FEVER WITHOUT SOURCE

UKK INFEKSI DAN PEDIATRI TROPIKIKATAN DOKTER ANAK INDONESIA

• Demam : suhu rektal ≥ 38 0C (<1th), atau ≥ 38,40C anak > 1th• 19%-30% penyebab kunjungan ke dokter • 5%-20% demam tanpa penyebab yang jelas (FWS).• Penyebab: ( 3-36 bulan )

• infeksi virus (self limited) 20%• UTI• SBI (Pneumonia, meningitis )• Occult bakterimia• Osteomyelitis Finkelstein at al. 2000; 105:260 – 266

Barraff at al. 2006; 327 : 1094 -1097Brook at al. 2003; 36 : 602 - 14

• Penanganan : dasar anak tampak toksik atau tidak• Umur < 3 tahun toksik dirawat• Tidak toksis:• Usia < 28 hari• Usia 28 – 90 hari• Usia 3 – 36 bulan

KASUS I• Anak perempuan 11 bulan• BB 10 kg TB 70 cm• Keluhan utama : demam naik turun• Anak demam selama 3 hari, demam naik turun, batuk (-), pilek (-), kadang muntah (+), BAB/BAK (N), nafsu makan menurun.

• Pemeriksaan Fisik :• KU: rewel • T 90/60 mmHg, N 98x/mnt, T 38,60C RR 32x/mnt.• Pem fisik: dalam batas normal• Lab. • Darah :Hb 12,6 gr/% Al 15.400/mm3

(-/-/63/24/13),Ht 38%, AT306.000/mm3

• Urin :•Warna : kuning jernih, BJ 1.020 Reduksi (-), Alb (-), Nitrit (-), keton (-) Bil (-), Urobilinogen (-)• Sedimen :

Epitel (-), Eritrosit: 0-1/lpb, Leukosit: 5-8/lpb , Silinder (-), kristal (-).

1. Apa diagosis ?

• Insiden 2,5 – 5 % pada anak dengan demam• Anak perempuan < 24 bulan paling sering (8%)• Laki laki : sirkumsisi (2%), tanpa sirkumsisi (6%)

2. Pemeriksaan penujang ?

1. Urine angka kuman2. Kultur urin

• Indikasi pemeriksaan urin pada FWS• Umur < 12 bulan• Wanita• Temperatur ≥ 39 0C• Demam ≥ 2 hari • Tidak ada gejala kas• Sensitivitas 95 % false positif rate 69 – 90% (Goreleick et al. 2000)

1. Urin angka kuman > 100.000 cfu/ml( urin pagi)

2. Kultur Urin : E .coli

• Kultur urin merupakan gold standar• Angka kuman ≥ 100.000/cfu sent/spes (85%)• 20% nitrit dan urinalisis normal• Kombinasi leukosituria ≥10/lpb + Gram sensitivitas > 88%( Brown L et al.2005)

• Penyebab UTI:• E. coli• Klebsiela pneumonia• Proteus• Streptococcus sp (Bonsu BK et al.2003 )

3. Terapi antibiotik ?

1. Kotrimoksazol atau2. Cefiksim

3. Cefaleksin

4. Dosis dan Lamanya ?

1. Trimetropim 8 -10 mg/kbbb/hr sulfametoksazol 25-40 mg/kgbb/hr 2. Cefiksim 5 – 8 mg/kgbb/hr3. Cefaleksin 25 – 100 mg/kgbb/hr4. Lamanya pengobatan 7 – 14 hari ( Huicho L. et t al. 2002 )

SOAL 2.

• Nama : An TA. • Umur : 3 tahun 2 bulan • Jenis Kelamin : Perempuan• Berat badan : 12 kg

• Anamnesis• Demam mendadak tinggi sejak 3 hari, mual/muntah (+),batuk (-) pilek(-), kejang (-), BAB/BAK N

• Pemeriksaan fisik• KU : CM• T 100/70 mmHg, N 112x/mnt, RR 40xmnt, Temp 39,30C

• Hepar teraba 3 cm/bpx – 2 cm dibawah arcus costa.• Lain lain dalam batas normal • Lab : Hb 12,3 gr% AL. 3200/mm3

(-/-/34/52/12), Hmt 38%, AT 158. 000/mm3,RL (-)

1. Apa kemungkinan diagnosis pada kasus

diatas?2. Apakah perlu

dirawat di RS?

1. Demam Dengue2. Rawat jalan dengan edukasi kontrol

• Viral diseases penyebab 20%• Leukopenia dan limfositosis prediksi infeksi virus dengue (NDP 68%) -- Kalayanorooj et al. 2007.• RL (-) pada DBD 47 %• Hepatomegali 67 % (Hartoyo, 2008 dan S. Ubol et al. 2007).

2. Usulan pemeriksaan?

1. Ulang darah rutin hari ke 4/5

2. Serologi IgG/IgM hari ke 5/6

3. Ro Thorax RLD

• Hasi darah hari ke 4:• Hb 12,3 gr/%, AL. 3.400/mm3, Hmt 36,8% (-/-/27/61/12). AT. 98.000/mm3

• Serologi hari ke 6:• Serologi : IgG (-), IgM (+)• Ro Thorax :dbn

Manifestasi infeksi virus DengueInfeksi virus DengueInfeksi virus Dengue

AsimptomatikAsimptomatik

SimptomatikSimptomatik

Demam yang tak jelas

(sindrom virus)

Demam yang tak jelas

(sindrom virus)

Demam DengueDemam Dengue

Tanpa perdarahanTanpa perdarahan

Dengan perdarahanDengan perdarahan

Demam Berdarah Dengue

(kebocoran plasma)

DBD Dengan renjatan

DBD Tanpa renjatanDBD Tanpa renjatan

Demam DengueDemam Dengue Demam Berdarah Dengue

RESPON ANTIBODI TERHADAP INFEKASI VIRUS DENGUE

3. Apakah antibiotik diperlukan pada kasus ini?

3. Tidak diperlukan

Guideline Fever Without Source s/d umur 3 tahun

Beatriz et al. 2009

TERIMA KASIH

FEVER WITHOUT SOURCE

Documents

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162 Fever Without a Focus