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Studi Kasus Penyakit Tropik dan

Infeksi
Rudi Wisaksana
Divisi Penyakit Tropik dan Infeksi, Ilmu
Penyakit Dalam, RS Hasan Sadikin
Pusat Studi TB-HIV, FK UNPAD

Kasus 1: Demam 4 Hari

Keterangan Umum
Nama : Tn. R
Umur : 54 tahun
Pekerjaan : Satpam
Alamat : Parakan Saat Antapani Tengah,
Kec. Antapani, Bandung
Tgl MRS : 6 April 2011

Anamnesis

4 hari SMRS :
Panas badan
Mendadak tinggi,
terus menerus
Nyeri otot
Mual, nyeri ulu hati

1 hari SMRS :
Panas badan turun
Nyeri otot (+)
Nyeri ulu hati (+)

Anamnesis tambahan :
Tinggal di daerah
bebas banjir
Tidak ada
keluarga/tetangga
yang panas badan

Pemeriksaan Fisik
TD :
110/70

Suhu :
36,6 C

KU : Sakit
sedang,
CM

RR :
22 x/m

N = HR :
104 x/m

Kepala
Konjungtiva anemis (-)

Sklera ikterik (-)

Conjungtiva suffussion (-)

Thorax
Cor : kardiomegali (-), BJ S1 S2 normal S3 (-)
S4 (-) murmur (-)

Pulmo : ronkhi (-), wheezing (-)

Abdomen
Datar, lembut, BU (+) normal

Hepar/lien tidak teraba

NT (+) a/r epigastrium

R.. Traube kosong

Kemungkinan diagnosis?
Pemeriksaan apa diperlukan?
Pemeriksaan lab
Hb, Ht, L, Tr, Diff
Urin rutin
Toraks foto

Pemeriksan khsusus
etiologi:
Builion culture
IgM ?

Pemeriksaan Penunjang
Parameter

Hasil

Parameter

Hasil

Hb

12,0

Urine

Ht

34

Protein

+++

Lekosit

14.100

Glukosa

++

Trombosit

33.000

Nitrit

Diff count

0/1/0/94/2/3

Urobilinogen

1,0

Eritrosit

11-13

Lekosit

10

Rontgen thorax :
Kardiomegali dd/ posisi tanpa bendungan paru
Tidak tampak TB paru aktif
Elevasi diafragma kanan e.c. hepatomegali (?)

Ada yang tidak cocok?


Pemeriksaan tambahan?
Terapi?

Follow Up
40

Ikterik (+)

Lab Results

39.1

Suhu

39

1
37.8

38
37

37
36.6

36.9

37

Hb
Leko
37.4
Trombo37
Ureum

12,0

10,1

14.1001

14.300

38

33.000
22.000
36.8
36.7

Kreatin

36
35

38

Bil Total

4,66

Bil Direk

3,87

6
7SGOT 8
Hari Rawat
SGPT

1077 11
29

Ampicillin 4 x 2 g IV
Doxicyclin 2 x 100 mg PO
IgM anti Leptospira (+)

12

Follow Up
40

Ikterik (+)

Lab Results

Suhu

39
37.8

38
37

38
37.4

37
36.6

36.9

37

37

36.8

36.7

10

36
35

5
6
Hari Rawat

Ampicillin 4 x 2 g IV
Doxicyclin 2 x 100 mg PO
IgM anti Leptospira (+)

Ikterik (+)

Hb

12,0

10,1

10,2

11,2

10,2

9,8

7,6

9,0

Leko

14.1001

14.300

13.700

18.200

15.1002

16.1003

13.100

12.100

Trombo

33.000

22.000

31.000

59.000

96.000

114.000

272.000

456.000

Ureum

276/186*

139

62

45

18

Kreatin

6,30/3,73*

1,84

0,86

0,74

0,75

Bil Total

4,66

16,65

8,80

Bil Direk

3,87

14,9

7,77

SGOT

77

63

66

SGPT

29

31

Diff count 0/1/0/94/2/3


Diff count 0/1/1/79/13/6
3 Diff count 0/2/1/65/27/6
* Pasca HD
1
2

IgM Anti HCV (-)


HBsAg (-)
Gamma GT 496 645
Alkali Fosfatase 220

10

Kasus 2: Infeksi Jamur

Ilustrasi kasus
Seorang pria 28 tahun dibawa ke RS dengan
penurunan kesadaran
Penurunan kesadaran dikeluhkan sejak 3 hari
terlihat lebih sering mengantuk, masih dapat
menjawab pertanyaan

Bicara meracau dan kadang-kadang


mengamuk

Riwayat Penyakit Sekarang


Riwayat panas badan yang tidak terlalu tinggi
sejak 1 bulan sebelum masuk rumah sakit
Riwayat nyeri kepala yang bertambah berat
dalam 1 bulan terakhir
Riwayat penglihatan ganda, kelemahan
anggota gerak (-)

Riwayat Penyakit Dahulu


Riwayat IDU (+)
Riwayat tattoo (-)

Pemeriksaan Fisik

Kesadaran : delirium
Tekanan darah : 140/90 mmHg
Nadi = Heart rate : 90x/menit
Respiratory rate : 20x/menit
Suhu : 37,90 C
Status gizi : baik

Status Interna : dalam batas normal


Status neurologis
Rangsang meningen : kaku kuduk (+), laseque/kernig tak
terbatas,
Brudzinki
I/II/III (-)

Pemeriksaan Fisik
Saraf Otak

: pupil bulat isokor ODS 3mm,


refleks cahaya +/+
Gerak bola mata : baik
Funduskupi: normal
N. V : sulit dinilai
N. VII dan XII : kesan

simetris

Motorik : kesan lateraliasasi (-)

Vegetatif : baik
Sensibilitas : sulit dinilai

Fungsi luhur : sulit dinilai

Refleks fisiologis : Biceps-Triceps-Radialis Reflex +/+


Knee Reflex +/+ Achiles Reflex +/+

Refleks Patologis : Babinski -/-

Pemeriksaan Penunjang

Hemoglobin
Lekosit
Ureum
Kreatinin
Na
K
GDS

15,9 g/dL
10.000/mm3
23 mg/dL
0,89 mg/dL
124mEq/L
3.8mEq/L
136mg/dL

Pemeriksaan Penunjang
LCS :
Warna : tidak berwarna
Kejernihan : jernih
Jumlah sel
419/mm3
PMN 5%

MN 95%

Glukosa
8mg/dL
Protein 110 mg/dL
Tinta India (-), BTA langsung (-)

Diagnosis?

Diagnosis Kerja
Meningitis TB probable grade 2
Suspek HIV

Terapi

Bed rest
IVFD 2A 20gtt/mt
Diit TKTP
Pasang NGT
OAT kategori 1 + vitamin B6
Dexamethason
0,4 mg/kgBB (20 mg) i.v.

Follow up
Hasil mikrobiologi: kultur kriptokokus (+)
HIV testing dilakukan reaktif
CD4 count: 34

Follow up
Diagnosis: meningitis kriptokokus
Tindakan:
Stop OAT, stop dexamethason
Start flukonazol, 800 mg/hari

Penderita menjalani perawatan selama 2 pekan

Follow up
Lumbal Punksi sebelum pulang:

Tidak berwarna, jernih


Jumlah sel 73/mm3
PMN : 15% MN : 85%
Glukosa : 10mg/dL (GDS 91mg/dL)
Protein 220mg/dL
Kriptokokus (-)

Pasien dipulangkan dengan diagnosis: meningitis kriptokokus


Rencana lanjutan

Flukonazol 1 x 800 mg per hari


Rencana ARV di Klinik Teratai

Kasus 3: Malaria
Seorang Dokter akan bertugas di Tanah Merah, Digul, selama
6 bulan. Anjuran pencegahan malaria ?

Introduction
Malaria endemic in the eastern part of Indonesia
particulary hyperendemic in Papua
Increasing visitors or tourists come to Papua for short
or long term stay or transmigrants for permanent
stay
They considered non-immune and vunerable to
malaria with risk of death
This high risk groups need malaria prevention to
reduced morbidity and mortality

Risk of malaria for travelers


A study of Denmark travelers to Indonesia :
76 per 100.000 travelers contracted malaria
Risk of exposure to malaria for travelers to Southeast
Asia : 3,4 %

Malaria prevention for travelers in general


ABCD approach :
Awareness of risk
Bite prevention
Chemoprophylaxis
Diagnosis promptly and treat without delay
Education : all about malaria
benefit of prevention measures
benefit and risks of chemoprophylaxis

Awareness of risk
Risk related to endemicity of the visiting area :
Annual incidence of malaria cases in local population
Annual parasite rate of indigenous population
Length of stay : longer stay risk
Reasons of visit : bussiness, occupation ( miner
risk )
Activity : outdoor at dawn / night
risk
Season : rainy season
risk
Accomodation : room with AC, cycling fan risk
Visiting Area : capital, downtown, country side

Bite Prevention
Physical barrier :
mosquitoes screen to cover ventilation, door, window
Close the door and window after dawn
Use air condition or cycling fan in the living room /
bedroom
Insecticide-treated mosquito nets ( ITN )
Personal protective measures :
Apply skin with DEET 30 50 % repellent
Use long sleeves shirts or pants, socks, full- covered
footwear for outdoor activities at night
Use knockdown sprays / aerosolized or insecticide coils
Indoor residual-insecticide sprays

Insecticide-treated nets ( ITN )


WHO recommended Long-lasting insecticide-treated
nets ( LLITN ) that effective for 3 years
Indications :
In unstable malaria area : total population
Recommended for travelers sleep outdoor
or unscreen accommodation
Priority to pregnant woman and children
ITN must free of tears, tucked in under the mattres

Repellent DEET

Repell insect, not kill them


ACPM recommended DDET 30 50 %
For outdoor use, apply on exposed skin
Commonly safe even for pregnant women
Side effect : skin rashes
skin, mucous membrane iritation
Precautions :
Use for adult, children, infant > 2 month of age
Avoid contact to eye, mucous membrane, wound / iritated skin
Wash hand after handling repellent
Avoid over-appliance especially for children

Indoor- Residual insecticide spraying ( IRS )


The most popular Insecticide is DDT : cheapest, longest
duration, relatively safe
Problems :
Developing resistance by insects to DDT
Mosquitos behaviour : outdoors bitting and resting habits
Inadequate sprayingable surface / suitability of wall or roof
surface for spraying
Custom of people in some areas to sleep outdoor during
the hot season
Poor acceptance by community

Chemoprophylaxis
Administration of antimalaria drugs for prevention
Lower dose, longer duration
Antimalaria drugs for chemoprophylaxis :
Blood - stage prophylaxis :
Chloroquin + proguanil
Mefloquin
Doxycycline
Live- stage prophylaxis :
Atovaquone / proguanil
Primaquine : for P. vivax only
Chemoprohylaxis is not 100 % effective, efficacy rate 75 95 %

Chemoprophylaxis

Chemoprophylaxis

Chemoprophylaxis for children

Evidence of efficacy
Interventions

Evidence

benefits

Insecticide treated nets

18 RCTs

Reduced malaria episodde 39 %


Ruduced child mortality ( RR 0,83 )

Air conditioning , electric


fans

1 questionnaire
Survey,
1 observational
study

Reduced the incidence of malaria


Fan did not reduce catches of
Anopheles

Insecticide treated clothing

1 controled trial

Reduced mosquito bites

DEET

1 controled trial

Reduced malaria bites ( RR 99,9 % )

Doxycycline

2 RCT

1/67 cases vs 53/69 ( RR 99 % )


Protective efficacy 96,3 % P.
falciparum, 98 % P. vivax

mefloquin

5 RCT

Efficacy 100 %

Aerosol insecticide

1 survey

Not reduce the incidence of malaria

clothing

1 survey

Reduced the incidence of malaria

Insects electrocuters,
buzzers, smoke

1 observasional
study

Not reduced bites

Croft A. BMJ 2000 ; 321 : 154 - 160

Early diagnosis and prompt treatment


Stand-by Emergency Treatment ( SBET ) :
Use of antimalarial drugs carried by the traveler for
self- administration when malaria is suspected and
prompt medical attention is unavailable within 24
hours of onset of symptoms
Indications :
short or long-term travelers
Visiting low malaria transmission
Visit remote area with no diagnostic and therapeutic
facilities

Stand-by Emergency Treatment

Not indicated for very-short visit ( < 6 days )


Need written instructions
Need good education, responsible travelers
Drugs used for SBET different with chemoprophylaxis drugs
Disadvantages :
Overuse antimalarial drugs
Patients tend to miss medical attention as advised
Delay in diagnosis & treatment of others non-malaria
illness
Errors SBET dosage and regimen is high ( 88 % )

Antimalarial drugs for SBET

Prevention of malaria for short-term travelers


Short-term travelers have substantial risk of contracted
malaria
Short-term travelers : 3 weeks or less
Risk depend on endemicity area, activities
Prevention measures :
Bite prevention with personal protection measures
Chemoprophylaxis

Freedman DO. N Engl J Med 2008; 359 (6)

Prevention of malaria for short-term travelers


Personal protection against mosquitoes :
Wear long sleeves, long pants, fully closed shoes
with socks after dark
Use ITN if room is not well screened or airconditioned
Use DEET 30 50 % every 4 6 hours or more
frequent if use lower concentration

Chemoprophylaxis for short-term prophylaxis


Drug choices depent on :
Risks of malaria
Comorbidities
Cost

Safety :
Atovaquone proguanil : most tolerable
Followed by doxycycline
Mefloquin : rare, notorious side efect ( neurophsychiatry )

Indonesia : only doxycycline is available , recommended


Sclagenhauf P, Tschopp A, et al. BMJ 2003 ; 327 : 1078

Prevention of malaria in long-term travelers


Long term travelers are non-immune travelers visiting endemic
areas for longer than 6 months
Also include :
Visiting of less than 6 months
Frequent transient stays
Long- term travellers have higher risk of infection
P. falciparum OR = 1, 5 ; P. vivax OR = 2,44

Specific problems for long-term travelers :


Lower adherence to long term chemoprophylaxis
Worried about long-term chemoprophylaxis side effect
Confidence that infection could be managed effectively
Schlagenhauf P, Petersen E. Clinical Microbiology review 2008 ;
Chen LH, wilson ME, Schlagenhauf P. JAMA 2006

Chen LH, wilson ME, Schlagenhauf P. JAMA 2006

Summary of malaria prevention for long term travelers


Awareness of risk : Essential
Prevention of bite : Essential
Seasonal chemoprophylaxis :
Limited applicability, limited data
Not recommended in Indonesia
Continous chemoprophylaxis :
High risk area in Africa, PNG
Not recommended in Indonesia
Stand-by Emergency self treatment ( SBET ) :
Remote, low risk areas
Limited medical resources
Supplemented with rapid diagnostic test ( RDT )

Terima Kasih