laporan kasus meningo edit.ppt
DESCRIPTION
meningoensefalitisTRANSCRIPT
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Identifikasi os Nama : An Z Umur : 8 Tahun Jenis kelamin : Perempuan Alamat : Berembeng Agama : Islam Tgl masuk : 06/07/2013
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Tidak pernah mengalami kejang sebelumnya.
Tidak ada riwayat trauma ataupun kecelakaaan.
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Tidak ada riwayat kejang dalam keluarga.
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Keadaan umum : Tampak sakit berat
Kesadaran : Menurun GCS : E2V3M3
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Tekanan Darah : 100/75 mmHg Nadi : 94x/menit Suhu : 39,30 C Pernapasan : 24x/menit
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Bentuk : Normocephali, ubun-ubun normal Rambut : Hitam, distribusi merata, tidak mudah dicabut Wajah : Simetris, tidak tampak oedem Mata : Conjungtiva anemis -/-
Sklera ikterik -/- Pupil bulat isokor diameter 3mm
Refleks cahaya langsung +/+ Refleks cahaya tidak langsung +/+
Telinga : Tidak tampak oedem, hiperemis, dan sikatriks Hidung : Tidak ada pernapasan cuping hidung Mulut : Bibir tampak simetris, warna kecoklatan, tidak sianosis.
KESIMPULAN : DALAM BATAS NORMAL
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KGB: Tidak terdapat pembesaran pada KGB submental, submandibular, preaurikuler, retroaurikuler,
cervical
KESIMPULAN: DALAM BATAS NORMAL
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ParuInspeksi : bentuk normal, simetris, tidak ada retraksi.Palpasi : stem fremitus kanan dan kiri
normalPerkusi : sonor pada kedua lapang paruAuskultasi : suara dasar vesikuler, rh -/-,
wh-/-
KESIMPULAN: DALAM BATAS NORMAL
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JantungInspeksi : pulsasi ictus cordis tidak terlihat.Palpasi : pulsasi ictus cordis teraba pada ICS V 1 cm
medial linea midclavicularis sinistra. Perkusi : batas atas jantung : ICS III linea parasternalis sinistra.batas kiri jantung : ICS V 1 jari medial linea
midclavicularis sinistra.batas kanan jantung : ICS IV linea sternalis dextra.Auskultasi : BJ I-II regular, murmur ( - ), gallop ( - ).
KESIMPULAN: DALAM BATAS NORMAL
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Inspeksi : datar, umbilicus tidak menonjol. Auskultasi : bising usus ( + ) normal, tidak terdengar
artrial bruit, tidak terdengar venoushum. Perkusi : timpani di keempat kuadran abdomen,
pekak sisi ( + ) normal, pekak alih ( - ). Palpasi : supel, turgor kulit normal, nyeri
epigastrium( - ), hepar, lien dan ginjal tidak teraba.
KESIMPULAN: DALAM BATAS NORMAL
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Akral hangat (+) Oedem (-)
KESIMPULAN: DALAM BATAS NORMAL
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Kaku Kuduk (+) Brudzinksy I (+) Brudzinsky II (+)
KESIMPULAN: Tanda rangsang meningeal (+)
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WBC 9,86 NEU 6,09
61,8 % LYM 2,56
26,0 % MONO 1,08
11,0 % EOS 0,05
0,047 %
BASO 0,1171,19 %
RBC 4,38 HGB 12,0 HCT 35,4 MCV 80,7 MCH 24,4 MCHC 34,0 RDW 10,8 PLT 213 MPV 5,73
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GDS 100 mg/dl
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Elektrolit Lumbal Pungsi
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Meningitis DD/ Meningoencephalitis
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Pro ICU O2 3 liter/menit Pasang NGT dan kateter urin IVFD D5 ¼ NS 20 tpm Injeksi Dexamethason bolus 5mg (maintenance
1/3 ampul / 8 jam) Injeksi Ampicilin 1gr / 6 jam Injeksi Kloramfenikol 325mg / 6 jam Syringe pump: phenitoin 300mg loading, habis
dalam 20 menit) 75mg/24 JAM Luminal IM 75mg Diet cair per NGT 6x50cc
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S: kejang (-) kesadaran menurun (+)
O: KU : BeratKesadaran : MenurunE1V1M2TD 130/80mmHgHR 88x/menitRR 32x/menitSuhu 37oc
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (+)
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A: Meningoencephalitis P: 02 3 liter/menit
Posisi head up 30cmIVFD Kaen Mg3 12 tpmBenutrion 250cc/hariSonde susu 15-18 cc @ 3 jamManitol 40cc @ 8jam(sebelumnya berikan RL 150 cc)Phenitoin maintenance 2x37,5 mg (dalam syringepump 10cc NaCl 0,9%)Inj Ampicillin 4x1grInj Kloramfenikol 4x375mg
Inj Dexamethason 3x1 ampul PO: Phenobarbital 2x37,5 mg
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SGOT 39,6 U/L SGPT 23,2 U/L BILIRUBIN TOTAL 0,50 mg/dl BILIRUBIN DIREK 0,08 mg/dl BILIRUBIN INDIREK 0,42 mg/dl ALBUMIN 3,89 g/dl
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S: kejang (-) kesadaran menurun (+)
O: KU : BeratKesadaran : MenurunE2V2M3TD 120/80mmHgHR 89x/menitRR 30x/menitSuhu 370C
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)status neurologis tanda rangsang meningeal (+)
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A: Meningoencephalitis P: 02 3 liter/menit
Posisi head up 30cmIVFD Kaen Mg3 12 tpmBenutrion 125cc/hariSonde entrosol 20cc @ 3 jamManitol 40cc @ 8jam(sebelumnya berikan RL 150 cc) Phenitoin maintenance 2x37,5 mg (dalam syringepump 10cc NaCl 0,9%)Inj Ampicillin 4x1grInj Kloramfenikol 4x375mgInj Dexamethason 3x1 ampulPO: Phenobarbital 2x37,5 mg
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S: kejang (-) membuka mata (+)
O: KU : BeratKesadaran : MenurunE3V2M3TD 90/80mmHgHR 72x/menitRR 24x/menitSuhu 36,50C
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (+)
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A: Meningoencephalitis P: 02 3 liter/menit
Posisi head up 30cmIVFD Kaen Mg3 12 tpmBenutrion 125cc/hariSonde entrosol 20cc @ 3 jamManitol 40cc @ 8jam(sebelumnya berikan RL 150 cc) Phenitoin maintenance 2x37,5 mg Inj Ampicillin 4x1grInj Kloramfenikol 4x375mgInj Dexamethason 3x1 ampulPO: Luminal 2x37,5 mg
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UREA 23,5 mg/dl CREATININ 0,42 mg/dl
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S: kejang (-) kesadaran membaik (+)
O: KU : SedangKesadaran : MembaikE4V2M4TD 100/70mmHgHR 80x/menitRR 30x/menitSuhu 37oC
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (-)
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A: Meningoencephalitis P: 02 3 liter/menit
IVFD Kaen Mg3 10 tpmBenutrion 125cc/hariSonde entrosol 50cc @ 3 jamManitol 40cc @ 8jam(sebelumnya berikan RL 150 cc)Phenitoin maintenance 2x37,5 mgInj Ampicillin 4x1grInj Kloramfenikol 4x375mgInj Dexamethason 3x1 ampulPO: Luminal 2x37,5 mg
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S: kejang (-) kesadaran membaik (+)
O: KU : SedangKesadaran : MembaikE4V2M4TD 90/60mmHgHR 80x/menitRR 30x/menitSuhu 37oC
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (-)
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A: Meningoencephalitis P: 02 3 liter/menit
IVFD Kaen Mg3 10 tpmSonde entrosol 60cc @ 3 jamInj Ampicillin 4x1grInj Kloramfenikol 4x375mgInj Citicolin 1x150mg (im)Fenitoin 2x20 mg (tappering)PO: Luminal 2x37,5 mgBoleh pindah ke ruangan
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S: kejang (-) kesadaran membaik (+)
O: KU : SedangKesadaran : MembaikE4V2M4TD -HR 84x/menitRR 24x/menitSuhu 36oC
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (-)
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A: Meningoencephalitis P: 02 3 liter/menit
IVFD Kaen Mg3 8 tpmSonde entrosol 100cc @ 3 jamInj Ampicillin 4x1grInj Kloramfenikol 4x375mgInj Citicolin 1x150mg (im)PO: Luminal 2x37,5 mg
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S: kejang (-) kesadaran membaik (+)
O: KU : SedangKesadaran : MembaikE4V2M4TD -HR 84x/menitRR 30x/menitSuhu 36,5oC
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (-)
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A: Meningoencephalitis P: Sonde entrosol 100cc @ 3 jam
Inj Ampicillin 4x1grInj Kloramfenikol 4x375mgInj Citicolin 1x150mg (im)PO: Luminal 2x37,5 mg
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S: kejang (-) kesadaran membaik (+)
O: KU : SedangKesadaran : MembaikE4V2M4TD -HR 80x/menitRR 24x/menitSuhu 36,5oC
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (-)
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A: Meningoencephalitis P: Latih diet lewat mulut
(Diet entrasol 100cc @ 3 jam)Inj Ampicillin 4x1grInj Kloramfenikol 4x375mgInj Citicolin 1x150mg (im)PO: Luminal 2x37,5 mg L-Bio 2x1
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S: kejang (-) kesadaran membaik (+)
O: KU : SedangKesadaran : MembaikE4V2M4TD -HR 80x/menitRR 24x/menitSuhu 36,5oC
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (-)
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A: Meningoencephalitis P: Latih diet lewat mulut
(Diet entrasol 100cc @ 3 jam)Inj Ampicillin 4x1grInj Kloramfenikol 4x375mgInj Citicolin 1x150mg (im)PO: Luminal 2x37,5 mg L-Bio 2x1
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S: kejang (-) kesadaran membaik (+)
O: KU : SedangKesadaran : MembaikE4V2M4TD -HR 80x/menitRR 24x/menitSuhu 36,5oC
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (-)
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A: Meningoencephalitis P: Latih diet lewat mulut
(Diet entrasol 100cc @ 3 jam)Inj Citicolin 1x150mg (im)PO: Phenobarbital 2x37,5 mg L-Bio 2x1
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S: kejang (-) kesadaran membaik (+)
O: KU : SedangKesadaran : MembaikE4V2M4TD -HR 80x/menitRR 24x/menitSuhu 36,5oC
mata anemis -/- , ikterik -/-thoraks cor/ S1S2 reguler, Murmur (-), Gallop (-)
pul/ vesikuler +/+, Rh -/-, Wh -/-abdomen distensi(-), BU (+) normalekstremitas akral hangat (+), oedem (-)
status neurologis tanda rangsang meningeal (-)
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A: Meningoencephalitis P: Boleh pulang
PO: Luminal 2x37,5 mg L-Bio 2x1 Neurotam 2x1cth
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PROGNOSIS
Ad Vitam : dubiaAd functionam : dubiaAd Sanationam : dubia
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Meningoencephalitis adalah peradangan yang terjadi pada encephalon dan meningens.
Nama lain dari meningoencephalitis adalah cerebromeningitis, encephalomeningitis, dan meningocerebritis.
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MeningoencephalitisMeningitis Ensefalitis
Sakit kepala Sakit kepala
Demam Demam
Fotofobia Kelainan serebral:gangguan kesadaran,Tanda rangsangdefisit neurologikmeningeal
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Penyebab
Mikroorganisme (virus-nonvirus)
Pascaimunisasi
Pascainfeksi
Ensefalitik kronik atau penyakitensefalopatik
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Penyebab
VirusDitularkan antar manusia
Mumps, measles, rubella, HSV, HHV-6-7, CMV, EB,enterovirus, adenovirus
Ditularkan oleh serangga
Arbovirus, flavivirus
Ditularkan oleh mamalia
Rabies
Bakteria
Lain-lain: chlamydia, rickettsia, fungus, parasit
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Penyebab
PascaimunisasiMeasles,mumps,pertusis,tifoid,influenza
Toksoid tetanus/difteria
ATS/ADS
Reaksi imunologik, infeksi virus vaksin,kombinasi
PascainfeksiAcute disseminated encephalomyelitis-ADEM
Reaksi imunologik, subakut, lesi multifokal massa putih
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Penyebab
Penyakit ensefalitik kronik/ensefalopatikSlow infections: virus/prion
Leukoensefalopati multifokal progresif, SSPE,kuru, Jakob-Creutzfeldt
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Patogenesis-patofisiologi
Virus tumbuh mulai di jaringan ekstraneuralSaluran napas: mumps,measles,varicellaOral-saluran cerna: poliovirus, enterovirusInokulasi: gigitan binatang-nyamukPlacenta: rubella, CMV, HIV
Penyebaran ke SSP: hematogen-neuronalKerusakan neuron
Invasi langsung-multiplikasi aktif virusRespon autoimun terhadap antigen virus
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Manifestasi klinis
Gejala umum infeksi sistemik akutLemah, letargiaDemam, sakit kepala, rewelMual-muntahFotofobia,Sakit tengkuk - punggung - tungkaiTanda nasofaringitis
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Manifestasi klinis
Gejala ensefalopatiGangguan kesadaran
Kejang
Defisit neurologikHemiplegia, ataksiaNistagmus, anisokori, papil edema, hemianopsia.Disfasia, disartriaTIK↑, sindrom herniasi
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Diagnosis
Anamnesisusia, status imunisasi, infeksi virus -gejalasistemis yang mendahului, status imunologik,infeksi HSV ibu perinatal
exposures 2-3 minggu terakhirmanusia-hewan sakit, bepergian, serangga(nyamuk, roden, ticks)
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Diagnosis
Pemeriksaan fisikmukosa, kulit-ruam, jaringan limfe
Neurologikkesadaran,rangsang meningeal, sarafkranial,motorik, sensorik,edema otak, TIK↑, sindrom herniasi
defisit neurologik fokal (ensefalitis HSV)
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Cairan serebrospinal
Analisa sitokimia, virologi, serologiELISA
Japanese B
PCRbaku emas deteksi HSV (spes 100%, sens 75-95%)enterovirus, CMV, HHV-6, VZV, HIV
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Tabel 2. Gambaran cairan serebrospinal pada beberapa infeksi SSP. 6
Kondisi Leukosit(mm3) Protein(mg/dl) Glukosa(mg/dl)<5, ³ 75% limfosit 20-45 >50 (75%glukosaNormal
serum)100-10.000 ataulebih, biasanya 100-500 menurun,biasanya <40Meningitis bakterial akutbiasanya 300-2.000, (<50% glukosa serum)PMNJarang>1.000, awalnya biasanya 50-200 biasanya normalMeningitis/meningoensefalitisPMN, selanjutnya MNvirus10-500, awalnya 100-3000 atau > <50Meningitis tuber ulosakPMN, selanjutnya MN
Sumber: Prober CG. Central nervous system infections. Dalam Behrman RE, Kleigman RM, Jenson HB, penyunting. NelsonTeextbook of Pediatrics. Edisi ke-17, Philadelphia: Saunders; 2004.h.2038-2047
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Pencitraan
Nilai tingkat kerusakan SSP
Biasanya normal, tidak spesifik, subtleEdema otak, tanda radang
MRILebih unggul daripada CT scan
Pemeriksaan pilihan
HSV: lesi lobus temporal
ADEM: demielinisasi multifokal massa putih
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Elektroensefalogram
Normal
Perlambatan umum
Status epileptikus non-konvulsif
HSV: lesi fokal lobus temporal
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Diagnosis banding
Disfungsi otak global akut dan subakutEnsefalitis akut
Demam, kesadaran ↓, disfungsi otak umumInfeksi SSP (virus)
ADEMRadang SSP non-infektifDiobati steroid
EnsefalopatiDisfungsi otak difus non-inflamasiMetabolik, intoksikasi
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Pengobatan
Tidak spesifik, empiris
Perawatan penunjangBeratnya penyakit
Antisipasi penyulit potensial
Kemoterapi antivirus
Pantau ketat di ICU
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Keseimbangan cairan dan elektrolit
Cairan IV rendah natriumGlukosa 5-10% : NaCl 0,9% (3:1) + KCl rumat
75% kebutuhan rumatan
Pantau kadar glukosa, magnesium,kalsium, elektrolit lain
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Demam
Asetaminofen/parasetamol10-15 mg/kg/kali, 4-5 kali/hari
Ibuprofen5-10 mg/kg/kali, 3-4 kali/hari
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Peninggian tekanan intrakranial
Kepala setinggi 30°
Cairan 75% rumatan
HiperventilasipCO2 25 mmHg
Manitol 0,25-1gr/kg IV selama 30´/8 jam
Gliserol per NGT 0,5-1ml/kg/6 jam
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Kejang
Pada 15-50% penderita
Sulit diberantas dan refrakter
Singkat dan tidak sering, benzodiazepineDiazepam 0,25-0,5mg/IV (laju 2mg/menit,maksimal 20mg)
Lorazepam 0,05-0,1mg/kg/IV (laju <2mg/ mnt,maksimal 4 mg)
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Kejang
Status konvulsifFenitoin 15-20mg/kg (maksimal 1gr),IV-perdrip dalam NaCl 0,9%, 20 menitFenobarbital 10-20mg/kg (maksimal 1gr),IV-perdrip 5-10 menitMidazolam 0,1-0,2mg/kg, IV - selama 5 menit,dilanjutkan infus rumat 0,05mg/kg/jam,maksimal 0,4mg/kg/jam
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Pengobatan penyebab
HSVAcyclovir 10-20mg/kg/8 jam, 14 hari (VZV)
Foscarnet 60mg/8 jam, 14 hari
HHV-6, CMV : gancyclovir, foscarnet, zidovir
Measles : ribavirin
Japanese B : interferon alpha
HIV : zidozudine, didanosine, ritonavir
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Prognosis
Mortalitas dapat mencapai 40%HSV dengan acyclovir: 20%Rabies, HIV: 100%
Gejala sisa pada 50% survivalIntelektual, tingkah laku, psikiatrikMotorikEpileptikPenglihatan/pendengaran
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Pencegahan
VaksinasiPoliomielitis
Measles, Mumps, Rubella
Varicella
Japanese B
Pengendalian vektor seranggaPenyemprotan
Eradikasi sarang serangga
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Terima kasih