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8/8/2019 CHAPTER I Ensefalitis
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CHAPTER I
1.10. Treatment
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Initial stabilization
Patients frequently require ICU care with cardiorespiratory support. Minidose
subcutaneous heparin is standard forprophylaxis of intravascular thrombosis in
acutely ill adults, but is untested in the pediatric age group. Early involvement of
physical and occupational therapy is important.
General measures
Treatment of intracranial hypertension includes mannitol and hyperventilation,
usually with assistance from intensivists or neurology/neurosurgery
consultants; these measures should be reserved for situations in which vital or
neurologic signs indicate impending herniation. Intracranial pressure
monitoring is not routinely indicated. Consultation with an infectious disease specialist, neurologist, or neurosurgeon
may be helpful.
Special therapy
- iv fluids
Avoid fluid overload, which may exacerbate cerebral edema.
Requires strict attention to fluid/osmotic balance
Normal saline is preferred.
Closely monitor electrolytes, anticipating possible syndrome of inappropriate
antidiuretic hormone or diabetes insipidus.
- Medication
Anti-infective agents:
o
Depending on severity of the illness and clinicians level of suspicion
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o Initial treatment could include antibacterial and antiviral agents (acyclovir:
Monitor renal function) until the cause becomes clear or cultures are
negative.
Confirmed HSV encephalitis: Acyclovir:
o Infants: 20 mg/kg q8h for 21 days
o Older children: 10 mg/kg q8h for 1014 days
Cytomegalovirus (CMV): Consider ganciclovir or foscarnet.
HIV encephalitis: Consider zidovudine, didanosine, or ritonavir.
SSPE (diagnosed by spinal fluid titers): Consider isoprinosine.
Anticonvulsants:
o Reserved for clinical or electrographic evidence of seizure/epileptic activity
o Usual choices include lorazepam, phenytoin, phenobarbital, and
carbamazepine.
o Treatment of PLEDs without associated convulsions is controversial.
o Consider potential side effects and sedation.
1.11. Complication
Seizures disorders, focal or generalized
Syndrome of inappropriate secretion of antidiuretic hormone
Increased ICP
Coma
Seizure disorders, focal or generalized
Quadriparesis/hemiparesis
Ataxia
Learning disabilities
Aphasias
1.12. Prognosis
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The prognosis depends the virulence of the virus and on variables associated with
the patient's health status, such as extremes of age, immune status, and preexisting
neurologic conditions.
o Rabies, EEE, JE, and untreated HSE have high rates of mortality and severe
morbidity, including mental retardation, hemiplegia, and seizures.
o Increased mortality and morbidity rates are found in patients who are older
than 60 years and have St Louis encephalitis or WNE. Long-term sequelae
with St Louis encephalitis include behavioral disorders, memory loss, and
seizures.
o WEE is associated with relatively low mortality and morbidity rates, although
developmental delay, seizure disorder, and paralysis occur in children, and
postencephalitic parkinsonism occurs in adults.
o CE usually is a milder disease, with most patients making a full recovery,
though 25% of those with severe disease continue to have focal neurologic
dysfunction.
o The mortality rate in treated HSE averages 20% and is correlated with mental
status changes at time of first dose of acyclovir. Approximately 40% of
survivors have minor-to-major learning disabilities, memory impairment,
neuropsychiatric abnormalities, epilepsy, fine-motor-control deficits, and
dysarthria.
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CHAPTER II
2.1. Objective
The aim of doing this paper is to report a case of encephalitis of an -years-old boy
that was admitted at the Infection Unit of Haji Adam Malik general Hospital.
2.2. Case
Pasien baru unit IGD masuk pada tanggal 9 September 2010 pukul 19.00 WIB.
Nama : Rudianto, laki-laki, 1 tahun 9 bulan, BB: 7 kg, PB: 99 cm
KU : Penurunan kesadaran
Telaah :
Hal ini dialami os sejak 2 hari yang lalu, diawali dengan kejang. Kehang (+)
dialami os sejak 7 hari yang lalu, dengan frekuensi >3x/hari, lama kejang 10-20
menit/kali kejang, diawali dengan demam. Riwayat keang sebelumnya (+).
Demam (+) dialami os sejak 2 minggu ini, demam bersifat naik turun, turun
dengan obat penurun panas. Batuk (-), pilek (-). Riwayat keluar cairan dari telinga
(-). Riwayat kontak dengan penderita TB (-).
Riwayat kelahiran : spontan, ditolong bidan, segera menangis, BBL: 2500 gr, biru
(-).
Riwayat imunisasi : tidak jelas, BCG scar (+).
Riwayat pemberian makanan : 0-3 bulan PASI + bubur susu, 3-9 bulan bubur
lembek, 9 bulan-sekarang nasi biasa.
Riwayat perkembangan : os duduk usia 1 tahun. Saat ini os hanya bias jalan
ngesot, mengucapkan 2 kata. Bintik-bintik berisi nanah (+).
RPT : Os merupakan rujukan dari Puskesmas Karang Rejo dengan demam
tinggi + kejang
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RPO : -
Physical examination
SP : Sens : GCS II (E4V2M5) T: 37,3 C LK: 46 cm
Anemis (-), Dyspnoe (-), Edema (-), Sianosis (-)
SL : Kepala : Mata : RC +/+, pupil isokor, Conj. palp. inf pucat -/-
T/H : dbn
M : ulkus (+) didaerah bibir, mukosa
Aksila : pustule (+)
Leher : Pembesaran KGB (-), kaku kuduk (-)
Thorax : Simetris fusiformis, retraksi (-)
HR : 116x/I, reg, desah (-)
RR : 20x/I, reg, ronki (-)
Abdomen : Soepel, peristaltic (+) N, H/L : ttb
Ekstremitas : Pols 116x/I, reg, t/v cukup
Spastic (+) pada ke-4 ekstremitas
Rangsang meningeal : (-)
R. Fisiologis : APR/KPR +/+
R. Patologis : Babinski (-), openheim (-), gordon (-),
klonus(+)
Pustule (+)
Laboratorium findings (
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Working diagnosis : Encephalitis
Differential diagnosis :
- Encephalitis
- Meningoencephalitis
- Meningitis
Management :
- Elevasi kepala 30
- 02 1L/i
- IVFD NaCl 0,9% 48 gtt/i mikro (retriksi 25%)
- Inj. Cefotaxim 650 mg/6 jam/iv, skin test
- Inj phenytoin loading dose 20 mg/kgBB
- 12 jam kemudian inj. Phenytoin maintenance 5 mg/kgBB
- Diet SV 1560 kkal + 26 gram protein
Investigation plan :
- Lumbal punksi
- Foto Thorax AP/lat
- Head CT scan
- Mantoux test
- Konsul divisi neurologi
- Konsul divisi infeksi
- Konsul divisi kulit dan kelamin
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Follow Up
Tanggal 10 September 2010
S : penurunan kesadaran (+), demam (-), kejang (-)
BB : 13 kg, PB : 92 cm, BB/TB 96,29%, BBI : 13,5 kg
O : Sens : GCS 6 (E1V1M4) T: 37,3C LK: 46 cm
Kepala : Mata : RC +/+, pupil isokor, Conj. palp. inf pucat -/-
T/H : dbn
M : ulkus (+) didaerah bibir, mulut
Aksila : pustule (+)
Leher : Pembesaran KGB (-), kaku kuduk (-)
Thorax : Simetris fusiformis, retraksi (-)
HR : 112x/i, reg, desah (-)
RR : 20x/i, reg, ronki (-)
Abdomen : Soepel, peristaltic (+) N, H/L : ttb
Ekstremitas : Pols 112x/I, reg, t/v cukup
Spastic (+) pada ke-4 ekstremitas, pustula (+)
Rangsang meningeal : (-)
R. Fisiologis : APR/KPR +/+
R. Patologis : Babinski (-), openheim (-), gordon (-),
klonus (-)
A : DD - ensefalitis
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- meningoensefalitis
- meningitis
P : - Elevasi kepala 30
- O2 1 L/i
- IVFD D5% NaCl 0,9% 36 gtt/i mikro
- Inj. Cefotaxim 650 mg/6 jam/IV
- Inj. Ampicillin 650 mg/6 jam/IV, skin test
- Jika kejang phenytoin loading dose 260 mg diencerkan dalam 30
cc NaCl 0,9% habis dalam 30 menit, 12 jam kemudian
maintenance 35 mg/12 jam/IV diencerkan dalam 10 cc NaCl
0,9% habis dalam 30 menit.
- Kenalog inorabase 2x1 applic
- Gentamycin Zalf 3x1 applic
- Diet SV 1150 kkal dengan 20 gr protein dalam 900cc cairan
(150cc/4 jam/NGT)
Recommended