Duration is less than a month with returning to normal condition and has disturbed her level of functioning like Academic performance, relationships and work place performance.
*C*. Not explained by other illness ‎ Anisocoria ✅
_______________

The combination of
*bradycardia*,
hypertension
&
altered breathing
known as *Cushing* triad can be a sign of life-threatening increased intracranial pressure (ICP) and should be evaluated in an ED.
__________________
*Anisocoria*
and a *sixth cranial* nerve palsy are other signs of increased ICP.

16/09/2025

Conversion disorder ✅
___________________

> *Summary ( not original word to word script) to DSM-5 criteria of Conservation disorder*

*A* . Symptoms of altered voluntry/Sensory function
( as in this case Paralysis)

*B*. Incompatiblity between symptoms and medical condition
( she's paralyzed but here neurological examination is incompatible)

*C*. Symptoms can't be explained medically
(her investigation and workup is normal)

*D*. Symptoms causing distress enough to warrant medical evaluation

*Remember*
(The new term used for Conversion disorder is *Functional Neurologic Symptom Disorder*. Some Examiners in Islamabad center expect these new terms in toacs) Factitious disorder✅
_____________________

> *Factitious disorder, imposed on others*
> DSM-V Criteria

*A*. Falsification of signs and symptoms with element of deception

*B*. They presented another individual as ill ( in this case a baby by her mom)

*C*. The deceptive behavior is evident even in the absence of obvious external reward

*D*. Not explained by any other condition

( Remember that facetious disorders are two types

1.FACTITIOUS DISORDER IMPOSED ON SELF
2.FACTITIOUS DISORDER IMPOSED ON ANOTHER ( as in this CASE, when mom is present the apnea is there)

Note: Initially the word *Manchausen syndrome by Proxy* was in use for such scenario. But term is now obsolete in DSM-V. Pica ✅
_________________
> Cpsp ka most favorite. Both for toacs and past paps.
Just for some Examiners I'm adding it's DSM-V CRITERIA.

*Pica, i.e. perverted appetite*, is the commonest eating disorder, defined as “

Pattern of eating non-nutritive nonfood substances for–
(a) at least one month
(b) inappropriate to the child’s developmental level, and
(c) not a part of culturally supported or socially normative practice” (DSM V criteria).

REMEMBER :
In new texts, it is mentioned that it is normal behavior developmentally upto 24 months.
As we are following cpsp exams. So we fo with scenario Tourette Disorder ✅
___________________

> *DSM-V criteria for tics disorder (it is a simplified form not exact words)*

*Tourette Disorder*
*A*. Both motor and vocal tics
*B*. Persisted for >1 year
*C*. Onset before 18 years
*D*. Not attributed to some identifiable cause

*Persistent Tics*
*A*. Motor or vocal tics ( not both)
*B*. B. Persisted for >1 year
*C*. Onset before 18 years
*D*. Not attributed to some identifiable cause

*Provisional Tic Disorder*
*A*. Motor or/and vocal tics
*B*. Persisted for In *nutshell*

*Tourrett* = Vocal + motor tics > 1 year
*Persistent* = vocal or motor > 1 year
*Provisional* = vocal/motor < 1year

16/09/2025

Somatic Symptoms disorder (SSD) ✅
___________________

> *Summary ( not original word to word script) to DSM-5 criteria of SSD*

*A*. Somatic symptoms *disturbing* daily life
(like pain Abdomen in this case)

*B*. At least one of the following
i. Disproportionate thought about seriousness of condition
ii, persistent Anxiety
III, Excessive time/energy wasted on condition .
(as in this case )

C. State of being symptomatic is persistent (*>6mon*)

16/09/2025

*Langerhan Cells Histiocytosis*

As these topics are relatively tough to understand without basic knowledge.
Let's have a little details before discussing LCH.

¬ Langerhan cells are predominant macrophages in the skin, presenting antigens to T cells.
It means if there is proliferation of these cells, there must be skin involvement. Secondly Langerhan cells have high tendency to infiltrate bones, that's why Skeletel involment is common.
¬ As we can recall that Proliferation of Phagocytes and lymphocytes gives a diff type of histiocytosis that's called Hemophagocytic Lymphohistiocytosis, the same way;
Proliferation of langerhan cells is named as Langerhan cell histiocytosis. The cells have tennis ricket shaped granules (Birbeck granule).

¬ So in nutshell we can divide

Histiocytosis classified into two major categories ( there are multiple others too. But these two are important)
1. Hemophagocytic Lymphohistiocytosis (already discussed as HLH)
2. Langer Cell Histiocytosis (LCH)

*LCH Discussion*

¶ What is the *Clinical Presentation* of LCH?
¬ Skeletal involvement --- Both long & Flat bones ie Tibia, vertebral, mandible, even ear bones. Ear infection is too much common ie recurrent otitis media leading to hearing loss
¬ Skin involvement --- Seborrheic dermatitis of axilla, nappy and scalp difficult to treat ( in clinical practice it may be the only initial manifestation)
¬ HSM & Lymphadenopathy
¬ GI symptoms --- Vomitting, pain Abdomen, bloody diarrhea
¬ Eye ---- Exopthalmos
¬ Pituitary Dysfunction --- mainly Diabetes insipidus
¬ *System* manifestation --- fever, weight loss, malaise, irritability, & failure to thrive.

¶ What are *risk organs* in LCH?
The risk organs are liver, spleen, and bone marrow. Risk organ involvement helps in deciding treatment intensity.
Moreover
1. Risk organ positive = High mortality n morbidity
2.Risk Organ Neg = Low mortality & morbidity

¶ How do you make *Dx of LCH*?
Tissue Biopsy ( mainly skin, bone lesions )
Besides other imp labs are = CBC, LFTs, coagulation studies, skeletal survey, chest radiograph, and measurement of urine osmolality.

¶ What are the *Xray skull* findings in LCH ?
Lytic lesions

¶ What are *three common forms* of LCH? ( Examiners sometimes ask this old-fashioned question)
1.Eosinophilic granuloma ( Benign, involves mainly bones and skin)
2.Hand-Schüller-Christian disease
3.Letterer-Siwe disease.
The last 2 are malignant

¶ How do you *treat* LCH?
Treatment, esp of multiorgan involvment is too much out of our scope. Just remember few drugs names.
1. *Single system* involvement ( skin/Bone/Lymph node) > usually follows spontaneous remission
2.When single system like bone is involved, but it is *Weight bearing* ie Tibia > treatment is given either as steroid injection or Local low dose radiation
3.*Multi system* involvement > multi-agent chemo is given like cyclosporine/antithymocyte globulin, imatinib, 2-chlorodeoxyadenosine, and clofarabine.

Reagrds. Dr Tanveer

16/09/2025

Ist of all palpate te**is . If absent .... Overvirilized female .
Causes
1)Virilising drugs like anabolic steroids
Anticonvulsants
2) virilizing tumore
Adrenal or ovarian tumors that produce androgens

If te**is present it means
Undervilized male
Causes
1) partial androgen insensitivity syndrome
2) 5 Alpha reductase def
3) danysdrash Syndrome

16/09/2025

> *Treatment of Tuberculosis*

¶ How Will you treat *Drug Susceptible* Tuberculosis?

First, we will decide, whether the patient should receive *shorter 4 months regimen* or longer *6 months* regimen.
¬ Nonsevere (isolated Pulmonary) smear negative, presumed drug-susceptible TB >> Prefer 4months regimen ie 2HRZE/2HR
¬ Otherwise Prefer 6 months regimen. 2HRZE/4HR.

¶ How will you treat Extra pulmonary TB?
First we will divide it into two groups.
¬ Ext Pulmonary TB (most forms, including cervical lymphadenopaghy) treated exactly the way we treat Pulmonary TB ie. 6 months regimen 2HRZE/4HR
¬ Ext Pul TB that's treated with 09 to 12 months regimen (2HRZE/10HR) . We memorize it with Mnemonic *ABCD*
A> Articular TB (Joint)
B > Bones TB
C > CNS TB
D > Disseminated TB.
So *ABCD = 09-12* months treatment

¶ What's *new 6 months* Regimen for TBM?
TBM (Clinically diagnosed or Bacteriologically confirmed )
6 months HRZ-Eto (Ethionamide instead of Ethambutol ) is enough to treat, instead of 12 months (2HRZE/10HR)
[Note: This update is also from SHINE trial, but not mentioned in Nelson]

¶ How will you treat *Drug Resistant* TB?
¬ Isolated *Isoniazid* resistant >>>
Treatment duration of 9 months with Rifampin, Pyrazinamide, and Ethambutol is usually adequate for isoniazid-resistant TB in children.

(I'm sharing here old regimen too, as some Examiners are unnecessarily interested in this one. The plan is,
Just *replace Isonizade with Levofloxacin* ie Rifampin, Ethambutol, Pyranzinamide & Levofloxacin for 6 months)

¬ *Rifampin Resistant or Multi drug resistant* >>> All three Group A agents and at least one Group B agent should be included to ensure that treatment starts with at least *four TB agents*.

If only one or two group A medications are used, then group B drugs should be added to make a regimen of *four drugs*.

¬ MDR with Additional *Floroquinolone resistance* >>> *BPaL* 6 to 9 months regimen ie Bedaquilin, Pretomanid, Linezolid
(BPal is recommended for >14yrz old patients)

¶ What are *drug groups* for MDR TB?
Group A (LLB, Linezolid, Levofloxacin, Bedaquilin)
Group B (CC, Clofazimine, Cycloserine)
Group C (All the remaining drugs)

¶ What should be the *duration* of treatment for MDR TB?
For Severe MDR TB/SAM patient/ immunosuppresed, duration is 12-18 months, otherwise 09-12 months

¶ What is *WHO definition* of severe MDR TB?
Severe MDR-TB = cavities or bilateral parenchymal disease on chest radiography or extrapulmonary forms of disease other than lymphadenopathy

¶ Who should receive *steroids* ?
*PETS* should receive steroids ( Prednisone for 4 to 6wks followed by a taper )
1. *P* ericardial effusion
2.*E* ndobronchial tuberculosis
3.*T* BM
4.*S* evere miliary tuberculosis

> Regards. Dr Tanveer

Dr Usama Zafar- Child Specialist

11/04/2026

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