DEMAM DAN INFEKSI TROPIS

Nur Muhammad Artha

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?

INTRODUCTION
Fever in childhood among the most likely reason to seek for medical help may be infectious / non-infectious; viral origin is the majority; serious bacterial infection may ensue Differentiation between viral and bacterial disease may be difficult, 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-evolving diagnostic technologies and therapies)

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 sources of inflammation

Definition
Normal variation in body temperature no single value 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 mode or above 99.50F (38.50C) in oral mode

UpToDate last updated Jan 2008

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

 The following degrees of temperature are accepted as fever : 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 mean temperature lies in the diurnal variation of normal body temp, reaches its highest level in early evening (5-7 pm).

Arch Dis Child Educ Pract Ed 2008;93:2629.

PATTERN OF FEVER
Continuous (sustained ) fever : persistent elevation of body temperature with a max fluctuation 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 fever shows 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 at regular

 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

 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 specific fever 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 of the day and becomes normal for remaining hours, e.g., malaria, kala-azar, pyaemia, or septicemia. In malaria, there may be a fever with a periodicity of 24 hours (quotidian), 48 hours (tertian fever), or 72 hours (quartan fever, indicating Plasmodium malariae). These patterns may be less clear in travelers.
Remittent fever: Temperature remains above normal throughout the day and fluctuates 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 is some debate as to whether this pattern truly exists.[10]

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 months children 3 months to 36 months children 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 wks 40%; 2 wks 5%

Demam tanpa tanda lokal

Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005

Demam tanpa tanda lokal

Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005

Demam Dengan Tanda Lokal

Demam dengan Tanda Lokal

Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005

Demam > 7 hari

Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005

Demam > 7 hari

Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005

DEMAM DENGAN RUAM PADA ANAK

PATOGENESIS RUAM
Patogenesis manifestasi kulit dari penyakit sistemik :
Penyebaran mikroorganisma melalui darah yang kemudian menghasilkan infeksi sekunder di kulit (Varicella, enterovirus, meningococcemia) Infeksi terjadi di lokasi tertentu, namun toksin yang dihasilkan kemudian menyebar dan mencapai kulit melalui darah (TSS, SSSS) Dugaan dasar imunologis (eritema multiforme eksudativum) Keterlibatan vaskuler

KLASIFIKASI DAN ETIOLOGI

Pembagian ruam dapat dilakukan menurut beberapa metode seperti :
Morfologi ruam Infeksi dan non infeksi Penyebab infeksi Gejala dan tanda penyerta Klaster temuan / syndromic diagnosis Potensi tingkat kegawatan

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

DEFINISI
SKIN LESION
Macule Patch Papule Plaque Nodule Vesicle Bulla Pustule Wheal Petechiae Ecchymosis Diffuse erythema

DESCRIPTION
Flat discoloration <1 cm in diameter Flat discoloration >1 cm in diameter Solid elevated lesion <1 cm in diameter Flat-topped 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 pus Well-demarcated raised lesion lasting <24 hours Pinpoint hemorrhage Large areas of bleeding into the skin Large area of redness that blanches with pressure

Bentuk dan Susunan Lesi Kulit

MORFOLOGI

Makula

Nodula

MORFOLOGI

Papula

Urtika

MORFOLOGI

Vesikula

Pustula

Klasifikasi Krugman

Krugman membuat deskripsi dari setiap penyakit di dalam daftar yang meliputi 5 aspek :

Riwayat penyakit infeksi dan imunisasi sebelumnya Gejala prodromal Bentuk ruam Tanda patognomonik dan tanda diagnostik lain Tes laboratorium

Klasifikasi Krugman
MAKULOPAPULAR
Measles Atypical measles Rubella Scarlet fever Staphylococcal scalded skin syndrome Staphylococcal toxic shock syndrome Meningococcemia Typhus and tick fever Toxoplasmosis Cytomegalovirus infection Erythema infectiosum (parvovirus) Roseola infantum (HHV-6) Enteroviral infections Infectious mononucleosis Toxic erythema Drug eruptions Sunburns Miliaria Kawasaki disease

PAPULOVESIKULAR
Varicella zoster infection Smallpox Eczema herpeticum Eczema vaccinatum Coxsackievirus infection Other enterovirus infections Atypical measles Rickettsialpox Impetigo Insect bites Papular urticaria Drug eruptions Molluscum contagiosum Dermatitis herpetiformis

Demam Dengan Ruam

Sumber: Guidelines for the Management of Common Illnesses with Limited Resources, 2005 . WHO, 2005

Ruam Campak

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.

TERIMA KASIH

Management of febrile ( 38C) healthy infant 28-90 days without source

Adapted from Baraff L. Ann emergency med 2000; 36:605