encephalitis viral-1.ppt [read-only] -...
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Encephalitis viralEncephalitis viralEncephalitis viralEncephalitis viral
Dr. Kiking Ritarwan MKT, SpSDr. Kiking Ritarwan MKT, SpS
Email: kritarwan@ yahoo.comEmail: kritarwan@ yahoo.com
ENCEPHALITIS VIRUSENCEPHALITIS VIRUS
Virus Representative virus for Neurologic DiseaseVirus Representative virus for Neurologic Disease
�� DNADNA
-- Herpesviruses HSV,VZV,CMV,EBVHerpesviruses HSV,VZV,CMV,EBV
-- Papovavirus PMLPapovavirus PML
-- Posvirus VacciniaPosvirus Vaccinia
-- Adenovirus Adenovirus serotypeAdenovirus Adenovirus serotype
�� RNARNA�� RNARNA
-- Enterovirus ( Picornavirus) Poliovirus, coxsackivirus, echovirus, enterovirus 70Enterovirus ( Picornavirus) Poliovirus, coxsackivirus, echovirus, enterovirus 70--71, Hepatitis A71, Hepatitis A
-- Togavirus, alphavirus ( arbovirus) Equine encephalitisTogavirus, alphavirus ( arbovirus) Equine encephalitis
-- Flavivirus (arbovirus) St louis enceph, Japanese and Tic Borne encephFlavivirus (arbovirus) St louis enceph, Japanese and Tic Borne enceph
-- Orbovirus (Arbovirus) Colorado Tick feverOrbovirus (Arbovirus) Colorado Tick fever
-- Bunyavirus (arbovirus) California encephBunyavirus (arbovirus) California enceph
-- Togavirus, rubivirus RubellaTogavirus, rubivirus Rubella
-- Orthomyxovirus InfluenzaOrthomyxovirus Influenza
-- Rhabdovirus RabiesRhabdovirus Rabies
-- Retrovirus HIV, HTLVRetrovirus HIV, HTLV
R��� I�������R��� I�������V���� ����� �� ����� ����� �������V���� ����� �� ����� ����� �������
�� Saluran pernafasan : parotitis, varicella, Saluran pernafasan : parotitis, varicella,
morbillimorbilli
�� Saluran makanan : polio, enterovirusSaluran makanan : polio, enterovirus
�� Mukosa kelamin : Herpes simpleksMukosa kelamin : Herpes simpleks
�� Inokulasi : spt gigitan binatang (rabies a Inokulasi : spt gigitan binatang (rabies a
nyamuk)nyamuk)
�� Placenta : CMV + RubellaPlacenta : CMV + Rubella
HIV and the brain (1)HIV and the brain (1)
�� MeningitisMeningitis�� HIV itselfHIV itself
�� TB TB
�� CryptococcalCryptococcal�� CryptococcalCryptococcal
�� SyphiliticSyphilitic
�� Space occupying lesionsSpace occupying lesions�� ToxoplasmosisToxoplasmosis
�� TuberculomasTuberculomas
�� Lymphoma Lymphoma
HIV and the brain (2)HIV and the brain (2)
�� EncephalitisEncephalitis
�� HIV dementiaHIV dementia
Progressive multifocal leukoencephalopathy Progressive multifocal leukoencephalopathy �� Progressive multifocal leukoencephalopathy Progressive multifocal leukoencephalopathy
(PML)(PML)
�� CMV, HSV, HZV encephalitisCMV, HSV, HZV encephalitis
�� ToxoplasmosisToxoplasmosis
�� Strokes and intracerebral haemorrhageStrokes and intracerebral haemorrhage
HIV and the spinal cordHIV and the spinal cord
�� Vacuolar myelopathyVacuolar myelopathy
�� SyphilisSyphilis
�� HZV, HSV, CMV, HTLVHZV, HSV, CMV, HTLV--11
TBTB�� TBTB
�� LymphomaLymphoma
HIV and the peripheral nervous system (1)HIV and the peripheral nervous system (1)
�� RadiculopathyRadiculopathy
�� TBTB
�� CMVCMV
�� Inflammatory demyelinating Inflammatory demyelinating polyneuropathiespolyneuropathies
�� GuillainGuillain--BarreBarre
�� CIDPCIDP
HIV and the peripheral nervous system (2)HIV and the peripheral nervous system (2)
�� Distal sensory neuropathyDistal sensory neuropathy
�� Mononeuropathies, mononeuritis multiplexMononeuropathies, mononeuritis multiplex
�� DrugsDrugs�� INHINH
�� D4T, ddID4T, ddI
�� D4T associated HIV neuromuscular weakness D4T associated HIV neuromuscular weakness syndromesyndrome
�� Diffuse Infiltrative Lymphocytosis Syndrome Diffuse Infiltrative Lymphocytosis Syndrome (DILS)(DILS)
�� Nutritional neuropathiesNutritional neuropathies
Mekanisme kerusakan neuron pada infeksi HIVMekanisme kerusakan neuron pada infeksi HIV
�� Untuk masuk ke dalam SSP, HIV harus terlebih dahulu menginfeksi sel Untuk masuk ke dalam SSP, HIV harus terlebih dahulu menginfeksi sel
yang memiliki reseptor CD4 yang memiliki reseptor CD4
�� Mekanisme masuknya virus HIV kedalam SSP adalah dengan cara Mekanisme masuknya virus HIV kedalam SSP adalah dengan cara
menumpang pada monosit yang terinfeksi virusmenumpang pada monosit yang terinfeksi virus
�� Selanjutnya di dalam SSP, monosit yang telah terinfeksi Selanjutnya di dalam SSP, monosit yang telah terinfeksi
berdeferensiasi menjadi mikrogliaberdeferensiasi menjadi mikroglia
Defenition Viral encephalitisDefenition Viral encephalitis
�� Is an acute febrile illness with evidence of Is an acute febrile illness with evidence of damage to the parenchymal tissue of the CNS, damage to the parenchymal tissue of the CNS, producing alteration of consciousness, focal producing alteration of consciousness, focal neurological signs and seizures.neurological signs and seizures.
�� Etiology:viral infection of the nervous system,Etiology:viral infection of the nervous system,Etiology:viral infection of the nervous system,Etiology:viral infection of the nervous system,
�� Herpes simpleksHerpes simpleks
�� Eastern equineEastern equine
�� Venezuela St LouisVenezuela St Louis
�� Japanese Japanese –– B B
�� Russian tickRussian tick--borneborne
�� RabiesRabies
Etiology viral encephalitisEtiology viral encephalitis
��Viral is the most common causeViral is the most common cause
��The commonest is HSV type I in adults The commonest is HSV type I in adults and type 2 in neonates.and type 2 in neonates.
�� It may occur sporadically or in epidemicsIt may occur sporadically or in epidemics�� It may occur sporadically or in epidemicsIt may occur sporadically or in epidemics
��5050--70% mortality if untreated70% mortality if untreated
��So establishment of on early specific So establishment of on early specific diagnosis and early initiation of antiviral diagnosis and early initiation of antiviral chemotherapy is of great importancechemotherapy is of great importance
��2/3 of cases involve patients over 40 yo.2/3 of cases involve patients over 40 yo.
Patogenesis.Patogenesis.
Bila virus patogen masuk kedalam tubuhBila virus patogen masuk kedalam tubuh
��pada SSP dapat terjadi:pada SSP dapat terjadi:
�� Radang akutRadang akut
Radang kronisRadang kronis�� Radang kronisRadang kronis
�� NeoplasmaNeoplasma
�� Virus hidup dalam keadaan latenVirus hidup dalam keadaan laten
Cara penyebaran ke SSP:Cara penyebaran ke SSP:
Cara penyebaran Contoh virusCara penyebaran Contoh virus�� Hematogen herpes simplexHematogen herpes simplex
sitomegalovirussitomegalovirus
EpsteinEpstein--BarrBarr
CoxsackieCoxsackieCoxsackieCoxsackie
HIVHIV
MorbilliMorbilli
EchovirusEchovirus
khoriomeningitis limfositikkhoriomeningitis limfositik
paravirus paravirus
�� Neurogen Herpes simpleksNeurogen Herpes simpleks
BB--virusvirus
VariselaVarisela--ZosterZoster
RabiesRabiesRabiesRabies
Gambaran klinik:Gambaran klinik:
�� Tanda dan gejala bervariasi tergantung Tanda dan gejala bervariasi tergantung virus penyebab.virus penyebab.
�� Umumnya: demam akut disertai tanda rangUmumnya: demam akut disertai tanda rang--sang meningeal, sakit kepala, mual, fotofobi, sang meningeal, sakit kepala, mual, fotofobi, muntah, ggn kesadaran, defisit neurologik muntah, ggn kesadaran, defisit neurologik muntah, ggn kesadaran, defisit neurologik muntah, ggn kesadaran, defisit neurologik fokal dan kejang2.fokal dan kejang2.
�� Mortalitas bervariasi dari tinggi (eastern Mortalitas bervariasi dari tinggi (eastern equine encephalitis) sampai rendah (Veneequine encephalitis) sampai rendah (Vene--zuelan equine encephalitis).zuelan equine encephalitis).
�� Gejala sisa termasuk kejang2Gejala sisa termasuk kejang2
�� Komplikasi : Komplikasi : -- perubahan kepribadianperubahan kepribadian
-- ggn ekstrapiramidalggn ekstrapiramidal
-- demensiademensia-- demensiademensia
-- ggn motorik ggn motorik -- sensoriksensorik
Kriteria diagnosis ensefalitis viralKriteria diagnosis ensefalitis viral
1.1. Bentuk asimptomatik Bentuk asimptomatik �� analisis LPanalisis LP
2.2. Bentuk abortif : Nyeri kepala, demam yg tdk Bentuk abortif : Nyeri kepala, demam yg tdk tinggi, kaku kuduk. ISPA/ Infeksi GITtinggi, kaku kuduk. ISPA/ Infeksi GIT
3.3. Bentuk fulminan: Berlangsung bbrp jam Bentuk fulminan: Berlangsung bbrp jam sampai dengan beberapa hari yg berakhir sampai dengan beberapa hari yg berakhir sampai dengan beberapa hari yg berakhir sampai dengan beberapa hari yg berakhir dengan kematian.dengan kematian.
4.4. Bentuk khas ensefalitis: NK, demam, Bentuk khas ensefalitis: NK, demam, keasadaran menurun, kejang fokal atau keasadaran menurun, kejang fokal atau umum, hemiparesis, ggn koordinasi, umum, hemiparesis, ggn koordinasi, disorientasi, ggn bicara, ggn mentaldisorientasi, ggn bicara, ggn mental
Prosedur diagnostik.Prosedur diagnostik.�� LP : CSF jernih, tekanan normal atau LP : CSF jernih, tekanan normal atau
meningkat, Pleositosis limfositik < 1000/ul, meningkat, Pleositosis limfositik < 1000/ul, glukosa dan klorida nornal, protein normal glukosa dan klorida nornal, protein normal atau sedikit meninggi ( 80atau sedikit meninggi ( 80--200 mg/dl200 mg/dl
�� MRI atau CT scan MRI atau CT scan �� SOL (?)SOL (?)�� MRI atau CT scan MRI atau CT scan �� SOL (?)SOL (?)
�� EEGEEG
�� Liquor Liquor �� virus DNA dg “polymerase chain virus DNA dg “polymerase chain reaction” (prosedur cepat, sensitif, akurat)reaction” (prosedur cepat, sensitif, akurat)
�� Virus kadang2 dikultur dari Virus kadang2 dikultur dari liquor,feces,urine nasofaring atau darah.liquor,feces,urine nasofaring atau darah.
�� Titer antibodi thd virus tertentu.Titer antibodi thd virus tertentu.
Pengobatan.Pengobatan.
�� Tidak bisa diidentifikasi Tidak bisa diidentifikasi �� dianggap dianggap sebagai ensefalitis herpes simpleks dan sebagai ensefalitis herpes simpleks dan terapi dgn. Acyclovir atau ganciclovirterapi dgn. Acyclovir atau ganciclovir
�� Jalan nafas diawasiJalan nafas diawasi�� Jalan nafas diawasiJalan nafas diawasi
�� Keseimbangan cairan dan elektrolit dijagaKeseimbangan cairan dan elektrolit dijaga
�� Atasi kejangAtasi kejang
�� Atasi peninggian ICP Atasi peninggian ICP
Komplikasi neurologi HIVKomplikasi neurologi HIV
�� Brain Predominantly nonfocalBrain Predominantly nonfocal
AIDS dementia complexAIDS dementia complex
Acute HIVAcute HIV--related encephalitisrelated encephalitis
Cytomegalovirus encephalitisCytomegalovirus encephalitisCytomegalovirus encephalitisCytomegalovirus encephalitis
VaricellaVaricella--zoster virus zoster virus encephalitisencephalitis
Herpes simplex virus Herpes simplex virus encephalitisencephalitis
Metabolic encephalopathies Metabolic encephalopathies
Predominantly focalPredominantly focal
Cerebral toxoplasmosisCerebral toxoplasmosis
Primary CNS lymphomaPrimary CNS lymphoma
Progressive multifocal leukoencephaloProgressive multifocal leukoencephalo--
pathypathy
CryptococcomaCryptococcomaCryptococcomaCryptococcoma
Brain abcess / tuberculomaBrain abcess / tuberculoma
Neurosyphilis (meningovascular)Neurosyphilis (meningovascular)
Vascular disorders Vascular disorders
�� Spinal cordSpinal cord
Vacuolar myelopathyVacuolar myelopathy
Herpes simplex or zoster myelitis Herpes simplex or zoster myelitis
�� Meninges Meninges
Aseptic meningitis (HIV)Aseptic meningitis (HIV)
Cryptococcal meningitisCryptococcal meningitisCryptococcal meningitisCryptococcal meningitis
Tuberculous meningitisTuberculous meningitis
Syphilitic meningitisSyphilitic meningitis
Metastatic lymphomatous meningitisMetastatic lymphomatous meningitis
�� Peripheral nerve and root and rootPeripheral nerve and root and root
infectiousinfectious
herpes zosterherpes zoster
cytomegalovirus lumbar polyradiculopathycytomegalovirus lumbar polyradiculopathy
�� Virus or immuneVirus or immune--relatedrelated
acute and chronic inflammatory HIV polyacute and chronic inflammatory HIV poly--
neuritisneuritisneuritisneuritis
mononeuritis multiplexmononeuritis multiplex
sensorimotor demyelinating polyneuropathysensorimotor demyelinating polyneuropathy
distal painful sensory polyneuritisdistal painful sensory polyneuritis
�� Muscle Muscle
polymyositis and other myopathies polymyositis and other myopathies
Perjalanan penyakit infeksi HIVPerjalanan penyakit infeksi HIV
�� Infeksi virus (2Infeksi virus (2--3 minggu) 3 minggu) �� sindroma sindroma retroretro-- viral akut (2viral akut (2--3 minggu) 3 minggu) �� gejala gejala menghilang + serokonversi menghilang + serokonversi �� infeksi infeksi kronis HIV asimpto matik (rata2 8 thn) kronis HIV asimpto matik (rata2 8 thn) ��infeksi HIV / AIDS simptomatik (rata2 1,3 infeksi HIV / AIDS simptomatik (rata2 1,3 infeksi HIV / AIDS simptomatik (rata2 1,3 infeksi HIV / AIDS simptomatik (rata2 1,3 thn) thn) �� kematian.kematian.
�� Window period Window period �� masa dimana masa dimana pemeriksapemeriksa-- an test serologis utk antibodi an test serologis utk antibodi HIV masih negatif, tapi virus sdh ada dlm HIV masih negatif, tapi virus sdh ada dlm darah (sudah mampu menularkan kpd darah (sudah mampu menularkan kpd orang lain)orang lain)
CEREBRAL TOXOPLASMOSISCEREBRAL TOXOPLASMOSIS
�� Reactivation of latent infectionReactivation of latent infection
�� Toxo seroprevalence 12Toxo seroprevalence 12--46% (SA)46% (SA)
�� IgG indicates past infection (FN <3IgG indicates past infection (FN <3--6%)6%)
CD4 > 200 virtually excludes ToxoCD4 > 200 virtually excludes Toxo�� CD4 > 200 virtually excludes ToxoCD4 > 200 virtually excludes Toxo
�� Over 80% have CD4 < 100Over 80% have CD4 < 100
�� Typically multiple ring enhancing lesions on CT/MRITypically multiple ring enhancing lesions on CT/MRI
�� 2727--43% have single lesions43% have single lesions
�� Up to 10% may have diffuse encephalitis without any Up to 10% may have diffuse encephalitis without any visible focal lesionsvisible focal lesions
The course of H IV/A IDS
Notes:
MRI
CT Scan
Atrofi Meningeal hidrosefalus SOL
Keluhan intrakranial
Skema-1. Algoritme Penatalaksanaan Keluhan Intraserebral bagi
Penderita HIV-AIDS
normal Atrofi Meningeal
enhancement
hidrosefalus SOL
Evaluasi LCS Shunt
(kalau perlu)
Positif Negatif
Terapi sesuai
etiologi
Observasi
Lesi massa(-) Lesi massa (+)
Skema 2
normal
Lesi massa intrakranial
Alert-lethargic
stabil
Steroid ? Stupor-koma
Perburukan cepat, massa besar
Dengan resiko herniasi
Lesi multipel Lesi tunggal
Serologi
Skema-2. Algoritme Penatalaksanaan Lesi massa Intrakranial pada penderita HIV-AIDS
Terapi toksoplasmosis
Seumur hidup
Terapi sesuai
etiologi
Dekompresi dan
biopsi terbuka
Serologi
toksoplasma
NegatifPositif
Obat antitoksoplasmosis
Perbaikan
Ya Tidak Biopsi stereotaktik
Ancaman herniasi
Toxoplasmosis Toxoplasmosis –– Clinical FeaturesClinical Features
�� Usually subacute over weeksUsually subacute over weeks
�� Headache Headache 50%50%
�� Fever Fever 45%45%�� Fever Fever 45%45%
�� Behaviour changes Behaviour changes 40%40%
�� Confusion Confusion 1515--52%52%
�� Focal signsFocal signs
�� Seizures Seizures 2424--29%29%
Toxoplasmosis treatmentToxoplasmosis treatment
�� Sulphadiazine and Pyrimethamine is first choiceSulphadiazine and Pyrimethamine is first choice
�� CoCo--trimoxazole (80/400mg) 4 tablets BD x 4/52trimoxazole (80/400mg) 4 tablets BD x 4/52
then 2 tablets BD x 8/52then 2 tablets BD x 8/52
�� Long term secondary prophylaxis 2 tabs DLYLong term secondary prophylaxis 2 tabs DLY
�� Till sustained CD4 > 200Till sustained CD4 > 200
�� 86% show clinical improvement by 7 days86% show clinical improvement by 7 days
�� 95% show CT improvement by 14 days95% show CT improvement by 14 days
CT CT -- Multiple ring enhancing lesionsMultiple ring enhancing lesions
�� Toxo more likelyToxo more likely
�� Tuberculomas still Tuberculomas still possiblepossiblepossiblepossible
HIV dementia (AIDS Dementia HIV dementia (AIDS Dementia
Complex)Complex)
�� This progressive dementia occurs in AIDS, This progressive dementia occurs in AIDS, owing to a direct primary HIV infection of owing to a direct primary HIV infection of neurons or an indirect neurotoxicity neurons or an indirect neurotoxicity induced by presence of the virus in the induced by presence of the virus in the induced by presence of the virus in the induced by presence of the virus in the brainbrain
�� Pathology: the virus may be transported Pathology: the virus may be transported into the brain by infected peripheral into the brain by infected peripheral monocytes (Trojan horse theory).monocytes (Trojan horse theory).
Manifestasi klinis demensia HIV:Manifestasi klinis demensia HIV:
Cognititive disordersCognititive disorders
Gangguan kognitif, kesulitan konsentrasi, Gangguan kognitif, kesulitan konsentrasi, forgetfullness, cognitive slowing. Kadang2 agitasi, forgetfullness, cognitive slowing. Kadang2 agitasi, forgetfullness, cognitive slowing. Kadang2 agitasi, forgetfullness, cognitive slowing. Kadang2 agitasi, mania. mania.
Pd std awal sulit membedakan dgn keluhan psikiatri.Pd std awal sulit membedakan dgn keluhan psikiatri.
Motor abnormalities: Motor abnormalities: ataksia, hiperreflels. Babinski ataksia, hiperreflels. Babinski refleks srg muncul. Pada std lanjut : paraparese dgn refleks srg muncul. Pada std lanjut : paraparese dgn inkontinansia urin et alviiinkontinansia urin et alvii
Behavioural dysfunction : ABehavioural dysfunction : Apathy, altered personality, pathy, altered personality, disorientasi. Std akhir disorientasi. Std akhir ��MutismMutism
Herpes simplex encephalitisHerpes simplex encephalitis
Encephalitis non virus:Encephalitis non virus:
�� Bakteri:Strepto,staphylo,meningo, salmonella, Bakteri:Strepto,staphylo,meningo, salmonella,
E.coliE.coli
�� Protozoa: P.Falcifarum, ToxoplasmosisProtozoa: P.Falcifarum, Toxoplasmosis�� Protozoa: P.Falcifarum, ToxoplasmosisProtozoa: P.Falcifarum, Toxoplasmosis
�� Cacing: CystisercosisCacing: Cystisercosis
�� Jamur: Aspergillus, ActinomycosisJamur: Aspergillus, Actinomycosis
�� Rickettsia: RickettsiosisRickettsia: Rickettsiosis
Matur nuwonMatur nuwon
TERIMA KASIHTERIMA KASIH