Demam Berdarah

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\li6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb0\sl-276\slmult0 \par\pard\ql\l
i6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb79\sl-276\slmult0 \up0 \expndtw-3
\charscalex100 \ul0\nosupersub\cf1\f2\fs24 BAB 2 \par\pard\ql \li4660\sb144\sl-2
76\slmult0 \up0 \expndtw-5\charscalex100 DEMAM BERDARAH DENGUE \par\pard\ql \li2
265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb268\sl-276\slmult0 \up0 \expndtw-5\
charscalex100 2.1 Definisi \par\pard\qj \li2265\ri1512\sb10\sl-414\slmult0\fi720
\up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf2\f3\fs24 Demam dengue/DF dan d
emam berdarah dengue/DBD (\ul0\nosupersub\cf3\f4\fs24 dengue haemorrhagic \up0 \
expndtw0\charscalex105 fever\ul0\nosupersub\cf2\f3\fs24 /DHF) adalah penyakit in
feksi yang disebabkan oleh virus dengue dengan \up0 \expndtw0\charscalex100 mani
festasi klinis demam, nyeri otot dan/atau nyeri sendi yang disertai lekopenia, \
up0 \expndtw0\charscalex102 ruam, limfadenopati, trombositopeniadan diathesis he
moragik. Pada DBD terjadi \up0 \expndtw0\charscalex100 perembesan plasma yang di
tandai oleh hemokonsentrasi (peningkatan hematokrit) \up0 \expndtw0\charscalex10
0 atau penumpukan cairan di rongga tubuh. Sindrom renjatan dengue (\ul0\nosupers
ub\cf3\f4\fs24 dengue shock \up0 \expndtw0\charscalex102 syndrome\ul0\nosupersub
\cf2\f3\fs24 ) adalah demam berdarah dengue yang ditandai oleh renjatan/
syok \up0 \expndtw-3\charscalex100 (Suhendro, Nainggolan, Chen, 2006). \par\pard
\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb264\sl-276\slmult0 \up0 \ex
pndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 2.2. Etiologi \par\pard\qj \li
2265\ri1513\sb31\sl-413\slmult0\fi720 \up0 \expndtw-2\charscalex100 \ul0\nosuper
sub\cf2\f3\fs24 Demam dengue dan demam berdarah dengue disebabkan oleh virus den
gue, \line \up0 \expndtw-2\charscalex100 yang termasuk dalam genus Flavivirus, k
eluarga Flaviviridae. Flavivirus merupakan \line \up0 \expndtw-3\charscalex100 v

irus dengan diameter 30nm terdiri dari asam ribonukleat rantai tunggal dengan be
rat \line \up0 \expndtw-4\charscalex100 molekul 4 x 10\ul0\super\cf4\f5\fs23 6\u
l0\nosupersub\cf2\f3\fs24 . \par\pard\qj \li2265\ri1508\sb406\sl-415\slmult0\fi7
20 \up0 \expndtw-3\charscalex100 Terdapat 4 serotipe virus tipe yaitu DEN-1, DEN
-2, DEN-3, dan DEN-4 yang \line \up0 \expndtw-3\charscalex100 semuanya dapat men
yebabkan demam dengue atau demam berdarah dengue keempat \line \up0 \expndtw0\ch
arscalex103 serotype ditemukan di Indonesia dengan DEN-3 merupakan serotype terb
anyak. \line \up0 \expndtw-1\charscalex100 Terdapat reaksi silang antara serotyp
e dengue dengan Flavivirus lain seperti \ul0\nosupersub\cf3\f4\fs24 Yellow \line
\up0 \expndtw-2\charscalex100 fever, Japanese encephalitis \ul0\nosupersub\cf2\
f3\fs24 dan \ul0\nosupersub\cf3\f4\fs24 West Nile virus \ul0\nosupersub\cf2\f3\f
s24 (Suhendro, Nainggolan, Chen). \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\p
ard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\par
d\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\
i8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8
187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li818
7\sb28\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf5\f6\fs20
Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\par
d\sb0\sl-240{\bkmkstart Pg2}{\bkmkend Pg2}\par\pard\ql \li2265\sb0\sl-276\slmult
0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0
\par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \p
ar\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par
\pard\ql\li2265\sb79\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersu
b\cf6\f7\fs24 2.3. Epidemiologi \par\pard\qj \li2265\ri1512\sb9\sl-416\slmult0\f
i719 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Demam berdarah de
ngue tersebar di wilayah Asia Tenggara, Pasifik Barat dan \up0 \expndtw0\charsca
lex100 Karibia. Indonesia merupakan wilayah endemis dengan sebaran di seluruh wi
layah \up0 \expndtw-2\charscalex100 tanah air. Insiden DBD di Indonesia antara 6
hingga 15 per 100.000 penduduk (1989 \up0 \expndtw0\charscalex102 hingga 1995);
dan pernah meningkat tajam saat kejadian luar biasa hingga 35 per \up0 \expndtw
-2\charscalex100 100.000 penduduk pada tahun 1998, sedangkan mortalitas DBD cend
erung menurun \up0 \expndtw-3\charscalex100 hingga mencapai 2% pada tahun 1999.
\par\pard\qj \li2265\ri1513\sb407\sl-413\slmult0\fi719 \up0 \expndtw0\charscalex
100 Penularan infeksi virus dengue terjadi melalui vektor nyamuk genus Aedes \li
ne \up0 \expndtw-3\charscalex100 (terutama \ul0\nosupersub\cf8\f9\fs24 A. aegypt
i dan A. albopictus\ul0\nosupersub\cf7\f8\fs24 ). Peningkatan kasus setiap tahun
nya berkaitan \line \up0 \expndtw0\charscalex104 dengan sanitasi lingkungan deng
an tersedianya tempat perindukan bagi nyamuk \line \up0 \expndtw0\charscalex105
betina yaitu bejana yang berisi air jernih \up0 \expndtw0\charscalex104 (bak man
di, kaleng bekas dan tempat \par\pard\ql \li2265\sb121\sl-276\slmult0 \up0 \expn
dtw-3\charscalex100 penampungan air lainnya). \par\pard\qj \li2265\sb0\sl-400\sl
mult0 \par\pard\qj\li2265\ri1514\sb62\sl-400\slmult0\fi719 \up0 \expndtw0\charsc
alex103 Beberapa faktor diketahui berkaitan dengan peningkatan transmisi virus
\up0 \expndtw-3\charscalex100 dengue yaitu : \par\pard\ql \li2548\ri1509\sb12\s
l-410\slmult0\tx2832\tx2832 \up0 \expndtw-1\charscalex100 1)\ul0\nosupersub\cf9\
f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Vektor : perkembang biakan vektor, kebiasa
an menggigit, kepadatan vektor di \line\tab \up0 \expndtw0\charscalex105 lingkun
gan, transportasi vektor dilingkungan, transportasi vektor dai satu \line\tab \
up0 \expndtw-3\charscalex100 tempat ke tempat lain; \par\pard\qj \li2548\ri1506\
sb2\sl-420\slmult0\tx2832 \up0 \expndtw-2\charscalex100 2)\ul0\nosupersub\cf9\f1
0\fs24 \ul0\nosupersub\cf7\f8\fs24 Pejamu : terdapatnya penderita di lingkungan
/keluarga, mobilisasi dan paparan \line\tab \up0 \expndtw-3\charscalex100 terhad
ap nyamuk, usia dan jenis kelamin; \par\pard\qj \li2548\ri1515\sb0\sl-420\slmult
0\tx2832 \up0 \expndtw0\charscalex104 3)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosup
ersub\cf7\f8\fs24 Lingkungan : curah hujan, suhu, sanitasi dan kepadatan pendudu
k (WHO, \line\tab \up0 \expndtw-3\charscalex100 2000). \par\pard\ql \li8187\sb0\
sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl
-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-2

30\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230
\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\s
lmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slm
ult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmul
t0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb197\sl-230\slmul
t0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumat
era Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkm
kstart Pg3}{\bkmkend Pg3}\par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li
\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\s
b79\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.4
. Patogenesis \par\pard\qj \li2265\ri1507\sb6\sl-420\slmult0\fi719 \up0 \expndtw
0\charscalex102 \ul0\nosupersub\cf7\f8\fs24 Patogenesis terjadinya demam berd
arah dengue hingga saat ini masih \up0 \expndtw-3\charscalex100 diperdebatk
an. \par\pard\qj \li2265\ri1509\sb400\sl-420\slmult0\fi719 \up0 \expndtw0\charsc
alex105 Berdasarkan data yang ada, terdapat bukti yang kuat bahwa mekanisme \up0
\expndtw0\charscalex103 imunopatologis berperan dalam terjadinya demam berdarah
dengue dan sindrom \up0 \expndtw-3\charscalex100 renjatan dengue. \par\pard\ql
\li2985\sb0\sl-276\slmult0 \par\pard\ql\li2985\sb243\sl-276\slmult0 \up0 \expndt
w-3\charscalex100 Respon imun yang diketahui berperan dalam pathogenesis DBD ada
lah : \par\pard\ql \li2548\ri1514\sb30\sl-415\slmult0\tx2832\tx2832\tx2832\tx283
2 \up0 \expndtw0\charscalex102 a)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\c
f7\f8\fs24 Respon humoral berupa pembentukan antibody yang berparan dalam proses
\line\tab \up0 \expndtw0\charscalex104 netralisasi virus, sitolisis yang dimeas
i komplemen dan sitotoksisitas yang \line\tab \up0 \expndtw0\charscalex100 dimed
iasi antibody. Antibody terhadap virus dengue berperan dalam \line
\tab \up0 \expndtw-1\charscalex100 mempercepat replikasi virus pad monosit atau
makrofag. Hipotesis ini disebut \line\tab \up0 \expndtw-5\charscalex100 \ul0\nos
upersub\cf8\f9\fs24 antibody dependent enhancement \ul0\nosupersub\cf7\f8\fs24 (
ADE); \par\pard\ql \li2548\ri1513\sb7\sl-413\slmult0\tx2832\tx2832\tx2832 \up0 \
expndtw-2\charscalex100 b)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\f
s24 Limfosit T baik T-helper (CD4) dan T sitotoksik (CD8) berepran dalam respon
\line\tab \up0 \expndtw0\charscalex105 imun seluler terhadap virus dengue. Difer
ensiasi T helper yaitu TH1 akan \line\tab \up0 \expndtw0\charscalex100 memproduk
si interferon gamma, IL-2 dan limfokin, sedangkan TH2 \line\tab \u
p0 \expndtw-3\charscalex100 memproduksi IL-4, IL-5, IL-6 dan IL-10; \par\pard\ql
\li2548\ri1512\sb0\sl-420\slmult0\tx2832\tx2832 \up0 \expndtw0\charscalex104 c)
\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Monosit dan makrolag b
erperan dalam fagositosis virus dengan opsonisasi \line\tab \up0 \expndtw0\chars
calex103 antibodi. Namun proses fagositosis ini menyebabkan peningkatan replikas
i \line\tab \up0 \expndtw-3\charscalex100 virus dan sekresi sitokin oleh makrofa
g; \par\pard\qj \li2548\ri1510\sb0\sl-420\slmult0\tx2832 \up0 \expndtw0\charscal
ex102 d)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Selain itu
aktivitasi komplemen oleh kompleks imun menyebabkan \line\tab \up0 \e
xpndtw-3\charscalex100 terbentuknya C3a dan C5a. \par\pard\ql \li8187\sb0\sl-230
\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\s
t0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0
\par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \
par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \pa
r\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb179\sl-230\slmult0 \up
0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Ut
ara \par\pard\sect\sectd\fs24\paperw12240\paperh15840{\shp
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d70f05adbc4d218e18d54a00ffd9}}}}}
\pard\sb0\sl-240{\bkmkstart Pg4}{\bkmkend Pg4}\par\pard\ql \li4771\sb0\sl-230\sl
mult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmu
lt0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult
ar\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb129\sl-230\slmult0 \u
p0 \expndtw-3\charscalex100 \ul0\nosupersub\cf11\f12\fs20 Secondary heterologus
dengue infections \par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb0\sl-230
\slmult0\par\pard\li2419\sb21\sl-230\slmult0\fi1439\tx6772 \up0 \expndtw-3\chars
calex100 Virus replication\tab \up0 \expndtw-3\charscalex100 Anamnestic antibody
response\par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb0\sl-230\slmult0\
par\pard\li2419\sb1\sl-230\slmult0\fi2615 \up0 \expndtw-3\charscalex100 Virus an
tibody complex\par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb226\sl-230\s
lmult0\fi719\tx5851\tx8481 \up0 \expndtw-3\charscalex100 Platelet aggregation\ta
b \up0 \expndtw-3\charscalex100 Coagulation activation\tab \up0 \expndtw-3\chars
calex100 Complement activation\par\pard\li2419\sb0\sl-230\slmult0\par\pard\li241
9\sb6\sl-230\slmult0\fi0\tx4713\tx7795 \up0 \expndtw-3\charscalex100 Impaired pl
atelet\tab \up0 \expndtw-3\charscalex100 Platelet factor\tab \up0 \expndtw-3\cha

rscalex100 Plasmin\par\pard\li2419\sb29\sl-230\slmult0\fi0\tx4713\tx6067\tx8899
\up0 \expndtw-3\charscalex100 function\tab \up0 \expndtw-3\charscalex100 III rel
ease\tab \up0 \expndtw-3\charscalex100 Activated Hagemen\tab \up0 \expndtw-3\cha
rscalex100 Anaphylatoxi\par\pard\li2721\sb0\sl-230\slmult0\par\pard\li2721\sb0\s
l-230\slmult0\par\pard\li2721\sb2\sl-230\slmult0\fi0 \up0 \expndtw-3\charscalex1
00 Platelet removal by RES\par\pard\li2721\sb0\sl-230\slmult0\par\pard\li2721\sb
1\sl-230\slmult0\fi2577\tx7458 \up0 \expndtw-3\charscalex100 Consumptive\tab \up
0 \expndtw-3\charscalex100 Klinin\par\pard\li2721\sb230\sl-230\slmult0\fi417\tx7
458 \up0 \expndtw-3\charscalex100 Thrombocytopeni\tab \up0 \expndtw-3\charscalex
100 Kini\par\pard\li2721\sb1\sl-230\slmult0\fi2576\tx8432 \up0 \expndtw-3\charsc
alex100 Clotting factors\tab \up0 \expndtw-3\charscalex100 Vascular permeablity\
par\pard\li5297\sb0\sl-230\slmult0\par\pard\li5297\sb226\sl-230\slmult0\fi0\tx74
57 \up0 \expndtw-4\charscalex100 Excessive\tab \up0 \expndtw-4\charscalex100 FDP
\par\pard\li5297\sb1\sl-230\slmult0\fi3752 \up0 \expndtw-4\charscalex100 Shock\p
ar\pard\li2265\sb0\sl-276\slmult0\par\pard\li2265\sb127\sl-276\slmult0\fi0\tx997
9 \up0 \expndtw0\charscalex102 \ul0\nosupersub\cf6\f7\fs24 Gambar 2.1. \ul0\nosu
persub\cf7\f8\fs24 Hipot esis \ul0\nosupersub\cf8\f9\fs24 secondary heterologus
infections\ul0\nosupersub\cf7\f8\fs24 (Sumber: Suvatt\tab \up0 \expndtw0\charsc
alex101 1977-\par\pard\li2265\sb2\sl-276\slmult0\fi0 \up0 \expndtw0\charscalex10
1 dikutip dari Sumarmo, 1983).\par\pard\ql \li2985\sb261\sl-276\slmult0\tx5227 \
up0 \expndtw0\charscalex103 Halstead pada tahun \tab \up0 \expndtw0\charscalex10
1 1973 mengajukan hipotesis \ul0\nosupersub\cf8\f9\fs24 secondary heterologous \
par\pard\qj \li2265\ri1509\sb34\sl-410\slmult0 \up0 \expndtw-1\charscalex100 inf
ection \ul0\nosupersub\cf7\f8\fs24 yang menyatakan bahwa DHF terjadi bila seseor
ang terinfeksi ulang virus \up0 \expndtw0\charscalex103 dengue dengan tipe yang
berbeda. Re-infeksi menyebabkan reaksi anamnestik \up0 \expndtw-3\charscalex1
00 antibodi sehingga mengakibatkan konsentrasi kompleks imun yang tinggi. \par\p
ard\qj \li2265\sb0\sl-412\slmult0 \par\pard\qj\li2265\ri1513\sb17\sl-412\slmult0
\fi719 \up0 \expndtw0\charscalex106 Kurang dan Ennis pada tahun 1994 merangkum p
endapat Halstead dan \line \up0 \expndtw0\charscalex102 peneliti lain; menyata
kan bahwa infeksi virus dengue menyebabkan aktivasi \line \up0 \expndtw-4\
charscalex100 makrofag yang me-fagositosis kompleks virus-antibody non netralisa
si sehingga virus \line \up0 \expndtw0\charscalex100 bereplikasi di makrofag
. Terjadinya infeksi makrofag oleh virus dengue \line \up0 \expndtw0
\charscalex100 menyebabkan aktivasi T helper dan T sitotoksik sehingga diprosuks
i limfokin dan \line \up0 \expndtw-2\charscalex100 interferon gamma. Interferon
gamma akan mengaktivasi monosit sehingga disekresi \par\pard\ql \li8187\sb0\sl-2
\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb39\sl-230\
slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas
Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240
{\bkmkstart Pg5}{\bkmkend Pg5}\par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\
i2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2
4 berbagai mediator inflamasi seperti TNF-\u945?, IL-1, PAF (\ul0\nosupersub\cf8
\f9\fs24 platelet activating factor\ul0\nosupersub\cf7\f8\fs24 ), IL-\par\pard\q
j \li2265\ri1509\sb54\sl-410\slmult0 \up0 \expndtw0\charscalex103 6 dan histamin
e yang mengakibatkan terjadinya disfungsi sel endotel dan terjadi \up0 \expndtw2\charscalex100 kebocoran plasma. Peningkatan C3a dan C5a terjadi melalui aktiva
si oleh kompleks \up0 \expndtw-3\charscalex100 virus-antibodi yang juga mengakib
atkan terjadinya kebocoran plasma. \par\pard\ql \li2985\sb121\sl-276\slmult0 \up
0 \expndtw-3\charscalex100 Trombositopenia pada infeksi dengue terjadi melalui m
ekanisme : \par\pard\ql \li2548\sb124\sl-276\slmult0 \up0 \expndtw-4\charscalex1
00 1)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Supresi sumsum tu
lang, dan \par\pard\ql \li2548\sb144\sl-276\slmult0 \up0 \expndtw-5\charscalex10
0 2)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Destruksi dan peme
ndekan masa hidup trombosit. \par\pard\qj \li2265\sb0\sl-412\slmult0 \par\pard\q
j\li2265\ri1511\sb40\sl-412\slmult0\fi719 \up0 \expndtw0\charscalex103 Gambaran

sumsum tulang pada fase awal infeksi (<5 hari) menunjukkan \line \up0 \expndtw0\
charscalex100 keadaan hiposeluler dan supresi megakariosit. Setelah keadaan nadi
r tercapai akan \line \up0 \expndtw-1\charscalex100 terjadi peningkatan pros
es hematopoiesis termasuk megakariopoiesis. Kadar \line \up0 \expndtw0\c
harscalex100 tromobopoietin dalam darah pada saat terjadi trombositopenia justru
menunjukkan \line \up0 \expndtw0\charscalex104 kenaikan, hal ini menunjukkan te
rjadinya stimulasi tromobositopenia. Destruksi \line \up0 \expndtw0\charscalex10
0 trombosit terjadi melalui pengikatan fragmen C3g, terdapatnya antibody
VD, \line \up0 \expndtw-1\charscalex100 konsumsi trombosit selama proses koagul
opati dan sekuestrasi di perifer. Gangguan \line \up0 \expndtw-1\charscalex100 f
ungsi trombosit terjadi melalui mekanisme gangguan pelepasan ADP, peningkatan \l
ine \up0 \expndtw-2\charscalex100 kadar b-tromoboglobulin dan PF4 yang merupakan
petanda degranulasi tromobosit. \par\pard\qj \li2265\sb0\sl-413\slmult0 \par\pa
rd\qj\li2265\ri1512\sb15\sl-413\slmult0\fi719 \up0 \expndtw0\charscalex102 Koagu
lopati terjadi sebagai akibat interaksi virus dengan endotel yang \line \u
p0 \expndtw0\charscalex102 menyebabkan disfungsi endotel. Berbagai penelitia
n menunjukkan terjadinya \line \up0 \expndtw0\charscalex100 koagulopati konsum
tif pada demam berdarah dengue stadium III dan IV. Aktivasi \line \up0 \expndtw0
\charscalex105 koagulasi pada demam berdarah dengue terjadi melalui aktivasi jal
ur ekstrinsik \line \up0 \expndtw0\charscalex104 (\ul0\nosupersub\cf8\f9\fs24 ti
ssue factor pathway\ul0\nosupersub\cf7\f8\fs24 ). Jalur intrinsik juga berperan
melalui aktivasi factor Xia \line \up0 \expndtw-3\charscalex100 namun tidak mela
lui aktivasi kontak (\ul0\nosupersub\cf8\f9\fs24 kalikrein C1-inhibitor complex\
ul0\nosupersub\cf7\f8\fs24 ) (Price, Wilson, \line \up0 \expndtw-4\charscalex100
2006). \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\s
t0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0
par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb49\sl-230\slmult0 \u
p0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera U
tara \par\pard\sect\sectd\fs24\paperw12240\paperh15840{\shp
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\pard\sb0\sl-240{\bkmkstart Pg6}{\bkmkend Pg6}\par\pard\ql \li3868\sb0\sl-253\sl
ar\pard\ql\li3868\sb133\sl-253\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupe
rsub\cf12\f13\fs22 Dengue virus infection \par\pard\li3148\sb0\sl-253\slmult0\pa

r\pard\li3148\sb0\sl-253\slmult0\par\pard\li3148\sb4\sl-253\slmult0\fi0\tx7469 \
up0 \expndtw-3\charscalex100 Asymptomatic\tab \up0 \expndtw-3\charscalex100 Symp
tomatic\par\pard\li2429\sb0\sl-253\slmult0\par\pard\li2429\sb0\sl-253\slmult0\pa
r\pard\li2429\sb0\sl-253\slmult0\par\pard\li2429\sb1\sl-253\slmult0\fi0\tx4382\t
x6917 \up0 \expndtw-4\charscalex100 Undifferentiated\tab \up0 \expndtw-4\charsca
lex100 Dengue fever\tab \up0 \expndtw-4\charscalex100 Dengue haemorrhagic\par\pa
rd\li2429\sb1\sl-253\slmult0\fi499\tx4704\tx7694 \up0 \expndtw-4\charscalex100 f
ever\tab \up0 \expndtw-4\charscalex100 syndrome\tab \up0 \expndtw-4\charscalex10
0 fever\par\pard\li3485\sb0\sl-253\slmult0\par\pard\li3485\sb253\sl-253\slmult0\
fi3263\tx8189 \up0 \expndtw-4\charscalex100 No shock\tab \up0 \expndtw-4\charsca
lex100 Dengue shock\par\pard\li3485\sb1\sl-253\slmult0\fi162\tx5424\tx8415 \up0
\expndtw-4\charscalex100 Without\tab \up0 \expndtw-4\charscalex100 With unusual\
tab \up0 \expndtw-4\charscalex100 syndrome\par\pard\li3485\sb1\sl-248\slmult0\fi
0\tx5290 \up0 \expndtw-4\charscalex100 haemorrhage\tab \up0 \expndtw-4\charscale
x100 haemorrhage\par\pard\li4858\sb0\sl-253\slmult0\par\pard\li4858\sb0\sl-253\s
lmult0\par\pard\li4858\sb5\sl-253\slmult0\fi0\tx6874 \up0 \expndtw-4\charscalex1
00 Dengue fever\tab \up0 \expndtw-4\charscalex100 D\ul0\nosupersub\cf15\f16\fs22
\ul en\ul0\nosupersub\cf12\f13\fs22 gue haemorrhagic\par\pard\ql \li8189\sb1\sl243\slmult0 \up0 \expndtw-4\charscalex100 fever \par\pard\ql \li2265\sb0\sl-276\
slmult0 \par\pard\ql\li2265\sb154\sl-276\slmult0\tx7872 \up0 \expndtw0\charscale
x103 \ul0\nosupersub\cf6\f7\fs24 Gambar 2.2. \ul0\nosupersub\cf7\f8\fs24 Manifes
tasi klinis infeksi virus dengue \tab \up0 \expndtw0\charscalex104 (Sumber : \ul
0\nosupersub\cf8\f9\fs24 Monograph on \par\pard\ql \li2265\sb144\sl-276\slmult0
\up0 \expndtw-3\charscalex100 Dengue/Dengue Haemorrahgic fever\ul0\nosupersub\cf
7\f8\fs24 , WHO 1983) \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li226
2.5. Manifestasi klinis dan perjalanan penyakit \par\pard\qj \li2265\ri1513\sb3
4\sl-410\slmult0\fi719 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf7\f8\fs24
Manifestasi klinis infeksi virus dengue dapat bersifat asimtomatik, atau dapat
\up0 \expndtw0\charscalex105 berupa demam yang tidak khas, demam dengue, demam b
erdarah dengue atau \up0 \expndtw-5\charscalex100 sindrom syok dengue (SSD). \pa
r\pard\qj \li2265\ri1510\sb408\sl-413\slmult0\fi719 \up0 \expndtw-3\charscalex10
0 Pada umumnya pasien mengalami fase demam 2-7 hari, yang diikuti oleh fase \up0
\expndtw0\charscalex104 kritis selam 2-3 hari. Pada waktu fase ini pasien sudah
tidak demam, akan tetapi \up0 \expndtw0\charscalex106 mempunyai risiko untuk te
rjadi renjatan jika tidak mendapat pengobatan tidak \up0 \expndtw-3\charscalex10
0 adekuat (Kabra, Jain, Singhal, 1999). \par\pard\ql \li8187\sb0\sl-230\slmult0
\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\p
ql\li8187\sb89\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10
\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paper
h15840\pard\sb0\sl-240{\bkmkstart Pg7}{\bkmkend Pg7}\par\pard\ql \li2265\sb0\sl276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-27
6\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\
slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\sl
mult0 \par\pard\ql\li2265\sb79\sl-276\slmult0 \up0 \expndtw-5\charscalex100 \ul0
\nosupersub\cf6\f7\fs24 2.6. Pemeriksaan penunjang \par\pard\ql \li2265\sb0\sl-2
76\slmult0 \par\pard\ql\li2265\sb128\sl-276\slmult0 \up0 \expndtw-3\charscalex10
0 2.6.1. Laboratorium \par\pard\qj \li2265\ri1502\sb31\sl-413\slmult0\fi719 \up0
\expndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 Pemeriksaan darah yang ruti
n dilakukan untuk menapis pasien tersangka \up0 \expndtw0\charscalex100 demam de
ngue adalah melalui pemeriksaan kadar hemoglobin, hematokrit, jumlah \up0 \expnd
tw-1\charscalex100 trombosit dan hapusan darah tepi untuk melihat adanya limfosi
tosis relative disertai \up0 \expndtw-3\charscalex100 gambaran limfosit plasma b
iru. \par\pard\ql \li2985\sb0\sl-276\slmult0 \par\pard\ql\li2985\sb245\sl-276\sl
mult0\tx9201 \up0 \expndtw0\charscalex105 Diagnosis pasti didapatkan dari hasil
isolasi virus dengue \tab \up0 \expndtw0\charscalex102 (\ul0\nosupersub\cf8\f9\f

s24 cell culture\ul0\nosupersub\cf7\f8\fs24 ) \par\pard\ql \li2265\sb144\sl-276\
slmult0\tx9691 \up0 \expndtw0\charscalex100 ataupun deteksi antigen virus RN
A dengue dengan teknik RT-PCR \tab \up0 \expndtw-5\charscalex100 (\ul0\nosup
ersub\cf8\f9\fs24 Reserve \par\pard\qj \li2265\ri1515\sb34\sl-410\slmult0 \up0 \
expndtw-1\charscalex100 Transcriptase Polymerase Chain Reaction\ul0\nosupersub\c
f7\f8\fs24 ), namun karena teknik yang lebih rumit, \up0 \expndtw0\charscalex103
saat ini tes serologis yang mendeteksi adanya antibody spesifik terhadap dengue
\up0 \expndtw-3\charscalex100 berupa antibody total, IgM maupun IgG. \par\pard\
ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb125\sl-276\slmult0 \up0 \exp
ndtw-3\charscalex100 Parameter Laboratoris yang dapat diperiksa antara lain : \p
ar\pard\ql \li2548\ri1511\sb31\sl-413\slmult0\tx2832\tx2832\tx2832 \up0 \expndtw
0\charscalex105 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24
Leukosit: dapat normal atau menurun. Mulai hari ke-3 dapat ditemui \l
ine\tab \up0 \expndtw-1\charscalex100 limfositosis relative (>45% dari total leu
kosit) disertai adanya limfosit plasma \line\tab \up0 \expndtw-4\charscalex100 b
iru \up0 \expndtw0\charscalex109 (LPB) > 15% dari jumlah total leukosit yang pad
a fase syok akan \line\tab \up0 \expndtw-3\charscalex100 meningkat. \par\pard\ql
\li2548\sb141\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupers
ub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Trombosit: umumnya terdapat trombo
sitopenia pada hari ke 3-8. \par\pard\ql \li2548\ri1508\sb17\sl-430\slmult0\tx28
32\tx2832 \up0 \expndtw0\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0
\nosupersub\cf7\f8\fs24 Hematokrit: Kebocoran plasma dibuktikan dengan ditemuka
nnya peningkatan \line\tab \up0 \expndtw0\charscalex104 hematokrit \u8805? 20% d
ari hematokrit awal, umumnya dimulai pada hari ke-3 \line\tab \up0 \expndtw-4\ch
arscalex100 demam. \par\pard\ql \li2548\ri1508\sb27\sl-410\slmult0\tx2832\tx2832
\up0 \expndtw0\charscalex103 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupers
ub\cf7\f8\fs24 Hemostasis: Dilakukan pemeriksaan PT, APTT, Fibrinogen, D-Dimer,
atau \line\tab \up0 \expndtw-2\charscalex100 FDP pada keadaan yang dicurigai te
rjadi perdarahan atau kelainan pembekuan \line\tab \up0 \expndtw-4\charscalex100
darah. \par\pard\ql \li2548\sb141\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Protein/albumi
n: Dapat terjadi hipoproteinemia akibat kebocoran plasma. \par\pard\ql \li2548\s
b144\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10
\fs24 \ul0\nosupersub\cf7\f8\fs24 SGOT/SGPT (serum alanin aminotransferase): d
apat meningkat. \par\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \expndtw-4\charsc
alex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Ureum,
Kreatinin: bila didapatkan gangguan fungsi ginjal. \par\pard\ql \li8187\sb0\sl230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-23
0\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universita
s Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-2
40{\bkmkstart Pg8}{\bkmkend Pg8}\par\pard\ql \li2548\sb0\sl-276\slmult0 \par\par
i2548\sb79\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\f
s24 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Elektrolit
: sebagai parameter pemantauan pemberian cairan. \par\pard\qj \li2548\ri1515\sb4
6\sl-420\slmult0\tx2832 \up0 \expndtw0\charscalex108 \u8226?\ul0\nosupersub\cf9\
f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Golongan darah: dan \ul0\nosupersub\cf8\f
9\fs24 cross\ul0\nosupersub\cf7\f8\fs24 macth (uji cocok serasi): bila akan dib
erikan \line\tab \up0 \expndtw-3\charscalex100 transfusi darah atau komponen dar
ah. \par\pard\ql \li2548\sb119\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u82
26?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Imuno serologi dil
akukan pemeriksaan IgM dan IgG terhadap dengue. \par\pard\qj \li2832\ri1512\sb26
\sl-420\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf6\f7\fs24 IgM\ul0
\nosupersub\cf7\f8\fs24 : terdeksi mulai hari ke 3-5, meningkat sampai minggu ke
-3, menghilang \up0 \expndtw-3\charscalex100 setelah 60-90 hari. \par\pard\qj \l
i2832\ri1510\sb17\sl-400\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf
6\f7\fs24 IgG\ul0\nosupersub\cf7\f8\fs24 : pada infeksi primer, IgG mulai terdet

eksi pada hari ke-14, pada infeksi \up0 \expndtw-3\charscalex100 sekunder IgG mu
lai terdeteksi hari ke-2. \par\pard\qj \li2548\ri1509\sb40\sl-400\slmult0\tx2832
\up0 \expndtw-1\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosuper
sub\cf7\f8\fs24 Uji III: Dilakukan pengambilan bahan pada hari pertama serta sa
at pulang dari \line\tab \up0 \expndtw-3\charscalex100 perawatan, uji ini diguna
kan untuk kepentingan surveilans. (WHO, 2006) \par\pard\ql \li2265\sb0\sl-276\sl
mult0 \par\pard\ql\li2265\sb267\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul
0\nosupersub\cf6\f7\fs24 2.6.2. Pemeriksaan radiologis \par\pard\qj \li2265\ri15
12\sb34\sl-410\slmult0\fi719 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f
8\fs24 Pada foto dada didapatkan efusi pleura, terutama pada hemitoraks kanan te
tapi \up0 \expndtw0\charscalex102 apabila terjadi perembesan plasma hebat, efusi
pleura dapat dijumpai pada kedua \up0 \expndtw-2\charscalex100 hemitoraks. Peme
riksaan foto rontgen dada sebaiknya dalam posisi lateral dekubitus \up0 \expndtw
-3\charscalex100 kanan (pasien tidur pada sisi badan sebelah kanan). Asites dan
efusi pleura dapat pula \up0 \expndtw-4\charscalex100 dideteksi dengan pemeriksa
an USG. (WHO, 2006) \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\
sb265\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2
.7. Diagnosis \par\pard\qj \li2265\ri1512\sb6\sl-420\slmult0\fi719 \up0 \expndtw
0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 Masa inkubasi dalam tubuh manusia se
kitar 4-6 hari (rentang 3-14 hari), \up0 \expndtw-3\charscalex100 timbul gejala
prodormal yang tidak khas seperti : nyeri kepala, nyeri tulang belakang \up0 \ex
pndtw-4\charscalex100 dan perasaan lelah. \par\pard\ql \li2265\sb0\sl-276\slmult
0 \par\pard\ql\li2265\sb123\sl-276\slmult0 \up0 \expndtw-5\charscalex100 \ul0\no
supersub\cf6\f7\fs24 2.7.1. Demam Dengue (DD). \par\pard\qj \li2265\ri1511\sb6\s
l-420\slmult0\fi719 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Mer
upakan penyakit demam akut selama 2-7 hari, ditandai dengan dua atau \up0 \expnd
tw-3\charscalex100 lebih manifestasi klinis sebagai berikut: \par\pard\ql \li254
8\sb119\sl-276\slmult0 \up0 \expndtw0\charscalex100 \u8226?\ul0\nosupersub\cf9\f
10\fs24 \ul0\nosupersub\cf7\f8\fs24 Nyeri kepala. \par\pard\ql \li2548\sb164\s
l-276\slmult0 \up0 \expndtw-2\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24
\ul0\nosupersub\cf7\f8\fs24 Nyeri retro-oebital. \par\pard\ql \li2548\sb144\sl
-276\slmult0 \up0 \expndtw-2\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24
\ul0\nosupersub\cf7\f8\fs24 Mialgia / artralgia. \par\pard\ql \li8187\sb0\sl-23
slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb82\sl-230\s
lmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas S
umatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{
\bkmkstart Pg9}{\bkmkend Pg9}\par\pard\ql \li2548\sb0\sl-276\slmult0 \par\pard\q
l\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\
li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li
48\sb79\sl-276\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24
\u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Ruam kulit. \p
ar\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul
0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Manifestasi perdarahan (
petekie atau uji bending positif). \par\pard\ql \li2548\sb164\sl-276\slmult0 \up
0 \expndtw0\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\c
f7\f8\fs24 Leukopenia. \par\pard\qj \li2265\ri1515\sb6\sl-420\slmult0 \up0 \exp
ndtw0\charscalex103 dan pemeriksaan serologi dengue positif, ayau ditemukan pasi
en DD/DBD yang \up0 \expndtw-3\charscalex100 sudah dikonfirmasi pada lokasi dan
waktu yang sama. \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb2
63\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.7.
2. Demam Berdarah Dengue\ul0\nosupersub\cf7\f8\fs24 \ul0\nosupersub\cf6\f7\fs24
(DBD). \par\pard\qj \li2265\ri1508\sb6\sl-420\slmult0\fi719 \up0 \expndtw-4\cha
rscalex100 \ul0\nosupersub\cf7\f8\fs24 Berdasarkan kriteria WHO 1997 diagnosis D
BD ditegakkan bila semua hal ini \up0 \expndtw-5\charscalex100 di bawah ini dipe
nuhi : \par\pard\ql \li2548\sb119\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \
u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Demam atau riwa
yat demam akut, antara 2-7 hari, biasanya bifasik. \par\pard\ql \li2548\sb164\sl
-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24

\ul0\nosupersub\cf7\f8\fs24 Terdapat minimal satu dari manifestasi perdarahan b
erikut : \par\pard\ql \li2692\sb144\sl-276\slmult0 \up0 \expndtw-2\charscalex100
-\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Uji bendung positif
. \par\pard\ql \li2692\sb124\sl-276\slmult0 \up0 \expndtw-3\charscalex100 -\ul0\
nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Petekie, ekimosis, atau pu
rpura. \par\pard\li2692\sb157\sl-276\slmult0\fi0\tx5222 \up0 \expndtw0\charscale
x103 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Perdarahan muk
osa\tab \up0 \expndtw0\charscalex103 (tersering epistaksis atau perdarahan g
usi), atau\par\pard\li2692\sb137\sl-276\slmult0\fi283 \up0 \expndtw0\charscalex
103 perdarahan dari tempat lain.\par\pard\ql \li2692\sb118\sl-276\slmult0 \up0 \
expndtw-2\charscalex100 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs
24 Hematemesis atau melena. \par\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \exp
ndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8
\fs24 Trombositopenia (jumlah trombosit <100.000/ul). \par\pard\qj \li2548\ri15
14\sb26\sl-420\slmult0\tx2832 \up0 \expndtw-2\charscalex100 \u8226?\ul0\nosupers
ub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Terdapat minimal satu tanda-tanda
plasma leakage (kebocoran plasma) sebagai \line\tab \up0 \expndtw-3\charscalex10
0 berikut : \par\pard\ql \li2692\ri1504\sb0\sl-420\slmult0\tx2975 \up0 \expndtw1\charscalex100 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Peni
ngkatan hematokrit >20% dibandingkan standar sesuai dengan umur dan \line\tab \u
p0 \expndtw-4\charscalex100 jenis kelamin. \par\pard\ql \li2692\ri1508\sb0\sl-42
0\slmult0\tx2975 \up0 \expndtw0\charscalex102 -\ul0\nosupersub\cf9\f10\fs24 \ul
0\nosupersub\cf7\f8\fs24 Penurunan hematokrit >20% setelah mendapat terapi cair
an, dibandingkan \line\tab \up0 \expndtw-3\charscalex100 dengan nilai hematokrit
sebelumnya. \par\pard\ql \li2692\sb99\sl-276\slmult0 \up0 \expndtw-3\charscalex
100 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Tanda kebocoran
plasma seperti : efusi pleura, asites atau hipoproteinemia. \par\pard\qj \li2265
\ri1514\sb286\sl-420\slmult0\fi359 \up0 \expndtw0\charscalex103 Dari keterangan
di atas terlihat bahwa perbedaan utama antara DD dan DBD \up0 \expndtw-3\charsca
lex100 adalah pada DBD ditemukan adanya kebocoran plasma. (WHO, 1997) \par\pard\
ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\q
8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb187\sl-230\slmult0 \up0 \expndtw-2
\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\par
d\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg10}{\bkmk
end Pg10}\par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\
lt0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb79\sl-276\slmul
t0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.8. Diagnosis Band
ing \par\pard\qj \li2265\sb0\sl-420\slmult0 \par\pard\qj\li2265\ri1508\sb6\sl-42
0\slmult0\fi719 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Diagno
sis banding perlu dipertimbangkan bilamana terdapat kesesuaian klinis \up0 \expn
dtw-4\charscalex100 dengan demam tiroid, campak, influenza, chikungunya dan lept
ospirosis. \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb243\sl276\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Sindrom Sy
ok Dengue\ul0\nosupersub\cf7\f8\fs24 \ul0\nosupersub\cf6\f7\fs24 (SSD). \par\pa
rd\qj \li2265\sb0\sl-420\slmult0 \par\pard\qj\li2265\ri1492\sb26\sl-420\slmult0\
fi719 \up0 \expndtw0\charscalex106 \ul0\nosupersub\cf7\f8\fs24 Seluruh kriteria
di atas untuk DBD disertai kegagalan sirkulasi dengan \up0 \expndtw-2\charscalex
100 manifestasi nadi yang cepat dan lemah, tekanan darah turun (\u8804? 20 mmHg)
, hipotensi \up0 \expndtw-2\charscalex100 dibandingkan standar sesuai umur, kuli
t dingin dan lembab serta gelisah. (Suhendro, \up0 \expndtw-3\charscalex100 Nain
ggolan L, Chen K, Pohan, 2006) \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard
\ql\li2265\sb263\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf
6\f7\fs24 2.9. Derajat penyakit infeksi virus dengue \par\pard\qj \li2265\ri1511
\sb6\sl-420\slmult0\fi719 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs
24 Untuk menentukan penatalaksanaan pasien infeksi virus dengue, perlu \u
p0 \expndtw-3\charscalex100 diketahui klasifikasi derajat penyakit seperti terte

ra pada tabel 1. \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0
\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\s
l-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-23
\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\p
ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb47\sl-230\slmult0 \up0 \expnd
tw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par
\pard\sect\sectd\fs24\paperw12240\paperh15840{\shp
ffd8ffe000104a46494600010101006000600000ffdb004300010101010101010101010101010101
01010101010101010101010101010101010101010101010101010101010101010101010101010101
010101010101010101ffdb0043010101010101010101010101010101010101010101010101010101
0101010101010101010101010101010101010101010101010101010101010101010101010101ffc0
001108000a023303012200021101031101ffc4001f00000105010101010101000000000000000001
02030405060708090a0bffc400b5100002010303020403050504040000017d010203000411051221
31410613516107227114328191a1082342b1c11552d1f02433627282090a161718191a2526272829
2a3435363738393a434445464748494a535455565758595a636465666768696a737475767778797a
0101010101010101010000000000000102030405060708090a0bffc400b511000201020404030407
05040400010277000102031104052131061241510761711322328108144291a1b1c109233352f015
6272d10a162434e125f11718191a262728292a35363738393a434445464748494a53545556575859
5a636465666768696a737475767778797a82838485868788898a92939495969798999aa2a3a4a5a6
f2f3f4f5f6f7f8f9faffda000c03010002110311003f00fef8b5dd6acfc3ba3ea3ae6a10ead7165a
5dac979730685a06bbe29d6258a21964d3bc3be19d3b57f106b17447fabb1d274cbebd98f10dbb9e
2bc57fe1a5fe1d7fd0b9fb407fe226fed4ff00fce6abe80a2803e7ff00f8697f875ff42e7ed01ff8
89bfb53fff0039aa3fe1a5fe1d7fd0b9fb407fe226fed4ff00fce6abe80a2803e7ff00f8697f875f
f42e7ed01ff889bfb53fff0039aa3fe1a5fe1d7fd0b9fb407fe226fed4ff00fce6abe80a2803e7ff
00f8697f875ff42e7ed01ff889bfb53fff0039aa3fe1a5fe1d7fd0b9fb407fe226fed4ff00fce6ab
e80a2803e7ff00f8697f875ff42e7ed01ff889bfb53fff0039aa86e3f69df86f6d0c93c9e1afda19
9225dccb6ffb22fed5f7731190311dbdafc169ae256e7eec513b63271804d7d0d45007cfff00f0d2
ff000ebfe85cfda03ff1137f6a7ffe73547fc34bfc3aff00a173f680ff00c44dfda9ff00f9cd57d0
145007cfff00f0d2ff000ebfe85cfda03ff1137f6a7ffe73547fc34bfc3aff00a173f680ff00c44d
fda9ff00f9cd57d0145007cfff00f0d2ff000ebfe85cfda03ff1137f6a7ffe73547fc34bfc3aff00
a173f680ff00c44dfda9ff00f9cd57d0145007cfff00f0d2ff000ebfe85cfda03ff1137f6a7ffe73
547fc34bfc3aff00a173f680ff00c44dfda9ff00f9cd57d0145007cfff00f0d2ff000ebfe85cfda0
3ff1137f6a7ffe73550bfed3bf0da39a185bc35fb4317b8f336327ec8bfb57c90af94a1dbceb88fe
0b3416d90711fda248bce6ca43bdc151f4351401f3ff00fc34bfc3affa173f680ffc44dfda9fff00
9cd51ff0d2ff000ebfe85cfda03ff1137f6a7ffe7355f4051401f3ff00fc34bfc3affa173f680ffc
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\pard\sb0\sl-240{\bkmkstart Pg11}{\bkmkend Pg11}\par\pard\ql \li2265\sb0\sl-276\
\up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Tabel 2.1. Klasifikas
i Derajat Penyakit Infeksi Virus Dengue (WHO, 1997).\par\pard\sect\sectd\sbknone
\cols2\colno1\colw7284\colsr160\colno2\colw4656\colsr160\ql \li2231\sb11\sl-276\
slmult0\tx3523\tx5601 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24
DD/DBD\tab \up0 \expndtw-4\charscalex100 Derajat\tab \up0 \expndtw-4\charscalex1
00 Gejala\par\pard\ql \li2231\sb8\sl-276\slmult0\tx4463 \up0 \expndtw-3\charscal
ex100 DD\tab \up0 \expndtw-3\charscalex100 Demam disertai 2 atau lebih\par\pard\
qj \li4502\ri302\sb5\sl-273\slmult0 \up0 \expndtw-3\charscalex100 tanda: sakit k
epala, nyeri \up0 \expndtw-3\charscalex100 retro-orbital, mialgia,\par\pard\ql \
li4502\sb3\sl-276\slmult0 \up0 \expndtw-4\charscalex100 artralgia.\par\pard\ql \
li4608\sb276\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Gejala di atas ditamba
h uji\par\pard\ql \li2231\sb1\sl-273\slmult0\tx3835\tx4603 \up0 \expndtw-3\chars
calex100 DBD\tab \up0 \expndtw-3\charscalex100 I\tab \up0 \expndtw-3\charscalex1
00 bendung positif\par\pard\ql \li2231\sb0\sl-276\slmult0 \par\pard\ql \li2231\s
b0\sl-276\slmult0 \par\pard\ql \li2231\sb0\sl-276\slmult0 \par\pard\ql \li4608\s
b1\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Gejala di atas ditambah\par\pard
\ql \li2231\sb2\sl-276\slmult0\tx3796\tx4603 \up0 \expndtw-3\charscalex100 DBD\t
ab \up0 \expndtw-4\charscalex100 II\tab \up0 \expndtw-3\charscalex100 perdarahan
spontan\par\pard\ql \li2231\sb0\sl-276\slmult0 \par\pard\ql \li2231\sb0\sl-276\
slmult0 \par\pard\ql \li4608\sb276\sl-276\slmult0 \up0 \expndtw-3\charscalex100

Gejala di atas ditambah\par\pard\ql \li2231\sb1\sl-273\slmult0\tx3753\tx4603 \up
0 \expndtw-3\charscalex100 DBD\tab \up0 \expndtw-3\charscalex100 III\tab \up0 \e
xpndtw-3\charscalex100 kegagalan sirkulasi (kulit\par\pard\qj \li4608\ri287\sb5\
sl-273\slmult0 \up0 \expndtw-3\charscalex100 dingin dan lembab serta \up0 \expnd
tw-3\charscalex100 gelisah)\par\pard\qj \li4608\ri38\sb275\sl-278\slmult0 \up0 \
expndtw-3\charscalex100 Syok berat disertai dengan \up0 \expndtw-3\charscalex100
tekanan darah dan nadi\par\pard\ql \li2231\sb1\sl-273\slmult0\tx3748\tx4603 \up
0 \expndtw-3\charscalex100 DBD\tab \up0 \expndtw-3\charscalex100 IV\tab \up0 \ex
pndtw-3\charscalex100 tidak terukur.\par\pard\column \ql \li457\sb11\sl-276\slmu
lt0 \up0 \expndtw-3\charscalex100 Laboratorium\par\pard\ql \li20\sb27\sl-276\slm
ult0\tx2435 \up0 \expndtw-3\charscalex100 Leucopenia\tab \up0 \expndtw-3\charsca
lex100 Serologi\par\pard\ql \li20\sb17\sl-276\slmult0\tx2435 \up0 \expndtw-3\cha
rscalex100 Trombositopenia,\tab \up0 \expndtw-4\charscalex100 Dengue\par\pard\qj
\li20\ri1528\sb0\sl-276\slmult0\tx2435 \up0 \expndtw-3\charscalex100 tidak dite
mukan bukti\tab \up0 \expndtw-4\charscalex100 Positif \up0 \expndtw-3\charscalex
100 kebocoran plasma\par\pard\ql \li20\ri2574\sb249\sl-273\slmult0 \up0 \expndtw
-3\charscalex100 Trombositopenia, \line \up0 \expndtw-3\charscalex100 (<100.000/
? l), bukti\par\pard\ql \li20\sb3\sl-276\slmult0 \up0 \expndtw-3\charscalex100 a
da kebocoran plasma\par\pard\ql \li7444\sb0\sl-273\slmult0 \par\pard\ql \li20\ri
2574\sb25\sl-273\slmult0 \up0 \expndtw-3\charscalex100 Trombositopenia, \line \u
p0 \expndtw-3\charscalex100 (<100.000/? l), bukti\par\pard\ql \li20\sb0\sl-273\s
lmult0 \up0 \expndtw-3\charscalex100 ada kebocoran plasma\par\pard\ql \li7444\sb
0\sl-273\slmult0 \par\pard\ql \li20\ri2574\sb26\sl-273\slmult0 \up0 \expndtw-3\c
harscalex100 Trombositopenia, \line \up0 \expndtw-3\charscalex100 (<100.000/? l)
, bukti\par\pard\ql \li20\sb4\sl-276\slmult0 \up0 \expndtw-3\charscalex100 ada k
ebocoran plasma\par\pard\ql \li7444\sb0\sl-273\slmult0 \par\pard\ql \li20\ri2574
\sb255\sl-273\slmult0 \up0 \expndtw-3\charscalex100 Trombositopenia, \line \up0
\expndtw-3\charscalex100 (<100.000/? l), bukti\par\pard\ql \li20\sb0\sl-273\slmu
lt0 \up0 \expndtw-3\charscalex100 ada kebocoran plasma \par\pard\sect\sectd\sbkn
one \ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb6\sl-276\slmult0 \up0 \
expndtw-3\charscalex100 DBD derajat III dan IV juga disebut sindrom syok dengue
(SSD) \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slm
ult0 \par\pard\ql\li2265\sb132\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0
\nosupersub\cf6\f7\fs24 2.10. Definisi gambaran enzim transaminase \par\pard\qj
\li2265\ri1513\sb310\sl-415\slmult0\fi719 \up0 \expndtw0\charscalex103 \ul0\nosu
persub\cf7\f8\fs24 Dalam pekerjaannya, hati kita membuat beberapa produk, termas
uk jenis \line \up0 \expndtw-3\charscalex100 protein yang disebut sebagai enzim.
Gambaran enzim transaminase adalah sejenis tes \line \up0 \expndtw0\charscalex1
00 yang digunakan untuk mengukur level beberapa jenis enzim hati, yang merupakan
\line \up0 \expndtw0\charscalex100 protein spesifik yang membantu tubuh un
tuk memecahkan dan menggunakan \line \up0 \expndtw0\charscalex100 (metabolism
e) substansi yang lain.Produk ini dapat keluar dari hati dan masuk ke \par\pard\
ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\q
8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb128\sl-230\slmult0 \up0 \expndtw-2
\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\par
d\sect\sectd\fs24\paperw12240\paperh15840{\shp
{\*\shpinst\shpleft2060\shptop8140\shpright10700\shpbottom10400\shpwr3\shpfblwtx
t0\shpbxpage\shpbypage\shpz202\shplid11
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3ff93d0f8fbff66c1fb227fead6fdb768037ff00e1a5fe1d7fd0b9fb407fe226fed4ff00fce6a8ff
008697f875ff0042e7ed01ff00889bfb53ff00f39aafa028a00f9fff00e1a5fe1d7fd0b9fb407fe2
26fed4ff00fce6a8ff008697f875ff0042e7ed01ff00889bfb53ff00f39aafa028a00f9fff00e1a5
fe1d7fd0b9fb407fe226fed4ff00fce6a8ff008697f875ff0042e7ed01ff00889bfb53ff00f39aaf
a028a00f9fff00e1a5fe1d7fd0b9fb407fe226fed4ff00fce6a8ff008697f875ff0042e7ed01ff00
889bfb53ff00f39aafa028a00f9fff00e1a5fe1d7fd0b9fb407fe226fed4ff00fce6a8ff008697f8
75ff0042e7ed01ff00889bfb53ff00f39aafa028a00f9fff00e1a5fe1d7fd0b9fb407fe226fed4ff
00fce6a8ff008697f875ff0042e7ed01ff00889bfb53ff00f39aafa028a00f9fff00e1a5fe1d7fd0
b9fb407fe226fed4ff00fce6a8ff008697f875ff0042e7ed01ff00889bfb53ff00f39aafa028a00f
9fff00e1a5fe1d7fd0b9fb407fe226fed4ff00fce6a8ff008697f875ff0042e7ed01ff00889bfb53
ff00f39aafa028a00f9fff00e1a5fe1d7fd0b9fb407fe226fed4ff00fce6a8ff008697f875ff0042
e7ed01ff00889bfb53ff00f39aafa028a00f9fff00e1a5fe1d7fd0b9fb407fe226fed4ff00fce6a8
ff008697f875ff0042e7ed01ff00889bfb53ff00f39aafa028a00f9fff00e1a5fe1d7fd0b9fb407f
e226fed4ff00fce6abc03f692f8e3e0bf18781fc0be1cd2744f8c169a86a3fb4ff00ec59f67b8f14
fecf5f1f7c0da0c7f63fdb0fe055fcbf6ef14f8dbe1a787fc31a5ef82d654b5fed3d5ed3edd78d6f
a7597da350bcb4b59feffaf983f6bbff009253e13ffb39ff00d88bff005b43e015007d3f45145007
cfff00b4bffc93af0e7fd9c07ec9bffad4ff0006abe80af9ff00f697ff009275e1cffb380fd937ff
005a9fe0d57d01400514514005145140051451400514514005145140051451400514514005145140
0514514005145140057cc1fb227fc929f167fd9cff00edbbff00ada1f1f6be9faf983f644ff9253e
2cff00b39ffdb77ff5b43e3ed007d3f4514500145145001451450014514500145145001451450014
51450014514500145145001451450015f30784ff00e4f43e3eff00d9b07ec89ffab5bf6ddafa7ebe
60f09ffc9e87c7dffb360fd913ff0056b7edbb401f4fd14514005145140051451400514514005145
1400514514005145140051451400514514005145140057cc1fb5dffc929f09ff00d9cffec45ffada
1f00abe9faf983f6bbff009253e13ffb39ff00d88bff005b43e015007d3f45145007cfff00b4bffc
93af0e7fd9c07ec9bffad4ff0006abe80af9ff00f697ff009275e1cffb380fd937ff005a9fe0d57d
01400514514005145140051451400514514005145140051451400514514005145140051451400514
5140057cc1fb227fc929f167fd9cff00edbbff00ada1f1f6be9faf983f644ff9253e2cff00b39ffd
b77ff5b43e3ed007d3f4514500145145001451450014514500145145001451450014514500145145
00145145001451450015f30784ff00e4f43e3eff00d9b07ec89ffab5bf6ddafa7ebe60f09ffc9e87
c7dffb360fd913ff0056b7edbb401f4fd14514005145140051451400514514005145140051451400
5145140051451400514514005145140057cc1fb5dffc929f09ff00d9cffec45ffada1f00abe9faf9
83f6bbff009253e13ffb39ff00d88bff005b43e015007d3f45145007cfff00b4bffc93af0e7fd9c0
7ec9bffad4ff0006abe80af2ef8c7e00d5fe25f81cf86b40f1169de14d72d3c63f0c7c6da3eb9ac7
876e7c59a4db6a7f0cbe26f843e2558db6a7e1eb2f127846f352b0d52e7c251695771daf89348b88
60bd92ea1b93240b149c87fc239fb53ffd165fd9ff00ff0011a3e22fff004595007d01457cff00ff
0008e7ed4fff004597f67fff00c468f88bff00d16547fc239fb53ffd165fd9ff00ff0011a3e22fff
004595007d01457cff00ff0008e7ed4fff004597f67fff00c468f88bff00d16547fc239fb53ffd16
5fd9ff00ff0011a3e22fff004595007d01457cff00ff0008e7ed4fff004597f67fff00c468f88bff
00d16547fc239fb53ffd165fd9ff00ff0011a3e22fff004595007d01457cff00ff0008e7ed4fff00
4597f67fff00c468f88bff00d16547fc239fb53ffd165fd9ff00ff0011a3e22fff004595007d0145
7cff00ff0008e7ed4fff004597f67fff00c468f88bff00d16547fc239fb53ffd165fd9ff00ff0011
a3e22fff004595007d01457cff00ff0008e7ed4fff004597f67fff00c468f88bff00d16547fc239f
b53ffd165fd9ff00ff0011a3e22fff004595007d01457cff00ff0008e7ed4fff004597f67fff00c4
68f88bff00d16547fc239fb53ffd165fd9ff00ff0011a3e22fff004595007d01457cff00ff0008e7
ed4fff004597f67fff00c468f88bff00d16547fc239fb53ffd165fd9ff00ff0011a3e22fff004595
007d01457cff00ff0008e7ed4fff004597f67fff00c468f88bff00d16547fc239fb53ffd165fd9ff
00ff0011a3e22fff004595007d01457cff00ff0008e7ed4fff004597f67fff00c468f88bff00d165
47fc239fb53ffd165fd9ff00ff0011a3e22fff004595007d015f307ec89ff24a7c59ff00673ffb6e
ff00eb687c7dadff00f8473f6a7ffa2cbfb3ff00fe2347c45ffe8b2ae0fe1c7c19fda3be18787b51
f0de85f1bfe095e596a5e3df8a9f10e79b56fd9bbc7735d26b3f177e27f8c3e2bf88ad627b3fda9a
c615d32c7c41e35d52c74589e07bab7d1adec20bebcd46f63b8d42e803ebca2be7ff00f8473f6a7f
fa2cbfb3ff00fe2347c45ffe8b2a3fe11cfda9ff00e8b2fecfff00f88d1f117ffa2ca803e80a2be7
ff00f8473f6a7ffa2cbfb3ff00fe2347c45ffe8b2a3fe11cfda9ff00e8b2fecfff00f88d1f117ffa
2ca803e80a2be7ff00f8473f6a7ffa2cbfb3ff00fe2347c45ffe8b2a3fe11cfda9ff00e8b2fecfff
00f88d1f117ffa2ca803e80a2be7ff00f8473f6a7ffa2cbfb3ff00fe2347c45ffe8b2a3fe11cfda9
ff00e8b2fecfff00f88d1f117ffa2ca803e80a2be7ff00f8473f6a7ffa2cbfb3ff00fe2347c45ffe
8b2a3fe11cfda9ff00e8b2fecfff00f88d1f117ffa2ca803e80a2be7ff00f8473f6a7ffa2cbfb3ff
00fe2347c45ffe8b2a3fe11cfda9ff00e8b2fecfff00f88d1f117ffa2ca803e80a2be7ff00f8473f
6a7ffa2cbfb3ff00fe2347c45ffe8b2a3fe11cfda9ff00e8b2fecfff00f88d1f117ffa2ca803e80a
2be7ff00f8473f6a7ffa2cbfb3ff00fe2347c45ffe8b2a3fe11cfda9ff00e8b2fecfff00f88d1f11
7ffa2ca803e80a2be7ff00f8473f6a7ffa2cbfb3ff00fe2347c45ffe8b2a3fe11cfda9ff00e8b2fe
cfff00f88d1f117ffa2ca803e80a2be7ff00f8473f6a7ffa2cbfb3ff00fe2347c45ffe8b2a3fe11c
fda9ff00e8b2fecfff00f88d1f117ffa2ca803e80af983c27ff27a1f1f7fecd83f644ffd5adfb6ed
6fff00c239fb53ff00d165fd9fff00f11a3e22ff00f4595707a77c19fda3b4df89fe30f8af07c6ff
00824fe20f1af80be1c7c3cd52c65fd9bbc76da35be8df0c3c43f153c49a15d58409fb5325ec7a9d
e5efc5df1143ab4b71a85d5acd6b63a2a59d9d8cd6f7d3ea201f5e515f3fff00c239fb53ff00d165
fd9fff00f11a3e22ff00f45951ff0008e7ed4fff004597f67fff00c468f88bff00d165401f40515f
3fff00c239fb53ff00d165fd9fff00f11a3e22ff00f45951ff0008e7ed4fff004597f67fff00c468
f88bff00d165401f40515f3fff00c239fb53ff00d165fd9fff00f11a3e22ff00f45951ff0008e7ed
4fff004597f67fff00c468f88bff00d165401f40515f3fff00c239fb53ff00d165fd9fff00f11a3e
22ff00f45951ff0008e7ed4fff004597f67fff00c468f88bff00d165401f40515f3fff00c239fb53
ff00d165fd9fff00f11a3e22ff00f45951ff0008e7ed4fff004597f67fff00c468f88bff00d16540
1f40515f3fff00c239fb53ff00d165fd9fff00f11a3e22ff00f45951ff0008e7ed4fff004597f67f
ff00c468f88bff00d165401f40515f3fff00c239fb53ff00d165fd9fff00f11a3e22ff00f45951ff
0008e7ed4fff004597f67fff00c468f88bff00d165401f40515f3fff00c239fb53ff00d165fd9fff
00f11a3e22ff00f45951ff0008e7ed4fff004597f67fff00c468f88bff00d165401f40515f3fff00
c239fb53ff00d165fd9fff00f11a3e22ff00f45951ff0008e7ed4fff004597f67fff00c468f88bff
00d165401f40515f3fff00c239fb53ff00d165fd9fff00f11a3e22ff00f45951ff0008e7ed4fff00
4597f67fff00c468f88bff00d165401f4057cc1fb5dffc929f09ff00d9cffec45ffada1f00ab7ffe
11cfda9ffe8b2fecff00ff0088d1f117ff00a2cab8ef1bfc1cfda03e2558f86b40f19fc66f83a7c3
5a3fc51f831f12754b6f0c7ecf7e35d175dd4d7e0efc5ef03fc5bb6d12c359d57f696f12e9fa4b6b
b7be08b6d1a7d4ee3c3fac8b0b5bf9eea3d3aea58a389803eb1a28a2803fffd9}}}}}
\pard\sb0\sl-240{\bkmkstart Pg12}{\bkmkend Pg12}\par\pard\qj \li2265\sb0\sl-400\
slmult0 \par\pard\qj\li2265\sb0\sl-400\slmult0 \par\pard\qj\li2265\sb0\sl-400\sl
mult0 \par\pard\qj\li2265\sb0\sl-400\slmult0 \par\pard\qj\li2265\ri1520\sb309\sl
-400\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 aliran da

rah. Tingkat produk tersebut dapat diukur dalam darah. (Wendon, Williams, \line
\up0 \expndtw-3\charscalex100 2008). \par\pard\ql \li2265\sb0\sl-276\slmult0 \pa
r\pard\ql\li2265\sb127\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosuper
sub\cf6\f7\fs24 2.11. Bagian gambaran enzim transaminase \par\pard\ql \li2265\sb
0\sl-276\slmult0 \par\pard\ql\li2265\sb148\sl-276\slmult0 \up0 \expndtw-2\charsc
alex100 \ul0\nosupersub\cf7\f8\fs24 Produk berikut biasanya diukur sebagai bagia
n dari gambaran enzim transaminase: \par\pard\ql \li2625\ri1513\sb286\sl-420\slm
ult0\tx2985 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf11\f12\fs20 \u8226?\
ul0\nosupersub\cf13\f14\fs20 \ul0\nosupersub\cf7\f8\fs24
ALT (alanin aminotr
ansferase), juga dikenal sebagai SGPT (serum glutamik \line\tab \up0 \expndtw-3\
charscalex100 piruvik transaminase) \par\pard\ql \li2625\ri1515\sb0\sl-420\slmul
t0\tx2985 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf11\f12\fs20 \u8226?\ul
0\nosupersub\cf13\f14\fs20 \ul0\nosupersub\cf7\f8\fs24
AST (aspartat aminotr
ansferase), juga dikenal sebagai SGOT (serum glutamik \line\tab \up0 \expndtw-4\
charscalex100 oksaloasetik transaminase) \par\pard\ql \li2687\sb0\sl-276\slmult0
\par\pard\ql\li2687\sb103\sl-276\slmult0 \up0 \expndtw-3\charscalex100 (Gowda,
Desai, Hull, Math, Kulkarni, Vernekar, 2009). \par\pard\ql \li2265\sb0\sl-276\sl
mult0 \par\pard\ql\li2265\sb148\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul
0\nosupersub\cf6\f7\fs24 Tabel 2.2. Nilai Rujukan Gambaran Fungsi Hati \par\pard
\li2265\sb0\sl-276\slmult0\par\pard\li2265\sb0\sl-276\slmult0\par\pard\li2265\sb
20\sl-276\slmult0\fi0\tx5102\tx7915 \up0 \expndtw-3\charscalex100 \ul0\nosupersu
b\cf7\f8\fs24 Ukuran\tab \up0 \expndtw-3\charscalex100 Satuan\tab \up0 \expndtw3\charscalex100 Nilai Rujukan\par\pard\li2265\sb146\sl-276\slmult0\fi0\tx5102\tx
7915\tx9028\tx10248 \up0 \expndtw-3\charscalex100 ALT (SGPT)\tab \up0 \expndtw-3
\charscalex100 U/L\tab \up0 \expndtw-3\charscalex100 <\tab \up0 \expndtw-3\chars
calex100 23\tab \up0 \expndtw-3\charscalex100 (P)\par\pard\ql \li7915\sb134\sl-2
76\slmult0 \up0 \expndtw-3\charscalex100 < 30 (L) \par\pard\li2265\sb154\sl-276\
slmult0\fi0\tx5102\tx7915\tx9028\tx10248 \up0 \expndtw-3\charscalex100 AST (SGOT
)\tab \up0 \expndtw-3\charscalex100 U/L\tab \up0 \expndtw-3\charscalex100 <\tab
\up0 \expndtw-3\charscalex100 21\tab \up0 \expndtw-3\charscalex100 (P)\par\pard\
ql \li7915\sb134\sl-276\slmult0 \up0 \expndtw-3\charscalex100 < 25 (L) \par\pard
\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\
ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb16\sl-276\slmult0 \up0 \expnd
tw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.12. Hasil Tes \par\pard\qj \li2
265\ri1511\sb291\sl-413\slmult0\fi719 \up0 \expndtw-1\charscalex100 \ul0\nosuper
sub\cf7\f8\fs24 Penyakit hati yang berbeda akan menyebabkan kerusakan yang berbe
da, dan \up0 \expndtw-3\charscalex100 tes fungsi hati dapat menunjukkan perbedaa
n ini. Hasil tes fungsi hati dapat memberi \up0 \expndtw-1\charscalex100 gambara
n mengenai penyakit apa yang mungkin menyebabkan kerusakan, tetapi tes \up0 \exp
ndtw-2\charscalex100 ini tidak mampu mendiagnosis akibat penyakit hati. \par\par
d\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard
\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\q
8187\sb19\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\
fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh1584
0\pard\sb0\sl-240{\bkmkstart Pg13}{\bkmkend Pg13}\par\pard\qj \li2265\sb0\sl-413
\slmult0 \par\pard\qj\li2265\sb0\sl-413\slmult0 \par\pard\qj\li2265\sb0\sl-413\s
lmult0 \par\pard\qj\li2265\sb0\sl-413\slmult0 \par\pard\qj\li2265\ri1512\sb246\s
l-413\slmult0\fi719 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Ha
sil tes ini juga bermanfaat untuk memantau perjalanan penyakit hati, tetapi \lin
e \up0 \expndtw0\charscalex100 sekali lagi, mungkin tidak memberi gambaran yang
tepat. Namun biasanya hasil tes \line \up0 \expndtw0\charscalex103 fungsi hati m
emberi gambaran mengenai tingkat peradangan (Wendon, Williams, \line \up0 \expnd
tw-3\charscalex100 2008). \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\l
i2265\sb125\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\
fs24 2.13. Enzim Hati \par\pard\qj \li2265\ri1508\sb291\sl-413\slmult0\fi719 \up
0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 ALT adalah lebih spesifik
untuk kerusakan hati. ALT adalah enzim yang \up0 \expndtw-1\charscalex100 dibuat
dalam sel hati (hepatosit), jadi lebih spesifik untuk penyakit hati dibandingka
n \up0 \expndtw0\charscalex107 dengan enzim lain. Biasanya peningkatan ALT terja
di bila ada kerusakan pada \up0 \expndtw0\charscalex102 selaput sel hati. Setiap
jenis peradangan hati dapat menyebabkan peningkatan pada \up0 \expndtw0\charsca
lex102 selaput sel hati. Setiap jenis peradangan hati dapat menyebabkan peningka
tan pada \up0 \expndtw0\charscalex105 ALT. Peradangan pada hati dapat disebabkan
oleh hepatitis virus, beberapa obat, \up0 \expndtw-3\charscalex100 penggunaan a
lkohol, dan penyakit pada saluran cairan empedu. \par\pard\qj \li2265\ri1513\sb2
87\sl-413\slmult0\fi719 \up0 \expndtw0\charscalex102 AST adalah enzim mitokondri
a yang juga ditemukan dalam jantung, ginjal \up0 \expndtw0\charscalex105 dan ota
k. Jadi tes ini kurang spesifik untuk penyakit hati. Dalam beberapa kasus \up0 \
expndtw-1\charscalex100 peradangan hati, peningkatan ALT dan AST akan serupa (Go
wda, Desai, Hull, Math, \up0 \expndtw-2\charscalex100 Kulkarni, Vernekar, 2009).
\par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0
\par\pard\ql\li2265\sb269\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosu
persub\cf6\f7\fs24 2.14. Hubungan infeksi dengue dengan gambaran enzim transamin
ase \par\pard\qj \li2265\sb0\sl-415\slmult0 \par\pard\qj\li2265\ri1509\sb15\sl-4
15\slmult0\fi719 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Organ
sasaran dari virus adalah organ RES meliputi sel kuffer hepar, endotel \line \up
0 \expndtw-2\charscalex100 pembuluh darah, nodus limfaticus, sumsum tulang serta
paru-paru. Data dari berbagai \line \up0 \expndtw0\charscalex103 penelitian men
unjukkan bahwa sel-sel monosit dan makrofag mempunyai peranan \line \up0 \expndt
w0\charscalex100 besar pada infeksi ini. Dalam peredaran darah, virus tersebut a
kan difagosit oleh sel \line \up0 \expndtw-3\charscalex100 monosit perifer. \par
\pard\qj \li2265\ri1514\sb18\sl-400\slmult0\fi719 \up0 \expndtw0\charscalex103 S
etelah virus dengue masuk dalam tubuh manusia, virus berkembang biak \line \up0
\expndtw0\charscalex102 dalam sel retikuloendotelial ( hepar) yang selanjutnya d
iikuiti dengan viremia yang \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql
i8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb161\sl-230\slmult0 \up0 \expndtw2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pa
rd\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg14}{\bkm
kend Pg14}\par\pard\qj \li2265\sb0\sl-410\slmult0 \par\pard\qj\li2265\sb0\sl-410
\slmult0 \par\pard\qj\li2265\sb0\sl-410\slmult0 \par\pard\qj\li2265\sb0\sl-410\s
lmult0 \par\pard\qj\li2265\ri1513\sb261\sl-410\slmult0 \up0 \expndtw0\charscalex
106 \ul0\nosupersub\cf7\f8\fs24 berlangsung 5-7 hari. Akibat infeksi virus ini m
uncul respon imun baik humoral \up0 \expndtw0\charscalex106 maupun selular, anta
ra lain anti netralisasi, anti-hemaglutinin, anti komplemen. \up0 \expndtw0\cha
rscalex105 Antibodi yang muncul pada umumnya adalah IgG dan IgM, pada infeksi de
ngue \up0 \expndtw-1\charscalex100 primer antibodi mulai terbentuk, dan pada inf
eksi sekunder kadar antibodi yang telah \up0 \expndtw-3\charscalex100 ada mening
kat (booster effect). \par\pard\qj \li2265\ri1512\sb6\sl-415\slmult0\fi719 \up0
\expndtw0\charscalex107 Antibodi terhadap virus dengue dapat ditemukan di dalam
darah sekitar \line \up0 \expndtw0\charscalex108 demam hari ke-5, meningkat pada
minggu pertama sampai dengan ketiga, dan \line \up0 \expndtw0\charscalex106 men
ghilang setelah 60-90 hari. Kinetik kadar IgG berbeda dengan kinetik kadar \line
\up0 \expndtw0\charscalex104 antibodi IgM, oleh karena itu kinetik antibodi IgG
harus dibedakan antara infeksi \line \up0 \expndtw-1\charscalex100 primer dan s
ekunder. Pada infeksi primer antibodi IgG meningkat sekitar demam hari \line \up
0 \expndtw0\charscalex102 ke-14 sedang pada infeksi sekunder antibodi IgG mening
kat pada hari kedua. Oleh \line \up0 \expndtw0\charscalex102 karena itu diagnosa
dini infeksi primer hanya dapat ditegakkan dengan mendeteksi \line \up0 \expndt
w0\charscalex100 antibodi IgM setelah hari sakit kelima, diagnosis infeksi sekun
der dapat ditegakkan \line \up0 \expndtw-3\charscalex100 lebih dini dengan adany
a peningkatan antibody IgG dan IgM yang cepat. \par\pard\qj \li2265\ri1505\sb5\s
l-415\slmult0\fi719 \up0 \expndtw0\charscalex100 Hipotesis tentang patogenes
is DBD/SSD seperti \ul0\nosupersub\cf8\f9\fs24 antibody-dependent \line \u
p0 \expndtw0\charscalex103 enhancement, virus virulence\ul0\nosupersub\cf7\f8\fs
24 , dan imunopatogenesis yang diprakarsai oleh IFN-\line \up0 \expndtw0\charsca
lex102 \u947?/TNF-\u945? dianggap belum cukup untuk menjawab terjadinya trombosi
topenia dan \line \up0 \expndtw-1\charscalex100 hemokonsentrasi pada DBD/SSD. Me

nurut Lei HY dkk, 2001, infeksi virus dengue \line \up0 \expndtw0\charscalex105
akan mempengaruhi sistem imun tubuh berupa perubahan dari rasio CD4/CD8, \line \
up0 \expndtw-3\charscalex100 overproduksi dari sitokin dan dapat menginfeksi sel
-sel endotel dan hepatosit dengan \line \up0 \expndtw0\charscalex100 akibat terj
adinya apoptosis serta disfungsi dari sel-sel tersebut. Begitu juga sistem \line
\up0 \expndtw0\charscalex103 koagulasi dan fibrinolisis ikut teraktivasi selama
infeksi virus dengue. Gangguan \line \up0 \expndtw-1\charscalex100 terhadap res
pon imun tidak hanya berupa gangguan dalam membersihkan virus dari \line \up0 \e
xpndtw-1\charscalex100 dalam tubuh, akan tetapi over produksi sitokin dapat memp
engaruhi sel-sel endotel, \line \up0 \expndtw-4\charscalex100 monosit dan hepato
sit. Kerusakan trombosit akibat dari reaksi silang otoantibodi anti-\line \up0 \
expndtw0\charscalex100 trombosit, karena overproduksi IL-6 yang berperan b
esar dalam terbentuknya \line \up0 \expndtw-4\charscalex100 otoantibodi anti-t
rombosit dan anti-sel endotel, serta meningkatnya level dari tPA dan \line \up0
\expndtw-5\charscalex100 defisiensi koagulasi. \par\pard\ql \li8187\sb0\sl-230\s
t0 \par\pard\ql\li8187\sb188\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\n
osupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\pap
erw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg15}{\bkmkend Pg15}\par\pard\qj
\li2265\sb0\sl-413\slmult0 \par\pard\qj\li2265\sb0\sl-413\slmult0 \par\pard\qj\
li2265\sb0\sl-413\slmult0 \par\pard\qj\li2265\sb0\sl-413\slmult0 \par\pard\qj\li
2265\ri1513\sb246\sl-413\slmult0\fi719 \up0 \expndtw0\charscalex100 \ul0\nosuper
sub\cf7\f8\fs24 Disimpulkan bahwa penyebab dari kebocoran plasma yang khas terja
di pada \line \up0 \expndtw0\charscalex108 pasien DBD dan SSD disebabkan oleh ke
rja bersama seperti suatu konser dari \line \up0 \expndtw0\charscalex100 aktivas
i komplemen, induksi kemokin dan kematian sel apoptotik.\ul0\super\cf14\f15\fs23
(18)\ul0\nosupersub\cf7\f8\fs24 Dihipotesiskan \line \up0 \expndtw0\charscalex
105 bahwa peningkatan sintesis IL-8 memegang peran penting dalam terjadi
nya \line \up0 \expndtw0\charscalex105 kebocoran plasma pada pasien DBD dan SSD.
Hal ini dapat dilihat dalam serum \line \up0 \expndtw0\charscalex100 pasien DBD
/DSS berat terjadi peningkatan level IL-8, dan dibuktikan secara \ul0\nosupersub
\cf8\f9\fs24 in vitro \line \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\
fs24 oleh Bosch I dkk (2002) melalui kultur primer dari monosit manusia yang dii
nfeksi \line \up0 \expndtw0\charscalex100 dengan virus dengue tipe 2, terjadi pe
ningkatan level IL-8 dalam supernatan kultur, \line \up0 \expndtw0\charscalex103
yang diperkirakan karena terjadi peningkatan aktivasi dari NF-kappaB. Penelitia
n \line \up0 \expndtw0\charscalex114 oleh Bethell dkk \up0 \expndtw0\charscalex
104 (1998) terhadap anak di Vietnam dengan DBD dan SSD \par\pard\qj \li226
5\ri1509\sb7\sl-413\slmult0 \up0 \expndtw0\charscalex105 menyebutkan bahwa pad
a anak dengan SSD ternyata level IL-6 dan \ul0\nosupersub\cf8\f9\fs24 solu
ble \up0 \expndtw0\charscalex102 intercellular adhesion molecule-1\ul0\nosupersu
b\cf7\f8\fs24 rendah, hal ini merefleksikan adanya kehilangan \up0 \expndtw0\ch
arscalex100 protein dalam sirkulasi karena kebocoran kapiler dan hanya level dar
i reseptor TNF \up0 \expndtw-3\charscalex100 terlarut (TNFR) yang meninggi seiri
ng dengan beratnya penyakit. \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\q
\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\s
b0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0
\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\s
l-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-23
up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera
Utara \par\pard\sect\sectd\fs24}

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{\rtf1{\fonttbl

{\f2 Times New Roman Bold;}

eluarga Flaviviridae. Flavivirus merupakan \line \up0 \expndtw-3\charscalex100 v

-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-2

{\sp{\sn pib}{\sv {\pict\jpegblip

atelet\tab \up0 \expndtw-3\charscalex100 Platelet factor\tab \up0 \expndtw-3\cha

j\li2265\ri1511\sb40\sl-412\slmult0\fi719 \up0 \expndtw0\charscalex103 Gambaran

rsub\cf12\f13\fs22 Dengue virus infection \par\pard\li3148\sb0\sl-253\slmult0\pa

isolasi virus dengue \tab \up0 \expndtw0\charscalex102 (\ul0\nosupersub\cf8\f9\f

6\f7\fs24 IgG\ul0\nosupersub\cf7\f8\fs24 : pada infeksi primer, IgG mulai terdet

-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24

p0 \expndtw-3\charscalex100 diketahui klasifikasi derajat penyakit seperti terte

slmult0 \par\pard\ql \li4608\sb276\sl-276\slmult0 \up0 \expndtw-3\charscalex100

-400\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 aliran da

topenia dan \line \up0 \expndtw-1\charscalex100 hemokonsentrasi pada DBD/SSD. Me

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