Patogenesis Ventilator Associated Pneumonia Terkini di Intensive Care UnitVol 5 No 4 (2018)
Febyan1, Soroy Lardo2
1 Fakultas Kedokteran, Universitas Kristen Krida Wacana, 2 Divisi Penyakit Tropik dan Infeksi, Departemen Penyakit Dalam, RSPAD Gatot Soebroto, Jakarta, Indonesia
Ventilator Associated Pneumonia (VAP) is part of hospital-acquired pneumonia (HAP) and predominantly caused by Pseudomonas aeruginosa. Several important factors in the pathogenesis of VAP are barrier to Na+-K+-Cl– transporter-1 (NKCC1) and endotracheal tube device without antibiofilm. VAP can be prevented by oral hygiene, endotracheal tube device made from antibiofilm, head up 30 degrees, and evaluation of cough ability and also swallowing function.
Keywords: ventilator associated pneumonia, intensive care unit
Ventilator Associated Pneumonia (VAP) merupakan bagian dari hospital-acquired pneumonia (HAP), terutama disebabkan oleh Pseudomonas aeruginosa. Beberapa faktor penting pada patogenesis VAP, antara lain sistem barier Na+-K+-Cl– transporter-1 (NKCC1) dan ETT (Endotracheal Tube) tanpa antibiofilm. Upaya pencegahan VAP berupa oral higiene, alat ETT berbahan antibiofilm, elevasi kepala 30 derajat, serta evaluasi kemampuan batuk dan fungsi menelan.
Kata kunci: ventilator associated pneumonia, instalasi perawatan intensif
Korelasi Nilai Cluster of Differentiation 4 (CD4) Dengan Kuantifikasi Deoxyrybonuclead (DNA) Pneumocystic Jiroveci Pada Penderita Human Immunodeficiency Virus (HIV) Dengan PneumoniaVol 5 No 4 (2018)
PPDS Ilmu Penyakit Dalam
Bagian Ilmu Penyakit Dalam, Fakultas Kedokteran, Universitas Andalas/RSUP Dr M Djamil Padang
Latar belakang: Human immunodeficiency virus (HIV) adalah virus yang menyebabkan berkurangnya CD4, ditandai dengan sistem kekebalan yang berkurang sehingga memudahkan infeksi oportunistik, salah satunya adalah infeksi Pneumocystic jiroveci. Meningkatnya insiden kolonisasi dan infeksi pneumocystic jiroveci seiring dengan penurunan CD4, sehingga perlu dilakukan penelitian untuk melihat korelasi nilai CD4 dengan kuantifikasi DNA P. Jiroveci pada pasien HIV dengan pneumonia.
Metode: Penelitian observasional dengan metode potong lintang dilakukan pada 30 kasus baru pasien HIV dengan pneumonia yang belum mendapat terapi profilaksis PCP (Pneumocystic jiroveci pneumonia) pada pasien Instalasi Penyakit Dalam RSUP Dr. M. Djamil Padang pada bulan Februari sampai Mei 2018. Pasien dengan tes HIV positif cepat diikuti oleh pengukuran kadar CD4 dengan menggunakan flow cytometry. Pemeriksaan kuantifikasi DNA P.jiroveci menggunakan alat quantitative realtime PCR/qRT-PCR
Hasil: Penelitian ini memperoleh nilai CD4 rata-rata rendah pada pasien HIV dengan pneumonia, 21,37 sel/mm3. Sedangkan rerata kuantifikasi DNA P.jiroveci pada pasien HIV dengan pneumonia, 6238,77 kopi/ml, dengan lebih banyak kejadian kolonisasi P.jiroveci.
Kesimpulan: Terdapat korelasi negatif dengan adanya korelasi kuat antara nilai CD4 dan kuantifikasi DNA P.jiroveci pada pasien HIV dengan pneumonia. Disarankan bahwa pada pasien HIV dengan pneumonia dengan nilai CD4 rendah perlu diwaspadai adanya risiko infeksi PCP.
Kata Kunci: HIV, CD4, kuantifikasi DNA P.Jiroveci
Profil Pasien Lost to Follow-up dan Faktor-Faktor yang Mempengaruhi pada pasien TB-HIV di RSCMVol 5 No 4 (2018)
Reagan Paulus Rintar Aruan1, Teguh Harjono Karyadi2, Gurmeet Singh3, Cleopas Martin Rumende3
1Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia –RSUPN Cipto Mangunkusumo
2Divisi Alergi Imunologi Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia-RSUPN Cipto Mangunkusumo
3Divisi Respirologi dan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia –RSUPN Cipto Mangunkusumo
Latar Belakang: Koinfeksi TB-HIV (Tuberkulosis-Human Immunodeficiency Virus) menunjukkan morbiditas dan mortalitas yang tinggi. Pasien TB-HIV yang mengalami lost to follow up dapat menjadi sumber penularan dan resistensi obat. Dibutuhkan data tentang proporsi lost to follow up pasien TB-HIV, serta faktor-faktor yang mempengaruhi.
Tujuan: Mengetahui proporsi lost to follow up pada pasien TB-HIV serta mengetahui besarnya pengaruh dari masing-masing faktor yaitu: jenis kelamin, usia, jumlah penghasilan, status fungsional, frekuensi transportasi, lama menunggu pengobatan, jumlah obat, tempat tinggal, efek samping, dan status imunodefisiensi.
Metodologi: Studi kohort retrospektif terhadap 100 pasien TB-HIV rawat jalan di POKDISUS RSCM tahun 2015-2017. Metode pengambilan sampel menggunakan non probability consecutive sampling. Dilakukan analisis bivariat untuk mengetahui hubungan faktor-faktor yang mempengaruhi lost to follow up pasien TB-HIV menggunakan uji chi square serta alternatifnya. Analisa multivariat menggunakan uji regresi logistik untuk mendapatkan Odds Ratio (OR) dari setiap faktor.
Hasil: Dari 100 pasien dengan TB-HIV rawat jalan POKDISUS RSCM didapatkan proporsi pasien lost to follow up sebesar 39% dan jumlah penghasilan <Rp 3,6 juta (OR 7,04; IK 95% 2,409-20,591)
Kesimpulan: Jumlah penghasilan merupakan faktor yang bermakna mempengaruhi lost to follow up pasien TB-HIV.
Kata Kunci: Lost to follow-up, TB-HIV
PENDEKATAN DIAGNOSIS DAN TATA LAKSANA MIOPATI TERINDUKSI STEROIDVol 5 No 4 (2018)
Niken Wahyuningsih1, Bambang Setyohadi2
1 Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia –
RSUPN Cipto Mangunkusumo
2 Divisi Rematologi, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia –
RSUPN Cipto Mangunkusumo
Miopati terinduksi steroid memiliki karakteristik adanya kelemahan otot dalam satu atau beberapa bulan setelah pemberian atau peningkatan terapi steroid. Gejalanya yang umum terjadi adalah adanya kelemahan otot proksimal secara bertahap selama periode beberapa minggu yang diikuti dengan perusakan otot. Tes untuk membuktikan hal tersebut adalah dengan mengurangi dosis steroid. Kelemahan yang diakibatkan oleh miopati terinduksi steroid akan mulai membaik dalam tiga atau empat minggu setelah pengurangan dosis yang memadai. Elektromiografi dan biopsi otot dapat membantu untuk menegakkan diagnosis. Penatalaksanaan pada keadaan yang mendasari kelebihan steroid sangat bermanfaat.
Kata Kunci: Diagnosis, tata laksana, miopati terinduksi steroid
Miopati telah dikenal sebagai efek samping dari terapi kortikosteroid (glukokortikoid) sejak pertama kali diperkenalkan sebagai agen terapeutik pada tahun 1950-an.1 Miopati dapat timbul pada setiap jenis sediaan kortikosteroid. Risikonya dapat meningkat pada pasien dengan usia lanjut dan pasien dengan kanker atau pasien dengan balans nitrogen yang negatif sebelum terapi dilaksanakan.2
TUBERKULOSIS PADA TRANSPLANTASI ORGANVol 5 No 4 (2018)
Melsa Aprima1, Fauzar2
1 Program Studi Pendidikan Dokter Spesialis Ilmu Penyakit Dalam, FK UNAND/RS M Djamil, Padang
2 Divisi Pulmonologi dan Kedokteran Respirasi, Departemen Ilmu Penyakit Dalam
FK UNAND/RS M Djamil, Padang
Tuberkulosis (TB) hingga saat ini masih menjadi masalah kesehatan masyarakat. Pasien transplantasi organ
memiliki risiko tinggi untuk terinfeksi Mycobacterium tuberculosis. Frekuensi dan angka mortalitas TB pada
pasien transplantasi organ lebih tinggi dibandingkan populasi umum. Diagnosis dan penatalaksanaan TB
aktif maupun TB laten harus dilakukan pada seluruh pasien transplantasi organ.
Kata kunci: Tuberkulosis, Transplantasi organ
Tuberculosis is still a public health problem. Organ transplant patients have a high risk of being infected
with mycobacterium tuberculosis. The frequency and mortality rate of TB in organ transplant patients is
higher than the general population. Screening, diagnosis, and management of active or latent TB should be
performed on all organ transplant patients.
Keywords: Tuberculosis, Organ Transplantation
CORELATION BETWEEN INHALED BETA 2 AGONIST AND CORTICOSTEROID WITH THE DEGREE OF CONTROL AND LUNG FUNCTION IN ASTHMAVol 5 No 3 (2018)
Muhammad Ranushar, Harun Iskandar, Nur Ahmad Tabri, Makbul Aman, Syakib Bakri
Departement of Internal Medicine Medical Faculty
Hasanuddin University Makassar
Background: Asthma is an important chronic airway disease and is still a serious and mass public
health problem in many countries. Asthma control has been difficult to achieve using conventional
therapies such as short-acting beta 2 agonist (SABAs), oral beta 2 agonists, oral corticosteroids
and theophylline, leading to asthma difficult to control. Treatment of asthma based on GINA uses
asthma control medications (controller) in the form of inhalation of beta 2 agonist combination
with inhaled steroid/Inhaled Corticosteroid (ICS) and can be a combination of both. Classification
of degree control based on GINA is considered more practical, easier to adapt, and more clinically
Objective: To know the relationship of type therapy with degree of control and lung function of
Methods: This study was a cross-sectional study. The samples used were patients with asthma
diagnosis both outpatient and inpatient according to GINA criteria. The subjects of the study were
data collection in the form of therapy method. Spirometry measurements determine FEV1% and
asthma control degree according to GINA criteria. The study was conducted in February-May
2016 at Pulmonology Polyclinic RS Wahidin Sudirohusodo Makassar and Hasanuddin University
hospital in Makassar
Results: The age of the subjects varied between 19 and 69 years old, the FEV1% score ranged from
18% to 98%, male subjects were 23 (33,8%) and 45 (66,2%). There was no significant association
of therapeutic method with lung function (p> 0,05). There is a significant relationship between
therapy method and degree of control asthma (p <0,001).
Conclusions: In patients with asthma who received combination therapy such as combination
budesonide and formoterol or salmeterol and fluticasone significantly more achieved a better
degree of control than in patients who only received agonist beta 2 inhalation or corticosteroid
Keywords: Asthma, therapeutic method, lung function, a degree of control, Forced Expiration
Volume 1, Inhalation of beta 2 agonists, inhaled corticosteroids, inhalation corticosteroid and beta-
2 agonist combination.
SUPRAVENTRICULAR TACHYCARDIA COMPLICATING DIFFUSE ST DEPRESSION WITH ST ELEVATION IN AVRVol 5 No 3 (2018)
Raymond Pranata1, Emir Yonas2, Veresa Chintya3 Vito Anggarino Damay1,4
1Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Banten, Indonesia
2Faculty of Medicine, YARSI University, Jakarta, Indonesia
3Sanjiwani General Hospital, Gianyar, Bali, Indonesia
4Department of Cardiology and Vascular Medicine, Siloam Hospital Lippo Village, Tangerang, Banten, Indonesia
Background: Lead aVR is frequently neglected in routine clinical practice. Usually, basal septum
receives blood supply from very proximal septal branches of the left anterior descending artery.
Transmural infarction of this area usually causes lead ST segment elevation in lead aVR signaling
proximal left coronary artery (proximal LAD or left main) occlusion. Ischemia and infarction
leads to metabolic and electrophysiological changes that may cause silent and symptomatic lifethreatening
Case Report: We reported 50 years old male patient presented to the ED 15 minutes since the
onset of severe pain in the abdomen accompanied by nausea and sweating. With ECG of diffuse
ST-segment depression with STE-aVR. The patient was then diagnosed with NSTE-ACS with
probable left main coronary artery (LMCA) obstruction with differential diagnosis of cholecystitis/
cholelithiasis with accompanying stable coronary artery disease. Patient felt better and rejected
hospitalization. The patient then came 7 hours later with dyspnea and worsening abdominal pain.
ECG of PSVT 189x/minute. Troponin was >10 ng/mL. Patient refused cardioversion and adenosine/
ATP was unavailable. Amiodarone 150 mg over 10 minutes was administered. After consideration,
patient was then referred to coronary angiography capable center for immediate invasive strategy.
Conclusion: ST elevation in lead aVR may signal a severe proximal left coronary artery disease
(LMCA or proximal LAD). Regardless whether it is caused by proximal left coronary artery disease
or not, it is also an independent predictor of mortality.
Keywords: supraventricular tachycardia, ST elevation aVR, left main coronary obstruction
KETIDAKPATUHAN TERHADAP PENGOBATAN PADA PASIEN KOINFEKSI TB HIVVol 5 No 3 (2018)
Zulkifli Amin1, Intan Pratiwi2
1 Divisi Respirologi dan perawatan kritis, Departemen Ilmu Penyakit Dalam, Rumah Sakit Umum Nasional Cipto Mangunkusumo Indonesia 2 Asisten Penelitian di Departemen Penyakit Dalam, Rumah Sakit Umum Nasional Cipto Mangunkusumo, Indonesia
Tuberkulosis (TB) dan HIV/AIDS masih menjadi masalah kesehatan di dunia. Tuberkulosis adalah penyakit yang paling umum di antara orang yang hidup dengan HIV. Pasien koinfeksi TB/HIV adalah masalah yang kompleks. Oleh karena itu, perawatan seringkali dapat menjadi rumit disebabkan kondisi medis dan adanya kesulitan kondisi sosial. Kondisi ini dapat membuat pasien tidak patuh dalam menjalani pengobatan. Tenaga kesehatan masyarakat memiliki peran penting dalam menyelesaikan masalah ini.
Kata kunci: ketidakpatuhan, pengobatan, koinfeksi, TB/HIV
LAPORAN TIGA KASUS TUBERKULOSIS EKSTRA PARUVol 5 No 3 (2018)
Dewi Resnawita, Marlina Rays, Harun Iskandar, Eliana Muis, Muhammad Ilyas,
Nur Ahmad Tabri, Irawati Djaharuddin, Erwin Arief, A. Makbul Aman, Syakib Bakri
Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Hasanuddin
Tuberkulosis (TB) merupakan penyakit infeksius yang dapat mengancam nyawa dengan angka
insidensi yang tinggi di dunia, terutama di negara-negara berkembang seperti Indonesia. Meskipun
sebagian besar kasus TB ditemukan pada paru-paru, proporsi pasien yang mengalami infeksi TB
ekstra paru juga menunjukkan angka yang signifikan. Berikut dilaporkan tiga kasus TB ekstra paru.
Kasus pertama, wanita 63 tahun dengan gambaran klinis benjolan pada daerah mulut yang awalnya
diperkirakan menderita tumor kemudian dilakukan pemeriksaan histopatologis diperoleh hasil
peradangan kronik granulomatous. Kasus kedua, wanita 32 tahun dengan gambaran klinis berupa
plak hiperkeratosis, eritema dan skuama regio interphalang digiti dua dextra kemudian dilakukan
pemeriksaan histopatologis diperoleh hasil Tuberkulosis kutis verukosa. Kasus ketiga, laki-laki 32
tahun, dengan nyeri dan bengkak pada lutut kanan kemudian dilakukan pemeriksaan histopatologis
diperoleh hasil radang kronik granulomatosa supuratif. Terhadap ketiga pasien ini diberikan obat
anti tuberkulosis (OAT) kategori I 2(HRZE)/4(HR)3 dan terjadi perbaikan klinis.
Kata kunci: TB ekstra paru, obat anti tuberkulosis
SUCCESSFUL MANAGEMENT OF RESPIRATORY FAILURE FOLLOWING SNAKEBITE IN GERIATRIC PATIENTVol 5 No 3 (2018)
Randy Adiwinata1, Josephine Rasidi1,
Muhammad Reza Arifianto2,
Mohammad Darwis Dahlan3,
Restu Ratnaningsih6, Erni Juwita Nelwan7
1Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
2Faculty of Medicine, Hang Tuah University, Surabaya, East Java, Indonesia
3Department of Surgery, Kanujoso Djatiwibowo Hospital, Balikpapan, East Kalimantan, Indonesia
4Department of Neurology, Kanujoso Djatiwibowo Hospital, Balikpapan, East Kalimantan, Indonesia
5Department of Anesthesiology, Kanujoso Djatiwibowo Hospital, Balikpapan, East Kalimantan, Indonesia
6Department of Internal Medicine, Kanujoso Djatiwibowo Hospital, Balikpapan, East Kalimantan, Indonesia
7Division of Tropical and Infectious Disease, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.
Introduction: Neurotoxicity manifestations following venomous snakebite may lead to lifethreatening
conditions such as respiratory muscle paralysis leading to respiratory failure and loss
of consciousness. Prompt treatments are required.
Case illustration: A-90-year-old woman presented with loss of consciousness and respiratory
failure following snakebite. On general examination, a patient was unconscious (Glasgow Coma
Score [GCS] 3) with respiratory rate 4-6 rates per minute and frequent apnea period. Her blood
pressure was 267/155 mmHg with sinus tachycardia (150 bpm) and low oxygen saturation (50-
65%). Early intubation was performed due to respiratory failure. Rapid neurological improvement
was seen after snake antivenom and anticholinesterase administration. She was discharged on the
fifth day without any neurotoxic sign.
Discussion: The respiratory failure and loss of consciousness were regarded as acute and severe
neurotoxic envenoming. Geriatric patient may have reduced respiratory capacity which may further
accelerate the respiratory failure. Neurotoxin acted at the pre- and post-synapse neuromuscular
junction. Antivenom is the only definitive therapy in envenoming. Trial of anticholinesterase should
always be conducted in neurotoxic envenoming. Early mechanical ventilation support should be
given in respiratory failure cases.
Conclusion: Antivenom administration and trial of anticholinesterase should be performed in
neurotoxicity envenoming. Mechanical ventilation should not be delayed in present of respiratory
Keywords: venomous snakebite, respiratory failure, neurotoxin, snake antivenom
Perbandingan Perbaikan Nilai Peak Ekspiratory Flow Penggunaan Aminofilin Dan Salbutamol Pada Eksaserbasi AsmaVol 5 No 2 (2018)
Amelia Lorensia1, Zullies Ikawati2, Tri Murti Andayani2, Daniel Maranatha3
1Department of Clinical pharmacy-Community, Faculty of Pharmacy, University of Surabaya, Jl. Raya Kalirungkut, 60293 Indonesia
2Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy Universitas Gadjah Mada, Sekip Utara Yogyakarta, 55281 Indonesia
3Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Airlangga, General Hospital Dr. Soetomo, Surabaya
Background: Intravenous aminophylline is one of the most frequent exacerbations of asthma therapy in Indonesia. Even abroad, the use of aminophylline / theophylline is often used because of higher and better effectiveness than the first line, ie salbutamol nebulasi.
Objective: To determine the effectiveness of salbutamol mebulasi and aminophylline intravenously on exacerbation of asthma in improving lung function with peak expiratory flow (PEF) value with peak flow meter.
Method: This study used quasi experimental method, with research variable is PEF value. The study was conducted from January 2014 to June 2016. The study subjects were adult patients with asthma exacerbations in hospital in Surabaya, with consecutive sampling method. Test the dependent sample t-test (scale scale) to see the population in one group and test the independent sample t-test (scale scale) to see the differences between groups.
Results: This study activated 27 subjects in group A (intravenous aminophylline) and 30 people in group B (salbutamol nebulasi). The comparison of PEF improvements between the two groups used an independent sample t-test, which had previously been tested for normality with Shapiro Wilk with a p value of 0.001 (group A) and 0.001 (group B) which was not published by parametric tests. And after administration of asthma therapy, there is no number equal to both, both intravenous aminophylline and nebulized salbutamol.
Conclusion: The effectiveness of intravenous aminophylline is no different from salbutamol nebula in the improvement of PEF values.
Keywords: exacerbation of asthma, intravenous aminophylline, salbutamol nebulation, peak expiratory flow
Efikasi dan Manfaat Klinis Terapi Steroid Sistemik dan Inhalasi pada Pasien Community-Acquired PneumoniaVol 5 No 2 (2018)
Fahreza Akbar Siregar1, Gurmeet Singh2
1Program Studi Pendidikan Dokter, Fakultas Kedokteran Universitas Indonesia, Jakarta
2Divisi Pulmonologi dan Kedokteran Respirasi, Departemen Ilmu Penyakit Dalam, Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo, Jakarta
Background: Community-acquired pneumonia (CAP) is one of the top leading causes of mobidity and mortality worldwide. CAP also becomes the sixth most prevalent cause of overall mortality in adults. Corticosteroids are known to be the most potent anti-inflammatory drugs and have physiologic rationale for their use in patients with infection. Its efficacy in the treatment of CAP is still debatable. Objective: This study aims to evaluate the efficacy and clinical outcomes of systemic and inhaled steroid therapy for patients with community-acquired pneumonia.
Methods: We used four databases for literature searching process, Pubmed, EBSCO, ProQuest, and Science Direct, which selected articles are those therapeutic studies with relevant clinical question and met the inclusion-exclusion criterias. Critical appraisal was performed by assessed its validity, importance, and applicability based on Oxford Center of Evidenced-Based Medicine 2011. Results: Three retrieved articles feature cohort studies. Two studies conducted systemic steroid therapy research which other conducted inhaled steroid. Two of three articles show steroid therapy was associated with lower mortality and shorter clinical stability.
Conclusion: We suggested that steroid therapy, both systemic and inhaled steroids help hasten clinical recovery, prevent pneumonia-related complication, lower mortality, and reduction in the duration of mechanical ventilation and length of hospital stay.
Keywords: community-acquired pneumonia, steroid, inhalation, therapeutics, clinical outcomes
Interstitial Lung Disease in Systemic SclerosisVol 5 No 2 (2018)
Puji Astuti Tri K1, Anak Agung Arie1, Cleopas Martin Rumende2, Zulkifli Amin2
1)Internal Medicine Department, Cipto Mangunkusumo National General Hospital-Faculty of Medicine, Universitas Indonesia
2)Division of Respirology and Critical Care, Internal Medicine Department, Cipto Mangunkusumo National General Hospital-Faculty of Medicine, Universitas Indonesia
Systemic sclerosis (SSc) is a chronic tissue disorder characterized by immune dysfunction, microvascular injury, and fibrosis. Many organs involved in patients with SSc; especially, pulmonary involvement occurs in up to 90% of patients with SSc. Interstitial lung disease (ILD) is a major complication in SSc and causing high mortality rate. The SSc-ILD therapy is basically consistent with the progress of scleroderma pathophysiology. We reported a case of 59-years-old female patient with a blackened ulcer on her left hand ring finger with disappearing of her distal finger segment, and also a chronic white phlegm cough followed by dyspnea in exertion. Clinical examination and evaluation showed that she had a scleroderm, accompanied with ILD. Her complaint did not improve, so she got an immunosuppresant and supportive therapy to control her worsening disease.
Keywords: systemic sclerosis, interstitial lung disease
Premature Ventricular Complex-Induced CardiomyopathyVol 5 No 2 (2018)
Raymond Pranata1, Emir Yonas2, Veresa Chintya3
1Assistant Physician, Siloam General Hospital - Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Banten, Indonesia
2Faculty of Medicine, YARSI University, Jakarta, Indonesia
3General Practitioner, Sanjiwani General Hospital, Gianyar, Bali, Indonesia
Introduction: Frequent premature ventricular complexes (PVCs) have theability to cause or contribute to cardiomyopathy and heart failure symptoms in long-term.
Case Illustration: A 46 years old male presented with recurrent palpitations, the latest since 6 hours before admission. PMH of hypertension, diabetes and heart disease were denied. BP: 120/80 mmHg, HR: 138 bpm, RR 22x/minute. ECG: LV focus multifocal PVC bigeminy. Lab: within normal limits. CXR: cardiomegaly. Echocardiography: MR and LVH. The patient was administered diltiazem IV in the ED. Bisoprolol was given during discharge.
Discussion: PVC-induced cardiomyopathy’s mechanisms are not entirely clear; a more likely explanation is abnormal ventricular activation resulting in mechanical dyssynchrony, >10.000 PVCs/day has high risk and this patient’s PVC burden should be calculated. It is a diagnosis of exclusion andmade after exploring possible causes and excluding them.Pharmacotherapy to suppress PVCs includes β-Blockers, CCB, and other antiarrhythmic drugs. Results of the use of β-Blockers and CCB are modest with reported efficacy rates in the 20% range.In patients with PVC-induced cardiomyopathy, successful elimination of PVCs with ablation frequently restores ventricular function acutely and has aprocedural success rate of PVC elimination of 84%. Unfortunately, this patient is not a suitable candidate for catheter ablation. Hence, β-Blockers was chosen for long-term therapy.
Conclusion: Frequent PVCs with high burden has potential to cause adverse cardiovascular events and should be treated to prevent its deleterious consequences. Suppression of PVCs using either antiarrhythmic pharmacological agents or emerging catheter ablation techniques appears to reverse the LV dysfunction.
Keywords: PVC, Cardiomyopathy, burden
Tranquilizer effect in premature ventricular contractionsVol 5 No 2 (2018)
Lidya Lustoyo Putrajaya1, Ari Sisworo2
1General Practitioner at East Belitung District Regional Public Hospital, East Belitung, Indonesia; 2Internist at East Belitung District Regional Public Hospital, East Belitung, Indonesia
Premature ventricular contractions (PVCs) are early depolarizations begin in the ventricle instead of the usual place, the sinus node. Frequent and complex PVCs could occur in apparently healthy individuals, they also showed it could be associated with a benign prognosis. PVCs may occur at rest or during exertion, or as a result of excessive caffeine intake, smoking, drinking alcohol, the use of illicit drugs (e.g., cocaine, amphetamines), or the use of over-the-counter medications (e.g., diet pills, antihistamines) that contain ingredients that mimic the effects of sympathetic nervous system stimulation. In individuals with and without heart disease, hypokalemia and hypomagnesaemia often contribute to the development of PVCs. The symptoms that can occur are palpitations, lightheadedness, passing out, chest pain, and shortness of breath. If the patient without heart disease feels any discomfort, he/ she could be given minor tranquilizer such as benzodiazepine.
Keywords: Premature Ventricular Contractions, Sympathetic nervous system, Tranquilizer, Benzodiazepine
Uji Validasi Skor Expanded-CURB-65 Sebagai Prediktor Mortalitas 30 Hari Pasien Pneumonia Komunitas di Rumah Sakit Umum Pusat Nasional Cipto MangunkusumoVol 5 No 1 (2018)
Background: Community acquired pneumonia is a major health problem with high mortality rate, especially in Indonesia. The CURB-65 score is a widely used scoring system, but has some drawbacks so a new scoring system is needed to assess the severity of community pneumonia. This study aims to assess the expanded-CURB-65 scoring system as a predictor of 30-days mortality of community pneumonia.
Aim : To evaluate calibration and discrimination performance of the expanded-CURB-65 score in predicting 30 days mortality of community acquired pneumonia patients at the National Center General Hospital dr.Cipto Mangunkusumo.
Metho : This study was a prospective cohort study with the study subjects of community pneumonia patients who came to the Emergency Room (ER), pulmonary polyclinics or hospitalized in RSCM. The assessed outcome was patient mortality within 30 days. Discrimination performance of the expanded-CURB-65 score assessed using the area under the curve (AUC). Calibration performance was evaluated with calibration plot and Hosmer-Lemeshow test.
Results : 267 patients participated in the study with a mortality rate of 31.5%. Calibration plot of expanded-CURB-65 score showed r= 0,9697 and Hosmer-Lemeshow test showed p = 0,210. Discrimination was shown by ROC curve with AUC 0,701 (CI95% 0,633-0,768). Conclusion: Mortality increases with increasing risk class of expanded-CURB-65. Expanded-CURB-65 showed a good calibration and discrimination performance in predicting 30-day mortality higher in community acquired pneumonia patients in Cipto Mangunkusumo Hospital.
Keywords : Community acquired pneumonia patient, 30 days mortality, expanded-CURB-65 score
Early pleurodesis for malignant pleural effusionVol 5 No 1 (2018)
Background: Many cases of malignancy, either inside the thoracic cavity or fromother body organs, accompanied by massive pleural effusion. The treatment for those cases isdone by drainage and continued with pleurodesis after pleural fluid production <150 ml/day. This method takes long drainage duration and care, and the cost is enourmous. To solve that problem we proposea way of management of malignant pleural effusion more efficiently.
Methods: From July 2008 to July 2009 there were 60 patients with pleural effusion due to malignancy. In the case group we performed pleurodesis early (pleural fluid production> 1000/day), while in the control group pleurodesis performed if pleural fluid production <150 ml/day. Pleurodesis is succes if acchieve pleural fluid production <100 ml/day before third days after procedure. Both groups used pleurodesis with chest tube (no.28-32).
Results: There were 60 patients which is elligible for this research. Allocation to groups were 30 patients performed early palliative therapy with talk and 30 patients performed conventional therapy (conventional pleurodesis). From the demographic depiction, tumor type, disease characteristic and length of stay both pleurodesis group result were no significant difference (p> 0,05). The duration of drainage and length of care was much shorter in group early pleurodesis (p <0.01).
Conclusion:Early pleurodesis methods can shorten the drainage time and length of care without affecting the effectiveness of pleurodesis results
Keywords: massive pleural effusion, malignancy, pleurodesis, talc
Durasi Operasi Sebagai Prediktor Komplikasi Paru Pasca Operasi Non Kardiak di RSCMVol 5 No 1 (2018)ABSTRAK
Latar belakang: Di Indonesia, sebanyak 18,4 % pasien yang menjalani operasi non-kardiak di RSUPN Cipto Mangunkusumo Indonesia mengalami Komplikasi Paru Pasca Operasi(Post-operative Pulmonary Complication/PPC).Beberapa penelitian menunjukkan durasi operasi memiliki hubungan dengan PPC.Penelitian ini bertujuan untuk mengetahui peranan durasi operasi sebagai prediktor kejadian komplikasi gagal napas dan pneumonia dalam 30 hari pasca operasi.
Metode: Penelitian menggunakan desain kohort retrospektifpada November 2016-Juli 2017dengan data rekam medis pasien yang menjalani operasi di RSUPN Cipto Mangunkusumo tahun 2012-2016.Sampel penelitian diambil dengan metode consecutive samplingyang memenuhi kriteria inklusi dan eklusi, dilihat luarannya selama 30 hari pasca operasi.
Hasil: Dari 102 pasien diketahui 58,8 % perempuan, 35,5 % 41-50 tahun, 25,5 %berpendidikan SMA, 34,3 % tidak bekerja, 77,5 % tidak mengalami penurunan berat badan, 80,4 % tidak merokok, tidak ada yang memiliki riwayat PPOK, 61,8 % anestesi umum, 64,7 % operasi elektif dan 51,96 % lokasi operasi di abdomen. Didapatkan 10,8 % mengalami gagal napas dan 6,9 % mengalami pneumonia. Dari analisis bivariat, durasi operasi tidak dapat digunakan sebagai prediktor kejadian gagal napas (p 0,106; RR 3,56; CI 95 % 0,885 -14,280) maupun pneumonia (p 0,701; RR 1,61; CI 95 % 0,342-7,601).
Kesimpulan:Durasi operasi tidak dapat digunakan sebagai prediktor tunggal dalam memprediksi kejadian komplikasi gagal napas maupun pneumonia pasca operasi.
Kata kunci:durasi operasi, gagal napas,komplikasi paru pasca operasi,pneumonia
A Case of Spontaneous Hemorrhagic Transformation in a patient with Cardioembolic Stroke due to Atrial FibrillationVol 5 No 1 (2018)
INTRODUCTION: Hemorrhagic transformation (HT) refers to aspectrum of ischemia-related brain hemorrhage and is associated with increased morbidity and mortality of acute ischemic stroke.
CASE ILLUSTRATION: An 83 years old female presented with loss of consciousness 30 minutes before admission. Her past medcal history of congestive heart failure, hypertension, atrial fibrillation (AF), and stroke. Physical examination showed GCS 7 andBP 190/100 mmHg. Electrocardiography showed Atrial Fibrillation NormoVentricular Response and Left Ventricular Hypertrophy. Laboratory examination showed thrombocytopenia, hypokalemia,and INR of 1,8. National Institutes of Health Stroke ScaleScore: 16CHA₂DS₂-VASc: 7, HAS-BLED: 4.Thorax Xray revealed cardiomegaly and Thorax CT Scan depicted characteristic of hemorrhagic transformation of an ischemic infarct. The patient was treated with hemorrhagic stroke protocol and mannitol.
DISCUSSION: Atrial fibrillation is associated with greater volumes of more severe baseline hypoperfusion, leading to higher infarct growth, more frequent severe HT and worse stroke outcomes. This patient has massive infarction andAFwhich were independent predictors of HT risk. In patients with AF probability of bleeding was about 95% if the volume of infarction edema >10 cm3.Hemorrhagic transformations may occur in patients with acute ischemic stroke who received thrombolytic, however, it may also occur spontaneously in 12.3 % of patients with ischemic stroke. Warfarin has been associated with increased HT riskirrespective of INR and aPTT values. Hemorrhage risk stratification score might be used to predict HT in acute ischemic stroke.Anticoagulant may be reinitiated after 4-8 weeks. Long-term anticoagulation with NOAC (similar efficacy with lower bleeding risk compared to VKA) or Left atrial appendage occlusion.
CONCLUSION: One-third of ischemic stroke patient may experience hemorrhagic transformation.Physician must strike a balance between stroke recurrence and HT.
Keywords:Atrial Fibrillation, Stroke, Anticoagulant
Acute Digitalis Toxicity presenting as Bradycardia in patient with Atrial Fibrillation with Heart FailureVol 5 No 1 (2018)
INTRODUCTION: Digitalis is used for atrial fibrillation to reduce the ventricular rate and has narrow therapeuticwindow. Mortality associated with unrecognized digitalis intoxication is high and often unacknowledged.
CASE ILLUSTRATION:A86 years old male presented with fatigue since 1 day before admission. PMH of AF, HHD, CHF and CKD.PE: BP 90/60, HR: 48 bpm, RR: 20x/minute. ECG: AF SVR 40-50x/minute ‘reverse tick sign’ ST depression, LAD. Lab: Hyperkalemia andeGFR 22.92 mL/min. Previous echocardiography: Grade III diastolic dysfunction + LVH. IV hydration was given using normal saline 200 mL initially, insulin and glucose were administered to reduce potassium level.
DISCUSSION:Digitalis cause an increase in vagal activity and prolong conduction in the AV node, excessive effect in this patient cause reduced ventricular rate. ST-segment depression resembling a ‘reverse tick’ signified digitalis effect not necessarily toxicity. Digitalis toxicity can emerge even when the serum digitalis concentration is within the therapeutic range.The narrow therapeutic index of and pharmacokinetic changes associated with aging increases the risk of toxicity. The elimination of digitalis is mainly by renal clearance and is prolonged inCKD. This patient was an elderly and has eGFR of 22.92 mL/min, hence in high risk of digoxin toxicity.Ideally, digitalis Fab fragments is indicated for a K + level greater than 5 mmol/L.
CONCLUSION:Atrial fibrillation is the most common sustained arrhythmia and digoxin is widely used as rate control especially in those with heart failure.Digitalistoxicity is important to recognize and receive prompt treatment should toxicity arises.
Keywords:digitalis, digoxin, toxicity, atrial fibrillation
KOMPLIKASI PADA PASIEN ATRIAL SEPTAL DEFECT DEWASA DENGAN SURVIVALITAS ALAMIVol 4 No 4 (2017)
Adhella Menur Naysilla
Dokter Umum RSUD Brigjen H. Hasan Basry, Kandangan,
Hulu Sungai Selatan, Kalimantan Selatan, Indonesia
The development of congenital heart disease management (PJB) causes patients to live an adult life now known as Congenital Heart Disease (GUCH) and Adult Congenital Heart Disease (ACHD). Patients with acute ureanotic ACHD with natural survival (no intervention measures in childhood) can suffer from complications of pulmonary hypertension and Eisenmenger syndrome. Complications can increase patient morbidity and
mortality and worsen the quality of life. The patient may need corrective surgery and even a heart transplant. Some conditions that can not be administered by surgery cause the patient to take medication and in high lifetime medical surveillance. This case report discusses a 26-year-old male Banjar tribe coming with cough and breath with oxygen saturation of four extremities of 80%. Patients have a history of congenital heart disease with no intervention measures in childhood. Patients were diagnosed with sekundum ASD with severe pulmonary hypertension and Eisenmenger syndrome, secondary polycythemia PJB, and pulmonary TB in advanced stage 1 treatment. Diagnosis is obtained from anamnesis, physical examination, and investigation. ECG, radiology, laboratory, spirometry, and echocardiography Doppler. Patients care in ICU and treated with oxygenation, pulmonary vasodilators, diuretics, and iron supplementation and folic acid. Advanced pulmonary TB treatment. The patient underwent flebotomy 3 times. After treating 18 days, the patient showed a clinical improvement and was referred to the Ulin Hospital Banjarmasin for further examination and management.
Keywords : ACHD asianotik, ASD sekundum, pulmonary hypertension, Eisenmenger syndrome
Pulmonary Hypertension in Obesity Hypoventilation Syndrome: A Case ReportVol 4 No 4 (2017)
Davin Takaryanto,1,2, Ade Erna1,2, Hendarsyah Suryadinata1,3
1 Faculty of Medicine, UniversitasPadjadjaran, Bandung, Indonesia
2Department of Internal Medicine, Sumedang Regional Public Hospital, Sumedang, Indonesia
3 Respiratory Critical Disease Division, Department of Internal Medicine, HasanSadikin General Hospital, Bandung, Indonesia
Introduction:The prevalence of obesity continues to increase every year across the world. Obesity has been a risk factor for developing some chronic and non-communicable diseases. Obesity hypoventilation syndrome (OHS) is one of non-communicable disease that emerges with obesity as its primary risk factor. We presented a case with severe obesity, chronic hypoventilation and multiorgan impairmentscaused by OHS, a disease that is often misdiagnosed and mistreated hence leads to higher mortality rate.
Case Report: A woman, 54 years old, was brought to hospital emergency ward with decrease of consciousness (hypersomnolent) and breathlessness. The patient had an excessive sleeping amount of time with morning or nocturnal headache, snoring, and sleeping apnea. She had been diagnosed as asthma and pulmonary hypertension and had been given therapy. She was severely obese with BMI of 44.07 kg/m2. The patient suffered multiorgan failures of respiratory failure, hepatic impairment, cardiac failure, and renal disease. She underwent positive pressure ventilatory assistance after being delayed until after fourth day of hospitalization. She suffered from cardiac arrest due to septic shock and respiratory failure. Cardiopulmonary resuscitation was carried out, but eventually the patient died.
Discussions:OHS is an alveolar hypoventilation or hypercapnia that occurs daily in obese patient without underlying disease that could lead to hypo ventilatory state. Majority of patients with OHS also experience obstructive sleep apnea hypopnea syndrome (OSAHS). Patients who complain respiratory problems are often misdiagnosed as asthma or chronic obstructive pulmonary disease even though theyshowsome obvious OHS clinical features. Chronic hypercapnia could lead to dyspnea worsened by physical activity, sleep problem, excessive daily sleeping time, delirium, myoclonus, and seizures. Along with clinical findings, further confirmatory examinations are needed to support OHS diagnosis. OHS could lead to some complications such as pulmonary hypertension and right heart failure (corpulmonale). Bariatric surgery and positive pressure ventilation with mechanical ventilator are primary therapies for OHS.
Conclusions: Diagnosis of OHS should be considered when finding obese patients who complain respiratory problems. Missed diagnosis and inadequate therapy in OHS patients could lead to high morbidity and mortality rate. Advance diagnostic tools are needed to accurately diagnose, follow up and treat OHS patients intensively.
Keywords: hypoventilation, hypercapnia, obesity, Pickwickian syndrome
LOWER-LIMB VENOUS-THROMBO EMBOLISM IN POST ELECTIVE PERCUTANEOUS CORONARY INTERVENTION: A CASE REPORTVol 4 No 4 (2017)
1Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia
Background:Most clinicians are focusing on artery’s complications that might be happen due to manipulation on artery while the PCI procedure. However, vein’s complication is also happen in rarity.
Case description: A 69-year-old female patient was undergone an elective-PCI procedure. Patient’s medical history with hypertension and hyperlipidemia; pacemaker implanted; decreased effort tolerance-shortness of breath; significant mid RCA and LAD lesion shown by CT Coronary Angiogram. The PCI procedure was done through access of the right common femoral artery. A 6-FrenchCordisExoseal for vascular closure device was utilized.
After discharging, the patient complained of a painful swelling of her right leg. Physical examination showed diffuse swelling of the entire right leg and bruising around the puncture site. A vascular Doppler study was performed. It demonstrated thrombus in the right proximal superficial femoral vein.
Correlation Between Inhaled Beta 2 Agonist and Corticosteroid with The Degree of Control and Lung Function in AsthmaVol 4 No 4 (2017)
Muhammad Ranushar, Harun Iskandar, Nur Ahmad Tabri, Makbul Aman,Syakib Bakri
Departement of Internal Medicine Medical Faculty
Hasanuddin University Makassar
Background: Asthma is an important chronic airway disease and is still a serious and mass public health problem in many countries. Asthma control has been difficult to achieve using conventional therapies such as short-acting beta 2 agonist (SABAs), oral beta 2 agonists, oral corticosteroids and theophylline, leading to asthma difficult to control. Treatment of asthma based on GINA uses asthma control medications (controller) in the form of inhalation of beta 2 agonist combination with inhaled steroid/Inhaled Corticosteroid (ICS) and can be a combination of both. Classification of degree control based on GINA is considered more practical, easier to adapt, and more clinically valuable.
Objective: To know the relationship of type therapy with degree of control and lung function of asthma patient.
Methods: This study was a cross sectional study. The samples used were patients with asthma diagnosis both outpatient and inpatient according to GINA criteria. The subjects of the study were data collection in the form of therapy method. Spirometry measurements determine FEV1% and asthma control degree according to GINA criteria. The study was conducted in February-May 2016 at Pulmonology Polyclinic RS Wahidin Sudirohusodo Makassar and Hasanuddin University hospital in Makassar
Results: The age of the subjects varied between 19 and 69 years old, the FEV1% score ranged from 18% to 98%, male subjects were 23 (33,8%) and 45 (66,2%). There was no significant association of therapeutic method with lung function (p> 0,05). There is a significant relationship between therapy method and degree of control asthma (p <0,001).
Conclusions: In patients with asthma who received combination therapy such as combination budesonide and formoterol or salmeterol and fluticasone significantly more achieved a better degree of control than in patients who only received agonist beta 2 inhalation or corticosetoid inhalation only.
Keywords: Asthma, therapeutic method, lung function, degree of control, Forced Expiration Volume 1, Inhalation of beta 2 agonists, inhaled corticosteroids, inhalation corticosteroid and beta-2 agonist combination.
The Impact of Genetic Profile Diversity of Mycobacterium Tuberculosis In Tb-HIV Compared to TB Non HIV PatientsVol 4 No 4 (2017)
KeikoYolanda Gunardi1, Telly Kamelia2
1Faculty of Medicine, Universitas Indonesia
2Respirology and Critical Illness Division, Internal Medicine Department
Cipto Mangunkusumo Hospital/ Faculty of Medicine Universitas Indonesia
Introduction: Tuberculosis (TB) remains as ignificant global health problem,but it is possibly curable when TB is detected and effectively treated. Drug resistant become the hardest challenge to cure this disease. The Multidrug resistance TB is of ten linked to the diversity of Mycobacterium tuberculosis genotype.This study aimed to investigate whether diversity of genetic profile M.tuberculosis influenced the drug resistance.
Methods: A literature search was conducted in several electronic databases. PubMed, Proquest, and Scopus were used to find articles which investigate the association between diversity of MTB genotype and drug resistant. After applying the inclusion and exclusion criteria,there were six eligible articles. However, after restricting more thoroughly, there were only one case control study was used for appraisal.
Results:One case control study identified the impacts of genetic profile diversity and drug resistant was found. It also compared HIV infected and non HIV patients.A total of 158 samples were used. The association between drug resistance mutation and genetic strain background was strongly established (P<0.0001). The most frequent mutations in Switzerland were poB (S531L) resistance to rifampin and katG (S315T) which was resistant to isoniazid. The study found that genetic background, especially lineage 2 (Beijing strain) of the M.TB had a high association with drug resistance.This association was stronger formulation drug resistance and in HIV positive patients. (OR19,70;95%CI,1,30to298,19;P=<0,0001).
Conclusion: Current evidence showes there was a clear evidence that the diversity of genetic give an impact to resistant of the drug. It is recommended that future studies in Indonesia is needed to demonstrate consistent effects in clinical settings since Indonesia is an endemic area for Tuberculosis
Keywords: M.Tuberculosis, genome, genotype, genetic Profile, TB-HIV, TB-Natïve, drug resistance