REFLEKSI KASUS

THYPOID FEVER

Disusun untuk Memenuhi Sebagian Syarat

Mengikuti Ujian Kepaniteraan Klinik di Bagian Anak dan Perinatologi
Rumah Sakit Umum Daerah Kota Jogjakarta

Disusun oleh
Tsani Antafani
20194010029

PROGRAM PENDIDIKAN PROFESI DOKTER

FAKULTAS KEDOKTERAN DAN ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH YOGYAKARTA
A. RANGKUMAN KASUS

Seorang anak laki-laki berusia 10 tahun rujukan dari klinik datang bersama ayahnya ke

IGD RS Jogja dengan keluhan demam dan lemas. Pasien datang dalam keadaan compos

mentis, tampak lemas dan gizi baik. Dari hasil anamnesis didapatkan data bahwa :

 13 HSMRS : anak merasa telinga kiri berdenging, mengganggu dan terasa nyeri

sejak pagi hari. BAB (+) normal, BAK (+) normal, Batuk dan pilek (+), makan

minum mau. Lalu sore harinya periksa ke dokter THT, saat diperiksa dokter

mengatakan bahwa telinga kotor, banyak serumen. Pasien diberi obat pulang

berupa obat antibiotic, anti radang dan obat batuk pilek.

 11 HSMRS : anak mulai panas dari jam 7 pagi dan diukur dengan thermometer

rumah (suhu 37-38oC), BAB (+) normal, BAK (+) normal, Batuk dan pilek (+),

makan minum mau anak diberi obat paracetamol dari apotek dan demam agak

turun.

 9 HSMRS : panas tidak turun setelah 2 hari minum paracetamol, BAB (+) normal,

BAK (+) normal, Batuk dan pilek (+), makan agak menurun, minum mau lalu anak

diperiksakan ke klinik Sp. A, diminta cek darah (hasil ; AL 11, AT 180, HMT 39)

dan diberi obat pulang berupa cespan dan antiradang.

 8 HSMRS : anak masih demam dan batuk pilek, BAB (+) normal, BAK (+) normal,

nafsu makan menurun, minum mau, sore harinya anak cek darah di Hidayatullah

(hasil ; AL 9.2, AT 206, HMT 41)

 6 HSMRS : anak masih demam dan batuk pilek, BAB (+) normal, BAK (+) normal,

makan menurun, minum mau sekitar jam 7 anak cek darah di klinik Sp. A (hasil ;

AL 12, AT 320, HMT 38)

  Malam harinya, pasien periksa ke dokter THT karena telinga masih berdenging,

dan diberi obat pulang berupa antibiotic, antiradang dan obat batuk pilek.

 3 HSMRS : demam agak turun (minum parasetamol terakhir malam harinya) BAB

(-), BAK (+) normal, Batuk dan pilek (+), makan menurin, minum mau dan orang

tua pasien tidak melanjutkan pemberian parasetamol

 2 HSMRS : demam tinggi lagi di pagi hari, sempat muntah 2x berisi makanan yang

sebelumnya dimakan bercampur dengan cairan jernih, tanpa ada darah +/- ½ gelas

belimbing.

 1 HSMRS : demam tetap tinggi, batuk dan pilek (+), BAB (+) 1x cair warna kuning,

berampas tanpa darah dan lendir

 4JSMRS : demam tetap tinggi dan anak tambah lemas, BAB (+) 2x cair warna

kuning berampas tanpa darah dan lendir, BAK (+) normal, Batuk dan pilek (+),

makan menurun, minum mau. Lalu anak diperiksakan ke Sp. A dan dirujuk ke RS

Jogja

Hasil pemeriksaan saat di bangsal :

Kesan Umum : Compos Mentis, tampak lemas, gizi baik

TD : 110/70 mmHg HR : 110x/menit

RR : 26x/menit S : 37,5oC

Kesan bradikardi relative (-)

Kepala : Mesosefal, mata cowong (-), edema palpebral (-), gusi berdarah (-), epitaksis (-),

mukosa bibir basah (+), tonsil (T2/T2), lidah tremor (-), lidah kotor (-), nyeri telan (-),

rhinorrhea (+), tinnitus (+/+), nyeri preaurikular (-/-), nyeri mastoid (-), serumen (+/+)
 Leher : simetris, pembesaran KGB (-), pembesaran tiroid (-)

Thorax : simetris, retraksi (-), ketertinggalan gerak (-), pulmo vesikuler (+) N, wheezing (-

ronki basah basal (-), stem fremitus (N), perkusi sonor (+/+) cor bising (-)

Abdomen : supel, perut kembung (+), distensi (-), rose spot (-), bising usus (+) 6x/menit,

hepar/lien tak teraba, undulasi (-)

Ekstremitas : akral hangat, nadi kuat, CRT <2”, myalgia (+), atralgia (-), tourniquet test –

Dari pemeriksaan penunjang tubex tf didapatkan = 3 (borderline). Selanjutnya pasien

didiagnosis prolonged fever ec bacterial infection dd thypoid fever, mendapatkan terapi

berupa IVFD D5 ½ NS 20tpm, inj. ceftriaxone 2x1g, parasetamol 3x300mg.

B. MASALAH YANG DIKAJI

1. Mengapa pemeriksaan tubex tf lebih dipilih dibandingkan dengan pemeriksaan widal?

Pemeriksaan Widal memiliki sensitivitas dan spesifisitas yang rendah, sehingga

penggunaannya sebagai satu-satunya pemeriksaan penunjang di daerah endemis dapat

mengakibatkan overdiagnosis. Pada umumnya antibodi O meningkat di hari ke-6-8 dan

antibodi H hari ke 10-12 sejak awal penyakit (idai) Interpretasi pemeriksaan Widal harus

dilakukan secara hati-hati karena dipengaruhi beberapa faktor yaitu stadium penyakit,

pemberian antibiotik, teknik laboratorium, endemisitas dan riwayat imunisasi demam tifoid.

Sensitifitas dan spesifisitas Widal rendah tergantung, kualitas antigen yang digunakan, bahkan

dapat memberikan hasil negatif hingga 30% dari sampel biakan positif demam tifoid.

Pemeriksaan Widal memiliki sensitivitas 69%, spesifisitas 83%.17 Hasil pemeriksaan Widal

positif palsu dapat terjadi oleh karena reaksi silang dengan non-typhoidal Salmonella, infeksi

bakteri enterobacteriaceae lain, infeksi dengue dan malaria, riwayat imunisasi tifoid Hasil
negatif palsu dapat terjadi karena teknik pemeriksaan tidak benar, penggunaan antibiotik

sebelumnya, atau produksi antibodi tidak adekuat.17,25 Pemeriksaan Widal pada serum akut

satu kali saja tidak mempunyai arti penting dan sebaiknya dihindari. Diagnosis demam tifoid

baru dapat ditegakkan jika pada ulangan pemeriksaan Widal selang 1-2 minggu terdapat

kenaikan titer agglutinin O sebesar 4 kali. The differences of the diagnostic tests between

Tubex and Widal based on the sensitivity and specificity of those two diagnostic

file:///C:/Users/user/Downloads/37180-95191-1-PB.pdf Tubex test effectively done in the

first week since symptoms appeared while effective Widal test done on the second and third

week. This is because due to IgM began to form on day 5 and the titre increased to reach at

day 14, last up to 3 months and then levels off until its disappear27,28. TUBEX is a serological

test for the detection of acute typhoid fever by the detection of specific IgM antibodies to

antigens of Salmonella typhi O9 lipopolisakarida11,12,13. Widal test is a serological test to

measure the levels of antibodies that agglutinate antigens O and H. Antibodies against the O

antigen usually appears on day 6-8 and last for 6 months. Antibodies against the H antigen

appeared at day 10-12 after the onset of illness and persist for 12 months. So the Widal test

is best done in the second and third week This research obtains the sensitivity and specificity

of Tubex is 84% and 69% respectively, positive predictive value 48%, and negative predictive

value of 93%. Tubex test has a sensitivity and specificity better than the Widal test. Sensitivity

and specificity of the Tubex test by Kawano et al in his study in the Philippines was 95.7% and

80.4%46. Research by Melisa et al. in 2012 in Bandung reported sensitivity and specificity of

Tubex were 92% and 53.7% respectively64. Lim et al. in 1998 reported the Tubex test had a

sensitivity of 91.2% and a specificity of 82.3% Positive Predictive Value (PPV) is the percentage

of patients with a positive Tubex test will get disease in the future that is 48%. Negative

predictive value (NPV) is the possibility that people with a negative test result does not have
 a condition that is equal to 93%. Research by Rachmajati in Semarang in 2011 mentioned the

sensitivity of Tubex is 100%, specificity 52.6%, positive predictive value 76.9% and negative

predictive value of 100% The Widal test measures agglutinating antibodies against LPS (O)

and flagellar (H) antigens of Salmonella serovar Typhi in the sera of individuals with suspected

enteric fever. Although usually discouraged due to inaccuracy, it is simple and inexpensive to

perform and is still widely used. The performance of the method has been hampered by a lack

of standardization of reagents and inappropriate result interpretation. The Widal test ideally

requires both acute and convalescent-phase serum samples taken approximately 10 days

apart, and a positive result is determined by a 4-fold rise or fall of antibody titer. However,

antibody titers in infected patients often rise before the clinical onset, making it difficult to

demonstrate the required 4-fold rise between initial and subsequent samples. In practice, the

result from a single, acute phase serum sample is often used, but false negative and false

positive results are common. Knowledge of the background levels of antibodies in the local

population may aid interpretation of the Widal test, and performance is best among patients

with a high prior probability of enteric fever

2. Apakah pemeriksaan gold standart untuk diagnosis demam thypoid?

Culture is the gold standard for diagnosing a Salmonella infection.[10] Using blood culture as

the standard and reference test for diagnosis of enteric fever, the sensitivity, specificity,

positive predictive value, and negative predictive value of the different tests were calculated

from the samples having growth of Salmonella species as true positives and samples with

growth of other organisms as true negatives. Blood, bone marrow and stool culture remains

the most reliable methods for diagnosis of typhoid fever. Isolation is highest in the first week

and becomes more difficult as time passes [6,7]. However, the methods of bacterial isolation

are long and slow, and are not always successful as it requires laboratory equipments and
technical training that are beyond the means of most primary health care facilities in the

developing world. That is why; serologic analysis becomes more important