Post on 07-Jul-2018
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Tropik InfeksiBIMBEL UKDI MANTAP
dr. Anindya K Zahra
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Transmission Factor
Virus
Vector
Host
(WHO, 2011)
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Vector
• Mosquito: Aedes (Stegomyia) aegypti, Aedes
(Stegomyia) albopictus
• Breed in the CLEAN WATER.
•
GEOGRAPHICAL LIMIT in winter min 10o
C.• >1000 m height asl uncommon
• MAX FLY DISTANCE : 50 m
• Dengue vector is the FEMALE
(WHO, 2009; WHO, 2011
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1-2 days
Stagnant water
4-5 days
Life cycle of the Aedes Mosquito
2-3 days
EggsLarvaePupae
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Transmission
EXTRINSIC INCUBATION
PERIOD8-12 days
INTRINSIC INCUBATION
PERIOD 5-7 days
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Diagnosis and Clinical Manifestations
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Classification (WHO, 1997) UKDI MANTAP
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Classification (WHO, 2009) UKDI MANTAP
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Classification (WHO, 2011) UKDI MANTAP
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(WHO, 2011)
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Expanded Dengue
• Unusual manifestations severe organ involvement
such as liver, kidneys, brain or heart associated with
dengue infection
• Reported in DHF and DF
• May be associated with coinfections, comorbidities
or complications of prolonged shock.
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(WHO, 2009)
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Management of DHF grade I, II (non-shockcases)
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Management of DHF grade I, II (non-shock cases)
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Management of shock: DHF Grade 3
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Management of prolonged/profound shock: DHF Grade 4
•
The initial fluid resuscitation in Grade 4 DHF is more vigorous in order toquickly restore the blood pressure
• Even mild hypotension should be treated aggressively
• Ten ml/kg of bolus fluid should be given as fast as possible, ideally within
10 to 15 minutes. When the blood pressure is restored, further
intravenous fluid may be given as in Grade 3.• If shock is not reversible after the first 10 ml/kg, a repeat bolus of 10
ml/kg and laboratory results should be pursued and corrected as soonas
possible
• Urgent blood transfusion should be considered as the next step (after
reviewing the preresuscitation HCT) and followed up by closermonitoring, e.g. continuous bladder catheterization, central venous
catheterization or arterial lines.
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Malaria
• Definisi: Penyakit infeksi parasit yang disebabkan
oleh Plasmodium yang menyerang eritrosit dan
ditandai dengan ditemukannya bentuk aseksual di
dalam darah.
• Transmisi di 103 negara
•
Melibatkan 1 milyar orang• Menyebabkan 1-3 juta kematian tiap tahun
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Patogen dan Vector
• Patogen:
▫ P. falciparum
▫ P. vivax
▫ P. ovale
▫ P. malariae
•
Vector:▫ Anopheles sp. (betina)
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Malaria
Malaria
Tanpa
Komplikasi Tx per oral
BeratTx
parenteral
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Uncomplicated Malaria
The classic paroxysm
• Shivering and chills (1-2 hours)
high fever
excessive diaphoresis body temperature drops
• Fatigue, Malaise, Shaking chills, Arthralgia, Myalgia
Less common symptoms
• Anorexia and lethargy
• Nausea and vomiting
• Diarrhea
• Headache
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Severe
Malaria
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Severe
Malaria
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Patogenesis• Cytoadherence
▫ Perlekatan EPmatur padaendotel
•
Rosetting▫ EP matur dikelilingi10 eritrosit normal obstruksi alirandarahsitoaderensi
• Sequestration▫ Pada jaringan otak,
hepar, ginjal(FALCIPARUM)
EP: eritrosit yg terinfeksi plasmodium
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Life Cycle
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Patogen UKDI MANTAP
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Blood Smear
• Criterion standard
• Giemsa-stained
• 1x hasil negatif belumdapat menyingkirkan
malaria
• Butuh 3x hasil negatif
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Blood smear –cont’d
• P. falciparum:
▫ Tropozoit
▫ Gametosit
• P. vivax
▫ Tropozoit
▫
Gametosit▫ Schizont
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Terapi Malaria Tanpa Komplikasi
1st line 2nd line Dosis
Falciparum DHP + Primakuin Kina + Primakuin +
(Doksisiklin/
Tetrasiklin)
• DHP (3 hari)
- BB >60kg: DHP
1x4tab
- anak: artesunat
1x2-4 mg/kg• Klorokuin (3 hari)
- (2x2, 2x2, 1x2)
• Kina (7 hari)
- 3x 10mg/kgBB
• Primakuin
- Vivax/ovale 1x1(14hari)
- Falciparum 1x3
(single dose)
Malariae DHP Kina + Primakuin +
(Doksisiklin/
Tetrasiklin)
Ovale Vivax DHP + Primakuin Kina + Primakuin
- RELAPS DHP + Primakuin
double doseHamil trimester 1 Kina + Klindamisin
Hamil trimester 2-
3
DHP
(DHP: FDC yang terdiri dari Dihidroartemisinin + Piperakuin)
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Tx Malaria Falciparum - WHO
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Tx Malaria dalam Kehamilan - WHO
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Severe Malaria Treatment: PARENTERAL
ARTESUNATE IV/IM▫ CDC: 2.4 mg/kg IV x4 doses over 3 days▫ WHO: 2.4 mg/kg IV/IM at 0, 12 hours, 24 hours,
THEN qDay
• Alternatives: Artemether or Quinine
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Tx Severe Malaria - WHO
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Evaluasi Terapi UKDI MANTAP
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Istilah Kekambuhan pada Malaria
• Rekurensi: Ditemukan kembali parasite aseksual
dalam darah setelah pengobatan selesai karena:
▫ Relaps: rekuren setelah 28 hari pengobatan (darihipnozoit P vivax atau P ovale)
▫ Rekrudensi: rekuren selama 28 hari pemantauan
(berasal dari parasite sebelumnya/aseksual lama)
▫ Reinfeksi: rekurens dari parasite aseksual setelah 28
hari pemantauan dinyatakan sembuh. Berasal dari
infeksi bary/sporozoit
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Kemoprofilaksis: Tergantung AREA.
• Klorokuin 2 tab/minggu, dari 1 minggusebelum sampai 4 minggu setelahkembali
Sensitif-klorokuin
• Doksisiklin 1 tab/hari atau
• Mefloquine 250 mg/minggu atau
Resisten
klorokuin
*diminum 2 hari sebelum pergi hingga 4 minggu setelah keluar/pulang dari daerah
endemis
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“Indonesia = resisten klorokuin” (CDC)
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Leptospirosis
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lepto
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Leptospirosis rash in an adolescent boy
that shows the generalized vasculitis
caused by this infection.
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Terapi dan Kemoprofilaksis Leptospirosis
Ringan
• Doksisiklin 2 x 100mg
• Ampisilin 4 x 500-750 mg
• Amoksisilin 4 x 500 mg
Sedang/berat
• Penisilin G 1,5 juta unit/ 6 jam IV
• Ampisilin 1 gr/ 6 jam IV• Amoksisilin 1 gr/ 6 jam IV
Kemoprofilaksis
• Doksisiklin 200 mg/ minggu
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Step Ladder Pattern
1st
Demam
Nyeri kepala
Batuk kering
Nyeri perut
Rose spotKonstipasi >> atau
Diare (“pea soup”)
Splenomegaly
2nd
Demam terus
menerus
Bradikardia relatif
Lidah kotor, tepihiperemis, tremor
Nyeri perut
Hepatomegaly(50%)
3rd
Komplikasi:
Perdarahan usus
Perforasi usus
Meningitis tifosa
Hepatitis tifosa
Cholecystitis, etc
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Patofisiologi Tifoid
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Penunjang
Isolasi organisme
• 1st week: darah dan sumsum tulang
• 2nd week: feses
• 3rd week: urin
Widal
• Reaksi antara antibodi aglutinin serum penderita terhadapantigen O (somatic) dan H (flagellar)
• Kenaikan titer O 1:320 atau kenaikan 4x support dx
• Sensitivitas 64-74%, spesifisitas 76-83%
TUBEX
• Deteksi IgM terhadap antigen O9 (spesifik Salmonellaserogroup D)
• Sens 100%/spec 100% -- 78%/94% --91,2%/82,3%
• (+) = >4. >6 indikasi kuat
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Pemberian antimikroba• Kloramfenikol
▫ Masih merupakan obat pilihan utama di Indonesia (PAPDI)
▫
KI: hamil trimester 3 (Grey Baby Syndrome)▫ Kloramfenikol 4x500 mg, PO atau IV, ~7 hari bebas
panas.
• Tiamfenikol▫ komplikasi hematologi lebih rendah daripada kloramfenikol
▫ Tiamfenikol 4 x 500mg
• Kotrimoksazol 2 x 2 tablet, selama 2 minggu.
• Ampsilin dan amoksisilin, kurang efektif dibandingkloramfenikol, 50-150 mg/kgBB, selama 2 minggu.
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Pemberian antimikroba—cont’d• Sefalosporin generasi ketiga
▫ Seftriakson 3-4 gram dalam dekstrosa 100 cc diberi selama
½ jam IV sekali sehari, 3-5 hari.• Fluorokuinolon
▫ Norfloksasin, 2 x 400 mg/hari selama 14 hari.
▫ Siprofloksasin, 2 x 500 mg/hari selama 6 hari.
▫ Ofloksasin, 2 x 400 mg/hari selama 7 hari.
▫ Pefloksasin, 400 mg/hari selama 7 hari
▫ Fleroksasin, 400 mg selama 7 hari.
• Kehamilan: Gunakan amoxicillin/ampicillin/cefalosporingenerasi 3
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Opportunistic Infection:
Mucocutaneous Manifestation
Oral Candidiasis
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Tx Oral Candidiasis:
Gentian violet 1% (dibuat segar/baru) atau larutan nistatin 100.000 – 200.000 IU/ml
yang dioleskan 2 – 3 kali sehari selama 3 hari
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Opportunistic Infection ~ CD4 Level
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Disentri Basiler vs Amoeba
Disentri basiler “LYING DOWN”
• Kausa: Shigella
• Mendadak, 6-24 jam pertamabisa tanpa darah
• Setelah 12-72 jamdarah dan
lendir (+)• Panas tinggi (39,5 - 40,0 C),
kelihatan toksik.
• Muntah-muntah
• Anoreksia
• Sakit kram di perut dan sakit dianus saat BAB.
• Kadang-kadang disertai dengangejala menyerupai ensefalitisdan sepsis (kejang, sakit kepala,letargi, kaku kuduk, halusinasi)
Disentri amoeba “WALKING”
• Diare disertai darah dan lendirdalam tinja.
• Frekuensi BAB umumnya lebihsedikit daripada disentri basiler
(≤10x/hari)• Sakit perut hebat (kolik)
• Gejala konstitusional (-)demam hanya ditemukan pada1/3 kasus)
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PROTOZOA
HELMINTH
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Giardia lamblia
Cyst of Giardia lamblia showing ellipsoidal
shape with 2 nuclei and curved axoneme(Iodine stain, 1000x)
Trophozoite of Giardia lamblia showing pear-shaped
with 2 nuclei and 2 axoneme (I-H stain, 1000x). B.
Trophozoite of Giardia lamblia showing 2 nuclei,
axoneme and flagella (Giemsa stain, 1000x).
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Entamoeba histolytica
Cyst of Entamoeba histolytica, 5-20
㎛ in size. Chromatoid bodies are
often present with thick rodlike
masses. The number of nuclei
is 1-4.
Amebiasis. Trophozoite of Entamoeba
histo lyt ica +RBC
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Balantidium coli
Makro dan mikronukleus
Habitat: colon ascendens
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Helminths
Trematoda
Nematoda
HELMINTH
Cestoda
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Trematoda
• Semua telur beroperkulum, kecuali schistosoma mansoni/haematobium• Telur besar beroperculum fasciola hepatica / fasciolopsis buski
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• Blood flukes• “Triple S”:
▫ Schistosoma
▫ Spina
terminalis
▫ Serkaria
Schistosoma
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Fasciolopsis buski
• Intestinal flukes• “Oper-Bus jalur
12”:
▫ Operculum
▫ F. Buski
▫ B12
▫ Duodenum
▫
Metaserkaria
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Nematoda
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• Prutitus ani
•
Bentukhuruf “D”
(ingat
dubur)
• Scotch
tape test
Nematoda
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• Prutitus ani
•
Bentukhuruf “D”
(ingat
dubur)
• Scotch
tape test
Nematoda
3 T:
•
Trichuris• Tempayan
(bentuk)
• “Turun”
(prolapsus
recti)
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• Prutitus ani
•
Bentukhuruf “D”
(ingat
dubur)
• Scotch
tape test
Nematoda
3 T:
•
Trichuris• Tempayan
(bentuk)
• “Turun”
(prolapsus
recti)
• Telur bulat-oval
dinding berlapis
• Keluar cacing
• Obstruktif
• Loeffler
syndrome
(sesak nafas)
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• Prutitus ani
•
Bentukhuruf “D”
(ingat
dubur)
• Scotch
tape test
Nematoda
3 T:
• Trichuris
• Tempayan
(bentuk)
• “Turun”
(prolapsus
recti)
• Telur bulat-oval
dinding berlapis
• Keluar cacing
• Obstruktif
• Loeffler
syndrome
(sesak nafas)
• Ancylostoma
duodenale &
Necator
americanus
• Segmented ovum
• Anemia
• Harada mori test
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Nana masak baso pake sasa bikin ngeces
•
Hymenolepis Nana• Babi T. Solium
• Sapi T. Saginata
• Cestoda
Cestoda
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Cestoda: proglottid & scolex
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Hymenolepis nana
• Telur bulat, 6 kait &filamen polar
• Telur = infektif &diagnostik
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Taenia
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T. SOLIUM vs T. SAGINATA
P r o
l o t t i d Segmen gravid
5-10 cabang
uterus
Segmen gravid
15-30 cabang
uterus
P r o g l o t t i d
S c o l e x
Rostellum (+) Rostellum (-)
S c o l e x
Taenia
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Neurosistiserkosis
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Antihelminthic drugs of choice
• Praziquantel
Trematoda
Nematoda
• Albendazole: DOC for potentially fatal cestode infections(cysticercosis—T solium)
• Praziquantel: DOC for hymenolepiasis
Cestoda
Enterobius Pyrantel pamoate Mebendazole Albendazole
Ascaris Mebendazole Pyrantel pamoate
Trichuris Mebendazole Albendazole
Ancylostoma Mebendazole Pyrantel pamoate Albendazole
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Filariasis
•
Agent: Wuchereria bancrofti,Brugia malayi, Brugia timori
• Vector: culex, anopheles, etc
• Acute (limfedenitis, limfangitis, fever)
• Chronic (elephantiasis): obstruction oflymphatic vessels by adult worms
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▫ Edema skrotum ▫ Chyluria
Wuchereria bancrofti
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Diagnostik
• DEC 3 x 6mg/kgBB per hari (12 hari)
Terapi
• DEC 6mg/kgBB + Albendazol 400mg per tahun (5 tahun)
Profilaksis
• Mikrofilaria dalam darah pada
malam hari (22.00-02.00)
Giemsa stain (MDT)
Filariasis
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P t d t UKDI MANTAP
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• Port d entree▫ Luka tusuk
dalam, lukabakar, kotor
▫ Otitis media,karies gigi,luka kronik.
▫ Pemotongantali pusattidak steril
• Risussardonicus
• Lock jaw
• Opistotonus
• Spasmelarynx & otot
nafas
TETANUS• Clostridium
tetani (basilGram (+)
anaerob
berspora)
•
Toksintetanolisin,
tetanospasmin
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Tetanus
Derajat I (tetanus ringan)
• Trismus ringan sampai sedang
• Kekakuan umum: kaku kuduk, opistotonus, perut papan
• Tidak dijumpai disfagia atau ringan
• Tidak dijumpai kejang
• Tidak dijumpai gangguan respirasi
Derajat II (tetanus sedang)
• Trismus sedang• Kekakuan jelas
• Dijumpai kejang rangsang, tidak ada kejang spontan
• Takipneu
• Disfagia ringan
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Tetanus
Derajat III (tetanus berat)
• Trismus berat
• Otot spastis, kejang spontan
• Takipne, takikardia
• Serangan apne (apneic spell)
• Disfagia berat
• Aktivitas sistem autonom meningkat
Derajat IV (stadium terminal), derajat III ditambah:
• Gangguan autonom berat
• Hipertensi berat dan takikardi, atau
• Hipotensi dan bradikardi
• Hipertensi berat atau hipotensi berat
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Ablett Classification of Tetanus Severity• Grade 1 (mild): mild trismus, mild rigidity without spasms, no
respiratory embarrassment, no spasms, no dysphagia.
• Grade 2 (moderate): moderate trismus, rigidity with short
spasms, mild dysphagia, moderate respiratory involvementwith respiratory rate more than 30 per minute, milddysphagia.
• Grade 3 (severe): Severe trismus, generalized spasticity withprolonged spasms, respiratory rate more than 40 per minuteand intercurrent apnoeic spells, severe dysphagia, pulseabove 120.
• Grade 4 (very severe): grade 3 with severe autonomicdisturbances involving the cardiovascular system.
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Talaksana umum
• Tempatkan di ruang yang tenang (stimulasi minimal), ICU, support ventilasi,
eksplorasi luka, pembersihan dan debridement
Netralisasi toksin
• Imunoglobulin tetanus manusia (TIG) / Tetagam,
• Antitetanus serum (ATS) 50.000 IU (im) + 50.000 IU (iv) single dose ATAU
20.000 IU/hari selama 5 hari
Menyingkirkan sumber infeksi:
• Metronidazole 500 mg tiap 6 jam atau 1 gram per 12 jam
• Penicillin 10-12.000.000 Unit iv setiap hari selama 10 hari
Terapi anti kejang
Imunisasi dasar tetanus
• Setelah sembuh. Karena toksin jumlah kecil yang menyebabkan tetanus
tidak menginduksi imunitas
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8/18/2019 Tropmed MANTAP Tutor
90/99
Pencegahan Tetanus pada LukaRiwayat
Imunisasi
sebelumny
a
Luka Kecil & Bersih Luka Lainnya
TD TIG TD TIG
Tidak Tahu/ 10tahun sejak
dosis terakhir
Tidak Tidak, kecuali
> 5 tahunsejak dosis
terakhir
Tidak
TIG: tetanus immunoglobulin 250 Unit IM
TD: Imunisasi aktif Tetanus Difteri
CNS Toxoplasma Infection UKDI MANTAP
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91/99
Congenital Toxoplasmosis• Diffuse hydrocephalus
• Multiple calcification at
periventricular area & choroid
plexus
Toxoplasmosis—HIV• Nodular lesion >1
• Ring enhancement
• Cerebral edema
• 75% at basal ganglia
CNS Toxoplasma Infection
UKDI MANTAP
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92/99
UKDI MANTAP
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93/99
Bacterial identification
Lactobacillales
Catalase (-)
Streptococcus
αoptochin susceptible: S. pneumoniae
optochin resistant: S. viridans
βGrup A, bacitracin susceptible: S. pyogenes
Group B, bacitracin resistant: S. agalactiae
γ Streptococcus bovis
Enterococcus Enterococcus faecalis
Bacillales
Catalase (+)
StaphylococcusCoagulase (+) S. aureus
Coagulase (-) S. epidermidis, S. saprophyticus
Bacillus Bacillus anthracis ,Bacillus cereus
Listeria Listeria monocytogenes
UKDI MANTAP
8/18/2019 Tropmed MANTAP Tutor
94/99
Streptococcus
Lisis sebagian,coklat-hijau:
• S. pneumoniae
• S. viridans
Lisis sempurna,bening:
• S. pyogenes
• S. agalactiae
Tidak ada lisis:• S. bovis
UKDI MANTAP
8/18/2019 Tropmed MANTAP Tutor
95/99
SIRS (Systemic Inflammatory Response Syndrome)
• SIRS + infection
Sepsis
• Sepsis + hypoperfusion
Severe Sepsis
• Severe sepsis + refractory hypotension
Septic shock
UKDI MANTAP
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96/99
MODS
UKDI MANTAP
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97/99
MODS
UKDI MANTAP
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98/99
Terima Kasih
UKDI MANTAP
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99/99
Paling umum buat bedain staph sm strep.Uji katalase: tetes H2O2 3%, katalase (+): gelembung (+),krn bakteri menghasilkan enzim katalase, merubah H2O2H2O+O2. Contoh: S. aureus.
STREPTOCOCCUS
• Streptococcus, kultur dengan agar darah utk hemolisis▫ Beta- : lisis sempurna, warna bening
▫ Alfa-: lisis sebagian, warna kehijauan/coklat
▫ Gamma: tidak lisis
•
S. Pneumoni pneumonia, osteomyelitis• S. Viridans dental caries, endokarditis infektif
• S. Pyogenes tonsillitis faringitis, GNA dll