Patofisiologi &

Diagnosis

Pada anak

MS ANAM
BAGIAN ILMU KESEHATAN ANAK
FK UNDIP/RSUP DR KARIADI
SEMARANG
 Pendahuluan
• COVID-19  Infeksi yang disebabkan oleh
virus SARS-Cov 2 (sebelumnya bernama novel
coronavirus 2019 – ncov 2019)
• Pertama ditemukan di Tiongkok, Desember
2019, diduga berasal dari Huanan wholesale
Seafood Market di Wuhan, Hubei, China
 Burden of disease
• COVID-19 – pandemi global
• Sampai 26 Mei 2020 – Jumlah kasus &
kematian
– Dunia  5.623.242 / 348.743 (6,2%)
– Indonesia  23.165 / 1418 (6,1%)
– Jawa Tengah  1368 / 91 (6,6%)
• WHO  Indonesia “community transmission”

Sumber: Worldometer. Covid19.go.id. Corona.jatengprov.go.id. WHO.int

Kasus COVID anak Global
 Age of Coronavirus Deaths Global
AGE Number Share of With Without Unknown if Share of deaths
of Deaths deaths underlying underlying with underlying of unknown +
(%) conditions conditions cond. w/o cond. (%)
0 - 17 years old 3 0,04 3 0 0 0

18 - 44 years old 309 4,5 244 25 40 1,0

45 - 64 years old 1,581 23,1 1,343 59 179 3,5

65 - 74 years old 1,683 24,6 1,272 26 385 6,0

75+ years old 3,263 47,7 2,289 27 947 14,2

TOTAL 6,839 100 5,151 137 1,551 24,68

Underlying illnesses include Diabetes, Lung Disease, Cancer, Immunodeficiency, Heart

Disease, Hypertension, Asthma, Kidney Disease, and GI/Liver Disease

Source. Worldometer. Acces May 12 2020

 INDONESIA
(sampai 12 Mei 2020)
Jumlah Kasus: 14.749
(10% kasus tidak ada data usia)

Jumlah kasus anak 29.40%

28.90%
0-5 tahun = ~ 172
6-17 tahun = ~ 570

TOTAL 18.90%
Kasus anak usia 17.20%
0-17 tahun

~742
4.30%

1.30%

0-5 tahun 6-17 tahun 18-30 tahun 31-45 tahun 46-59 tahun >60 tahun

Sumber: Covid19.go.id/peta-sebaran
Acces 12 Mei 2020
 JAWA TENGAH
(sampai 12 Mei 2020)
Jumlah Kasus: 980 (6.9% nasional)
(4% kasus tidak ada data usia)
32.60%

Jumlah kasus anak

0-5 tahun = ~ 16 25.70%
6-17 tahun = ~ 45

TOTAL
18.70%
Kasus anak
16.40%
usia 0-17 tahun

~ 61

4.80%

1.80%

0-5 tahun 6-17 tahun 18-30 tahun 31-45 tahun 46-59 tahun >60 tahun

Sumber: Covid19.go.id/peta-sebaran
Acces 12 Mei 2020
 Penyebab
• Virus zoonotic, berkapsul, Virus SARS – Cov 2
diameter 80-120 nm
• Replikasi di sitoplasma
sel binatang (unta,
kucing, kelelawar, ular)
• Single-strand 30 kb RNA
genom
• Family: Coronaviridae
• Genus: Beta coronavirus
• Subgenus: Sarbecovirus
• Species: SARS-CoV
• Strain: SARS-CoV-2
• Masa inkubasi 1-14 hari
 Penularan qBinatang  Manusia
Virus SARS – Cov 2 qManusia  Manusia
qBinatang/Manusia  Perantara 
Manusia
Penularan
Manusia  Manusia
v Melalui droplet saluran napas
(batuk, bersin)
v Kontak erat (kontak fisik)
v Menyentuh benda atau
permukaan yang terdapat virus
dan menyentuh mulut, hidung,
atau mata sebelum cuci tangan
v Kontaminasi feses

Virus dapat hidup lebih dari 5 hari pada suhu 22-25 C dan dengan kelembaban
relatif 40-45%
SARS-CoV mati pada suhu 56 C dalam waktu 15 menit
SARS-Cov dapat diinaktivasi oleh sinar UV, kondisi basa (pH > 12), atau kondisi
asam (pH < 3)
 The basic reproduction number (R0) = number of secondary infections
resulting from a single primary infection into an otherwise susceptible population.
It is used to measure the transmission potential of a disease and is the most widely
used estimator of how severe an epidemic outbreak can be

Disease Transmission R0
Measles Aerosol 12-18
Chickenpox (Varicella) Aerosol 10-12
Mumps Respiratory droplets 10-12
Polio Fecal-oral route 5-7
Rubella Respiratory droplets 5-7
Pertussis Respiratory droplets 5.5
COVID-19 Respiratory droplets 1.94-5.7
HIV-AIDS Body fluids 2-5
SARS Respiratory droplets 0.19-1.08
Common cold Respiratory droplets 2-3
Diphteria Saliva 1.7-4.3
Influenza (1918 pandemic strain) Respiratory droplets 1.4-2.8
Influenza (seasonal strain) Respiratory droplets 0.9-2.1
MERS Respirtaory droplets 0.3-0.8
Patogenesis
High level = small intestine, testis,
kidneys, heart, thyroid, and adipose
tissue

Medium level = lungs, colon, liver,

bladder, and adrenal gland

Low level = blood, spleen, bone marrow,

brain, blood vessels, and muscle
Patofisiologi
Stadium Klinis COVID-19
 Manifestasi Klinis

Manifestasi klinis bervariasi tergantung imunitas tubuh, virulensi

kuman mulai dari tidak bergejala, gejala ringan, progresif
sampai mengancam jiwa
vDemam seperti gejala flu batuk dan nyeri kepala
vInfeksi saluran pernapasan atas dan atau bawah disertai
kesulitan bernapas, sesak napas
vDiare, terutama setelah virus menyerang saluran pencernaan
vFatigue (letih, lemah, lesu)
vPada kasus yang berat, terdapat gejala pneumonia dengan
gambaran CT-Scan abnormal, batuk darah, limfopenia, dapat
disertai dengan komplikasi ARDS, gagal jantung, gagal ginjal,
sampai kematian
 Kriteria Klinis
Spektrum klinis
COVID-19

Pneumonia Pneumonia Acute respiratory

Uncomplicated illness disstress syndrome Sepsis Syok sepsis
ringan berat (ARDS)

Mild Moderate Severe Critical

WHO COVID-19 Disease Severity

(Clinical management of COVID-19, Interim Guideline May 2020)

Asimptomatic
 Diagnosis COVID-19
• ISPA
Klinis • Pneumonia
• Pneumonia dengan komplikasi

• Darah rutin, Diffcount, CRP

Laboratorium • Fungsi organ (hati, ginjal, hematologi)  mencari komplikasi
• Analisis gas darah

• Foto rontgen
Radiologis • CT Scan
• Pemeriksaan lain sesuai indikasi

• Swab tenggorokan naso/oro faring

Mikrobiologis • PCR/sekuensing
• Isolasi virus

(+) Riwayat epidemiologis

 tid
ak
je
l as

6.1%
ko
nt
ak
CO
VI
D
+
30.3%

ko
nt
ak
OD
P/
PD
P
51.6%

6.1%

ko
nt
ak
OT
G/
OD
R
(30/33 kasus)

15.2%

pe
rja
la
na
n
ak
tif
24.2%

tin
gg
Riwayat epidemiologis

al
d
33.3%

id
ae
ra
h
te
rja
ng
ki
t
9.1%
 Laboratorium
• Hemoglobin
– Normal = 24/28
– Anemia = 4/28 (12.1%)
• Lekosit (4000-14.000)
– Normal = 22/28
– Lekopeni = 1/28 (3%)
– Lekositosis = 5/28 (15.25)
• Trombosit (150-450 *103)
– Normal = 22/28
– Trombositopenia = 4/28
– Trombositosis = 2/28
• Absolut Netrofil (~usia)
– Normal = 23/27 (69,7%)
– Netropeni = 1/27
– Netrofilia = 3/27
• Absolut Limfosit (~usia)
– Normal =20/27
– Limfopenia = 5/27 (15.2%)
– Limfositosis = 2/27
• NLR
– < 3,5 = 20/27
– > 3,5 = 7/27 (21.2%)

Laboratorium tidak khas !!!

A B

Chest radiographs of two patients returned from Wuhan, China, with pneumonia
caused by SARS-CoV-2 in middle Taiwan.
(A) Case 1: increasing opacity at right middle and lower lung fields at hospital day 6.
(B) Case 2: patchy consolidation over bilateral lower lung fields of at hospital day 6
Chest CT images of a 29-year-old man with fever for 6 days. RT-PCR assay for the SARS-CoV-2
using a swab sample was performed on Feb. 5, 2020, with a positive result. (A column)
Normal chest CT with axial and coronal planes was obtained at the onset. (B column) Chest CT
with axial and coronal planes shows minimal ground-glass opacities in the bilateral lower lung
lobes (yellow arrows). (C column) Chest CT with axial and coronal planes shows increased
ground-glass opacities (yellow arrowheads). (D column) Chest CT with axial and coronal
planes shows the progression of pneumonia with mixed ground-glass opacities and linear
opacities in the subpleural area. (E column) Chest CT with axial and coronal planes shows the
absorption of both ground-glass opacities and organizing pneumonia. Image courtesy of
Radiology
Gambaran radiologis pasien COVID (+) pada anak
di RSUP Dr Kariadi Semarang

An Lk 3 tahun, ARDS COVID (+)

An Pr 2 tahun, Moderate COVID (+) An Pr 3 tahun, Moderate COVID (+)
An Lk 6 tahun,Mild COVID (+) An Lk 16 tahun, Mild COVID (+)
 Severity of COVID pneumonia clinical
presentation
Ventilatory
responsiveness
to hypoxemia
Severity of Time between
infection, host onset disease
response, and hospital
comorbidities observation
Time related
disease
spectrum 
“phenotype” L
&H

Gattinoni L, et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes?(2020) Intensive
Care Medicine; DOI: 10.1007/s00134-020-06033-2
 COVID-19 pneumonia phenotypes
Type L (70-80% ps) Type H (20-30% ps)
• Low elastance • High elastance
• Low ventilation to • High right to left shunt
perfusion (VA/Q) • High lung weight
• Low lung weight • High lung recruitability
• Low lung recruitability
 Clinical scenario of COVID-19 in children
(Lesson learned from COVID+ cases IDAI Jateng)

COVID-19 COVID COVID

(+) (+)
ALONE Secunder infection Comorbidities

Respiratory Non Respiratory Respiratory Non Respiratory

Infection Infection Disease Disease

• Upper • Neurologic
Usually • Dengue diseases
Respiratory
asimptomatic Infection
• Viral infection • Hematologic/m
• CMV • Asma
or mild disease • Pneumonia • Chronic lung
alignancy
• HIV-AIDS • Allergic dis
bacterial disease
• Sepsis • Cardiac
• Pneumonia viral • Congenital
• Urinary diseases
(other than respiratory
infection • Renal Disease
SARS-CoV-2) disease
• Other infection • Nutritional dis
• Tuberculosis
• Gastro-hepatic
diseases
• Congenital dis
I------------ Severity depend on secunder infection or comorbidities ------------I
Kenapa pada anak COVID jarang menyebabkan
Morbiditas dan Mortalitas ??

• Paparan yang rendah

• Kondisi paru yang normal
• Paru masih dalam tahap pertumbuhan…
jumlah alveoli sedikit
• Sistem imun dominasi innate
• ACE-2 receptor  sedikit, belum matur,
distribusi tidak merata
TERIMA KASIH