CHAPTER I Ensefalitis

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)

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CHAPTER I Ensefalitis