8/10/2019 Plena Ri

1/7

PLENARY DISCUSSION

BLOCK OF TROPICAL MEDICINE

DISUSUN OLEH:

TUTORIAL 1

ADIL HIJRI MUHAMMAD

AINAL FADLY

AJENG TITI

ARDILA WARADUHITA

ARYANTI AMBARSARI

DINAR SANDI AJI

DONNI TEGAR PAMBUDI

ESTIANNA KHOIRUNNISA

FATIMATUZZAROH

INDAH KURNIAWATY

MICHAEL WIJAYA

MIFTAKURROHMAH

PRIBADI MUSLIM

UNIVERSITAS MUHAMMADIYAH YOGYAKARTA

2012

8/10/2019 Plena Ri

2/7

KASUS PLENARY DISCUSSION

A 28 year old man had acute onset of fever, chill, nausea, vomiting, dizzy,

malaise, myalgia, and jaundice that started five days before admission to a

hospital. He also complain about his urine, less volume and looks like a tea water.

He is a farmer and reported that rats were common in his neighborhood and that

he was eposed to floodwaters one week prior to symptoms. !ast medical history

was unremarkable.

!hysical eamination

"ital sign

H# $ %&& times'minute

## $ 2& times.minute

( )ailla* $ +8, degrees celcius-! $ %&&'& mmHg

He was alert, jaundiced, lungs were clear to auscultation, hepar palpable 2 cm

below arcus costarum, gastrocnemius sign '.

-- $ & kg

(- $ %/ cm

0aboratory eamination

-lood counts showed %2&&& leukocytes'mm+. (he hematocrit was 21 and theplatelet count was 3+&&& cells'mm+. He had the following laboratory test values.

4erum creatinine $ /,5 mg'dl

4erum ureum $ %8& mg'dl

(otal bilirubin $ %% mg'dl

467( $ %/& 9'0

46!( $ %53 9'0

9rinalysis showed urine density $ %,&5&

!rotein level $ , bilirubin $ trace )*

9rine output was /&& ml in the first 25 hours

:9;4(7hat are differential diagnoses that relevant with the case= >hy=

+. >hat is the etiology of the disease and how the pathogenesis=

5. >hat is the treatment for the case=

/. >hat is the prognosis of the patient=

. >hat are complications that may arise in the patient=3. >hat are the preventions of the disease=

8/10/2019 Plena Ri

3/7

A;#4

%. (he interpretations of the physical eamination and lab results

!hysical eamination

"ital sign

H# $ increase

## $ normal

( )ailla* $ increase

-! $ decrease

He was alert, means there is no neurological deficits and the disease has

not influence the central nervous system. ?aundiced, means there is

increasing of bilirubin in the blood. Hepar palpable 2 cm below arcus

costarum, means the hepar is enlarged. 6astrocnemius sign ' is very

patognomonic in leptospirosis.

-- $ & kg

(- $ %/ cm, means the -@ is normal.

0aboratory eamination

-lood counts showed %2&&& leukocytes'mm+, means the leukocytes

increase, or there is infection. (he platelet count was 3+&&& cells'mm+,

means platelet decreases.

4erum creatinine $ /,5 mg'dl )decrease*4erum ureum $ %8& mg'dl )increase*

(otal bilirubin $ %% mg'dl, means increase )normal &,2/ %,&*

467( $ %/& 9'0, means increase )normal B2%*

46!( $ %53 9'0, means increase )normal B2+*

9rinalysis showed urine density $ %,&5& )increase*

!rotein level $ , bilirubin $ trace )* )increase*

9rine output was /&& ml in the first 25 hours )decrease*

t means that there is disturbance of hepar and renal functions. Also there

is infection in the body.

(his picture below shows the stage of leptospirosis considering the time

and it determine the clinical manifestations too. t can help us to

establishing diagnoses from the eamination based on the time scale.

8/10/2019 Plena Ri

4/7

2. Cifferential diagnoses from anamnesis and physical eaminations$

a. nfluenza$fever, chill, malaise, myalgia,dizzy. n influenza, there is no

specific'particular muscle pain )myalgia*. -esides that, the fever is

usually shorter on duration.

b. Hepatitis viral $ fever, jaundice, hepatomegali. 7( !( increased, urine

can be darker because of increasing in urobilin.

c. @alaria$ fever,chill, malaise, myalgia, dizzy, jaundice, hepatomegaly.

n malaria, there is intermitten fever, and history of travelling to

endemic area.d. 0eptospira$ same as malaria gastrocnemius pain

+. ;tiology and pathogenesis

0eptospires enter the host through abrasions in the skin or through intact

mucous membranes, especially the conjunctiva and the lining of the oroD

and nasopharyn. Crinking of contaminated water may introduce

leptospires through the mouth, throat, or esophagus. After entry of the

organisms, leptospiremia develops, with subseEuent spread to all organs.

@ultiplication takes place in blood and in tissues, and leptospires can beisolated from blood and cerebrospinal fluid )F4G* during the first 5%&

days of illness. F4G eamination during this period documents pleocytosis

in the majority of instances, but only a minority of patients develop

symptoms and signs of meningitis at this point. All forms of leptospires

can damage the wall of small blood vessels this damage leads to vasculitis

8/10/2019 Plena Ri

5/7

with leakage and etravasation of cells, including hemorrhages. (he most

important known pathogenic properties of leptospires are adhesion to cell

surfaces and cellular toicity.

Although leptospires mainly infect the kidneys and liver, any organ may

be affected. n the kidney, leptospires migrate to the interstitium, renaltubules, and tubular lumen, causing interstitial nephritis and tubular

necrosis. Hypovolemia due to dehydration or altered capillary

permeability may contribute to the development of renal failure. n the

liver, centrilobular necrosis with proliferation of Iupffer cells may be

found. However, severe hepatocellular necrosis is not a feature of

leptospirosis. !ulmonary involvement is the result of hemorrhage and not

of inflammation. nvasion of skeletal muscle by leptospires results in

swelling, vacuolation of the myofibrils, and focal necrosis. n severe

leptospirosis, vasculitis may ultimately impair the microcirculation and

increase capillary permeability, resulting in fluid leakage and

hypovolemia.>hen antibodies are formed, leptospires are eliminated from all sites in

the host ecept the eye, the proimal renal tubules, and perhaps the brain,

where they may persist for weeks or months. (he persistence of

leptospires in the aEueous humor occasionally causes chronic or recurrent

uveitis. (he systemic immune response is effective in eliminating the

organism but may also produce symptomatic inflammatory reactions. A

rise in antibody titer coincides with the development of meningitis this

association suggests that an immunologic mechanism is responsible.

5. (reatment and @anagement for the patient

(ough having jaundice, but other clinical symptoms of him showed us that

this patient still in the mi! "#$m #" %&'#(&i$#(i(. Hence, we offer these

antibiotics doycycline, ampicillin or amoicillin. Among these three, we

would like to give him doycycline. t can be taken twice a day only )the

other two taken four times a day* so we epect that the patient would get

easier way also more pursuance to have it. -eside, doycycline could be

taken with empty or full stomach.

(he dosage is 2%&& mg !7 and be administered for 3 days. (he patient

shouldnJt have it with antacid or iron product. >e should tell the patient

that he may have these as adverse effect$ dizziness, vertigo, nausea andeven vomit, so we suggest him to rest.

7ther symptoms such renal dysfunction will be back to normal when the

microbes killed. >e advise patient to take more drink in order to avoid

dehydration. 0ater, we can give him and people around the neighborhood

chemoprophylais because of their high population of rat to prevent them

from leptospirosis.

n easy way, this is the resume of the treatments and chemoprophylais for

leptospirosis

8/10/2019 Plena Ri

6/7

/. !rognoses

@ost patients with leptospirosis recover. @ortality rates are highest among

patients who are elderly and those who have >eilKs syndrome.

0eptospirosis during pregnancy is associated with high rates of fetal

mortality. 0ongDterm followDup of patients with renal failure and hepatic

dysfunction has documented good recovery of renal and hepatic function.

. Fomplications

4evere 0eptospirosis )>eilKs 4yndrome*

>eilKs syndrome, the most severe form of leptospirosis and also the

complication of leptospirosis, is characterized by jaundice, renal

dysfunction, and hemorrhagic diathesis by pulmonary involvement in

many cases and by mortality rates of /%/. n ;urope, this syndrome is

freEuently but not eclusively associated with infection due to serovar

cterohaemorrhagiae'Fopenhageni. (he onset of illness is no different

from that of less severe leptospirosis however, after 51 days, jaundice as

well as renal and vascular dysfunction generally develop. Although some

degree of defervescence may be noted after the first week of illness, abiphasic disease pattern like that seen in anicteric leptospirosis is lacking.

(he jaundice of >eilKs syndrome, which can be profound and give an

orange cast to the skin, is usually not associated with severe hepatic

necrosis. Ceath is rarely due to liver failure. Hepatomegaly and tenderness

8/10/2019 Plena Ri

7/7

in the right upper Euadrant are usually detected. 4plenomegaly is found in

2& of cases.

#enal failure may develop, often during the second week of illness.

Hypovolemia and decreased renal perfusion contribute to the development

of acute tubular necrosis with oliguria or anuria. Cialysis is sometimes

reEuired, although a fair number of cases can be managed without dialysis.

#enal function may be completely regained.

!ulmonary involvement occurs freEuently in some clusters of cases, it is a

major manifestation, resulting in cough, dyspnea, chest pain, and bloodD

stained sputum and sometimes in hemoptysis or even respiratory failure.

Hemorrhagic manifestations are seen in >eilKs syndrome$ epistais,

petechiae, purpura, and ecchymoses are found commonly, while severe

gastrointestinal bleeding and adrenal or subarachnoid hemorrhage are

detected rarely.#habdomyolysis, hemolysis, myocarditis, pericarditis, congestive heart

failure, cardiogenic shock, adult respiratory distress syndrome, necrotizing

pancreatitis, and multiorgan failure have all been described during severe

leptospirosis.

3. (he preventions$

a. Ieep clean the environment especially in stall, farm, swimming pool,

and houseb. mmunization for the high risk occupation for eample farmer or labor

c. mmunization for the animals, pets, but the successful rate depends on

antigenic potential that belongs to vaccines.

d. Avoid any skin damage or torture because it can be the port dJentry

)entrance* of the spirochaeta )leptospira* to get inside the body.

--076#A!HL

%. HarrisonJs !rinciple of nternal @edicine

2. -uku Ajar lmu !enyakit Calam GI9

+. @odul -lock of (ropical @edicine

5. IatzungJs -asic of !harmacology