PARAPNEUMONIC SYNDROME (Laporan Kasus)

Arismunandar H.P.U 0818011008

1. ANAMNESIS
Identitas Pasien Nama Umur Jenis Kelamin Pekerjaan Agama Alamat Tanggal Masuk WIB
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: Tn. S : 60 tahun : Laki-laki : Petani : Islam : Punggur : 19 Januari 2013, pukul 18.00

 Keluhan Utama Buang air besar cair sejak 1 hari SMRS Keluhan Tambahan Demam,batuk berdahak, pilek, sesak

 Riwayat Penyakit Sekarang Pasien datang ke IGD RSAY Metro dengan keluhan buang air besar cair sejak 1 hari SMRS. Buang air besar sebanyak 5 kali dengan konsistensi cair, ampas yang sedikit dan berlendir tanpa disertai darah. Pasien juga mengeluh demam yang naik turun sejak 2 hari SMRS dan disertai dengan pilek dan batuk berdahak, dahak berwarna hijau tanpa disertai darah. Pasien juga mengeluh sesak nafas dan dada terasa berat sejak 2 hari SMRS. Sesak nafas timbul saat istirahat dan tidak diperberat oleh aktivitas. Pasien juga mengaku tidak nafsu makan dan badan terasa lemas. Karena khawatir akan kondisi dirinya, maka pasien datang ke IGD RSAY Metro untuk berobat.

 Riwayat Penyakit Dahulu

Riwayat kencing manis : disangkal Riwayat darah tinggi : disangkal Riwayat sakit jantung : disangkal Riwayat minum OAT : disangkal Pasien belum pernah mengalami sakit seperti ini sebelumnya
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RiwayatPenyakit Keluarga Riwayat penyakit serupa : disangkal Riwayat darah tinggi : disangkal Riwayat kencing manis : disangkal

 PEMERIKSAAN FISIK Keadaan Umum : sakit berat, compos mentis, gizi kurang (berat badan 45 kg, tinggi badan 1,67 m, BMI = 16,1) Tanda Vital Tekanan darah : 60/40 mmHg Nadi : 124 x/menit , cepat dan lemah Pernapasan : 40 x/menit Suhu : 38,7 C Saturasi O2 : 90 %

Kepala Mata Hidung Telinga Mulut Leher Thorax

: normochepal, simetris. : Conjungtiva anemis (-/-), sclera ikterik (-/-) Pupil isokor (3 mm/3mm), Reflek cahaya (+/+). : Nafas cuping hidung (+), darah (-), secret (-). : darah (-), secret (-). : mukosa basah (+), sianosis (-), lidah kotor (-). : Simetris, limfonodi coli tidak membesar. : retraksi intercostal (+)

 Jantung Inspeksi Palpasi Perkusi Auskultasi

: ictus cordis tidak tampak : ictus cordis tidak teraba : batas jantung dalam batas normal : BJ I-II intensitas normal, reguler, murmur (-), gallop (-)

Paru Inspeksi

Palpasi Perkusi Auskultasi

: Saat statis bagian dada kanan sama dengan bagian kiri, saat dinamis, gerakan dada kanan tertinggal dari kiri. Retraksi intercostal, dan subcostal ditemukan : Fremitus taktil kanan lebih lemah dari kiri : pekak/sonor : ronki +/-, wheezing -/8

 Abdomen Inspeksi

Auskultasi Perkusi Palpasi

: tampak datar, dinding perut sejajar dengan dinding dada : bising usus (+) : Tympani : Supel, nyeri tekan (-), hepar/lien tidak teraba

Trunk Inspeksi : Skoliosis (-), kifosis (-), lordosis (-) Palpasi : Nyeri tekan (-), massa (-) Perkusi : Nyeri ketok (-) Ekstremitas : Oedem -/- Akral dingin -/9

 PEMERIKSAAN PENUNJANG Laboratorium (19 Januari 2013) : DL : Hb : 9,5 g/dL WBC : 34.600 /ul RBC : 4,46 juta /ul PLT : 437.000 /ul GDS : 94 mg/dL Ureum : 66,2 mg/dL Kreatinin : 2,02 mg/dL SGOT : 69,8 U/L SGPT : 33,4 U/L Albumin : 2,7 g/dL Globulin : 1,74 g/dL
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 UL : leukosit 10/ul, eritrosit 30/uL, epitel ++ Feses lengkap : macros : konsistensi lembek, lendir, darah negatif micros : leukosit, eritrosit negatif BTA sputum S-P-S : negatif-negatif-negatif Kultur darah (22-1-2013) : hasil steril

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 Foto Rontgen Thorax PA (23 Januari 2013) :

Kesan: Efusi pleura dextra bronkopneumonia kardiomegali dengan elongatio aorta

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USG Abdomen (21 Januari 2013) : Complex pleural effusion supradiafragma dextra Pielonefritis sinistra Hepar,, lien, pancreas, vesica urinaria dalam batas normal

Dilakukan pungsi pleura pada tanggal 19 januari 2013, kemudian dilakukan analisa dan sitologi cairan pleura, hasil : Analisa cairan pleura (21-1-2013) : Protein total serum : 5,76 g/dL, ratio 0,8 LDH serum : 291 U/L, ratio 3,2 Glukosa : 72 mg/dL Pewarnaan BTA : negatif, pewarnaan gram : kokus gram positif Sifat cairan pleura adalah eksudat dengan infeksi sekunder oleh kuman kokus gram positif. Patologi anatomi cairan pleura (24-1-2013) : Sel malignancy negative Peradangan kronis supuratif (abses)
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 Diagnosa kerja: 1.Pneumonia dengan efusi pleura dextra (parapneumonic syndrome) 2. Syok sepsis 2.Diarrhea 3. Malnutrisi underweight

5. PENATALAKSANAAN O2 2L/mnt IVFD RL guyur 1 liter maintenance 40 tetes/menit Levofloxacin 1 x 750 mg i.v Ceftriaxone 2 x gr i.v Metronidazol 3 x 500 mg i.v Ranitidine 2 x 1 amp i.v Metoclopramid 2 x 1 amp i.v Diet : TKTP Nasi + ekstra telur

6. PROGNOSIS Ad vitam Ad sanam Ad fungsionam

: dubia : dubia : dubia

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PARAPNEUMONIC SYNDROME

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INTRODUCTION
Parapneumonic syndrome :
Pneumonia symptoms with parapneumonic effusion (exudative pleural effusion) that results from pneumonia (CAP/NP) or lung abses

Between 20% and 57% of the 1 million patients hospitalized yearly in the U.S with pneumonia, develop a PPE. Empyema is less common, occurring in 5%10% of patients who experience PPE

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Figure 1. Causes of empyema in 14 prior studies. Of the 1383 patients in the studies, 70% were parapneumonic. For the other 30% of patients, trauma was the cause of empyema in 7%, empyema was postoperative in 6%, and prior tuberculosis was the cause in 4%; 12% of cases were due to other causes.

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CLASSIFICATION

Clinical classificationof PPE : 1. uncomplicated parapneumonic effusion (UPPE) 2. complicated parapneumonic effusion (CPPE) 3. Empyema Stages : 1. exudative 2. fibrinopurulent 3. final organizational
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CLINICAL PRESENTATION

Symptoms of pneumonia : Fever, malaise, cough, dyspnea, pleuritic chest pain Eldery patients >> asymptomatic

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 Pleural fluid analysis >>> to stage the PPE and guides initial management.
UPPEs : have a turbid appearance, with a pH >7.30, a glucose level >60 mg/dL, an LDH level <700 IU/L, and negative microbiologic test results. CPPEs : pleural fluid pH <7.20, a glucose level <40 mg/dL, and an LDH level >1000 IU/L; Gram stain and culture results may be positive.

Pus aspirated from the pleural space is diagnostic of empyema,

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 recommended that all patients with pneumonia be evaluated for the presence of pleural fluid. With the possible or definite presence of pleural fluid noted on a chest radiograph, an ultrasound-guided thoracentesis should be performed. Ultrasonography can detect stranding or septation in the fluid suggestive of a CPPE and can facilitate its drainage.
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Figure 3. A complex, septate pleural effusion demonstrated by ultrasonography in a patient with spontaneous hemorrhage into a pre-existing pleural effusion. This precise pattern is typical of a complicated parapneumoniceffusion as well. 23

PATHOPHYSIOLOGY

Figure 2. The estimated time course of untreated or inappropriately treated parapneumonic effusions. In general, an empyema will develop 46 weeks after the onset of aspiration 24 of bacteria into the lung.

MANAGEMENT
In general, early and appropriate antibiotic treatment will prevent the development of a PPE and its progression.

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 Antibiotic therapy : Early antibiotic therapy will prevent the development of a PPE and its progression to a CPPE and empyema. Pleural space drainage : Clinical factors that suggest pleural space drainage include : prolonged pneumonia symptoms, Comorbid disease, failure to respond to antibiotic therapy, and presence of anaerobic organisms . Chest radiograph findings that suggest the need for pleural space drainage include an effusion involving >50% of the hemothorax Stranding or septation noted on an ultrasound suggests the need for pleural space drainage. Intrapleural fibrinolytics : fibrinolytic agents (urokinase and tissue plasminogen activator) most effective in the early fibrinolytic stage in avoiding the need for surgical drainage. Surgery : pleural space drainage by tube thoracostomy has been ineffective in controlling the pleural infection. (VATS).
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MANAGEMENT

1. Early antibiotic treatment usually prevents the development of a PPE and its progression to a complicated PPE and empyema. 2. Pleural fluid analysis provides diagnostic information and guides therapy. 3. If the PPE is small to moderate in size, free-flowing, and nonpurulent (pH, >7.30), it is highly likely that antibiotic treatment alone will be effective. 4. Prolonged pneumonia symptoms before evaluation, pleural fluid with a pH <7.20, and loculated pleural fluid suggest the need for pleural space drainage. 5. The presence of pus (empyema) aspirated from the pleural space always requires drainage. 6. Fibrinolytics are most likely to be effective during the early fibrinolytic stage and may make surgical drainage unnecessary. 7. If pleural space drainage is ineffective, video-assisted thoracic surgery should be performed without delay.
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CONCLUSIONS

TERIMA KASIH

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