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Abstrak

Asma Persisten Sedang, Penyakit Graves, Sirosis Hepatis Kompensata Dan Ikterus ec Drug induce PTU
Andri Rais, Regan Lesmana S, RM. Dewi*, Yulianto K*, Alwi Shahab*
Divisi Endokrin dan Metabolik, Departement Ilmu Penyakit Dalam FK UNSRI/RSMH Palembang*

Pendahuluan : Asma merupakan suatu penyakit hipersensitifitas yang ditandai adanya obstruksi saluran napas reversibel, yang dapat membaik secara spontan atau pengobatan. Penyakit graves merupakan penyakit autoimun pada tiroid yang ditandai adanya thyrotropin receptor stimulating antibodies sehingga terjadi tirotoksikosis. Sirosis hepatis merupakan suatu penyakit hati stadium akhir yang bersifat progresif ditandai dengan fibrosis hati dan nodulus regeneratif. Kasus ini diangkat karena masalah terapi, dimana terapi penyakit Graves (PTU dan propanolol) dapat memperburuk penyakit asma bronkial dan sirosis hati, sebaliknya terapi penyakit asma (aminofilin dan salbutamol oral)) juga dapat memperburuk penyakit Graves. Laporan Kasus : Anamnesis. Seorang wanita 28 tahun datang dengan keluhan utama sesak nafas sejak 1 hari SMRS. Dari perjalanan penyakit, sejak 1 bulan sebelum masuk rumah sakit pasien mengeluh sesak nafas, terutama saat terkena cuaca dingin dan debu, sesak disertai mengi, ada batuk berdahak putih. Pasien juga mengeluh tangan sering gemetar, banyak keringat, dan berdebar-debar, berat badan menurun. Pasien berobat ke rumah sakit dan dikatakan sakit asma dan tiroid, lalu diberi obat PTU dan lainnya sehingga keluhan berkurang. Sejak 2 minggu sebelum masuk rumah sakit pasien mengeluh mata menjadi kuning tapi tidak berobat, pasien masih tetap meneruskan minum obat lamanya. Sejak 1 hari sebelum masuk rumah sakit pasien mengeluh sesak napas hebat, disertai mengi, os bicara dengan kalimat terputus-putus, disertai batuk berdahak putih. Mata kuning makin bertambah bahkan sampai ke seluruh badan, BAK seperti teh tua. Lalu pasien berobat ke RSMH dan dirawat. Dari riwayat penyakit dahulu pasien pernah menderita asma sejak 5 tahun yang lalu, Rinitis sejak 6 tahun yang lalu, alergi makanan (ikan laut dan udang). Asma dalam keluarga ada yaitu ibu, nenek dan pamannya. Pemeriksaan fisik dan penunjang, Data yang mendukung Asma adalah respirasi 30 x/ menit, ekspirasi memanjang, wheezing ekspirasi, feses rutin normal, spirometri terdapat obstruksi berat, rontgen toraks normal. Data yang mendukung penyakit Graves adalah Nadi 120 x/menit, reguler, eksoftalmus, tidak ada struma, indeks wayne 22, T3 1,39 nmol/l, T4 157,4 nmol/l, FT4 1,31 nmol/l, TSH < 0,005 nmol/l, EKG sinus takikardi, konsul mata tidak ada tanda-tanda eksoftalmus, TRAb 10,9 iu/L (positif). Data yang mendukung Sirosis hati adalah venektasi di abdomen, trombositopenia (49.000/mm3), HBsAg negatif, Anti HCV negatif, AMA (negatif), USG abdomen terdapat sirosis hati. Data yang mendukung ikterus ec drug induced PTU (riwayat makan obat PTU bulan, sklera ikterik, Ikterus (bilirubin total 7,94 mg/dl, direk 4,18 mg/dl, indirek 3,56 mg/dl), SGOT 50 u/l, SGPT 26 u/l, LDH 719 U/l, GGT 32 u/L, alkali fosfatase 132 u/L, ikterus membaik setelah PTU distop (bilirubin total 3,54 mg/dl, direk 2,02 mg/dl, indirek 1,52 mg/dl. Kesimpulan. Pasien didiagnosis dengan asma persisten sedang, penyakit Graves, sirosis hepatis kompensata, dan Ikterus ec drug unduced PTU, yang ditatalaksana dengan stop PTU (diganti dengan metimazole tab 1x10 mg), ventolin inhaler 200 mcg (jika sesak), budenoside inhaler 3 x 200 mcg, dan digoksin 1 x 0,125 mg. Kata kunci: Asma persisten sedang, Graves disease, Sirosis hepatis, ikterus.

Abstract

Moderate Persistent Asthma, Grave's Disease, Compensated liver cirrhosis, And Icteric ec Drug Induced PTU
Andri Rais, Regan Lesmana S, RM. Dewi, Yulianto K, Alwi Shahab* Endocrine and Metabolic Division, Department of Medicine FK UNSRI / RSMH Palembang*

Introduction. Asthma is a hypersensitivity disease characterized by reversible airway obstruction, that may resolve spontaneously or treatment. Graves Disease is an autoimmune disease characterized by thyrotropin receptor stimulating antibodies that cause thyrotoxicosis. Hepatic cirrhosis is an endstage liver disease progressively that is characterized by liver fibrosis and regenerative nodules. This case is very interesting because there is a treatment problem, some drugs for Graves disease (PTU and propanolol) can worsen bronchial asthma and hepatic cirrhosis condition, conversely drugs for brochial asthma (oral aminofilin and salbutamol) can worsen Graves disease condition. Case Report : Anamnesa. A 28 years old woman comes with a chief complaint of shortness of breath since 1 day before entering the hospital. From the course of disease, since 1 months before entering the hospital the patient complained of shortness of breath, especially when exposed to cold weather and dust, also accompanied by wheezing, cough with white phlegm. Patients also complain of frequent hand shaking, a lot of sweat, and palpitations, weight loss. Patients treated at the hospital and said to asthma and thyroid, then the patient is given PTU drug and others that grievance is reduced. Since 2 weeks before entering the hospital the patient complained of the eyes become yellow but did not seek treatment, patients still continue taking medication ever. Since 1 day before entering the hospital the patient complained of severe shortness of breath, also accompanied by wheezing, patient speak with disjointed sentences, coughing with white phlegm. Yellow eyes growing even to the body, old teacolored urine. Then the patient went to RSMH and treated. From the history of the disease before the patient suffered from asthma since 5 years ago, rhinitis since 6 years ago, there was a food allergy (fish and shrimp). His family have asthma to (mother, grandmother and uncle). Physical and additional examination, supporting data to bronchial asthma are respiratory rate 30 bpm, lengthening expiration, expiratory wheezing, routine stool is normal, there is a severe obstruction from spirometry, chest X-ray is normal. The data support to Grave's disease are pulse 120 bpm, regular, eksoftalmus, no goitre, wayne index is 22, T3 level 1.39 nmol/l, T4 level 157.4 nmol/l, FT4 level 1.31 nmol/l, TSH level < 0.005 nmol/l, ECG is sinus tachycardia, no signs of exopthalmus according to opthalmologist, TRAb level 10.9 IU/L (positive). The data support to liver Cirrhosis are abdomen venectasy, thrombocytopenia (49.000/mm3), HBsAg is negative, Anti HCV is negative, AMA is negative, there is liver cirrhosis from abdominal ultrasound. The data support to icteric ec drug induced PTU are medication history of PTU since months before, icteric schlera, icteric (total bilirubin 7.94 mg/dl, direct 4.18 mg/dl, indirect 3.56 mg/dl), AST 50 U/L, ALT 26 U/L, LDH 719 U/L, GGT 32 U/L, alkaline phosphatase 132 U/L, icteric improved after PTU was stopped (total bilirubin 3.54 mg/dl, direct 2.02 mg/dl , indirect 1.52 mg/dl. Conclusion. Patients diagnosed with moderate persistent asthma, Grave's disease, compensated liver cirrhosis, and icteric ec drug unduced PTU, which is treated by stop PTU (replaced by metimazole tab once daily), Ventolin inhaler 200 mcg (if crowded), budenoside inhalers 200 mcg three times daily, and digoxin 0.125 mg once daily. Keywords. Moderate Persistent Asthma, Grave's Disease, Compensated Hepatic Cirrhosis, Icteric.