12-mikrobiologi reproduksi
TRANSCRIPT
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Mardhia
Fakultas Kedokteran Untan
2013
MIKROBIOLOGI SISTEM
REPRODUKSI
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Seorang pria berusia 24 tahun datang ke klinik dengan keluhan nyeri saat berkemih dan sekret non-purulent
Pria mengaku kehidupan seksualnya aktif, berganti pasangan dan tidak selalu menggunakan kondom.
Diagnosis ?
Pewarnaan gram tidak ditemukan bakteri diplokokus gram negatif intraselular
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Pertahanan sistem genitourinaria
A. Epidermis dan mukosa Mukosa uretra (P/L) Epitelium simpleks kolumnar Endoservik Epitelium simpleks kolumnar Ektoservik Epitelium stratified squamos Vagina Epitelium stratified squamos
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Pertahanan sistem genitourinaria
B.Flora normal Pria : Uretra S. epidermidis Wanita : Vagina
108 – 109 bakteri/g dari cairan vagina Fakultatif S. Epidermidis Anaerob Lactobacillus
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5Normal flora in vagina: Lactobacillus sp. (Gram positive rods)
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Ekosistem Vagina
Glikogen
Lactobacili
Produksi
asam laktat
Keseimbangan ekosist
em
. Produksi
bakteriosin dan
bacteriocins like
substance
. Produk
si Hidroge
n peroksi
da
Mekanisme
kompetitif
. Proliferasi Epitelium
. Pematangan epitelium
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Patogenesis infeksi
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Penyebab infeksi pada wanita
Lokasi Organisme
Vulva Treponema pallidum Haemophilus ducreyi Chlamydia Herper virus Jamur
Vagina Trichomonas vaginalis Candida albicans Bakterial vaginosis
Servik N. Gonorrhoeae Chlamydia Herpes virus Human papiloma virus
Bagian uretra atas N. Gonorrhoeae Chlamydia Bakteri aerobik dan anaerobik
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Infeksi menular seksual
No Bakteri Penyakit
1. Treponema pallidum Syphilis
2. Neisseria gonorrhoeae Gonorhoea
3. Donovania granulomatis Granuloma inguinale
4. Haemophilus ducreyi Chancroid
5. Gardnerella vaginalis Non-specific vaginitis
6. Chlamydia trachomatis Non-specific genital infection
7. Chlamydia A LGV
8. Mycoplasma / Ureaplasma Non-specific urethritis
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Discharge vagin
a
Discharge
uretra
Ulkus genit
al
Vegetasi
genital
Bubo inguin
al
Nyeri
perut
bawah Pembe
ngkakan
skrotum
Konjungtivitis neonatorum
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DISCHARGE / DUH TUBUH
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Gonorrohea
•Organisme : Neisseria gonorrhoeae•Diplokokus intraselular; Gram negatif•Memiliki pili menempel pada permukaan mukosa
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Gonorrhoea (1)
•Masa inkubasi : 1-10 hari (rata” 2 hari)•Pria infeksi dengan gejala•Wanita infeksi tanpa gejala perantara utama
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Port de entry
Orofaring
Anal atau genital
Kolonisasi saat persalinan
Infeksi servik
Penyebaran sistemik :
artritis, meningitis,
endocarditis
Infeksi mata
Asimptomatik
Iritasi lokal, discharge
Faringitis
Infeksi asenden ke tuba falopi, kavum uteri (PID, infertilitas, kehamilan ektopik)
• Kebutaan• Konjungtivitis
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Gonorrhoea pada pria
•Gejala klinis :•Discharge uretra•Disuria• Rektum : discharge, tenesmus• Faringeal gonorrrhea
•Komplikasi :• Uretritis posterior Striktura uretra• Prostatitis• Epididymo-orchitis akut• Bakterimia infeksi kulit dan sendi
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Gonorrhoea pada wanita
• Gejala klinis :• Asimptomatik•Discharge vagina•Disuria• Simptomatik Gonorrohea rektum dan faringeal
•Komplikasi :• Bartholinitis• Pelvic inflamatory diseases• Bakterimia kulit• Artritis•Optalmia neonatorum
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Pemeriksaan mikrobiologi
Pria1. Discharge uretra :o Pewarnaan gram o Kultur :o Medium selektif : Thayer martino Transport medium : Stuarts / charcoal
2. Rektum atau Faring : Kultur3. Epididymo-orchitis/kulit/sendi : Kultur
darah
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Pemeriksaan mikrobiologi
Female :• Pewarnaan gram dan kultur :
a. Uretra
b. Discharge servik
c. Rektum
d. Faring
e. Pus (Abses glandula bartolini)
•Kultur darah :a. PID
b. Arthritis
c. Disseminated gonococcal disease
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Bakterial vaginosis
• Organisme : Gardnerella vaginalis + bakteri anaerobik• Gambaran klinik :• Discharge Bau amis, putih keabuan, encer• Diagnosis : - Kriteria AMSEL - Kriteria Nugent’s
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Kriteria AMSEL
• Discharge abnormal• ‘Clue’ cells• pH > 4.5• Tes Amine (Whiff test)• Pewarnaan gram : Banyak ditemukan bakteri anaerobik
3 dari 4 kriteria
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Kriteria Nugent’s
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Non spesifik genital infection (NSGI)
• Penyebab :• Chlamydia trachomatis• Ureaplasma urealyticum
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Gambaran klinis
•Uretritis•Discharge encer, mukoid, purulent
•Servisitis•Discharge vagina
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Komplikasi NSGI oleh C. trachomatis
1. PID infertilitas dan gangguan ginekologi.2. Trachoma inclusion conjunctivitis (TRIC)
discharge purulen3. Prostatitis atau epididymitis; bartholinitis4. Reiter’s syndrome arthritis, conjunctivitis,
uveitis, pustular hyperkeratosis pada kulit kaki, circinate balanitis
5. Fitz-Hugh-Curtis Syndrome Chlamydial perihepatitis, pleuritis
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Pemeriksaan mikrobiologi
• Mikroskop : discharge uretra atau vagina; usap• Chlamydia• Kultur : McCoy atau kultur jaringan• ELISA : deteksi antigen chlamydia• PCR / LCR
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Candidiasis vaginitis
• Organisme : Candida albicans• Gambaran klinis :
• Vulvovaginitis• Pruritus• Discharge vagina : cottage cheese like• Rash, eritema di area inguinal atau perianal
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Faktor predisposisi
• Diabetes mellitus• Kontrasepsi oral• Kehamilan• Antibiotik spektrum luas• Terapi steroid
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Pemeriksaan mikrobiologi
• Spesimen : Swab vagina• Pewarnaan gram atau sediaan basah• Kultur pada agar Saboraud
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NYERI PERUT BAWAH
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Pelvic inflamatory disease
• Penyebab : 1. Neisseria gonorrhoeae 2. Chlamydia trachomatis 3. Coliforms dan streptococci 4. Anaerobes : Bacteroides dan anaerobic cocci
•Gambaran klinis : nyeri perut bagian bawah, malaise, dispareunia, menstruasi memanjang
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Pemeriksaan mikrobiologi
• Sesuai dengan penyebab yang paling mungkin
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BUBO INGUINAL
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Granuloma inguinale
• Organisme: Calymmatobacterium granulomatis atau Klebsiella granulomatis• Gram negatif, intraselular• Klinis : Papul pada genitalia atau inguinal • Diagnosis: biopsi daerah lesi Donovan bodies
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Tissue smear stained by rapid Giemsa (RapiDiff) technique showing numerous Donovan bodies in monocytes including some in intracytoplasmic cysts (arrow)
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Limfogranuloma venerum
• Organisme : Chlamydia trachomatis• Gambaran klinis :
• Ulkus kecil• Nyeri• Pembesaran limfe nodi• Abses multipel
• Diagnosis: - Serology - Pewarnaan Giemsa atau fluorescent : badan inklusi intrasitoplasmic (perinuclear)
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ULKUS
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Chancroid
•Organisme : Haemophylus ducreyi•Gambaran klinik : soft chancre (satu atau multipel)•Diagnosis : Hasil usap lesi basil pendek, gram negatif
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Sifilis
• Organisme Treponema pallidum
• Spirochaetta : 6-14 spiral
• Bergerak
• Tidak dapat dikultur in vitro
• Pewarnaan khusus : Mikroskop lapang gelap, Mikroskopik dengan immunostaining (perak, imunofluorescent antibody)
• PCR
• Rabbit infectivity testing (RIT)
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Sifilis
• Inkubasi 10-90 hari (rata” 3 minggu)• Stadium primer (I) hingga 6 minggu• Ulkus durum • Pembesaran limfe
• Stadium sekunder (II) 6-8 minggu sejak S.I• Condyloma lata• Malaise, febris, nyeri kepala, tenggorokan kering• Menyebar sistemik maculopapular rash, tidak gatal• limfadenopati general
Note: The patient is potentially infectious during the primary and secondary stages !!
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Sifilis (stadium)
• Stadium latent : 3-30 tahun sebelum sifilis tersier• Stadium akhir • Tersier Gumma (ghost cell necrosis)• Quarter 5-30 tahun sejak infeksi awal • Komplikasi ke kardiovaskular, SSP
• Sifilis kongenital trans placental
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Pemeriksaan mikrobiologi
• Mikroskopik : Mikroskop lapang gelap• Test serologi• Non treponemal : cardiolipin (reagin) antibodi test Non spesific
VDRL ( Veneral diseases reference laboratory) Rapid plasma reagin (RPR) Wasserman reaction (WR) Kahn test
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Pemeriksaan mikrobiologi
• Tes antibodi treponema spesific• TPHA (Treponema pallidum haemagglutination assay)• FTA-Abs (Fluorescent treponemal antibody test absorbed)• TPI (Treponema pallidum immobilization)
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Algoritme Tradisional VS Algortime Modern
Tradisional ModernA Terpercaya
Murah Cepat
Spesific
L False positif Mahal Hasil tetap positif
setelah terapi
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Infeksi genital akibat virus
No Virus Penyakit1 Herpes symplex (Tipe I
dan II)Herpes genital
2 Human papiloma virus Warts3 Poxvirus Moluscum
contangiosum
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Herpes genital
•Organisme : Herpes simpleks Tipe II• Inkubasi : 3-7 hari•Gambaran klinis :• Vesikel berkelompok•Demam, malaise
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Komplikasi herpes
•Sistem saraf pusat : meningitis aseptik, ensefalitis•Hepatitis (Jarang)• Neonatal disseminated herpes atau ensefalitis herpetik
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HSV virion and its two major modes of entry into cells. Structural components of a typical HSV virion are shown (box). HSV virions can enter into cells via a pH-independent fusion of viral envelope with the plasma membrane (I) or alternatively, via an endocytic pathway that may be phagocytosis-like (II) in terms of the viral uptake. In both pathways HSV particles may initially associate with filopodia-like membrane protrusions via heparan sulfate proteoglycan (HSPG). Unidirectional transport of extracellular particles bound to filopodia (HSV surfing) then brings the particles closer to the cell body for entry via interactions with the cellular receptors including gD receptor and possibly gB receptor. Fusion at the plasma membrane results in the release of the naked viral nucleocapsid in the cytoplasm for transport to the nucleus. Similarly, endocytosis also requires fusion of the enveloped particles with the vesicular membrane for the release of the viral nucleocapsid proximal to the nucleus.
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Molecular interactions that facilitate HSV entry. Initial attachment to cells is mediated by interaction between heparan sulfate proteoglycans (HSPGs) with HSV glycoproteins gC and/or gB. Membrane fusion is required for the penetration of viral nucleocapsid and the tegument into the cytoplasm. Interaction between gD, gH-gL and a gD receptor may be sufficient to bring conformational changes within gD to trigger merging of viral and cellular membranes or lipid mixing. However, a fourth glycoprotein, gB, is also required for complete fusion and content mixing, which basically results in the release of the tegument and the nucleocapsid into the cytoplasm. A receptor for gB, PILR-α is also expected to play a role during the fusion process. Its precise role is still emerging and therefore, it is not shown above.
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Pemeriksaan mikrobiologi
•Spesimen : cairan dari vesikel, dasar ulkus, LCS•Pemeriksaan :
• Tzank Test• Kultur jaringan• ELISA :
•Mendeteksi antigen herpes simplex• PCR, Western blot : Membedakan tipe I dan II
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VEGETASI GENITAL
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Wart dan Kanker servix
• Organisme : Human papiloma virus• Masa inkubasi : 1-6 bulan; Kanker Tahunan• Gambaran klinis :
• Wart pada vulva, vagina bawah, regio perianal, penis• Bisa bertahan hingga berbulan-bulan
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Human papilloma virus
• Genotip > 100• Menginfeksi sel epitelial• Replikasi tergantung pada tahap diferensiasi sel• Kanker servik HPV 16 dan HPV 18• Wart HPV 6 dan HPV 11
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68Replikasi tergantung pada tahap diferensiasi sel
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Pemeriksaan mikrobiologi
• Swab servikal cytobrush• Biopsi• Cervicovaginal lavage• Kerokan
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Mikroskopik
• Pap smear• Koilocytes Infeksi HPV
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Molluscum contagiosum
• Organisme : Poxvirus – moluscum contagiosum virus• Virus DNA• Punya selubung• Replikasi di Inti• MCV 1 s/d MCV 4 MCV 2
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PENGAMBILAN SPESIMEN
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Pengambilan spesimen
A. Wanita Bersihkan vulva dengan aquades steril
atau saline Masukkan spekulum dengan hati-hati Bersihkan discharge yang berlebihan Usap fornik posterior atau endoservix
2 usap Anak/virgin : Usap vagina distal
dengan hati-hati setelah membersihkan vulva
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Pengambilan spesimen
B. Pria Ambil eksudat dari uretra Apabila tidak terlihat, masukkan ke dalam
uretra ± 2 cm Spesimen genital : usap lesi setelah
dibersihkan dengan aquades atau saline
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TERIMA KASIH