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Gejala demam

Prihatini
Patologi klinik UWKS
2016

prihatini/pk/2016 1
DAFTAR PUSTAKA
FISBACH ,f.,a MANUAL OF
LABORATORY& DIAGNOSTIC
Starlin,lin,goodenberger,infectious
subspesially consultan

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Macam demam
FUO
FEVER IN ICU
FEVER & RASH
NEUTROPENIC FEVER
FEVER IN TE RETURNED TRAVELLER

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DEFINISI DEMAM
Kenaikan suhu tubuh diatas normal
(rentang sikardian) hasil dari perubahan
pusat pengatur suhu (thermoregulator)
terletak di anterior hypothalamus & pre-
optic area

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pengatur suhu
(thermoregulator)
Suhu badan panas umum ok:
a) Aktivitas metab basal
b) Gerakan otot & hilang oleh
konduksi, konveksi(angin,
kipas ,
penguapan menambah keringat
bertambah )

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Suhu tubuh normal

Suhu diatur pusat suhu noraml


37 0.5C,
Diperlukan fungsi banyak enzim
& proses metabolik .

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Tanggap terhadap suhu
Rangsangan luar (eksogen) /dlm
(endogen) thd sel inang, sel monosit &
makrofag yg merangsang sintesisi dan
melepas beragam pyrogenik sitokin :
1)interleukin-1, interleukin-6
2)TNF-,
3)IFN-.

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Rangsangan luar(eksogen)
Rangsangan diluar inang :
mikroorganism, produknya dan , atau
toksins disebut Endotoxin

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Endotoxin (endotoksin)
lipopolysaccharide ( LPS)
Terdapat di luar membran (outer
membrane ) semua mikroorganisme
Gram negatif
aksi :
1) melalui rangsangan monosit &
makrofag
2) langsung di sel endotel otak
menghasilkan demam
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Endogenous pyrogens
polypeptides dihasilkan tubuh ( oleh
monocytes &makrofag )tanggap
rangsangan umum dipicu infeksi atau
rangsangan inflamasi

Pyrogens:
bahan penyebab demam

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Sitokin (Cytokines)

Definisi :
Cytokines adalah pengatur
polypeptides yg dihasilkan oleh:
1) monocytes / macrophages
2) lymphocytes

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Kekuatan pyrogen
Paling penting :
Interleukin 1 & 1 - :lebih pyrogenic
Tumor necrosis factor
Interferon
Interleukin 6 kurang pyrogenic
cytokines bila >demam ssd 1h injeksi

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Mekanisme sitokin
Interaksi sitokin di regio anterior
hypothalamus =>fosfolipase A aktif
membebaskan arachidonic acid sbg
substrate jalur cyclog-
oxyenase=>mediator prostaglandin E2
mengubah:
neuron termosensitif=> pusat
termoregulator

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Variasi Diurnal

6 am : 37.24pm : 37.7
Rectal temperature>0.6o C oral
temperature
Fever: Morning : AM >37.2o C
Evening : PM >37.7o C

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Demam didapat
Rasa panas
tak diperlukan untukan demam
Rigors.
menggigil hubungan dgn gigi dan
menyatakan suhu badan cepat naik
,ditemukan:
1) brucellosis & malaria
2) sepsis dgn abscess
3) lymphoma
Banyak keringat
malam berkeringat khas tuberculosis, tetapi
berkeringat penyebab lain biasanya keadaan
yg buruk bila malam
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Ketentuan demam
Nyeri kepala (Headache).
demam dari kebanyakan penyebab
memicu sakit kepala. Bila nyeri kepala
berat & fotofobia ,dugaan
meningitis.
Delirium.
Kecacauan mental(Mental confusion)
selama demam relatif sering pada anak
muda & usia lanjut
Muscle pain.nyeri otot ( Myalgia) khas
infeksi virus seperti influenza;
Malaria & brucellosis
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Hyperthermia

Kenaikan suhu tanpa kenaikan titik


hipotalamus .
Penyebab : kehilangan panas tak
memadai
Contoh:
1) Heat stroke
2) Drug induced misal tricyclic
antidepressant
3) Malignant hyperthermiaterkait obat
psikiatri
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Mengapa demam
Kenaikan suhu tubuh sbg pertahanan
Suhu meningkat
1) fagosit & aktivitas bakterisidal
neurtrophils &
3) pengaruh sitotoksik lymphocytes
.. Sehingga
pertumbuhan & virulensi bbp spesies
bakteri rusak pada suhhu tinggi

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Pola demam
Intermittent fever =sebentar-bentar
demam
Remittent fever= demam berhenti
berkala
Hectic fever= kebiasaan demam
Sustained fever=terus menerus demam
Relapsing= demam kambuh/berhenti kmd
berulang
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Intermittent fever =sebentar-bentar
demam
Berlebihan ritmever
circardian bila variasi
besar disebut hectic disebabkan :
a)infeksi dijarngan > dlm
b)Maligna
c)Obat demam
demam Quotidian : demam hectic
terjadi tiap hari.

prihatini/pk/2016 20
demam berhenti berkala
(Remittent fever )
Suhu turun tapi tidak normal .
penyebab :
tuberculosis
infeksi virus
kebanyakan infeksi bakterial

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demam kambuh-
kambuh(Relapsing fever )
Masa demam berlangsung terpisah dari interval
suhu normal
a) demam Malaria tiap 3 hari(tertian) pada P.
falciparum atau tiap 4 hari(quartan) pada P.
.vivax
b) Borrelia ..tiap hari diikuti tanpa demam

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POLA DEMAM (1)

DEMAM Pel-Ebstein : 3 - 10 hari


diikuti tanpa demam 3 - 10 hari
penyebab : a) Hodgkin lymphoma
b) Tuberculosis

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POLA DEMAM (2)

Pola demam tak dpt digunakan


diagnostik untuk sebagian
penyakit / macam penyakit yg
tidak umum akibat penggunaan:
1) Antipyretics
2) Steroids
3) Antibiotics

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POLA DEMAM (3)

Suhu berkaitan denyut nadi( Relative bradicardia )


A) Demam tifoid
B) Brucellosis
C) leptospirosis
D) Demam dibuat (factitious fever )
E) ARF(acute rheumatic fever) dgn abnormal
konduksi kardiak
F) Viral myocarditis

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Derajat pola demam
Demam dgn suhu ekstrem :
Bakteremia Gram-negatif ,
penyakit Legionnaires ,
Pyelonefritis bacteremik
Demam penyebab noninfeksi :
heat stroke,perdarahan intraserebral

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Riwayat penyakit (1)
1. Riwayat penyakit secara lengkap dari
pasien dengan gejala yang rinci
2. Obat yg tidak biasa digunakan
penicillin &
cephalosporin
sulphonamide
anti tuberculous agents
anticonvulsants particularly phenytoin

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Riwayat penyakit
Riwayat penyakit (2)
(2)
3)pembedahan/perawatan gigi
pasien tahu penyakit RHD beresiko
endocarditis bila tak diberi
pencegahan(profilaks)
4)secara alami menggunakan
bahan protetik/peralatan implan
:
sendi, katub protetik

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Riwayat penyakit
Riwayat penyakit (3)
(3)
5).riwayat pekerjaan termasuk:
terpajan hewan: brocellosis
terinfeksi penyakit
rumah..tuberculosis / infleunza
6) daerah dimana dia tinggal

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Riwayat penyakit
Riwayat penyakit (4)
(4)
4) Riwayat perjalanan
Selalu bepergian
a) kemana? daerah
endemik/bukan?
b) apa yg dikerjakan?
c) berapa lama mereka?
d) pernah digihit serangga /kontak
dgn hewan ?
e) pernah terserang/profilaksis thd
malaria ?
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Bila pasien berada di daerah
endemik
Diagnosis akhir umumnya:
Malaria
demam tifoid ,
hepatitis Viral
demam Dengue
Malaria harus disingkirkan bila terdapat
gejala malaria

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Riwayat penyakit (5)
5) Pekerjaan dicerobong (Household
pits)
6) Minum susu tanpa pasteurisasi /keju
7) Kebiasaan hubungan (Sexual practice)
8)Penyalah gunaan obat (Iv drug abuse)
9) Pengguna Alkohol
10) Sebelum transfusi/imunisasi
11) Alergi obat

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Gejala infeksi saluran
napas
1. nyeri tenggorok,keluar cairan
dihidung,pilek,ISPA
2. nyeri kepala & sinus dugaan sinusitis
3. Ispb:batuk,dahak,sesak,napas bunyi

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Gejala urogenital
Spesifik : sering kencing,nyeri
kencing,nyeri pinggang & sekret vagina
/uretra dugaan..
a) ISK (Urinary tract infection),
b) penyakit inflamasi pelvik (Pelvic
inflammatory disease )
c) infeksi hubungan seksual(STI)

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Gejala abdomen
diarrhea dgn/tanpa darah , berat
badan kurang & nyeri abdomen
dugaan..:
a) penyakit perut
(Gastroenteritis)
b) sepsis (Intra-abdominal),
c) penyakit inflamasi usus
(Inflammatory bowel disease),
d) Malignancy
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Gejala sendi
Nyeri sendi , bengkak /sukar gerak ,
A) tersebar : mono , oligo / poly
artritis
B) tampak : bersamaan /
tambahan(fleeting or additive)
dugaan1) infeksi arthritisoligo
2) collagen vascular
disease..bersamaan
3) reactive arthritis
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Riwayat bepergian(travel)
Selalu bercerita perjalanan asing
Bila di daerah endemik:malaria,demam
tifoid,hepatitis virus,demam dengue

Malaria didingkirkan bila nterdapat


gejala

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Riwayat obat
Drug fever is uncommon and therefore
easily missed.
The culprits include :
penicillin and
cephalosporin
sulphonamide
anti tuberculous agents
anticonvulsants particularly
phenytoin
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Alcohol consumption.

Alcoholic hepatitis,
hepatocellular carcinoma
are all recognized causes of fever.

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Family history OF

a) Tuberculosis
b) Arthritis
c) Other infectious diseases
d) Any one with symptomatology of
Polyserositis or bone pain

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Ethnic origin of the patient

is important. .Example:
Turks , Arabs , Armenians likely to
have
Familial Mediterranean fever

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Physical examination
Repeated meticulous examination on a
regular basis until diagnosis is made .
Temperature should be taken
1) Orally ..or
2) Rectally .
Axillary temperature is notoriously
unreliable

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Cautions while taking oral
temperature

1) Recent consumption of hot or cold


drinks
2) Smoking
3) Hyperventilation

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pemeriksaan
FACTITIOUS FEVER

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FACTITIOUS FEVER
This is defined as fever engineered by the
patient By manipulating the thermometer
and/or temperature chart apparently to obtain
medical care.
uncommon and typically presents in young
women who work in paramedical professions
Examples include
The dipping of thermometers into hot drinks
to fake a fever,
The factitious disorder is usually medical
but may relate to a psychiatric illness with
reports of depressive illness.
.

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CLUES TO THE DIAGNOSIS
OF FACTITIOUS FEVER
A patient who looks well
Absence of temperature-related changes in pulse
rate
Temperature > 41C
Absence of sweating during defervescence
Normal ESR and CRP despite high fever

Useful methods for the detection of factitious


fever include
1) Supervised (observed) temperature
measurement
2) Measuring the temperature of freshly voided
urine
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A careful examination is vital
and must be repeated
regularly
Particular attention should be paid to :
The skin .for skin rash
Throat.for pharyngitis
Eyesfor jaundice , scleritis.
Nail bed .for clubbing, splinter
hemorrhage.
lymph nodes.. for enlargmant
abdomen for ascitis or sign of
peritonitis
heart ...for murmurs indicating
endocarditis.
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2) Look for RASH

a) Erythmatous rash ( rash that


blanch on pressure )
Causes :
1) Meseals : often accompanied by
upper respiratory tract symptoms
and conjunctivitis
2) other viral infection like : rubella
, scarlet fever
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B) a purpuric or petechial rash :
(donot blanch on pressure )
May suggest meningococcal
septecemia

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Vesicular rash : may be caused
by
chickenpox or shingles

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Mouth and oropharynx

Vesicular lesions ,tonsillar exudate


:suggest
Infectious aetiology:
1) streptococcal pharyngitis
2) coxsakie infection

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Hairy leukoplakia.OR
oropharyngeal candidiasis
suggest :
HIV /AIDS

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oropharyngeal
candidiasis..suggest
Immunodefficiency syndrom

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Eyes

Conjunctival petechiae.
may suggest
..meningococcal meningitis
Jaundice may
suggest acute hepatitis A
Cervical lymphnodes
enlargment :
Tonsillar LN enlargmant
.suggest :
Acute pharyngitis or
tonsillitis
Posterior
lymphadenopathysuggest :
1) Infectious mononucleosis
2) HIV infection

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Axillary lymph node
enlargement may suggests:

1) Sepsis
2)leukemia
3) lymphoma
Joints ( any joing but commonly the
knee and ankle )
Look for swelling , redness,hest
and effusion suggest active
arthritis ..?infective
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Factidious fever
Neck ..look for stiffness..may
suggest meningitis
Abdomen :
Look for : Tenderness especially in
the RIF
acute appendicitis
Chest and heart
1) Sign of consolidation
2) Pleural effeusion
3) Pericardial rub
4) Cardiac murmurEndocarditis
or acute rheumatic fever

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20 years male who is heroin drug abuser for long time
came to ER c/o:
of left thigh pain and fever .
Look at the picture and guess what is his problem

Hip flexor spasm due to psoas


abscess
Secondary to staphylococcus
septicemia with seeding into the
muscle

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Laboratory investigation is indicated if

presentation suggests more than


Simple viral infection or
acute pharingitis in children,

Lab test can be focused if the


history is suggesting certain
diagnosis

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investigations:
1) complete blood count with
deifferential ,
** band forms and toxic
granulation ..suggest bacterial
infection
** Neutropenia : may be seen with :
Infection :
Typhoid,brucellosis ,viral infection
vasculitis : systemic lupus
erythromatosis prihatini/pk/2016 61
investigations:
** lymphocytosis : may be seen in :
a) Tuberculosis , brucellosis , Viral
disease.
** Monocytosis : is seen with
a) Tuberculosis , typhoid and
brucellosis
b) lymphoma
**Eosinophilia is seen in :
a) Hypersensitivity drug syndrom
b) Hodgkin disease
c) Adrenal insufficiency
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investigations:
blood films to exclude Malaria
Urinalnalysis
Sample any fluid and examine :
pleural, peritoneal or joint
Bone marrow biopsy for
histopathology study if :
an infiltrative disease is
suspected
Stool inspection for occult blood
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investigations:
2) chemistry : electrolytes ,glucose,
urea , and liver function
3) microbiology
Samples from : sputum , urethra and
other sites like joint, pleural fluid ,
ascetic fluid ..and send for
smears and culture
Sputum evaluation :a) Gram staining
b) Z-N staining for
asid fast bacilli
Culture for :blood, abnormal fluid
collection and urine
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SPECIAL BLOOD TEST :

HIV screening for patient who has risk


factor :
1)Recent travel with sexual exposure
2) injection drug user
3) sex workers
4) blood transfusion recipient
Radilology
chest x ray is indicated for any patient
with significant febrile illness.

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Outcome of diagnostic
efforts
1) patient recover spontaneously
suggesting : viral illness or some of the
spontaneously recovering bacterial
infection : mainly intracellular
organism like typhoid or brucellosis
2) diagnosis is reached
3)If fever persist for more than 2-3
weeks with no diagnosis is reached by :
a) repeated physical examination
b) laboratory test .then
It is pyrexia of unknown origin

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Pengobatan demam
Is it fever or hyperthermia
Hyperthermia
1.Heat stroke
Classic heat stroke
2.Drug-induced hyperthermia
3.Malignant hyperthermia

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Pengobatan demam
Heat stroke
Thermoregulatory failure in association
with a worm environment
1) Exertional : young person exercising
at ambient temperature and or
humidities that are higher than normal .
2)non Exertional :typically occur in
elderly.

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Pengobatan demam
Hyperpyrexia : more than 40 should
be treated by : anti pyretics and
physical cooling
While resetting the hypothalamic set
point with antipyretic will speed the
process.
Antipyretics also help for :
Headache , myalgia , chills .

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Pengobatan demam
Low grade or moderate fever is not
harmful ;
So no antipyretics use except for
1)pregnant women
2) child with febrile seizures

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Why no antipyretics for mild
fever
Obscure the natural history of the
patient disease or syndrome.
Gives false feeling of well being
..may miss meningitis
Imminently life- threatening

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Antibiotics use In ER
Pathogens
Infection focus
host factors (Immune factors)
Common infection in ER
1. UTI
2. Respiratory tract infection
3. CNS infection
4. Cellulitis

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Antibiotics use in-UTI
Upper urinary tract infection
Symptomes : Fever , flank pain,
dysuria
lab test : Pyuria , bacturia
Treatment : cotrimoxasole ,
Cephalosporin or
aminoglycoside .duration: 7-
10 days
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Antibiotics use In-Respiratory
tract infection
Pneumonia
1. Cough, fever, sputum or not
clinical manifestations: consolidation
CXR : .opacity with air
bronchogram
interstitial infiltrate
sputum : grams stain
Treatment :3rd generation
cephalsporine and macrolides
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Antibiotic use in-respiratory
tract infection
Nosocomial fever
Fever aquired after 48 hours of
admittion to the hospital
1) pneumonia
2) catheter related infection
3) UTI

Consider hospital pathogen while


selecting antibiotics

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Antibiotics use in-CNS
infection
Bacterial meningitis
1. Aggressive antibiotics-due to
prognosis and sequence
2. cephalosporin
Vancomycin
Viral meningitis
1. Observation, s/s Tx
2. Herpes meningitis- acyclovir
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Antibiotics use in-CNS
infection
TB meningitis
1. Anti-TB agents
2. Prognosis: variation
Fungal meningitis: antifungal agents

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Antibiotics use In-
cellulitis
Pathogens: common streptococcus,
or
staphylococcus
Cellulitis
Antibiotics: PCN G or oxacillin

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Kesulitan (Pitfalls)
Depend on laboratory data
Incomplete Hx.&EX

Atypical presentation
1. Immunocompromised patient
2. Newborn
3. Early sign
4. Dehydration
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