44975892 Case Report Print

8/11/2019 44975892 Case Report Print

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CHAPTER II

2.1. Epidemiology

nce!ha$itis is more common in chi$dren and young adu$ts" %bout in 200,000

!eo!$e deve$o! ence!ha$itis each year in the 1nited States" #hi$e anyone can

succumb, chi$dren, the e$der$y, and those 'ith 'eaened immune systems are

more vu$nerab$e"2

3ncidence o& ence!ha$itis throughout the 'or$d is di&&icu$t to determine

because the disease is o&ten underre!orted" %!!roimate$y )0 to (000 cases,

most o& 'hich are mi$d, may occur each year in the 1nited States" 4er!esvirus

accounts &or most cases o& ence!ha$itis in the 1nited States" %rbovira$

ence!ha$itis is more !reva$ent in 'arm c$imates and incidence varies considerab$y

&rom area to area and &rom year to year" St" Louis ence!ha$itis is the most

!reva$ent ty!e o& arbovira$ ence!ha$itis in the 1nited States, and 5a!anese

ence!ha$itis is the most !reva$ent ty!e in other !arts o& the 'or$d" 2

2.2. Deinition

nce!ha$itis is an in&$ammatory !rocess o& the brain !arenchyma that usua$$y is an

acute !rocess, but maybe a !ostin&ectious ence!ha$omye$itis, a chronic

degenerative disease, or a s$o' vira$ in&ection" nce!ha$itis resu$ts &rom

in&$ammation o& the brain !arenchyma, $eading to cerebra$ dys&unction"

nce!ha$itis may be di&&use or $oca$ized" 6rganisms cause ence!ha$itis by one o&

t'o mechansms : " Direct in&ection o& the brain !arenchyma or 2" %n a!!arent

immunemediate res!onse in the 7NS tahat usua$$y begins severa$ days a&ter the

a!!earance o& etraneura$ mani&estations o& the in&ection"2

2.!. Etiology

8iruses are the !rinci!a$ causes o& acute in&ectious ence!ha$itis" nce!ha$itis a$so

may resu$t &rom other ty!es in&ection and metabo$ic, toic, and neo!$astic

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disoerder" The most common vira$ causes o& ence!ha$itis in the 1"S" are the

arboviruses, enteroviruses, and her!esviruses" 438 is an im!ortant cause o&

ence!ha$itis in chi$dren and ado$escents and may !resents as an acute &ebri$e

i$$ness, but more common$y is insidious in onset"2

%cute disseminated ence!ha$omye$itis 9%D; is the abru!t deve$o!ment

o& mu$ti!$e neuro$ogic signs re$ated to an in&$ammatory, demye$inating disorder o&

the brain and s!ina$ cord" %cute disseminated ence!ha$omye$itis &o$$o's

chi$dhood vira$ in&ections, such as meas$es and chicen!o or vaccinations" %cute

disseminated ence!ha$omye$itis resemb$es mu$ti!$e sc$erosis"2

Primary nce!ha$itis


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* astern e-uine

* #estern e-uine

* 8enezue$an e-uine

* St" Louis" Po'asson

* isce$$aneous 7a$i&ornia

8ascu$itis

Tab$e " Pathogens o& nce!ha$itis 3

2.(. P)t*op*y+iology

There are at $east t'o &orms o& in&ection*re$ated ence!ha$itis:!rimary and !ost* or

!arain&ectious" % !rimary ence!ha$itis resu$ts &rom direct 7NS invasion by the

o&&ending agent, and the gray matter o&ten is targeted" % !ostin&ectious or

!arain&ectious ence!ha$itis !resents much $ie a !rimary ence!ha$itis, but the

i$$ness is not caused by direct 7NS in&ection" 3n !ost/!arain&ectious ence!ha$itis,

neuro$ogic e&&ects are the conse-uence o& the host@s immune res!onse, 'hich

o&ten a&&ects the 'hitematter"(

The !athogenesis o& !rimary ence!ha$itis is diverse and incom!$ete$y

understood" 6rganisms in&ecting the brain direct$y &irst must gain entry to the

7NS" Some !athogens such as arboviruses initia$$y cause b$oodstream in&ection,

then enter the 7NS via endothe$ia$ ce$$ in&ection, endothe$ia$ ce$$ trans!ort, or

carriage in ce$$s entering the 7NS" nce!ha$itis tends to be a rare com!$ication

a&ter viremia because entry to the brain is care&u$$y regu$ated at the b$ood*brain

barrier" %n a$ternative mechanism used by

her!es sim!$e virus 94S8;, rabies,and !ossib$y !o$iovirus is retrograde trans!ort in neurons" This strategy may be

success&u$because !athogens trave$ing inside neurons avoid immune survei$$ance"

%n a$ternative mechanism used by the amoebaNaegleria fowleriis entry through

the o$&actory mucosa"(

6nce an organism has entered the brain, a variety o& anatomic sites can

become in&ected" For eam!$e, 4S8 ty!ica$$y in&ects neurons in the tem!ora$

$obe= rabies !redominant$y a&&ects the !ons, medu$$a, cerebe$$um, and

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hi!!ocam!us= and 5a!anese ence!ha$itis virus a&&ects the brainstem and basa$

gang$ia" Neuro$ogic signs and sym!toms deve$o! a&ter in&ection as the resu$t o&

directneurona$ inAury, the host in&$ammatory res!onse, or both" 4isto$ogica$$y, the

host res!onse can inc$ude !erivascu$ar in&$ammation, g$iosis, and brain edema"

Postin&ectious ence!ha$itis occurs days to 'ees a&ter the onset o& an

in&ection" 7urrent$y in the 1nited States, a minor res!iratory tract in&ection is

$ie$y to be the inciting event" .e&ore the 'ides!read use o& vira$ vaccines, a

distinctive i$$ness such as meas$es or varice$$a 'as $ie$y to be the !receding

event,and ence!ha$itis may &o$$o' these in&ections in regions 'here they remain

common" .ecause the inciting !athogen is not detected in the 7NS in

!ostin&ectious ence!ha$itis, the i$$ness is hy!othesizedto be caused by an aberrant

immune res!onse against brain antigenssuch as mye$in basic !rotein" Subse-uent

demye$ination causes&oca$ or g$oba$ 7NS dys&unction" Postin&ectious ence!ha$itis

o&ten is ca$$ed acute disseminated ence!ha$omye$itis 9%D;"(

2.,. Di)gno+i+

Hi+tory

* %s about a vira$ !rodrome 'ith sym!toms such as u!!er res!iratory

in&ection, cough, coryza, ma$aise, anoreia, decreased entera$ intae, diarrhea,

nausea, and vomiting"

* nce!ha$itis is o&ten hera$ded by headaches, !hoto!hobia, a sti&& nec,

increased s$ee!ing, change in menta$ status, irritabi$ity, con&usion,

ha$$ucinations, seizures"

* Prodroma$ sym!toms can range &rom hours to 'ees= seizures or sudden

$a!se o& consciousness are uncommon as initia$ sym!toms o& ence!ha$itis"

* 3n-uire about recent trave$ history, !ets, and tic or mos-uito bites" 3

P*y+ic)l E-)m

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%$though the causes di&&er, the c$inica$ sym!toms o& ence!ha$itis is more or $ess

the same and uni-ue so it can be used as diagnostic criteria" 3n genera$, sym!toms

o& ence!ha$itis triad consisting o& &ever, convu$sions and decreased

consciousness"7

%&ter an incubation !eriod o& a!!roimate$y )*0 days there 'i$$ be a

sudden increase in tem!erature, o&ten occur hi!er!iresia, big headache in

chi$dren, screaming at the chi$d" Found signs o& 7NS stimu$ation 9coma, stu!or,

$ethargy;, sti&& nec, increased tendon re&$ees, tremors, musc$e 'eaness and

sometimes !ara$ysis" 7$inica$ mani&estations o& bacteria$ ence!ha$itis, in the

beginning there are no ty!ica$ sym!toms such as genera$ized in&ection, then

emerged signs o& increased intracrania$ !ressure headache, vomiting, no a!!etite,

&ever, b$urred vision, genera$ or &oca$ seizures and decreased consciousness"

Sym!toms o& crania$ Nervi de&icit, hemi!aresis, increased tendon re&$ees, sti&&

nec, a!hasia, hemiano!ia, nistagmus and ataia"8

7auses o& neuro$ogica$ abnorma$ities 9neuro$ogica$ de&icit; is a direct

invasion and destruction o& brain tissue by a virus that is being breed= nerve tissue

reaction against vira$ antigens that 'i$$ resu$t in demye$ination, vascu$ar damage,

and !aravasu$ar= and because the activation reaction neurotro!hic virus that is

$atent"7

3n vira$ ence!ha$itis ear$y sym!toms o& mi$d headache, &ever, sym!toms o&

u!!er res!iratory in&ections or gastrointestina$ tract &or a &e' days $ater came the

signs o& 7NS in&$ammation, such as sti&& nec, a sign o& !ositive ernig, aniety,

'eaness and di&&icu$ty s$ee!ing" Neuro$ogic de&icits that arise de!ending on

'here the damage" Furthermore, consciousness begins to dec$ine unti$ the coma,

or &oca$ seizures may occur common$y, hemi!aresis, im!aired coordination,

!ersona$ity disorders, disorientation, im!aired s!eech and menta$ disorders"

7$inica$ &indings in ence!ha$itis is determined by 9; 'eight and anatomica$

$oca$ization o& nervous system that $oos 92; !athogenicity agents that attac 9(;

immunity and reactive mechanisms other !atients"6

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Di)gno+tic Te+t

Ty!ica$$y, a doctor 'i$$ as &or a b$ood sam!$e and order a $umbar !uncture

9sometimes ca$$ed a s!ina$ ta!;, in 'hich a need$e is inserted into the $o'er bac

and a sma$$ amount o& &$uid 9ca$$ed 7SF or cerebra$*s!ina$ &$uid; is taen &rom the

s!ina$ cana$" Some hos!ita$s are a$so e-ui!!ed to tae a bio!sy, 'here a tiny

amount o& tissue is taen &rom the brain 'hi$e the !atient is under genera$

anesthesia" Doctors a$so &re-uent$y order a 7T scan or agnetic ?esonance 3mage

9?3;, in 'hich com!uterized images o& the brain are obtained that sho' the

etent o& the s'e$$ing and damage to the brain" %nother test sometimes used to

he$! con&irm a diagnosis is an e$ectroence!ha$ogram 9>;, 'hich records

e$ectrica$ events in the brain"6

2.. Dierenti)l Di)gno+i+

* eningitis

* nce!ha$o!athy

* .rain %bscess

* Subarachnoid hemorrhage

* .rain tumor" 6

2./. Complic)tion

Neuro$ogica$ com!$ications that may be !ermanent or im!rove as the in&ection

runs its course inc$ude the &o$$o'ing= %$tered menta$ state 9e"g", disorientation,

!ersona$ity changes;, convu$sions, droo!ing eye$ids 9!tosis;, doub$e vision

9di!$o!ia;, crossed eyes 9strabismus;, hy!eractive dee! tendon re&$ees, increased

intracrania$ !ressure, $oss o& consciousness, menta$ retardation, motor

dys&unction, !artia$ !ara$ysis 9!aresis; o& the etremities, !roAecti$e vomiting,

!u!i$ irregu$arities, rest$essness, seizures and tremor"3

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2./. Tre)tment

Treatment &or ence!ha$itis de!ends on the cause" Some cases o& vira$ ence!ha$itis

can be treated success&u$$y i& medication is started as soon as !ossib$e" 3& her!es

sim!$e ence!ha$itis is sus!ected, antivira$ medication such as acyc$ovir

9BoviraC; or ribavirin 98irazo$eC; is o&ten administered immediate$y to im!rove

chances &or recovery and !revent com!$ications" Side e&&ects o& these medications

inc$ude nausea, vomiting, and headache" Treatment &or vira$ ence!ha$itis a$soinc$udes !a$$iative care" There is no cure &or arbovira$ ence!ha$itis and the goa$ o&

treatment is to re$ieve sym!toms 9!a$$iative;"2,3,6

Pa$$iative care may inc$ude intravenous &$uids 9to !revent dehydration;,

antibiotics 9to !revent secondary in&ections;, and other medications 9to !revent

com!$ications;" Diuretics 9e"g", &urosemide, mannito$; may be administered to

reduce intracrania$ !ressure and benzodiaze!ines 9e"g", $oraze!am %tivanCE; may

be administered to !revent seizures"2,3,6

Ne' !atients 'ith !ossib$e ence!ha$itis shou$d be hos!ita$ized unti$ the

disa!!earance o& neuro$ogic sym!toms" anagement obAective is to maintain

organ &unction by $aboring air'ay remains o!en, entera$ or !arentera$ &eeding,

maintaining &$uid and e$ectro$yte ba$ance and acid*base disorders correction o&

b$ood" >overnance is done as &o$$o's 4:

" 6vercoming cram!s are vita$ action, because seizures in ence!ha$itis is usua$$y

severe" >iving Phenobarbita$ mg/g../2 )* hours" 3& seizures occur &re-uent$y,

shou$d be given diaze!am 90" to 0"2 mg / g; 38, in the &orm o& in&usion &or (

minutes"

2" 3m!roving homeostasis, 'ith intravenous &$uids D) * / 2 S or D) * / S

9de!ending on age; and oygen de$ivery"

(" ?educe cerebra$ edema and to reduce the im!act by anosia cerebra$ 'ith

deamethasone 0") to "0 mg / g / day iv divided into ( doses"

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" Lo'ering the intracrania$ !ressure rises 'ith annito$ is given intravenous$y at

a dose o& ") to 2"0 g / g &or (0*G0 minutes" >iving can be re!eated every *2

hours" >$ycero$ can a$so, through the !i!e nasogastri, 0") to "0 m$ / g di$uted

'ith t'o !arts orange Auice" This materia$ is not toic and can be re!eated every G

hours &or a $ong time"

)"7ausative treatment"

.e&ore eti$ogi got rid o& bacteria, es!ecia$$y brain abscess 9bacteria$ ence!ha$itis;,

it must be given !arentera$ antibiotic treatment" Treatment &or ence!ha$itis due to

her!es sim!$e virus in&ection %cyc$ovir is given intravenous$y, 0 mg / g to (0

mg / g !er day &or 0 days" 3& there is to$erance then given %denine arabinose

9vidarabin;" So a$so 'hen there is recurrence a&ter treatment 'ith %cyc$ovir" #ith

the ece!tion o& the use o& %denine arabinosid to !atients by her!es sim!$e

ence!ha$itis, the treatment is done is non*s!eci&ic and em!irica$ in order to sustain

$i&e and su!!ort every organ system a&&ected" The e&&ectiveness o& various

treatments are recommended not been assessed obAective$y"

G" Physiothera!y and rehabi$itative e&&orts a&ter the !atient recovered

H" Foods high in !rotein ca$orie diet thera!y"

" 6ther, better treatment, ear$y consu$ting 'ith an anesthesio$ogist to antici!ate

the need &or arti&icia$ res!iration

2.0. Progno+i+

The !rognosis &or ence!ha$itis varies de!ends on the ty!e o& ence!ha$itis, the

!atientIs age, overa$$ hea$th, and status o& the immune system" Some cases are

mi$d, short and re$ative$y benign and !atients have &u$$ recovery" 6ther cases are

severe, and !ermanent im!airment or death is !ossib$e" The acute !hase o&

ence!ha$itis may $ast &or to 2 'ees, 'ith gradua$ or sudden reso$ution o& &ever

and neuro$ogica$ sym!toms" Neuro$ogica$ sym!toms may re-uire many months

be&ore &u$$ recovery" #ith ear$y diagnosis and !rom!t treatment, most !atients

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recover &rom meningitis" 4o'ever, in some cases, the disease !rogresses so

ra!id$y that death occurs during the &irst hours, des!ite ear$y treatment" 2,4,9

2.. O3ecti4e

The aim o& this !a!er is to re!ort a case o& nce!ha$itis in a boy aged years and

J months o$d"

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CHAPTER III

!.1. C)+e Report

?, a year and J months o$d boy, 'eight Hg 'ith the height o& JJcm 'as

admitted to 4" %dam a$i 4os!ita$ on Se!tember J th 200, 'ith the chie&

com!$ain is unconsciousness" This has been e!erienced by the !atient since $ast 2

days" This !atient been having seizure H days in a ro', &recuency K( times !er day

&or 0*20 minutes" 4istory o& seizure be&ore 9M;"Fever 'as &ound since 2 'ees

ago" 3t 'as very high &ever but shiverring 'as not &ound" 7ough 9*;, &$u 9*;"

1rination and de&ecation 'as norma$" 4istory o& contact 'ith T.7 !atients

negati&" There is ye$$o'ish &$uid, thic and no odor 'as &ound &rom $e&t ear since (

'ees ago"

4istory o& de$ivery 'as norma$ and aided by a mid'i&e, crying s!ontaneous$y,

and cyanosis 'as not &ound, her 'ight is 2)00 gram and $enght 'as &orgotten"4istory o& !regnancy 'as norma$" 4istory o& immunization 'as com!$ete"

Feeding history : 0*) months 'ith breast mi$"

.e&ore she 'as admitted to 4% >enera$ 4os!ita$, she 'as consu$ted &rom

!usesmas arang ?eAo" The !atient 'as initia$$y diagnosed 'ith high &ever and

seizure"

P*y+ic)l e-)min)tion

6n !hysica$ eamination, the &o$$o'ing &indings 'ere con&irmed"

% boy, 'ith body 'eight H g, body $ength 'as JJ cm, and 3D inde 'as 2,()

+, nutritiona$ status 'as normo'eight= body tem!erature 'as (H,(O 7" The $eve$

o& consciousness o& this !atient 'as >S7 982);, anemia 9*; dys!noe 9*;,

edema 9*;, cyanotic 9*;, Aaundice 9*;"

4ead :

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ye : $ight re&$ees 9M/M;, isochoric !u!i$" Pa$e in&erior !a$!ebra

conAunctive 9*/*;

ars : norma$

Nose : norma$

outh : u$cus 9M; in mucosa and $i!s

Nec : norma$, no $ym!h nodes en$argement

7hest : Symmetrica$ &usi&orm, retraction 9M; e!igastria$, su!rasterna$

4? : G b!m, regu$ar, no murmur

?? : 20 t!m, regu$ar, no ra$es

%bdomina$ : soe!e$, !erista$tic 'as norma$" 4/L : im!a$!ab$e

tremities : Pu$se 'as G t!m, regu$ar, norma$ tone and vo$ume

S!astic 9M; at &our etremities

Lym!h nodes en$argement 'as not &ound

Physio$ogy ?e&$e: %P? M/M = P? M/M

Patho$ogic ?e&$e: .abinsy 9*;, 6!!enheim 9*;,

eningea$ ?e&$e: 9*;

>enita$ia : .oy, there 'ere no abnorma$ities !resent

L)or)tory inding+ 5Septemer 6 271789

?outine .$ood amination

* #.7: )") 0(/uL * ?.7 : "H) 0G/uL

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* 4b : 2"0 g/dL * PLT : 2J( 0(/uL

.$ood $ectro$ic

* Na : ( m-/L

* : (, m-/L

* 7$ : 0 m-/L

Liver Pro&i$e

* S>6T 9%ST; : 2H u/L

* S>PT 9%LT; : 2( u/L

idney Pro&i$e

* 1reum : mg/d$

* 7reatinine : 0,G mg/d$

%rteria$ .$ood >as

* !4 : H"H * Pco2 : 2J"0 mm4g

* Po2 : JG") mm4g * .icarbonate : 20"H

* Tota$ 762 : 2,) * .ase es : *"J

* 62 Saturation : JJ,H +

:or;ing Di)gno+i+ 9

* nce!ha$itis

* eningoence!ha$itis

* eningitis

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'urt*er E-)min)tion+ 9

* 7om!$ete b$ood, LFT, ?FT, $ectro$it, %>D%

* LP

* Q*ray

* 4ead 7T scan

#edic)tion 9

* 4ead e$evated (0R

* 62*2 L/i

* 38FD D)+ Na7$ 0,J+ = gtt/i micro

* 3nA" 7e&otaim G)0mg / G hours / 38

* 3nA" Phenytoin $oading dose 20mg/gbb in 20 cc Na7$ 0,J+ 9i& seizure;

* ena$og in orabase 2 a!!$ic

* >entamycin za$& ( a!!$ic

* Diet S8 )G0 a$ M 2G gr !rotein

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!.2. D)ily 'ollo< &p

Fo$$o' 1! Septemer 17t*6 2717

S 9 1nconciousness 9M;, Seizure 9*;, Fever 9*;

O 9Sens: >S7 G 98;, T: (H,(7, .#: (g, .L: J2cm .#/.L:JG,2J+

4ead :

yes: $ight re&$ees 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not

con&irmed"

ars : norma$

Nose : norma$

outh : u$cus 9M; at $i!s and mouth

Nec : Lym!h nodes en$argement 9*;

%i$$a : !ustu$e 9M;

7hest : Symmetrica$ &usi&ormic, 4? : 0 b!m, regu$ar$y, murmurs 9*;

?? : t!m, regu$ar$y, ra$es 9*;,

stridor 9M;

%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e

tremities: Pu$se 0 b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"

S!astic 9M; at etremities, !ustu$e 9M;


Patho$ogic ?e&$e: .abinsy 9*;, 6!!enheim 9*;, >ordon 9*;

eningea$ ?e&$e : 9*;

A 9 *nce!ha$itis M stomatitis M im!etigo bu$osa

*eningoence!ha$itis M stomatitis M im!etigo bu$osa

*eningitis M stomatitis M im!etigo bu$osa

P 9 * 4ead e$evated (0R

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* 38FD D)+ Na7$ 0,J+ (G gtt/i miro

* 3nA" 7e&otaim G)0 mg/G Aam/38

* 3nA" %m!ici$$in G)0 mg/G Aam/38, sin test

* !henytoin $oading dose 2G0 mg in (0 cc Na7$ 0,J+ in (0 minutes,

2 hours $ater maintenance () mg/2 Aam/38 in 0 cc Na7$ 0,J+ in (0

minutes"

* ena$og inorabase 2 a!!$ic

* >entamycin Ba$& ( a!!$ic

* Diet S8 )0 a$ dengan 20 gr !rotein da$am J00cc cairan

9)0cc/ Aam/N>T;

Fo$$o' 1! Septemer 11t* = 1(t*6 2717


O 9Sens: >S7 0 9(82);, T: (G,7, .#: (g, .L: J2cm .#/.L:JG,2J+

4ead :


con&irmed"

ars : norma$

Nose : norma$



%i$$a : !ustu$e 9M;

7hest : Symmetrica$ &usi&ormic, 4? : G b!m, regu$ar$y, murmurs 9*;

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?? : t!m, regu$ar$y, ra$es 9*;,


tremities: Pu$se G b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"





A 9 *nce!ha$itis M stomatitis M im!etigo bu$osa

*eningoence!ha$itis M stomatitis M im!etigo bu$osa

*eningitis M stomatitis M im!etigo bu$osa

P 9 * $evasi e!a$a (0R




* Phenytoin maintenance () mg/2 Aam/38 dienceran da$am 0 cc Na7$

0,J+ habis da$am (0 menit 9i& seizure;



* Diet S8 )0 a$ 'ith 20 gr !rotein in J00cc &$uid

9)0cc/ Aam/N>T;

>=R)y Re+ult

%bnorma$ity radio$ogica$ o& the heart and $ung 'ere not &ound

LCS Re+ult

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19/38

* 7o$our : c$ear

* LD4 : 1/L

* Protein : 0,0 mg/dL

* Tota$ o& ce$ : ,0 mm(

* >$ucose : )H,0 mg/dL

* !4 : H

* PN : di&&icu$t to ana$ize

* N : di&&icu$t to ana$ize

* 7u$ture : Sta!hy$ococcus Sa!ro!hyticus

#)ntou- Te+t Re+ult

3nduration 9*;

4i!eremis 9*;

?esu$t : 9*;

Fo$$o' 1! Septemer 1,t* ? 1t*6 2717

S 9 1nconciousness 9M;, Seizure 9M;, Fever 9*;

O 9Sens: >S7 0 9(82);, T: (H,(7, .#: (g, .L: J2cm .#/.L:JG,2J+

4ead :


con&irmed"

ars : norma$

Nose : N>T


19


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?? : t!m, regu$ar$y, ra$es 9*;







A 9 *nce!ha$itis M i$iaria ?ubra M Stomatitis

*eningoence!ha$itis M i$iaria ?ubra M Stomatitis

*eningitis M i$iaria ?ubra M Stomatitis





* 5ia eAang !henytoin $oading dose 2G0 mg dienceran da$am (0

cc Na7$ 0,J+ habis da$am (0 menit, 2 Aam emudian maintenance ()

mg/2 Aam/38 dienceran da$am 0 cc Na7$ 0,J+ habis da$am (0 menit"




9)0cc/ Aam/N>T;

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Fo$$o' 1! Septemer 1/t* ? 1t*6 2717

S 9 1nconciousness 9M;, Seizure 9M;, Fever 9*;

O 9Sens: >S7 982);, T: (H,)7, .#: 2g, .L: J2cm .#/.L:,+

4ead :


con&irmed"

ars : norma$

Nose : N>T











A 9 *nce!ha$itis M i$iaria ?ubra

*eningoence!ha$itis M i$iaria ?ubra

*eningitis M i$iaria ?ubra



21


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* 5ia eAang !henytoin $oading dose 2G0 mg dienceran da$am (0

cc Na7$ 0,J+ habis da$am (0 menit, 2 Aam emudian maintenance ()

mg/2 Aam/38 dienceran da$am 0 cc Na7$ 0,J+ habis da$am (0 menit"

* 3nA" anito$ 20+ 0,) gr/g..(0cc/2 Aam




9)0cc/ Aam/N>T;

He)d CT Sc)n re+ult

%tro&i cerebra$ corte, hidrose&a$us comunicans, ischemic, and in&ar

bi$atera$occi!ita$ $obes e"c meningitis

Fo$$o' 1! Septemer 27t* 6 2717


O 9Sens: >S7 982);, T: (G,)7, .#: g, .L: J2cm

4ead :


con&irmed"

ars : norma$

Nose : N>T

outh : norma$

22


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7hest : Symmetrica$ &usi&ormic, 4? : 2G b!m, regu$ar$y, murmurs 9*;









*eningoence!ha$itis M i$iaria ?ubra

*eningitis M i$iaria ?ubra





* 3nA" anito$ 20+ 0,) gr/g..(0cc/2 Aam 94(a&&;

* Phenytoin 2 )0 mg



* ?es!eridon 0,(mg 9night; &or ( days


9)0cc/ Aam/N>T;

23


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Fo$$o' 1! Septemer 21t* ? 2!t*6 2717


O 9Sens: >S7 982);, T: (G,)7, .#: g, .L: J2cm

4ead :


con&irmed"

ars : norma$

Nose : N>T

outh : norma$


7hest : Symmetrica$ &usi&ormic, 4? : 2G b!m, regu$ar$y, murmurs 9*;












* 3nA" %m!ici$$in G)0 mg/G Aam/38

24


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* Phenytoin 2 )0 mg

* 1rda&a$ (0 mg


* Diet S8 200 a$ dengan 20 gr !rotein da$am J00cc cairan

9)0cc/ Aam/N>T;

* Fisiotera!i

EE$ Re+ult

Norma$

.anya diAum!ai arte&a 7>

Fo$$o' 1! Septemer 2(t* ? 2t*6 2717

S 9 1nconciousness 9M;, Fever 9*;, 1ncontro$$ed movement 9M;

O 9Sens: >S7 ( 98);, T: (G,7, .#: g, .L: J2cm

4ead :


con&irmed"

ars : norma$

Nose : N>T

outh : norma$

Nec : Lym!h nodes en$argement 9*;, nec sti&ness 9*;


?? : 2G t!m, regu$ar$y, ra$es 9*;


25


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* Phenytoin 2 )0 mg


* >entamycin Ba$&

* 1rda&a$ (0mg 94;


9)0cc/ Aam/N>T;

Fo$$o' 1! Septemer 2/t*6 2717

S 9 1nconciousness 9M;, Fever 9*;, 1ncontro$$ed movement 9M;

O 9Sens: >S7 2 98();, T: (H,(7, .#: g, .L: J2cm

4ead :


con&irmed"

ars : norma$

26


27/38

Nose : N>T



7hest : Symmetrica$ &usi&ormic, 4? : G b!m, regu$ar$y, murmurs 9*;

?? : (G t!m, regu$ar$y, ra$es 9*;











* Phenytoin 2 )0 mg


* >entamycin Ba$&

* 1rda&a$ (0mg 94;


9)0cc/ Aam/N>T;

Fo$$o' 1! Septemer 20t*@ !1t*6 2717

27


28/38

S 9 1nconciousness 9M;, Fever 9M;, 1ncontro$$ed movement 9M;

O 9Sens: >S7 2 98();, T: (,07, .#: g, .L: J2cm

4ead :


con&irmed"

ars : norma$

Nose : N>T

outh : norma$



?? : (0 t!m, regu$ar$y, ra$es 9*;









* 3nA" 7e&otaim G)0 mg/G Aam/38a&&

* 3nA" %m!ici$$in G)0 mg/G Aam/38a&&

* Phenytoin 2 )0 mg


* >entamycin Ba$&

28


29/38

* 1rda&a$ (0mg 94;

* Diet S8 )0 a$ 'ith 20 gr !rotein in J00cc &$uid

9)0cc/ Aam/N>T;

* Fisiotera!i

Fo$$o' 1! Octoer 1+t 6 2717


O 9Sens: >S7 2 98();, T: (H,J7, .#: (,)g, .L: J2cm

4ead :


con&irmed"

ars : norma$

Nose : N>T




?? : 2 t!m, regu$ar$y, ra$es 9*;


tremities: Pu$se 20 b!m, regu$ar$y, .P : 00/G0 mmhg, Pressure/8o$ume'as ade-uate"





P 9 * 4ead $evated (0R

29


30/38


* Phenytoin 2 )0 mg


* >entamycin Ba$&

* 1rda&a$ (0mg 94;

* 7etrizin tab

* 4ydrocortison cream 2,)+


9)0cc/ Aam/N>T;

* Fisiotera!i

Fo$$o' 1! Octoer 2nd@ t*6 2717


O 9Sens: 7, T: (H,07, .#: g, .L: J2cm

4ead :


con&irmed"

ars : norma$

Nose : N>T

outh : norma$



?? : (0 t!m, regu$ar$y, ra$es 9*;

30


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tremities: Pu$se 20 b!m, regu$ar$y, .P : 00/G0 mmhg, Pressure/8o$ume

'as ade-uate"







* Phenytoin 2 )0 mg


* >entamycin Ba$&

* 7etrizin tab

* 7a$adin cream


* 1rda&a$ (0mg

R% 9* Physiothera!y (/minggu

L) 'inding Octoer ,t*6 2717

?outine .$ood amination

* #.7: ("HH 0(/uL * ?.7 : ("JH 0G/uL

* 4b : J"H g/dL * PLT : 2GJ 0(/uL

31


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Fo$$o' 1! Octoer 2nd@ t*6 2717


O 9Sens: 7, T: (H,07, .#: g, .L: J2cm

4ead :


con&irmed"

ars : norma$

Nose : N>T

outh : norma$



?? : (0 t!m, regu$ar$y, ra$es 9*;



'as ade-uate"







* Phenytoin 2 )0 mg


* >entamycin Ba$&

32


33/38

* 7etrizin tab

* 7a$adin cream


* 1rda&a$ (0mg


Fo$$o' 1! Octoer /t*@ 0t*6 2717

S 9 1nconciousness 9M;, Fever 9M;, Seizure 9M;, genera$ized, &re- 2, duration )

inutes, !a!u$e erythema 9M;

O 9Sens: >7S G 92822;, T: (,27, .#: g, .L: J2cm

4ead :


con&irmed"

ars : norma$

Nose : norma$, N>T 9M;

outh : norma$



?? : 2 t!m, regu$ar$y, ra$es 9*;



'as ade-uate"



33


34/38



P 9 * 4ead e$evated (0R

* 38FD D)+ Na7$ 0,J+ 20 gtt/i miro

* Phenytoin $oading dose 20mg in 2cc Na7$ 0,J+maintenance inA"

Phenytoin )0mg/2 Aam in )cc Na7$ 0,J+


* 7armabaze!in )mg/g..

* >entamycin Ba$&

* 7etrizin tab

* 7a$adin cream


* 1rda&a$ 20mg


L) 'inding+ Octoer t*6 2717

%rteria$ .$ood >as

* !4 : H"2(0 * Pco2 : 2)"0 mm4g

* Po2 : (2"0 mm4g * .icarbonate : 0

* Tota$ 762 : "0 * .ase es : *)

* 62 Saturation : JG"0 +

.$ood $ectro$ic

34


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* Na : )H m-/L

* : (,( m-/L

* 7$ : 2) m-/L

>$ucose

* .$ood : (2 mg/dL

* 1rine : *

T*e p)tient p)++ed )


36/38

3n&ection is usua$$y does not !roduce sym!toms 9ca$$ed asym!tomatic; or causes

&$u*$ie sym!toms such as &ever, headache, and ma$aise"

3n this case, the diagnosis is estab$ished based on historica$ taing and c$inica$

eamination that $ead to ence!ha$itis" 4istorica$ taing gained an unconsciousness

that has been e!erienced by the !atient since $ast 2 days" Fever 'as &ound 'ith

the tem!erature around (H,) *(,)O7" This !atient been having seizure H days in a

ro' be&ore admitted, &re-uency K( times !er day &or 0*20 minutes, rigid hand

'as &ound" 6ther then that, the !hysio$ogy re&$ees o& this !atient are higher then

usua$"

To con&irm the diagnosis a doctor 'i$$ as &or a b$ood sam!$e and order a $umbar

!uncture, in 'hich a need$e is inserted into the $o'er bac and a sma$$ amount o&

&$uid 9ca$$ed 7SF or cerebra$*s!ina$ &$uid; is taen &rom the s!ina$ cana$" Some

hos!ita$s are a$so e-ui!!ed to tae a bio!sy, 'here a tiny amount o& tissue is taen

&rom the brain 'hi$e the !atient is under genera$ anaesthesia" Doctors a$so

&re-uent$y order a 7T scan or agnetic ?esonance 3mage 9?3;, in 'hich

com!uterized images o& the brain are obtained that sho' the etent o& the s'e$$ing

and damage to the brain" %nother test sometimes used to he$! con&irm a diagnosis

is an e$ectroence!ha$ogram 9>;, 'hich records e$ectrica$ events in the brain"

For this !atient 'e had done severa$ !rocedures such as LFT, .$ood cu$ture,

Lumbar Puncture, mantou test, Q*ray, >, and 4ead 7T scan" The resu$t &or

the $umbar !uncture is L7S ana$ize 'ithin norma$ $imits" The resu$t &or > is

norma$" For radio$ogy the resu$t is norma$ and antou test 'as negati&" Fina$$y

4ead 7T resu$t are atro&i cerebra$ corte, hidrose&a$us comunicans, ischemic, and

in&ar bi$atera$occi!ita$ $obes e"c meningitis"

Treatment &or vira$ ence!ha$itis a$so inc$udes !a$$iative care" There is no cure &or

arbovira$ ence!ha$itis and the goa$ o& treatment is to re$ieve sym!toms 9!a$$iative;"

Pa$$iative care may inc$ude intravenous &$uids 9to !revent dehydration;, antibiotics

9to !revent secondary in&ections;, and other medications 9to !revent

com!$ications;" Diuretics 9e"g", &urosemide, mannito$; may be administered to

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reduce intracrania$ !ressure and benzodiaze!ines 9e"g", $oraze!am %tivanCE; may

be administered to !revent seizures"

The !atient 'as given oygen, 38FD D)+ Na7$ 0,22)+, 3nA" 7e&otaime, inA"

%m!ici$$in, inA" Phenytoin, 3nA" anito$, Paracetamo$ tab$et, ?is!eridon tab$et, and

7etrizine tab$et"

(.2. Summ)ry

3t has been re!orted a case o& a boy, year and J months years o$d 'ith

ence!ha$itis" The diagnosis 'as estab$ished based on anamnesis, c$inica$ sign,

sym!toms, and !hysica$ eamination" The !rognostic o& this !atient 'as not good"

Fina$$y, the !atient !assed a'ay on the J tho& march 200 at H") 'ith cause o&

death being metabo$ic asidosis"

RE'ERENCES

"

2" $iegman, 5enson, arcdante, .ehrman 200G, ssentia$s o& !ediatrics,

Fi&th edition, 4 : (*G, Ste00, Phi$ade$!hia"

3. Le'is, P" >$aser, 7%, Pediatrics in revie', nce!ha$itis" 6&&icia$ 5ourna$

6& The %merican %cademy 6& Pediatrics" 200)"

4. %nonim J), nse&a$itis da$am 4asan ?", 3$mu esehatan %na, h : G22*

G2, Fau$tas edoteran 1niversitas 3ndonesia" 5aarta"

5. >ondim, F%%" 6$iveira, >" Thomas, FP" 8ira$ nce!ha$itis cited 200

6ctober E" %vai$ab$e &rom: 1?L:

htt!://emedicine"medsca!e"com/artic$e/GGJ*overvie' "

%ccessed 6ctober 2), 200

6. Ne$son, d" eningoense&a$itis 8irus, 3$mu esehatan %na Ne$son, h :

2*" 7>" 5aarta

37
http://emedicine.medscape.com/article/1166498-overviewhttp://emedicine.medscape.com/article/1166498-overview


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7. %nonim 2000, nse&a$itis da$am %ri& , a!ita Se$eta edoteran, disi

(, 5i$id 2, h: G0*GG, edi %escu$a!ius F 13, 5aarta"

" em!e, 7"4", J2, 3n&ections, bacteria$ and S!irochaeta$ 3n 5erry L" $$er,

7urrent Pediatric Diagnosis and Treatment, H ed", ! : H(2*H((, Lange

edica$ Pub$ications, Los %t$os, 7a$i&ornia"

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