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PEMERIKSAAN

LABORATORIUM
DEMAM
PRIHATINI
PATOLOGI KLINIK FKUWKS
2016

Prof Dr Prihatini dr SpPK(K)2016 1


PEMERIKSAAN DEMAM
• 1/3
ortu 38-40ºC(100.4-104ºF), 2/3 40-41ºC(104-
106ºF), kerusakan otak >41ºC(106ºF).
• 5-20% tak ada asal & riwayat demam(-)
• Sebagian besar anak demam parah,
• Hampirsebagian kecil penyebab tersembunyi
atau berlanjut dgn infeksi bakteri

Prof Dr Prihatini dr SpPK(K)2016 2


DEMAM SESUNGGUHNYA(TRUE FEVER)
• IL-1, IL-6, TNF-ά /cytokines DILEPAS dari
monocytes & macrophages tanggap thd infeksi
,kerusakan jaringan,obat&proses inflamasi yl .
• anterior hypothalamus mempertahankan suhu
36ºC(98.6ºF).
• Normal circadian rhythm, ( 2ºC, 3ºF) ~6pm
terendah sesudah 6am. Demam ss pola
mengikuti waktu tsb.

Prof Dr Prihatini dr SpPK(K)2016 3


False’ fever, ( hyperthermia) /
DEMAM PALSU
• Secara tak langsung mempengaruhi suhu tubuh:
• Penyakit SSP memepengaruhi hypothalamus--ICH, infeksi .
• Penyakit yg meningkatkan suhu tubuh:D --hyperthyroidism,
malignant hyperthermia, salicylate overdose.
• Muatan Demam berlebihan meninggalkan
kendaraaan/meninggalkan tempat pemanas lama
• Mekanisme kehilangan panas teganggu : luka bakar , heat
stroke, obat mempengaruhi aliran darah dan mekanisme
keringat .
• SUHU Normal karena aktifitas fisik,ovulasi,dan suhu lingkungan
.

Prof Dr Prihatini dr SpPK(K)2016 4


Pengukuran suhu tubuh
• All measurements are estimates of the body’s true core
temp—central circulation=aorta and pulmonary artery.
• RECTAL—gold standard
• Esophageal—accurate but impractical
• Tactile and axillary—inaccurate, varies considerably
with environmental temperature
• Tympanic—inaccurate in age <3 years

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Benefits of fever
• The hypothalamus will not allow the temp to rise above
41.5ºC(107ºF).
• WBCs work best and kill the most bacteria at 38-
40ºC(100.4-104ºF).
• Neutrophils make more superoxide anion, and there is
more and increased activity of interferon.
• Coxsackie and polio virus replication is directly
inhibited.

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Fever without a source(FWS)
•5to 20% of febrile children have no localizing
signs on PE and nothing in the history to explain
the fever. By definition, less than 7 days.
• FWS(like
fever) is most common in children
younger than age 5, with a peak prevalence
between 6 and 24 months of age.
• Those <6 months retain protective maternal antibodies
against common organisms, while those 18-24 months
old are more immune competent, and are at a lower
risk of developing bacteremia

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Diagnostic Assessment in Children
• Age
is important as 1) etiologic
pathogens, 2) clinical exam, and 3)
immune system capacity changes as the
newborn ages.
• Most break them into the :
first 2-4 weeks of life(neonatal),
1-3 months, and 3 to 36 months.

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Neonates
• The majority of febrile neonates presenting to the ED
have a nonspecific viral illness
• 12% have serious bacterial infections (SBI)
• Infected by more virulent bacteria
• More likely to develop serious sequelae from viral
infections
• GBBS is associated with high rates of meningitis(39%),
non-meningeal foci(10%), and sepsis(7%)
• The most common bacterial infections are UTI and
occult bacteremia
Prof Dr Prihatini dr SpPK(K)2016 9
Neonates
• Risk Factors
• Preterm
• Membrane rupture: before labor onset or prolonged>12
hours
• Chorioamnionitis or maternal peripartum fever
• UTI
• Multiple pregnancy
• Hypoxia or Apgar score <6
• Poverty or age <20

• 1/3-1/2 neonatal sepsis will have no risk factors!


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Neonatal
• PE is felt to be unreliable in detecting many serious bacterial
infections. Meningitis should always be considered—up to 10%
appear well, only 15% have a bulging fontanelle, and 10-15% have
nuchal rigidity. So, a high index of suspicion is important!!! ~20%
will not have fever initially.
• Hyperthermia or hypothermia
• Lethargy or irritability
• Poor feeding or vomiting
• Apnea
• Dyspnea
• Jaundice
• Hypotension
• Diarrhea or abdominal distension
• Bulging fontanelle
• seizures

Prof Dr Prihatini dr SpPK(K)2016 11


Neonates
• Screening tests: WBC<5000 or >20,000, PMN
<4000, I:T>.2, Plt<100,000, CRP>1, LFTs
elevated(suggest HSV)
• So, if <28 days of age and rectal temp> 38ºC
• Admit
• Blood Culture
• Urine Culture—cath specimen
• Lumbar Puncture
• Cell count, protein, glucose, culture, PCR
• Parenteral Antibiotics
• Ampicillin + Gentamicin(Cefotaxime), consider Acyclovir(primary
maternal infxn, esp if delivered vaginally, PROM, fetal scalp
electrodes, skin eye or mouth lesions, seizures, CSF pleocytosis)

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Infants 1 to 3 months
• Causes
• HSV(17% are 15 days to 6 weeks of age)
• Bacterial sepsis/meningitis
• Group B Strep, S. Pneumoniae, H. influenza, N. meningitidis,
Enterobacteriaceae
• Bone and joint infections
• UTI
• Bacterial enteritis(esp Salmonella)
• Pneumonia
• Enterovirus sepsis/meningitis(July-October)
• The risk of bacteremia/meningitis is 3.3%, pneumonia, bone/joint
infections and bacterial enteritis is 13.7%
• 30-50% of those who are ultimately diagnosed with bacterial
meningitis have been seen by a physician within the prior
week(usually 1-2 days before) and were diagnosed as having a
trivial illness and discharged on oral
Prof Dr Prihatini antibiotics.
dr SpPK(K)2016 13
Infants 1 to 3 months
• Rochester Criteria/Low Risk Criteria
• Nontoxic—most critical and difficult
• Previously healthy, not low birth weight
• No focal bacterial infection on PE except Otitis Media
• WBC 5,000-15,000/mm3 (normal)
• Bands<1500/mm3 (normal)
• Normal urinalysis, including gram stain
• If diarrhea, must be non-bloody and WBC<5/hpf.
• If respiratory symptoms present, normal CXR

• Negative predictive value 98.9%


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Infants 1 to 3 months
• If
all of the criteria are met, then there are 2
options for outpatient management:
• Blood, Urine Cultures, LP,
1)
Ceftriaxone 50mg/kg IM (to 1g), and
return for reevaluation within 24
hours.
• 2) Blood, Urine Cultures and careful
observation

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Infants 1 to 3 months
• Follow-up of low risk infants
• If all cultures negative: afebrile, well
appearingCareful observation
• Blood cultures negative: well appearing,
febrileCareful observation, may consider second
dose of Ceftriaxone
• Blood culture positiveadmit for sepsis workup and
parenteral antibiotics pending results
• Urine culture positive: if persistent feveradmit for
sepsis workup, parenteral antibiotics pending results.
If afebrile and welloutpatient antibiotics
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Occult Bacteremia
5 % of children with FWS have OCCULT
BACTEREMIA
• The presence of a positive blood culture in
kids who look well enough to be treated as
outpatients and in whom the positive results
are not anticipated.

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Occult Bacteremia
• Streptococcus pneumonia is responsible for 2/3
to ¾ of all cases.
• Peak prevalence between 6 and 24 months
• Association with high fever(39.4ºC or 103ºF)
• High WBC count(>15,000)
• Absence of evident focal soft tissue infection.

• Neisseria meningitidis, Haemophilus influenzae


type b, and salmonellae account for most of the
remaining cases.

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Risk of Occult Bacteremia
Low Risk High Risk
Age >3yr
Temp <39.4ºC
<2yr
WBC >5000 & >40ºC(104ºF)
<15,000
<5000 or >15,000

Hx of contact with H. Flu


or N. meningitidis

Prof Dr Prihatini dr SpPK(K)2016 19


Risk of Occult Bacteremia
Therefore, blood culture is the gold
standardstill has a high number of false
positives, take 24-48hrs, and most cases
of occult pneumococcal bacteremia clear
without treatment.

Prof Dr Prihatini dr SpPK(K)2016 20


Risk of Occult Bacteremia
• Empiric antibiotics should be targeted against
S. pneumoniae, N. meningitidis, and H. influenza
• Amoxicillin
• Augmentin, Bactrim, 2nd or 3rd gen
Cephalosporins
• Single dose Ceftriaxone 50-75mg/kg

• Followup is essential!

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