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INFEKSI SUSUNAN

SARAF PUSAT

Oleh :
Dr. Budi Wahyono, SpS

ANATOMI SELAPUT OTAK

Piamater
Arakhnoid
Duramater

Perjalanan Infeksi
Masa

Inkubasi
Gejala prodromal
Masa infeksi abortif
Bakteriemi
Septikemi
Gejala lokalisatorik

Infeksi Virus

Infeksi Bakteri
Invasi

hematogen

Dapat berasal dari nasofaring, paru, jantung

Perkontinuitatum

dari jaringan di

sekitarnya
Pembuluh

darah meningeal yang


kecil dan sedang mengalami
hiperemi sel PMN ke ruang
subarakhnoid eksudat (2 lapisan;
lapisan PMN dan fibrin, makrofag)

MENINGITIS
Inflamasi

pada selaput otak


Manifestasi klinis nya adalah tanda
meningeal ; nyeri kepala, kaku kuduk
dan fotofobia
Menurut lamanya gejala, terbagi
atas 2 ; akut (beberapa minggu-1
bulan) dan kronis (>4 minggu)

Risk and/or Predisposing Factor


Age 3 months to 18 years

Bacterial Pathogen
N meningitidis
S pneumoniae
H influenzae

Age 18-50 years

S pneumoniae
N meningitidis
H influenzae

Age older than 50 years

S pneumoniae
N meningitidis
L monocytogenes
Aerobic gram-negative bacilli

Immunocompromised state

S pneumoniae
N meningitidis
L monocytogenes
Aerobic gram-negative bacilli

Intracranial manipulation, including


neurosurgery

Staphylococcus aureus
Coagulase-negative staphylococci
Aerobic gram-negative bacilli, including
Pseudomonas aeruginosa

Basilar skull fracture

S pneumoniae
H influenzae
Group A streptococci

CSF shunts

Coagulase-negative staphylococci
S aureus
Aerobic gram-negative bacilli
Propionibacterium acnes

Virus
Enterovirus ; Polio, Echovirus, Coxsackie
Herpes ; HSV
Paramyxovirus ; Mumps, measles
Togavirus ; Rubella
Flavivirus ; Japanese ensefalitis
Retrovirus ; HIV

Meningitis TB
Radang

pada selaput otak


disebabkan oleh Mycobacterium
tuberculosa
Cairan otak jernih
Riwayat kontak TB
Pengguna obat kortikosteroid
Belum pernah di vaksin BCG

lama

Gejala meningitis

Tanda rangsang
meningeal

Pemeriksaan Penunjang
Agent

Opening Pressure

WBC count per L

Glucose (mg/dL)

Protein (mg/dL)

Microbiology

Bacterial meningitis

200-300

100-5000; >80% PMNs*

<40

>100

Specific pathogen
demonstrated in 60% of
Gram stains and 80% of
cultures

Viral meningitis

90-200

10-300; lymphocytes

Normal, reduced in LCM


and mumps

Normal but may be


slightly elevated

Viral isolation,
PCR assays

Tuberculous meningitis

180-300

100-500; lymphocytes

Reduced, <40

Elevated, >100

Acid-fast bacillus stain,


culture, PCR

Cryptococcal meningitis

180-300

10-200; lymphocytes

Reduced

50-200

India ink, cryptococcal


antigen, culture

Aseptic meningitis

90-200

10-300; lymphocytes

Normal

Normal but may be


slightly elevated

Negative findings on
workup

Normal values

80-200

0-5; lymphocytes

50-75

15-40

Negative findings on
workup

Penatalaksanaan
Tirah

baring
Pantau respirasi
Pemilihan antibiotik yang tepat dan
cepat

Penisilin G 1-2 juta unit setiap 2 jam


Kloramfenikol 4x1 gram /24 jam
Ampisilin 4x3 gram /24 jam
Gentamisin

Pada meningitis TB
2HRZE-7RH
2 bulan pertama
INH: 300 mg/hari, oral
Rifampisin: 10 mg/kgBB per hari, oral
Pirazinamid: 30 mg/kgBB/hari, oral
Streptomisin: 15 mg/kg/hari, oral
Etambutol: 15-20 mg/kg/hari, oral

7-12

bulan berikutnya

INH: 300 mg/hari, oral


Rifampisin: 10 mg/kgBB/hari, oral

Steroid
Dexametasone 10 mg bolus intravena,

kemudian 4 kali 5 mg intravena selama


2-3 minggu selanjutnya turunkan
perlahan selama 1 bulan.

ENSEFALITIS
Inflamasi

pada parenkim otak


disertai dengan kelainan neurologis
difus maupun fokal
Ensefalitis akut banyak terjadi
karena infeksi virus

Virus

penyebab ensefalitis dapat


dibagi menjadi dua kelompok
Virus RNA adalah enterovirus (polio,

coxsakie grup A dan B, echo), arbovirus,


flavivirus (Japan B, yellow fever,
dengue).
Virus DNA adalah virus herpes, pox,
retrovirus (AIDS).

Manifestasi klinis
demam

tinggi yang akut


tanda-tanda rangsang meningeal
(nyeri kepala, demam dan kaku kuduk)
kelainan fokal neurologi (kejang,
penurunan kesadaran dari lethargy
hingga koma)
gejala-gejala spesifik lainnya yang
disebabkan oleh virusnya.

Pemeriksaan fisik
Perubahan

status mental
Kelainan fokal (hemiparese, kejang
fokal, gangguan otonom)
Ataksia
Kelainan saraf kranialis

CSF Finding (Normal)

Bacterial Meningitis

Viral Meningitis*

Pressure (5-15 cm H2O)

Increased

Normal or mildly increased

Cell counts, mononuclear cells/mm3


Preterm (0-25)
Term (0-22)
6 mo+ (0-5)

No cell count excludes bacterial


meningitis

Usually <500, nearly 100%


mononuclear

Typically thousands of
polymorphonuclear cells, but
counts may not change
dramatically or even be normal
(classically in very early
meningococcal meningitis or in
extremely ill neonates)

<48 hours, clinically significant


polymorphonuclear pleocytosis
may be indistinguishable from
early bacterial meningitis,
particularly with EEE

Nontraumatic RBCs in 80% of


patients with HSV
meningoencephalitis, though 10%
have normal CSF results

Lymphocytosis with normal CSF


chemistry results observed in 1525% of patients, especially if
counts <1000 or if patient is
partially treated

About <90% of patients with


ventriculoperitoneal shunts and
CSF WBC count >100
cells/mm3 are infected; CSF
glucose level usually normal, and
these patients' pathogens are less
pathogenic than others'

Cell count and chemistry levels


normalize slowly (days) with
antibiotics

Gram stain 80% effective

Inadequate decolorization may


causeHaemophilus
influenzae to be mistaken for
gram-positive cocci

Pretreatment with antibiotics


may affect stain uptake,
causing gram-positive species
to appear to be gram-negative
and decrease culture yield by
an average of 20

Glucose
Euglycemia (>50% serum)
Hyperglycemia (>30% serum)

Protein
Preterm (65-150 mg/dL)
Term (20-170 mg/dL
6 mo+ (15-45 mg/dL)

Microorganisms (none)

No organism

Decreased

Normal

Usually >150 mg/dL

Mildly increased

May be >1000 mg/dL

CT

Scan

Penatalaksanaan
Tirah

baring
Pemberian nutrisi parenteral
e/ virus :
Asiklovir diberikan dengan dosis 10 mg/kgBB setiap 8 jam
selama 10 hari atau peroral 200 mg/kgBB 5-6 kali sehari.
Kadar Hemoglobin harus terus dipantau, bila Hb turun sampai
9 g/dl maka dosis diturunkan menjadi 200 mg setiap 8 jam.
Jika Hb turun sampai 7 g/dl maka pengobatan dihentikan
sementara waktu dan diberikan lagi setelah kadar Hb normal
kembali.

e/

bakteri :

Antibiotik ; Ampisilin 4 x 3-4 gram


Kloramfenikol 4x1 gram

Steroid

(dexamethasone)

POLIOMYELITIS

Enterovirus
Fecal oral
transmission

Pembagian Polio
Non

Paralitik Poliomyelitis
Paralitik Poliomyelitis
Paralitik Poliomyelitis dengan
kerusakan bulbar

Penatalaksanaan
Fisioterapi
Intervensi Pembedahan
Vaksin pencegahan

Terima Kasih