2. demam pada bayi dan anak umy
TRANSCRIPT
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DEMAM DANINFEKSI TROPIS
Nur Muhammad Artha
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Kasus I
Seorang anak perempuan 8 tahun di bawa ke puskesmas
dengan keluhan demam hilang timbul sejak 2 minggu yang lalu
disertai menggigil dan berkeringat. Buang air kecil berwarna
merah gelap. Dari pemeriksaan fisik didapatkan anak sakit
berat, delirium,pucat. Suhu 390C, nafas 30x/menit. Pada
pemeriksaan abdomen ditemukan hepar teraba per 1/3, lien
S2. Pada pemeriksaan laboratorium, didapatkan Hb: 4,8
leukosit 19000, trombosit 85000. Apakah diagnosis yang
paling mungkin?
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INTRODUCTION
Fever in childhood
among the most likely reason to seek for medical help
may be infectious / non-infectious; viral origin is themajority; serious bacterial infection may ensue
Differentiation between viral and bacterial disease may bedifficult, especially in neonates and young infants
Evaluation and management is evolving at a rapid pace (1.amount of research conducted, 2. introduct of HIB vaccine,3. Streptococus pneumoniae vaccine, 4. ever-evolvingdiagnostic technologies and therapies)
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What is fever
A rise in the temperature set point at hypothalamus by a
variety of physiological mechanism
Fever usually occurs as a result of the bodys exposure to
infecting micro organism, immune complexes or other sourcesof inflammation
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Definition
Normal variation in body temperature no singlevalue defined as fever
Generally accepted values:
rectal temperature above 100.40F (380C)oral temperature above 99.50F (38.50C)axillary (armpit) temperature above 990F (37.40C)ear temperature above 100.40F (380C) in rectal modeor above 99.50F (38.50C) in oral mode
UpToDate last updated Jan 2008
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Definition of fever
Pathophysiologically : is an IL-1 mediated elevation of the
thermoregulatory set point of the hypothalamic center
Clinically: fever is body temperature of 1 C (1.8F) or greater
above the mean at the site of temperature recording.
El Radhi et al 2009
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The following degrees of temperature are accepted asfever :
Rectal : > = 38.0 C
Oral : > = 37.6 C
Axillary : > = 37.4 C Tympanic membrane : > 37.6 C
The importance of at least 1C higher than the meantemperature lies in the diurnal variation of normal body
temp, reaches its highest level in early evening (5-7 pm).
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Arch Dis Child Educ Pract Ed 2008;93:2629.
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PATTERN OF FEVER
Continuous (sustained ) fever :
persistent elevation of body temperature with a maxfluctuation of 0.4 C during a 24-h period
Remitten : a fall in temp each day but not to a normal
level Intermitten : temp returns to normal each day, usually in
the morning and peaks in the afternoon
Hectic (septic) : when remitten or intermittent fevershows a very large difference between the peak and the
nadir Recurrent : describes a single illness involving the same
organ or multiple organ system in which fever recurs atregular
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Prolonged : a single illness in which duration of fever exceeds
that expected for this illness (for viral ARI > 10 days)
Recurrent : involving the same organ or
multiple organ system in which fever recurs at irregular
intervals
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The pattern of temperature changes may occasionally hint at the diagnosis: Continuous fever: Temperature remains above normal throughout the day and
does not fluctuate more than 1 C in 24 hours, e.g.lobar pneumonia, typhoid,urinary tract infection, brucellosis, or typhus. Typhoid fever may show a specificfever pattern, with a slow stepwise increase and a high plateau. (Drops due to
fever-reducing drugs are excluded.)
Intermittent fever: Elevated temperature is present only for some hours ofthe dayand becomes normal for remaining hours, e.g., malaria, kala-azar, pyaemia, orsepticemia. In malaria, there may be a fever with a periodicity of24 hours(quotidian), 48 hours (tertian fever), or 72 hours (quartan fever, indicatingPlasmodium malariae). These patterns may be less clear in travelers.
Remittent fever: Temperature remains above normal throughout the day andfluctuates more than 1 C in 24 hours, e.g., infective endocarditis.
Pel-Ebstein fever: A specific kind of fever associated with Hodgkin's lymphoma,being high for one week and low for the next week and so on. However, there issome debate as to whether this pattern truly exists.[10]
http://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Lobar_pneumoniahttp://en.wikipedia.org/wiki/Typhoidhttp://en.wikipedia.org/wiki/Urinary_tract_infectionhttp://en.wikipedia.org/wiki/Brucellosishttp://en.wikipedia.org/wiki/Typhushttp://en.wikipedia.org/wiki/Typhoid_feverhttp://en.wikipedia.org/wiki/Typhoid_feverhttp://en.wikipedia.org/wiki/Typhoid_feverhttp://en.wikipedia.org/wiki/Typhoid_feverhttp://en.wikipedia.org/wiki/Lobar_pneumoniahttp://en.wikipedia.org/wiki/Typhoidhttp://en.wikipedia.org/wiki/Urinary_tract_infectionhttp://en.wikipedia.org/wiki/Brucellosishttp://en.wikipedia.org/wiki/Typhushttp://en.wikipedia.org/wiki/Typhoid_feverhttp://en.wikipedia.org/wiki/Typhoid_feverhttp://en.wikipedia.org/wiki/Malariahttp://en.wikipedia.org/wiki/Kala-azarhttp://en.wikipedia.org/wiki/Pyaemiahttp://en.wikipedia.org/wiki/Septicemiahttp://en.wikipedia.org/wiki/Malariahttp://en.wikipedia.org/wiki/Kala-azarhttp://en.wikipedia.org/wiki/Pyaemiahttp://en.wikipedia.org/wiki/Septicemiahttp://en.wikipedia.org/wiki/Plasmodium_malariaehttp://en.wikipedia.org/wiki/Plasmodium_malariaehttp://en.wikipedia.org/wiki/Infective_endocarditishttp://en.wikipedia.org/wiki/Infective_endocarditishttp://en.wikipedia.org/wiki/Pel-Ebstein_feverhttp://en.wikipedia.org/wiki/Hodgkin%27s_lymphomahttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Hodgkin%27s_lymphomahttp://en.wikipedia.org/wiki/Pel-Ebstein_feverhttp://en.wikipedia.org/wiki/Pel-Ebstein_feverhttp://en.wikipedia.org/wiki/Pel-Ebstein_feverhttp://en.wikipedia.org/wiki/Pel-Ebstein_feverhttp://en.wikipedia.org/wiki/Pel-Ebstein_feverhttp://en.wikipedia.org/wiki/Infective_endocarditishttp://en.wikipedia.org/wiki/Plasmodium_malariaehttp://en.wikipedia.org/wiki/Plasmodium_malariaehttp://en.wikipedia.org/wiki/Septicemiahttp://en.wikipedia.org/wiki/Pyaemiahttp://en.wikipedia.org/wiki/Kala-azarhttp://en.wikipedia.org/wiki/Kala-azarhttp://en.wikipedia.org/wiki/Kala-azarhttp://en.wikipedia.org/wiki/Malariahttp://en.wikipedia.org/wiki/Typhoid_feverhttp://en.wikipedia.org/wiki/Typhushttp://en.wikipedia.org/wiki/Brucellosishttp://en.wikipedia.org/wiki/Urinary_tract_infectionhttp://en.wikipedia.org/wiki/Typhoidhttp://en.wikipedia.org/wiki/Lobar_pneumoniahttp://en.wikipedia.org/wiki/Medical_diagnosis -
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ETIOLOGIES OF FEVER
Infectious and non-infectious processes (drug fever, CNS dysfunction,chronic inflammatory conditions)
Children with FWS are clinically categorized:
infants younger than 3 monthschildren 3 months to 36 monthschildren who have fever lasting for 7-10 days
Fever during the first 2 mos, uncommon, serious
temp 38.90C suggests SBI in 36% cases infants 4 wks40%; 2 wks5%
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Demam tanpa tanda lokal
Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005
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Demam tanpa tanda lokal
Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005
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Demam Dengan Tanda Lokal
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Demam dengan Tanda Lokal
Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005
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Demam > 7 hari
Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005
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Demam > 7 hari
Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005
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DEMAM DENGAN RUAM PADA
ANAK
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PATOGENESIS RUAM
Patogenesis manifestasi kulit dari penyakitsistemik :
Penyebaran mikroorganisma melalui darah yangkemudian menghasilkan infeksi sekunder di kulit
(Varicella, enterovirus, meningococcemia) Infeksi terjadi di lokasi tertentu, namun toksin yang
dihasilkan kemudian menyebar dan mencapai kulitmelalui darah (TSS, SSSS)
Dugaan dasar imunologis (eritema multiformeeksudativum)
Keterlibatan vaskuler
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KLASIFIKASI DAN ETIOLOGI
Pembagian ruam dapat dilakukan menurut beberapa metodeseperti :
Morfologi ruam
Infeksi dan non infeksi
Penyebab infeksi
Gejala dan tanda penyerta
Klaster temuan / syndromic diagnosis
Potensi tingkat kegawatan
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KLASIFIKASI MORFOLOGI
RUAM
Krugman : makulopapular dan papulovesikular
Pakar lain : Makular
Makulopapular Vesikular, Bullosa, dan Pustular
Petekial dan Purpural
Urtikarial
Papular, Nodular, Ulseratif
Eritema Multiforme
Eritema Nodosum
Eritroderma Difus
Distinctive Rashes
Ruam Anulare
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DEFINISI
SKIN LESION DESCRIPTION
Macule
Patch
PapulePlaque
Nodule
Vesicle
Bulla
PustuleWheal
Petechiae
Ecchymosis
Diffuse erythema
Flat discoloration 1 cm in diameter
Solid elevated lesion 1.5 cm in diameter
Rounded elevated lesion >1 cm in diameter
Fluid-filled elevated lesion up to 1 cm in diameter
Vesicle >1 cm in diameter
Elevated lesion filled with pusWell-demarcated raised lesion lasting
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Bentuk dan Susunan Lesi Kulit
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MORFOLOGI
Makula Nodula
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MORFOLOGI
Papula Urtika
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MORFOLOGI
Vesikula Pustula
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Klasifikasi Krugman
Krugman membuat deskripsi darisetiap penyakit di dalam daftar yangmeliputi 5 aspek : Riwayat penyakit infeksi dan imunisasi
sebelumnya Gejala prodromal Bentuk ruam Tanda patognomonik dan tanda
diagnostik lain Tes laboratorium
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Klasifikasi KrugmanMAKULOPAPULAR PAPULOVESIKULAR
MeaslesAtypical measlesRubellaScarlet feverStaphylococcal scalded skin syndromeStaphylococcal toxic shock syndromeMeningococcemiaTyphus and tick feverToxoplasmosisCytomegalovirus infectionErythema infectiosum (parvovirus)Roseola infantum (HHV-6)Enteroviral infectionsInfectious mononucleosisToxic erythema
Drug eruptionsSunburnsMiliariaKawasaki disease
Varicella zoster infectionSmallpoxEczema herpeticumEczema vaccinatumCoxsackievirus infectionOther enterovirus infectionsAtypical measlesRickettsialpoxImpetigoInsect bitesPapular urticariaDrug eruptionsMolluscum contagiosumDermatitis herpetiformis
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Demam Dengan Ruam
Sumber: Guidelines for the Mana ement of Common Illnesses with Limited Resources 2005 . WHO 2005
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Ruam Campak
http://www.google.com/url?sa=i&rct=j&q=ruam%20campak&source=images&cd=&cad=rja&docid=vP9SYhelVDesDM&tbnid=JNCV8lk19BMdBM:&ved=0CAUQjRw&url=http%3A%2F%2Fhealth.kompas.com%2Fread%2F2012%2F07%2F17%2F06361637%2FCampak.Bisa.Dicegah.dengan.Imunisasi&ei=Z483UujeC4OpkAXL_IGoAQ&psig=AFQjCNFrfrgaym7TYeRtxy05mpRY6leWGA&ust=1379459021077354http://www.google.com/url?sa=i&rct=j&q=ruam%20campak&source=images&cd=&cad=rja&docid=htJEan_uAny-KM&tbnid=Icvdzl4-V4z0tM:&ved=0CAUQjRw&url=http%3A%2F%2Fparamedik.bbfr.net%2Ft8243-demam-campak-measles&ei=aI43UrjMApDvkAWjiIDwBA&bvm=bv.52164340,d.dGI&psig=AFQjCNFrfrgaym7TYeRtxy05mpRY6leWGA&ust=1379459021077354 -
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Summary
Several clinical practice guidelines established and evaluated. could
be useful to improve clinicians ability in handling patients
especially the management of febrile illness in young infants
Clinical evaluation, observation, history, and physical exam
represent the most effective means of determining the cause of
fever without apparent source.
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TERIMA KASIH
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Adapted from Baraff L. Ann emergency med 2000; 36:605
Management of febrile ( 38C) healthy infant 28-90 days without source
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