Laporan Kasus Meningitis Pada Anak

8/17/2019 Laporan Kasus Meningitis Pada Anak

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Presentasi Kasus

MENINGITISPembimbing :

dr. Ajuar Arif, Sp.Adr. Chares !utas"it, Sp.A

#eh :

Ed$ard Indra G" %&''()'*+)+-

/ebr0 1"udr0an %&''()'*+)&2


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Identitas

• Nama : an. A.3

• 4enis 5eamin : a5i)a5i

•

6mur : + tahun• 7erat badan : 8 5g

• Masu5 9S tangga : +& Mei &'++


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Anamnesis

• ia5u5an se;ara a"anamnesisterhadap ibu < a0ah pasien

• Keuhan utama : penurunan5esadaran

•

Keuhan tambahan : demam, sa5it5epaa, muntah&, batu5


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9i$a0at pen0a5it se5arang

• + buan SM9S, pasien mengaami demam.Menurut 5euarga pasien, demam mun;utiba&, suhu pada saat itu tida5 diu5ur.

Terdapat batu5 tida5 berdaha5. an batu5han0a 5adang&. pasien sudah diberi5an"bat penurun panas. 4i5a diberi "batpenurun panas, demam turun, tapiseteah itu nai5 agi.

• + minggu SM9S pasien merasa5an sa5it5epaa 0ang sangat hebat dan terdapatmuntah&.


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9i$a0at Pen0a5it Se5arang

• Tida5 ada ri$a0at trauma 5epaa.

• 9i$a0at batu5 ama disang5a, ri$a0atpenurunan berat badan < 5eringatmaam disang5a.

• 9i$a0at 5"nta5 %=, a0ah pasienpernah didiagn"sa menderita T7C

dengan ri$a0at peng"batan tida5tuntas, se5arang a0ah pasienmenga5u masih batu5&


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• Pasien au dira$at inap di 9S Sanggau.• i 9S Sanggau pasien mendapat terapi :

– Cef"ta>ime > +,8 gr – e>ametas"ne >8 mg – 9anitidin > -' mg – rip ?uinin >8' mg –

7ufe;t f"rte > + ;th – #AT :

• 9ifampisin +>+ tab• P0ra@inamid +>+,8 tab• IN! +>& tab

• & hari SM9S pasien mengaamipenurunan 5esadaran, au pasiendiruju5 5e 9SSA dengan diagn"sa 5erja :meningitis susp.ba5teriais S#1

intra5rania = T7 paru = maaria = ISK


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Pemeri5saan /isi5

• Keadaan umum : tampa5 sa5it berat

• Kesadaran : s"mn"en %GCS B E- M8+ B +'

• Te5anan darah :+'2' mm!g

• 1aju den0ut jantung : 88>menit

•1aju napas : &'>menit

• Suhu : D,2 "C


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Pemeri5saan /isi5

• Kepaa : n"rm";ephai, def"rmitas

• Mata : 5"njungtiFa tida5 anemis, s5eratida5 i5teri5, pupi anis"5"r, diameterpupi -mmmm, ree5s ;aha0a ))

• !idung : septum nasi di tengah, se5ret))

• Muut : suit diniai

• Teinga : se5ret ))


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• Th"ra5s paru – I : simetris daam 5eadaan statis dan dinamis – P : pengembangan paru 5anan)5iri simetris – P: s"n"r pada 5edua apangan paru – A : suara napas br"n;h"Fesi5uar, $hee@ing )),

r"n5i ))

• 4antung –

I : i;tus ;"rdis tida5 terihat – P : i;tus ;"rdis tida5 teraba – P : batas jantung daam batas n"rma – A : bun0i jantung I < II reguer, ga"p ), murmur )

• Abd"men – I : datar, Fene5tasi %) – P: hepar ien tida5 teraba, ba"tement %) – P : timpani pada semua apangan abd"men – A : bising usus =, ->menit


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Pemeri5saan Neur""gis

• Pemeri5saan 5a5u 5udu5 =,brud@ins5i I, II, 5ernig =

• 9ee5s babins5i ==

• 9ee5s patea 5anan ) 5iri : ==,hiperree5s.


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CT s;an

• Tampa5 gambaran hip"dens

• entri5e aga5 meebar

•

Tida5 ada midine shift

• Kesimpuan : ;uriga meningitis

dengan hidr"sefaus ringan• Saran : CT s;an dengan 5"ntras


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iagn"sa 5erja

• Meningitis e.; susp T7C

•

meningitis e.; susp ba5terais


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Tataa5sana

• 9a$at daam IC6

• I/ 8 -';;jam

•

iet +8'' 55a = 8( gr pr"tein• Manit" >+'' ;;

• Mer"bat > ',8 gr

• Neur"tam &>+ gr• epa;hen s0rp &>+ ;th


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/""$ 6p %+&8++

• Kesadaran : s"mn"en

• Ka5u 5udu5 : =

•

T : +')+-' 2')+'' mm!g• N : 8+)D'>menit

• 99 : +D)&&>menit

• S : *, *,2 "C


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/""$ 6p %+8++

• !asi r"ntgen : ;"r pum" tida5 tampa5 5eainan• Terapi :

– Infus 91 ' ;;jam – Mer"bat >',8 gr – Manit" >+'' ;; – Neur"tam &>+ gr – Strept"m0;in +>D8' mg – /armad" infus 8' ;; – S0rp depa5en &>+ ;th – Cap ;amp +>+ %9if '' = IN! '' = etambut"

'' – Cap ;amp &>+ %p0ra@inamid '' = prednis"n +''


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/""$ 6p %+-8++

• Ka5u 5udu5 %=, pupi anis"5"r

• Suhu : D,8 2 "C

•

T : ++' +-' D' +''mm!g

• N : D* (* >menit

•

99 : &' - >menit


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/""$ up %+88++

• emam %) %*,+ D,- "C

• !asi ab :

–

H7C : +*,'( – !b : +,2

– !t : -'

– P1T : *2


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/""$ up %+**++

• Keadaan umum : tampa5 sa5itberat

• Kesadaran : s"mn"en < geisah

• Suhu : * *,8 "C

• N : 2* (& >menit

• Pasien pindah 5e ruangan %1id$ina


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/""$ up %+D*++9.1id$ina



• Suhu : *,D D "C

• N : 2* (& >menit


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/""$ up %+2*++9.1id$ina



• Suhu : *,D D,- "C

• N : 2* (& >menit


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MENINGITIS

eniti"n• Meningitis is inammati"n "f the membranes

surr"unding the brain and spina ;"rdin;uding the dura, pia mater, and the

ara;hn"id, due t" a Fariet0 "f ;auses.• 7a;teria meningitis resuts m"st ;"mm"n0

fr"m seeding "f the ept"meninges fr"m adistant f";us %hemat"gen"usba;teremi;spread. 6n;"mm"n0, it ;an as" resut fr"m

a dire;t e>tensi"n fr"m a ;"ntigu"us f";us%e.g., sinusitis, "titis media, mast"iditis "r b0dire;t inFasi"n %e.g., head trauma,mening"m0e";ee.


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ETI#1#GI

Neonatal perioda. Gr"up 7 strept";";;i%G7S

b. Gram)negatiFe enteri;ba;ii %Escherichia coli,

Enterobacter spp.;. Listeria monocytogenes

Age 1 to 3 monthsa. Streptococcus pneumoniae

b. Neisseria meningitidis %f"r mening";";;emia;. Haemophilus infuenzae t0pe bd. Listeria monocytogenes

Age over 3 monthsa. S. pneumoniaeb. N. meningitidis %seeMening";";;emia

;. H. infuenzae t0pe b%unFa;;inated ;hidren

Neurosurgical patients(e.g., patients withventriculoperitonealshunts)

a. C"aguase negatiFeStaphylococcusepidermidisb. Staphylococcus aureus


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C1INICA1 /EAT69ES•

The in;iden;e "f meningitis ;aused b0 H. infuenzae has de;ined dramati;a0 sin;e the intr"du;ti"n "f the;"njugate Fa;;ine.

• S. pneumoniae is n"$ the m"st ;"mm"n eti""g0during infan;0 %+ t" & m"nths, and N. meningitidis isthe m"st ;"mm"n eti""g0 bet$een & and +2 0ears "f

age.• The g"d standard f"r diagn"sing meningitis is

;erebr"spina e>aminati"n %CS/ b0 perf"rming aumbar pun;ture %1P – #n0 ;"ntraindi;ati"n f"r an 1P is in;reased intra;rania

pressure %ICP – If the patient has f";a neur""gi; signs "r papiedema,treat the patient $ith antibi"ti;s rst, f""$ed b0 a CTs;an prior to perf"rming 1P.

– Antigen dete;ti"n tests %e.g., ate> aggutinati"n,;"unter;urrent immun"ee;tr"ph"resis ma0 hep inpartia0 treated meningitis.

– India in5 stain is re;"mmended f"r immun";"mpr"mised


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• E>aminati"n "f the CS/ sh"$s pe";0t"sis $ith ap"0m"rph"nu;ear pred"minan;e, eeFated pr"tein, andde;reased gu;"se in ba;teria meningitis. Grams stainma0 be p"sitiFe f"r the presen;e "f ba;teria and

subse?uent CS/ ;uture $"ud be p"sitiFe %uness thepatient has re;eiFed pri"r antibi"ti; therap0• E>aminati"n "f the CS/ sh"$s pe";0t"sis $ith

0mph";0tes, sight0 eeFated "r n"rma pr"tein, andn"rma gu;"se in asepti; meningitis. Neutr"phis ma0pred"minate ear0 in the ;"urse "f eFen Fira meningitis.

e;reased CS/ gu;"se ma0 as" ";;ur in mumps andherpes mening"en;ephaitis.• Tuber;u"us meningitis ma0 present $ith a gradua "nset

"Fer seFera $ee5s %+ t" $ee5s. 1"$)grade feFer,$eight "ss, aden"path0, F"miting, etharg0, ;rania nerFepasies, and ;"ma are ;"mm"n presentati"ns.

•

#ther ab"rat"r0 tests sh"ud in;ude C7C $ith pateet;"unt, b""d ;uture, serum ee;tr"0tes %m"nit"ring f"rs0ndr"me "f inappr"priate se;reti"n "f antidiureti;h"rm"ne LSIA!, gu;"se, and ;"aguati"n pr"e%m"nit"ring f"r disseminated intraFas;uar ;"aguati"n.

• Pa;e a 8 T6 PP tuber;uin test "n the f"rearm "f a

patients $ith meningitis in areas $here tuber;u"sis isendemi;.


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• 9adi"graphi; tests – !ead CT s;an need not be r"utine0 perf"rmed

in patients $ith a ;ini;a diagn"sis "f

un;"mpi;ated meningitis %e.g., absen;e "ff";a neur""gi;a signs pri"r t" perf"rming an1P.

– A head CT s;an sh"ud be "btained pri"r t" 1P ifeeFated ICP "r mass esi"n is suspe;ted %e.g.,t" e>;ude abs;ess, subdura emp0ema, braintum"r, "r intra;rania hem"rrhage.

– A head CT s;an "r M9I is perf"rmed in patients$ith meningitis $ith f";a neur""gi;a ndings%e.g., suspe;ted f";a ;"mpi;ati"ns su;h assubdura eusi"n "r emp0ema, pr""nged

"btundati"n "r irritabiit0, sei@ures, $"rseningICP, persistent feFer, persistent0 abn"rma CS/indi;es, and ne"nates %$h" are pr"ne t"abs;ess f"rmati"n.

• C"mpi;ati"ns "f meningitis in;ude sei@ures,

subdura eusi"n, h0dr";ephaus, ;erebrainfar;ti"n, hearing "ss, and deFe"pmenta dea0


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Signs and s0mpt"ms "fmeningitis

Neonate (signs andsymptoms are oftensubtle and nonspecic)

• /eFer "r h0p"thermia• P""r su;5p""r feeding• 1etharg0 "r irritabiit0•

Hea5 "r high)pit;hed ;r0• Sei@ures• Apnea "r respirat"r0 distress• Septi; sh";5Infants • /eFer

• 1etharg0 "r irritabiit0• "miting• 7uging anteri"r f"ntanee• Sei@ures• C"ma•

Septi;• sh";5

• Older child • /eFer• 1etharg0menta status

;hanges %;"nfusi"n;"ma• Pete;hiae "r purpura

%espe;ia0 mening";";;ainfe;ti"ns

• !eada;he• Ph"t"ph"bia• Sei@ures• Septi; sh";5• /";a neur""gi;a ndings

Ata>ia %ab0rinthined0sfun;ti"n "r Festibuarneur"nitis


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ierentia diagn"sis

• 7a;teria meningitis "fFari"us eti""gies

• Asepti; meningitis "rmening"en;ephaitis

• Tuber;u"us meningitis

• /unga meningitis %e.g.,Cryptococcus neoormans,Coccidioides immitis

• 7rain abs;ess,tuber;u"ma

• Parameningeaparaspina

infe;ti"n %e.g., subdura "repidura abs;ess

• Sepsis Sei@ures fr"m "thereti""gies and p"stit;astate

• 9etr"phar0ngea abs;ess• CerFi;a adenitis

• Trauma• Subara;hn"id hem"rrhage

%ruptured AManeur0sm• /";a intra;rania mass

esi"ns %e.g., intra;rania

"r brainstem tum"r• ic!ettsia • Spir";hetes• Metab"i; disturban;es• 7a;teria end";arditis $ith

emb"ism• T">i; ingesti"nsphen"thia@ines

• C"agen Fas;uardiseases

• Maaria• T0ph"id feFer


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Treatment•

Empiri; treatment "f ba;teria meningitis inpatients O- $ee5s "f age: – Pr"Fide ;"Ferage f"r G7S, E. coli, and Listeria. – Ampi;iin %+'')&'' mg5g per da0 diFided eFer0 *

h"urs and ;ef"ta>ime %'' mg5g per da0 diFided

eFer0 2 h"urs or ampi;iin and an amin"g0;"side%e.g., gentami;in – C"nsider antiFira therap0 if herpes is suspe;ted

%$hie a$aiting ;"nrmati"n "f ba;teria meningitis.

• Empiri; treatment "f ba;teria meningitis inpatients - $ee5s t" +& $ee5s "f age: – Pr"Fide ;"Ferage f"r H. infuenzae, pneum";";;i,

and mening";";;i. – an;"m0;in %*' mg5g per da0 diFided eFer0 *

h"urs and ;ef"ta>ime %&&8 t" '' mg5g per da0diFided eFer0 2 h"urs or ;eftria>"ne %+'' mg5g per

da0 diFided eFer0 +& t" &- h"urs


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• Empiri; treatment "f ba;teriameningitis in patients +& $ee5s "f

age: – Pr"Fide ;"Ferage f"r pneum";";;i and

mening";";;i.

– an;"m0;in and ;ef"ta>ime or ;eftria>"ne

• !"spitai@e a patients $ith a ;ini;adiagn"sis "f meningitis. – Patients presenting $ith septi; sh";5

re?uiring resus;itati"n %e.g.,

mening";";;emia $i need IC6 m"nit"ring. – Patients as" need standard and dr"pet

pre;auti"ns f"r the rst &- h"urs afterinstituti"n "f appr"priate antibi"ti;s.

Laporan Kasus Meningitis Pada Anak

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