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CASE REPORT

ENCEPHALITIS
Presenter : Debby Lidyanita Fachriza
Febrina Siregar
Day/Date : Tuesday, November 2,200
Su!ervisor : Dr" #isman Da$imunthe, S!"%
CHAPTER I
Introduction
The death rate &or ence!ha$itis are sti$$ high, ranging bet'een ()*)0+" Patients
'ho $ive 20*,0+ have com!$ications or se-ue$ae invo$ving the centra$ nervous
system 'hich can on inte$$igence, motor, !sychiatric, e!i$e!sy, vision or hearing
even the cardiovascu$ar system" .abies 'ho have e/!erienced com!$ications and
ence!ha$itis due to residua$ heavier" .esides, there is no s!eci&ic treatment &or
ence!ha$itis" Treatment is carried out so &ar are nons!eci&ic and em!irica$ aims to
maintain and sustain the $i&e o& every organ system a&&ected"
4
1
CHAPTER II
2.1. Epidemiology
0nce!ha$itis is more common in chi$dren and young adu$ts" %bout in 200,000
!eo!$e deve$o! ence!ha$itis each year in the 1nited States" #hi$e anyone can
succumb, chi$dren, the e$der$y, and those 'ith 'ea2ened immune systems are
more vu$nerab$e"
2
3ncidence o& ence!ha$itis throughout the 'or$d is di&&icu$t to determine
because the disease is o&ten underre!orted" %!!ro/imate$y )0 to (000 cases,
most o& 'hich are mi$d, may occur each year in the 1nited States" 4er!esvirus
accounts &or most cases o& ence!ha$itis in the 1nited States" %rbovira$
ence!ha$itis is more !reva$ent in 'arm c$imates and incidence varies considerab$y
&rom area to area and &rom year to year" St" Louis ence!ha$itis is the most
!reva$ent ty!e o& arbovira$ ence!ha$itis in the 1nited States, and 5a!anese
ence!ha$itis is the most !reva$ent ty!e in other !arts o& the 'or$d"
2
2.2. Deinition
0nce!ha$itis is an in&$ammatory !rocess o& the brain !arenchyma that usua$$y is an
acute !rocess, but maybe a !ostin&ectious ence!ha$omye$itis, a chronic
degenerative disease, or a s$o' vira$ in&ection" 0nce!ha$itis resu$ts &rom
in&$ammation o& the brain !arenchyma, $eading to cerebra$ dys&unction"
0nce!ha$itis may be di&&use or $oca$ized" 6rganisms cause ence!ha$itis by one o&
t'o mechansms : " Direct in&ection o& the brain !arenchyma or 2" %n a!!arent
immunemediate res!onse in the 7NS tahat usua$$y begins severa$ days a&ter the
a!!earance o& e/traneura$ mani&estations o& the in&ection"
2
2.!. Etiology
8iruses are the !rinci!a$ causes o& acute in&ectious ence!ha$itis" 0nce!ha$itis a$so
may resu$t &rom other ty!es in&ection and metabo$ic, to/ic, and neo!$astic
2
disoerder" The most common vira$ causes o& ence!ha$itis in the 1"S" are the
arboviruses, enteroviruses, and her!esviruses" 438 is an im!ortant cause o&
ence!ha$itis in chi$dren and ado$escents and may !resents as an acute &ebri$e
i$$ness, but more common$y is insidious in onset"
2
%cute disseminated ence!ha$omye$itis 9%D0:; is the abru!t deve$o!ment
o& mu$ti!$e neuro$ogic signs re$ated to an in&$ammatory, demye$inating disorder o&
the brain and s!ina$ cord" %cute disseminated ence!ha$omye$itis &o$$o's
chi$dhood vira$ in&ections, such as meas$es and chic2en!o/ or vaccinations" %cute
disseminated ence!ha$omye$itis resemb$es mu$ti!$e sc$erosis"
2
Primary 0nce!ha$itis<this ty!e resu$ts &rom vira$ in&ection o& the brain
and s!ina$ cord" Primary ence!ha$itis may occur in iso$ated cases 9s!oradic; or
occur in many !eo!$e at the same time in the same area 9e!idemic;" The most
common ty!e o& s!oradic in&ection is her!es sim!$e/ ence!ha$itis, 'hich is caused
by the her!es virus" This ty!e carries a high ris2 &or serious neuro$ogica$ damage
and death and can occur in ne'borns i& the virus is !assed &rom the mother to the
in&ant during birth" %rthro!od*borne viruses 9transmitted through the bite o&
insects and tic2s; may cause arbovira$ ence!ha$itis" :os-uitoes are the most
common agents o& transmission and most cases occur during 'armer 'eather,
'hen the insects are more active" %rbovira$ ence!ha$itis and rabies ence!ha$itis
9usua$$y transmitted through the bite o& an in&ected anima$; may be s!oradic or
e!idemic"
3
6ther ty!es o& arbovira$ ence!ha$itis inc$ude the &o$$o'ing= 5a!anese
9'ides!read in %sia;, :urray 8a$$ey 9endemic in %ustra$ia;, Po'assan
9transmitted by tic2s= occurs in 7anada and the northern 1nited States;, Tic2*
borne 9occurs throughout 0uro!e= vaccine avai$ab$e; and 8enezue$an e-uine
9common in 7entra$ and South %merica;"
3
Secondary 0nce!ha$itis<this ty!e deve$o!s as a com!$ication o& a vira$
in&ection or reactivation o& a $atent virus" 8iruses can become reactive 'hen the
immune system is su!!ressed by other conditions 9e"g", ma$nutrition, stress,
3
disease;" 3n&ections that may cause secondary ence!ha$itis inc$ude in&$uenza,
chic2en!o/ 9varice$$a*zoster;, meas$es 9rubeo$a;, mum!s, and >erman meas$es
9rube$$a;" Secondary ence!ha$itis that deve$o!s as a resu$t o& a vario$a virus
in&ection &o$$o'ing sma$$!o/ vaccination or reactivation o& another vira$ in&ection
9ca$$ed acute disseminated ence!ha$itis; is o&ten &ata$"
3
"IRAL
#ENIN$ITIS%ENCEPHALITIS
NON"IRAL CA&SES O'
ENCEPHALITIS
4er!esviruses
* 4er!es sim!$e/
* 8arice$$a*zoster
* 0!stein .arr
* 7ytomega$ovirus
:y/o/!aramy/oviruses
* 3n&$uenza/!arain&$uenzae
* :um!s
* :eas$es
* %denoviruses
* ?abies
* 438
0nteroviruses
* Po$ioviruses
* 7o/sac2ieviruses
* 0choviruses
* Toga viruses /&$aviviruses
508 /#est Ni$e
?oc2y :ountain s!otted &ever
Ty!hoid ,Ty!hus
:yco!$asma
.ruce$$osis
Subacute bacteria$ endocarditis
Sy!hi$is 9meningovascu$ar;
?e$a!sing &ever
Lyme disease
Le!tos!irosis
Tubercu$osis
7ry!tococcus
4isto!$asma
Naeg$eria
%canthamoeba
To/o!$asma
P$asmodium &a$ci!arum
Try!anosomiasis
#hi!!$e@s disease
.ehcet@s disease
4
* 0astern e-uine
* #estern e-uine
* 8enezue$an e-uine
* St" Louis" Po'asson
* :isce$$aneous 7a$i&ornia
8ascu$itis
Tab$e " Pathogens o& 0nce!ha$itis
3
2.(. P)t*op*y+iology
There are at $east t'o &orms o& in&ection*re$ated ence!ha$itis:

!rimary and !ost* or
!arain&ectious" % !rimary ence!ha$itis

resu$ts &rom direct 7NS invasion by the
o&&ending agent, and

the gray matter o&ten is targeted" % !ostin&ectious or
!arain&ectious

ence!ha$itis !resents much $i2e a !rimary ence!ha$itis, but

the
i$$ness is not caused by direct 7NS in&ection" 3n !ost/!arain&ectious

ence!ha$itis,
neuro$ogic e&&ects are the conse-uence o& the

host@s immune res!onse, 'hich
o&ten a&&ects the 'hite

matter"
(
The !athogenesis o& !rimary ence!ha$itis is diverse and incom!$ete$y
understood" 6rganisms in&ecting the brain direct$y &irst must

gain entry to the
7NS" Some !athogens such as arboviruses initia$$y

cause b$oodstream in&ection,
then enter the 7NS via endothe$ia$

ce$$ in&ection, endothe$ia$ ce$$ trans!ort, or
carriage in ce$$s

entering the 7NS" 0nce!ha$itis tends to be a rare com!$ication
a&ter viremia because entry to the brain is care&u$$y regu$ated

at the b$ood*brain
barrier" %n a$ternative mechanism used by

her!es sim!$e/ virus 94S8;, rabies,
and !ossib$y !o$iovirus

is retrograde trans!ort in neurons" This strategy may be
success&u$

because !athogens trave$ing inside neurons avoid immune survei$$ance"
%n a$ternative mechanism used by the amoeba Naegleria fowleri

is entry through
the o$&actory mucosa"
(
6nce an organism has entered the brain, a variety o& anatomic

sites can
become in&ected" For e/am!$e, 4S8 ty!ica$$y in&ects

neurons in the tem!ora$
$obe= rabies !redominant$y a&&ects the

!ons, medu$$a, cerebe$$um, and
5
hi!!ocam!us= and 5a!anese ence!ha$itis

virus a&&ects the brainstem and basa$
gang$ia" Neuro$ogic signs

and sym!toms deve$o! a&ter in&ection as the resu$t o&
direct

neurona$ inAury, the host in&$ammatory res!onse, or both" 4isto$ogica$$y,

the
host res!onse can inc$ude !erivascu$ar in&$ammation, g$iosis,

and brain edema"
Postin&ectious ence!ha$itis occurs days to 'ee2s a&ter the onset

o& an
in&ection" 7urrent$y in the 1nited States, a minor res!iratory

tract in&ection is
$i2e$y to be the inciting event" .e&ore the

'ides!read use o& vira$ vaccines, a
distinctive i$$ness such

as meas$es or varice$$a 'as $i2e$y to be the !receding
event,

and ence!ha$itis may &o$$o' these in&ections in regions 'here

they remain
common" .ecause the inciting !athogen is not detected

in the 7NS in
!ostin&ectious ence!ha$itis, the i$$ness is hy!othesized

to be caused by an aberrant
immune res!onse against brain antigens

such as mye$in basic !rotein" Subse-uent
demye$ination causes

&oca$ or g$oba$ 7NS dys&unction" Postin&ectious ence!ha$itis
o&ten is ca$$ed acute disseminated ence!ha$omye$itis 9%D0:;"
(
2.,. Di)gno+i+
Hi+tory
* %s2 about a vira$ !rodrome 'ith sym!toms such as u!!er res!iratory
in&ection, cough, coryza, ma$aise, anore/ia, decreased entera$ inta2e, diarrhea,
nausea, and vomiting"
* 0nce!ha$itis is o&ten hera$ded by headaches, !hoto!hobia, a sti&& nec2,
increased s$ee!ing, change in menta$ status, irritabi$ity, con&usion,
ha$$ucinations, seizures"
* Prodroma$ sym!toms can range &rom hours to 'ee2s= seizures or sudden
$a!se o& consciousness are uncommon as initia$ sym!toms o& ence!ha$itis"
* 3n-uire about recent trave$ history, !ets, and tic2 or mos-uito bites"
3
P*y+ic)l E-)m
6
%$though the causes di&&er, the c$inica$ sym!toms o& ence!ha$itis is more or $ess
the same and uni-ue so it can be used as diagnostic criteria" 3n genera$, sym!toms
o& ence!ha$itis triad consisting o& &ever, convu$sions and decreased
consciousness"
7
%&ter an incubation !eriod o& a!!ro/imate$y )*0 days there 'i$$ be a
sudden increase in tem!erature, o&ten occur hi!er!ire2sia, big headache in
chi$dren, screaming at the chi$d" Found signs o& 7NS stimu$ation 9coma, stu!or,
$ethargy;, sti&& nec2, increased tendon re&$e/es, tremors, musc$e 'ea2ness and
sometimes !ara$ysis" 7$inica$ mani&estations o& bacteria$ ence!ha$itis, in the
beginning there are no ty!ica$ sym!toms such as genera$ized in&ection, then
emerged signs o& increased intracrania$ !ressure headache, vomiting, no a!!etite,
&ever, b$urred vision, genera$ or &oca$ seizures and decreased consciousness"
Sym!toms o& crania$ Nervi de&icit, hemi!aresis, increased tendon re&$e/es, sti&&
nec2, a!hasia, hemiano!ia, nistagmus and ata/ia"
8
7auses o& neuro$ogica$ abnorma$ities 9neuro$ogica$ de&icit; is a direct
invasion and destruction o& brain tissue by a virus that is being breed= nerve tissue
reaction against vira$ antigens that 'i$$ resu$t in demye$ination, vascu$ar damage,
and !aravas2u$ar= and because the activation reaction neurotro!hic virus that is
$atent"
7
3n vira$ ence!ha$itis ear$y sym!toms o& mi$d headache, &ever, sym!toms o&
u!!er res!iratory in&ections or gastrointestina$ tract &or a &e' days $ater came the
signs o& 7NS in&$ammation, such as sti&& nec2, a sign o& !ositive 2ernig, an/iety,
'ea2ness and di&&icu$ty s$ee!ing" Neuro$ogic de&icits that arise de!ending on
'here the damage" Furthermore, consciousness begins to dec$ine unti$ the coma,
or &oca$ seizures may occur common$y, hemi!aresis, im!aired coordination,
!ersona$ity disorders, disorientation, im!aired s!eech and menta$ disorders"
7$inica$ &indings in ence!ha$itis is determined by 9; 'eight and anatomica$
$oca$ization o& nervous system that $oo2s 92; !athogenicity agents that attac2 9(;
immunity and reactive mechanisms other !atients"
6
7
Di)gno+tic Te+t
Ty!ica$$y, a doctor 'i$$ as2 &or a b$ood sam!$e and order a $umbar !uncture
9sometimes ca$$ed a s!ina$ ta!;, in 'hich a need$e is inserted into the $o'er bac2
and a sma$$ amount o& &$uid 9ca$$ed 7SF or cerebra$*s!ina$ &$uid; is ta2en &rom the
s!ina$ cana$" Some hos!ita$s are a$so e-ui!!ed to ta2e a bio!sy, 'here a tiny
amount o& tissue is ta2en &rom the brain 'hi$e the !atient is under genera$
anesthesia" Doctors a$so &re-uent$y order a 7T scan or :agnetic ?esonance 3mage
9:?3;, in 'hich com!uterized images o& the brain are obtained that sho' the
e/tent o& the s'e$$ing and damage to the brain" %nother test sometimes used to
he$! con&irm a diagnosis is an e$ectroence!ha$ogram 900>;, 'hich records
e$ectrica$ events in the brain"
6
2... Dierenti)l Di)gno+i+
* :eningitis
* 0nce!ha$o!athy
* .rain %bscess
* Subarachnoid hemorrhage
* .rain tumor"
6
2./. Complic)tion
Neuro$ogica$ com!$ications that may be !ermanent or im!rove as the in&ection
runs its course inc$ude the &o$$o'ing= %$tered menta$ state 9e"g", disorientation,
!ersona$ity changes;, convu$sions, droo!ing eye$ids 9!tosis;, doub$e vision
9di!$o!ia;, crossed eyes 9strabismus;, hy!eractive dee! tendon re&$e/es, increased
intracrania$ !ressure, $oss o& consciousness, menta$ retardation, motor
dys&unction, !artia$ !ara$ysis 9!aresis; o& the e/tremities, !roAecti$e vomiting,
!u!i$ irregu$arities, rest$essness, seizures and tremor"
3
8
2./. Tre)tment
Treatment &or ence!ha$itis de!ends on the cause" Some cases o& vira$ ence!ha$itis
can be treated success&u$$y i& medication is started as soon as !ossib$e" 3& her!es
sim!$e/ ence!ha$itis is sus!ected, antivira$ medication such as acyc$ovir
9Bovira/C; or ribavirin 98irazo$eC; is o&ten administered immediate$y to im!rove
chances &or recovery and !revent com!$ications" Side e&&ects o& these medications
inc$ude nausea, vomiting, and headache" Treatment &or vira$ ence!ha$itis a$so
inc$udes !a$$iative care" There is no cure &or arbovira$ ence!ha$itis and the goa$ o&
treatment is to re$ieve sym!toms 9!a$$iative;"
2,3,6
Pa$$iative care may inc$ude intravenous &$uids 9to !revent dehydration;,
antibiotics 9to !revent secondary in&ections;, and other medications 9to !revent
com!$ications;" Diuretics 9e"g", &urosemide, mannito$; may be administered to
reduce intracrania$ !ressure and benzodiaze!ines 9e"g", $oraze!am D%tivanCE; may
be administered to !revent seizures"
2,3,6
Ne' !atients 'ith !ossib$e ence!ha$itis shou$d be hos!ita$ized unti$ the
disa!!earance o& neuro$ogic sym!toms" :anagement obAective is to maintain
organ &unction by $aboring air'ay remains o!en, entera$ or !arentera$ &eeding,
maintaining &$uid and e$ectro$yte ba$ance and acid*base disorders correction o&
b$ood" >overnance is done as &o$$o's
4
:
" 6vercoming cram!s are vita$ action, because seizures in ence!ha$itis is usua$$y
severe" >iving Phenobarbita$ mg/2g../2, )*F hours" 3& seizures occur &re-uent$y,
shou$d be given diaze!am 90" to 0"2 mg / 2g; 38, in the &orm o& in&usion &or (
minutes"
2" 3m!roving homeostasis, 'ith intravenous &$uids D) * / 2 S or D) * / , S
9de!ending on age; and o/ygen de$ivery"
(" ?educe cerebra$ edema and to reduce the im!act by ano2sia cerebra$ 'ith
de/amethasone 0") to "0 mg / 2g / day iv divided into ( doses"
9
," Lo'ering the intracrania$ !ressure rises 'ith :annito$ is given intravenous$y at
a dose o& ") to 2"0 g / 2g &or (0*G0 minutes" >iving can be re!eated every F*2
hours" >$ycero$ can a$so, through the !i!e nasogastri2, 0") to "0 m$ / 2g di$uted
'ith t'o !arts orange Auice" This materia$ is not to/ic and can be re!eated every G
hours &or a $ong time"
)"7ausative treatment"
.e&ore eti$ogi got rid o& bacteria, es!ecia$$y brain abscess 9bacteria$ ence!ha$itis;,
it must be given !arentera$ antibiotic treatment" Treatment &or ence!ha$itis due to
her!es sim!$e/ virus in&ection %cyc$ovir is given intravenous$y, 0 mg / 2g to (0
mg / 2g !er day &or 0 days" 3& there is to$erance then given %denine arabinose
9vidarabin;" So a$so 'hen there is recurrence a&ter treatment 'ith %cyc$ovir" #ith
the e/ce!tion o& the use o& %denine arabinosid to !atients by her!es sim!$e/
ence!ha$itis, the treatment is done is non*s!eci&ic and em!irica$ in order to sustain
$i&e and su!!ort every organ system a&&ected" The e&&ectiveness o& various
treatments are recommended not been assessed obAective$y"
G" Physiothera!y and rehabi$itative e&&orts a&ter the !atient recovered
H" Foods high in !rotein ca$orie diet thera!y"
F" 6ther, better treatment, ear$y consu$ting 'ith an anesthesio$ogist to antici!ate
the need &or arti&icia$ res!iration
2.0. Progno+i+
The !rognosis &or ence!ha$itis varies de!ends on the ty!e o& ence!ha$itis, the
!atientIs age, overa$$ hea$th, and status o& the immune system" Some cases are
mi$d, short and re$ative$y benign and !atients have &u$$ recovery" 6ther cases are
severe, and !ermanent im!airment or death is !ossib$e" The acute !hase o&
ence!ha$itis may $ast &or to 2 'ee2s, 'ith gradua$ or sudden reso$ution o& &ever
and neuro$ogica$ sym!toms" Neuro$ogica$ sym!toms may re-uire many months
be&ore &u$$ recovery" #ith ear$y diagnosis and !rom!t treatment, most !atients
10
recover &rom meningitis" 4o'ever, in some cases, the disease !rogresses so
ra!id$y that death occurs during the &irst ,F hours, des!ite ear$y treatment"
2,4,9
2.1. O23ecti4e
The aim o& this !a!er is to re!ort a case o& 0nce!ha$itis in a boy aged years and
J months o$d"
11
CHAPTER III
!.1. C)+e Report
?, a year and J months o$d boy, 'eight H2g 'ith the height o& JJcm 'as
admitted to 4" %dam :a$i2 4os!ita$ on Se!tember J
th
200, 'ith the chie&
com!$ain is unconsciousness" This has been e/!erienced by the !atient since $ast 2
days" This !atient been having seizure H days in a ro', &recuency K( times !er day
&or L0*20 minutes" 4istory o& seizure be&ore 9M;"Fever 'as &ound since 2 'ee2s
ago" 3t 'as very high &ever but shiverring 'as not &ound" 7ough 9*;, &$u 9*;"
1rination and de&ecation 'as norma$" 4istory o& contact 'ith T.7 !atients
negati&" There is ye$$o'ish &$uid, thic2 and no odor 'as &ound &rom $e&t ear since (
'ee2s ago"
4istory o& de$ivery 'as norma$ and aided by a mid'i&e, crying s!ontaneous$y,
and cyanosis 'as not &ound, her 'ight is 2)00 gram and $enght 'as &orgotten"
4istory o& !regnancy 'as norma$" 4istory o& immunization 'as com!$ete"
Feeding history : 0*) months 'ith breast mi$2"
.e&ore she 'as admitted to 4%: >enera$ 4os!ita$, she 'as consu$ted &rom
!us2esmas Narang ?eAo" The !atient 'as initia$$y diagnosed 'ith high &ever and
seizure"
P*y+ic)l e-)min)tion
6n !hysica$ e/amination, the &o$$o'ing &indings 'ere con&irmed"
% boy, 'ith body 'eight H 2g, body $ength 'as JJ cm, and 03D inde/ 'as F2,()
+, nutritiona$ status 'as normo'eight= body tem!erature 'as (H,(O 7" The $eve$
o& consciousness o& this !atient 'as >S7 90,82:);, anemia 9*; dys!noe 9*;,
edema 9*;, cyanotic 9*;, Aaundice 9*;"
4ead :
12
0ye : $ight re&$e/es 9M/M;, isochoric !u!i$" Pa$e in&erior !a$!ebra
conAunctive 9*/*;
0ars : norma$
Nose : norma$
:outh : u$cus 9M; in mucosa and $i!s
Nec2 : norma$, no $ym!h nodes en$argement
7hest : Symmetrica$ &usi&orm, retraction 9M; e!igastria$, su!rasterna$
4? : G b!m, regu$ar, no murmur
?? : 20 t!m, regu$ar, no ra$es
%bdomina$ : soe!e$, !erista$tic 'as norma$" 4/L : im!a$!ab$e
0/tremities : Pu$se 'as G t!m, regu$ar, norma$ tone and vo$ume
S!astic 9M; at &our e/tremities
Lym!h nodes en$argement 'as not &ound
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;,
:eningea$ ?e&$e/: 9*;
>enita$ia : .oy, there 'ere no abnorma$ities !resent
L)2or)tory inding+ 5Septem2er 16 271789
?outine .$ood 0/amination
* #.7: )"F) / 0
(
/uL * ?.7 : ,"H) / 0
G
/uL
13
* 4b : 2"0 g/dL * PLT : 2J( / 0
(
/uL
.$ood 0$ectro$ic
* Na : (F m0-/L
* N : (,, m0-/L
* 7$ : 0F m0-/L
Liver Pro&i$e
* S>6T 9%ST; : 2H u/L
* S>PT 9%LT; : 2( u/L
Nidney Pro&i$e
* 1reum : , mg/d$
* 7reatinine : 0,G, mg/d$
%rteria$ .$ood >as
* !4 : H",H * Pco2 : 2J"0 mm4g
* Po2 : JG") mm4g * .icarbonate : 20"H
* Tota$ 762 : 2,) * .ase 0/es : *"J
* 62 Saturation : JJ,H +
:or;ing Di)gno+i+ 9
* 0nce!ha$itis
* :eningoence!ha$itis
* :eningitis
14
'urt*er E-)min)tion+ 9
* 7om!$ete b$ood, LFT, ?FT, 0$ectro$it, %>D%
* LP
* Q*ray
* 4ead 7T scan
#edic)tion 9
* 4ead e$evated (0R
* 6
2
*2 L/i
* 38FD D)+ Na7$ 0,J+ = ,Fgtt/i micro
* 3nA" 7e&ota/im G)0mg / G hours / 38
* 3nA" Phenytoin $oading dose 20mg/2gbb in 20 cc Na7$ 0,J+ 9i& seizure;
* Nena$og in orabase 2/ a!!$ic
* >entamycin za$& (/ a!!$ic
* Diet S8 )G0 22a$ M 2G gr !rotein
15
!.2. D)ily 'ollo< &p
Fo$$o' 1! Septem2er 17
t*
6 2717
S 9 1nconciousness 9M;, Seizure 9*;, Fever 9*;
O 9 Sens: >S7 G 908:,;, T: (H,(S7, .#: (2g, .L: J2cm .#/.L:JG,2J+
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : norma$
:outh : u$cus 9M; at $i!s and mouth
Nec2 : Lym!h nodes en$argement 9*;
%/i$$a : !ustu$e 9M;
7hest : Symmetrica$ &usi&ormic, 4? : 0 b!m, regu$ar$y, murmurs 9*;
?? : ,F t!m, regu$ar$y, ra$es 9*;,
stridor 9M;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 0 b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
S!astic 9M; at , e/tremities, !ustu$e 9M;
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M stomatitis M im!etigo bu$osa
*:eningoence!ha$itis M stomatitis M im!etigo bu$osa
*:eningitis M stomatitis M im!etigo bu$osa
P 9 * 4ead e$evated (0R
16
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* 3nA" 7e&ota/im G)0 mg/G Aam/38
* 3nA" %m!ici$$in G)0 mg/G Aam/38, s2in test
* !henytoin $oading dose 2G0 mg in (0 cc Na7$ 0,J+ in (0 minutes,
2 hours $ater maintenance () mg/2 Aam/38 in 0 cc Na7$ 0,J+ in (0
minutes"
* Nena$og inorabase 2/ a!!$ic
* >entamycin Ba$& (/ a!!$ic
* Diet S8 )0 22a$ dengan 20 gr !rotein da$am J00cc cairan
9)0cc/, Aam/N>T;
Fo$$o' 1! Septem2er 11
t*
= 1(
t*
6 2717
S 9 1nconciousness 9M;, Seizure 9*;, Fever 9*;
O 9 Sens: >S7 0 90(82:);, T: (G,FS7, .#: (2g, .L: J2cm .#/.L:JG,2J+
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : norma$
:outh : u$cus 9M; at $i!s and mouth
Nec2 : Lym!h nodes en$argement 9*;
%/i$$a : !ustu$e 9M;
7hest : Symmetrica$ &usi&ormic, 4? : G b!m, regu$ar$y, murmurs 9*;
17
?? : F t!m, regu$ar$y, ra$es 9*;,
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se G b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
S!astic 9M; at , e/tremities, !ustu$e 9M;
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M stomatitis M im!etigo bu$osa
*:eningoence!ha$itis M stomatitis M im!etigo bu$osa
*:eningitis M stomatitis M im!etigo bu$osa
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* 3nA" 7e&ota/im G)0 mg/G Aam/38
* 3nA" %m!ici$$in G)0 mg/G Aam/38, s2in test
* Phenytoin maintenance () mg/2 Aam/38 diencer2an da$am 0 cc Na7$
0,J+ habis da$am (0 menit 9i& seizure;
* Nena$og inorabase 2/ a!!$ic
* >entamycin Ba$& (/ a!!$ic
* Diet S8 )0 22a$ 'ith 20 gr !rotein in J00cc &$uid
9)0cc/, Aam/N>T;
>=R)y Re+ult
%bnorma$ity radio$ogica$ o& the heart and $ung 'ere not &ound
LCS Re+ult
18
* 7o$our : c$ear
* LD4 : 1/L
* Protein : 0,0 mg/dL
* Tota$ o& ce$ : ,0 mm(
* >$ucose : )H,0 mg/dL
* !4 : H
* P:N : di&&icu$t to ana$ize
* :N : di&&icu$t to ana$ize
* 7u$ture : Sta!hy$ococcus Sa!ro!hyticus
#)ntou- Te+t Re+ult
3nduration 9*;
4i!eremis 9*;
?esu$t : 9*;
Fo$$o' 1! Septem2er 1,
t* ?
1.
t*
6 2717
S 9 1nconciousness 9M;, Seizure 9M;, Fever 9*;
O 9 Sens: >S7 0 90(82:);, T: (H,(S7, .#: (2g, .L: J2cm .#/.L:JG,2J+
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : u$cus 9M; at $i!s and mouth
19
Nec2 : Lym!h nodes en$argement 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 0 b!m, regu$ar$y, murmurs 9*;
?? : ,F t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 0 b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
S!astic 9M; at , e/tremities, !ustu$e 9M;
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra M Stomatitis
*:eningoence!ha$itis M :i$iaria ?ubra M Stomatitis
*:eningitis M :i$iaria ?ubra M Stomatitis
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* 3nA" 7e&ota/im G)0 mg/G Aam/38
* 3nA" %m!ici$$in G)0 mg/G Aam/38, s2in test
* 5i2a 2eAang !henytoin $oading dose 2G0 mg diencer2an da$am (0
cc Na7$ 0,J+ habis da$am (0 menit, 2 Aam 2emudian maintenance ()
mg/2 Aam/38 diencer2an da$am 0 cc Na7$ 0,J+ habis da$am (0 menit"
* Nena$og inorabase 2/ a!!$ic
* >entamycin Ba$& (/ a!!$ic
* Diet S8 )0 22a$ dengan 20 gr !rotein da$am J00cc cairan
9)0cc/, Aam/N>T;
20
Fo$$o' 1! Septem2er 1/
t* ?
11
t*
6 2717
S 9 1nconciousness 9M;, Seizure 9M;, Fever 9*;
O 9 Sens: >S7 90,82:);, T: (H,)S7, .#: 22g, .L: J2cm .#/.L:FF,FF+
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : u$cus 9M; at $i!s and mouth
Nec2 : Lym!h nodes en$argement 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 0 b!m, regu$ar$y, murmurs 9*;
?? : ,F t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 0 b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
S!astic 9M; at , e/tremities, !ustu$e 9M;
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
*:eningoence!ha$itis M :i$iaria ?ubra
*:eningitis M :i$iaria ?ubra
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
21
* 3nA" 7e&ota/im G)0 mg/G Aam/38
* 3nA" %m!ici$$in G)0 mg/G Aam/38, s2in test
* 5i2a 2eAang !henytoin $oading dose 2G0 mg diencer2an da$am (0
cc Na7$ 0,J+ habis da$am (0 menit, 2 Aam 2emudian maintenance ()
mg/2 Aam/38 diencer2an da$am 0 cc Na7$ 0,J+ habis da$am (0 menit"
* 3nA" :anito$ 20+ 0,) gr/2g..(0cc/2, Aam
* Nena$og inorabase 2/ a!!$ic
* >entamycin Ba$& (/ a!!$ic
* Diet S8 )0 22a$ dengan 20 gr !rotein da$am J00cc cairan
9)0cc/, Aam/N>T;
He)d CT Sc)n re+ult
%tro&i cerebra$ corte/, hidrose&a$us comunicans, ischemic, and in&ar2
bi$atera$occi!ita$ $obes e"c meningitis
Fo$$o' 1! Septem2er 27
t*
6 2717
S 9 1nconciousness 9M;, Seizure 9*;, Fever 9*;
O 9 Sens: >S7 90,82:);, T: (G,)S7, .#: ,2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : norma$
22
Nec2 : Lym!h nodes en$argement 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 2G b!m, regu$ar$y, murmurs 9*;
?? : ,F t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 0 b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
S!astic 9M; at , e/tremities, !ustu$e 9M;
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
*:eningoence!ha$itis M :i$iaria ?ubra
*:eningitis M :i$iaria ?ubra
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* 3nA" 7e&ota/im G)0 mg/G Aam/38
* 3nA" %m!ici$$in G)0 mg/G Aam/38, s2in test
* 3nA" :anito$ 20+ 0,) gr/2g.. (0cc/2, Aam 94( a&&;
* Phenytoin 2 / )0 mg
* Nena$og inorabase 2/ a!!$ic
* >entamycin Ba$& (/ a!!$ic
* ?es!eridon 0,(mg / 9night; &or ( days
* Diet S8 )0 22a$ dengan 20 gr !rotein da$am J00cc cairan
9)0cc/, Aam/N>T;
23
Fo$$o' 1! Septem2er 21
t* ?
2!
t*
6 2717
S 9 1nconciousness 9M;, Seizure 9*;, Fever 9*;
O 9 Sens: >S7 90,82:);, T: (G,)S7, .#: ,2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : norma$
Nec2 : Lym!h nodes en$argement 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 2G b!m, regu$ar$y, murmurs 9*;
?? : ,F t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 0 b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
S!astic 9M; at , e/tremities, !ustu$e 9M;
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* 3nA" 7e&ota/im G)0 mg/G Aam/38
* 3nA" %m!ici$$in G)0 mg/G Aam/38
24
* Phenytoin 2 / )0 mg
* 1rda&a$2 (/,0 mg
* ?es!eridon 0,(mg / 9night; &or ( days
* Diet S8 200 22a$ dengan 20 gr !rotein da$am J00cc cairan
9)0cc/, Aam/N>T;
* Fisiotera!i
EE$ Re+ult
Norma$
.anya2 diAum!ai arte&a2 07>
Fo$$o' 1! Septem2er 2(
t* ?
2.
t*
6 2717
S 9 1nconciousness 9M;, Fever 9*;, 1ncontro$$ed movement 9M;
O 9 Sens: >S7 ( 90,8,:);, T: (G,FS7, .#: ,2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : norma$
Nec2 : Lym!h nodes en$argement 9*;, nec2 sti&ness 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 2 b!m, regu$ar$y, murmurs 9*;
?? : 2G t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
25
0/tremities: Pu$se 2 b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* 3nA" 7e&ota/im G)0 mg/G Aam/38
* 3nA" %m!ici$$in G)0 mg/G Aam/38, s2in test
* Phenytoin 2 / )0 mg
* ?es!eridon 0,(mg / 9night; &or ( days
* >entamycin Ba$&
* 1rda&a$2 (/,0mg 94;
* Diet S8 )0 22a$ dengan 20 gr !rotein da$am J00cc cairan
9)0cc/, Aam/N>T;
Fo$$o' 1! Septem2er 2/
t*
6 2717
S 9 1nconciousness 9M;, Fever 9*;, 1ncontro$$ed movement 9M;
O 9 Sens: >S7 2 90,8(:);, T: (H,(S7, .#: ,2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
26
Nose : N>T
:outh : u$cus 9M; at $i!s and mouth
Nec2 : Lym!h nodes en$argement 9*;, nec2 sti&ness 9*;
7hest : Symmetrica$ &usi&ormic, 4? : G b!m, regu$ar$y, murmurs 9*;
?? : (G t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 2 b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* 3nA" 7e&ota/im G)0 mg/G Aam/38
* 3nA" %m!ici$$in G)0 mg/G Aam/38, s2in test
* Phenytoin 2 / )0 mg
* ?es!eridon 0,(mg / 9night; &or ( days
* >entamycin Ba$&
* 1rda&a$2 (/,0mg 94;
* Diet S8 )0 22a$ dengan 20 gr !rotein da$am J00cc cairan
9)0cc/, Aam/N>T;
Fo$$o' 1! Septem2er 20
t*
@ !1
t*
6 2717
27
S 9 1nconciousness 9M;, Fever 9M;, 1ncontro$$ed movement 9M;
O 9 Sens: >S7 2 90,8(:);, T: (F,0S7, .#: ,2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : norma$
Nec2 : Lym!h nodes en$argement 9*;, nec2 sti&ness 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 2F b!m, regu$ar$y, murmurs 9*;
?? : (0 t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 2F b!m, regu$ar$y, Pressure/8o$ume 'as ade-uate"
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* 3nA" 7e&ota/im G)0 mg/G Aam/38 a&&
* 3nA" %m!ici$$in G)0 mg/G Aam/38a&&
* Phenytoin 2 / )0 mg
* ?es!eridon 0,(mg / 9night; &or ( days
* >entamycin Ba$&
28
* 1rda&a$2 (/,0mg 94;
* Diet S8 )0 22a$ 'ith 20 gr !rotein in J00cc &$uid
9)0cc/, Aam/N>T;
* Fisiotera!i
Fo$$o' 1! Octo2er 1
+t
6 2717
S 9 1nconciousness 9M;, Fever 9M;, 1ncontro$$ed movement 9M;
O 9 Sens: >S7 2 90,8(:);, T: (H,JS7, .#: (,)2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : u$cus 9M; at $i!s and mouth
Nec2 : Lym!h nodes en$argement 9*;, nec2 sti&ness 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 20 b!m, regu$ar$y, murmurs 9*;
?? : 2F t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 20 b!m, regu$ar$y, .P : 00/G0 mmhg, Pressure/8o$ume
'as ade-uate"
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
P 9 * 4ead 0$evated (0R
29
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* Phenytoin 2 / )0 mg
* ?es!eridon 0,(mg / 9night; &or ( days
* >entamycin Ba$&
* 1rda&a$2 (/,0mg 94;
* 7etrizin / T tab
* 4ydrocortison cream 2,)+
* Diet S8 )0 22a$ dengan 20 gr !rotein da$am J00cc cairan
9)0cc/, Aam/N>T;
* Fisiotera!i
Fo$$o' 1! Octo2er 2
nd
@ .
t*
6 2717
S 9 1nconciousness 9M;, Fever 9M;, 1ncontro$$ed movement 9M;
O 9 Sens: 7:, T: (H,0S7, .#: ,2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : norma$
Nec2 : Lym!h nodes en$argement 9*;, nec2 sti&ness 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 20 b!m, regu$ar$y, murmurs 9*;
?? : (0 t!m, regu$ar$y, ra$es 9*;
30
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 20 b!m, regu$ar$y, .P : 00/G0 mmhg, Pressure/8o$ume
'as ade-uate"
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* Phenytoin 2 / )0 mg
* ?es!eridon 0,(mg / 9night; &or ( days
* >entamycin Ba$&
* 7etrizin / T tab
* 7a$adin cream
* 4ydrocortison cream 2,)+
* 1rda&a$2 (/,0mg
R% 9 * Physiothera!y (//minggu
L)2 'inding Octo2er ,
t*
6 2717
?outine .$ood 0/amination
* #.7: ("HH / 0
(
/uL * ?.7 : ("JH / 0
G
/uL
* 4b : J"HF g/dL * PLT : 2GJ / 0
(
/uL
31
Fo$$o' 1! Octo2er 2
nd
@ .
t*
6 2717
S 9 1nconciousness 9M;, Fever 9M;, 1ncontro$$ed movement 9M;
O 9 Sens: 7:, T: (H,0S7, .#: ,2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : N>T
:outh : norma$
Nec2 : Lym!h nodes en$argement 9*;, nec2 sti&ness 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 20 b!m, regu$ar$y, murmurs 9*;
?? : (0 t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 20 b!m, regu$ar$y, .P : 00/G0 mmhg, Pressure/8o$ume
'as ade-uate"
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
P 9 * 0$evasi 2e!a$a (0R
* 38FD D)+ Na7$ 0,J+ (G gtt/i mi2ro
* Phenytoin 2 / )0 mg
* ?es!eridon 0,(mg / 9night; &or ( days
* >entamycin Ba$&
32
* 7etrizin / T tab
* 7a$adin cream
* 4ydrocortison cream 2,)+
* 1rda&a$2 (/,0mg
R% 9 * Physiothera!y (//minggu
Fo$$o' 1! Octo2er /
t*
@ 0
t*
6 2717
S 9 1nconciousness 9M;, Fever 9M;, Seizure 9M;, genera$ized, &re- 2/, duration )
:inutes, !a!u$e erythema 9M;
O 9 Sens: >7S G 90282:2;, T: (F,2S7, .#: ,2g, .L: J2cm
4ead :
0yes: $ight re&$e/es 9M/M;, isochoric !u!i$, $o'er eye$ids !a$e 'ere not
con&irmed"
0ars : norma$
Nose : norma$, N>T 9M;
:outh : norma$
Nec2 : Lym!h nodes en$argement 9*;, nec2 sti&ness 9*;
7hest : Symmetrica$ &usi&ormic, 4? : 0 b!m, regu$ar$y, murmurs 9*;
?? : 2F t!m, regu$ar$y, ra$es 9*;
%bdomen : Soe!e$, norma$ !erista$tic" 4/L : in!a$!ab$e
0/tremities: Pu$se 20 b!m, regu$ar$y, .P : 00/G0 mmhg, Pressure/8o$ume
'as ade-uate"
Physio$ogy ?e&$e/: %P? M/MP = NP? M/MP
Patho$ogic ?e&$e/: .abins2y 9*;, 6!!enheim 9*;, >ordon 9*;
33
:eningea$ ?e&$e/ : 9*;
A 9 *0nce!ha$itis M :i$iaria ?ubra
P 9 * 4ead e$evated (0R
* 38FD D)+ Na7$ 0,J+ 20 gtt/i mi2ro
* Phenytoin $oading dose 2F0mg in 2Fcc Na7$ 0,J+ maintenance inA"
Phenytoin )0mg/2 Aam in )cc Na7$ 0,J+
* ?es!eridon 0,(mg / 9night; &or ( days
* 7armabaze!in )mg/2g..
* >entamycin Ba$&
* 7etrizin / T tab
* 7a$adin cream
* 4ydrocortison cream 2,)+
* 1rda&a$2 2/,0mg
R% 9 * Physiothera!y (//minggu
L)2 'inding+ Octo2er 1
t*
6 2717
%rteria$ .$ood >as
* !4 : H"2(0 * Pco2 : 2)"0 mm4g
* Po2 : (2"0 mm4g * .icarbonate : 0
* Tota$ 762 : "0 * .ase 0/es : *)
* 62 Saturation : JG"0 +
.$ood 0$ectro$ic
34
* Na : )H m0-/L
* N : (,( m0-/L
* 7$ : 2) m0-/L
>$ucose
* .$ood : (2 mg/dL
* 1rine : *
T*e p)tient p)++ed )<)y on O;to2er 1
t*
2717 )t 1/.17 p.m.
CHAPTER I"
(.1. Di+cu++ion
0nce!ha$itis is irritation and s'e$$ing 9in&$ammation; o& the brain" 3t o&ten coe/ists
'ith in&$ammation o& the covering o& the brain and s!ina$ cord 9meningitis; and
most cases are caused by vira$ in&ection" 3n&$ammation changes the norma$ b$ood
&$o' in the brain" 3t usua$$y resu$ts &rom an in&ection, most o&ten by a virus, but
sometimes by bacteria, a &ungus, or !arasites" 3n rare cases, it is caused by brain
inAury, a drug or vaccine reaction, or !oison"
.ase on theory the sym!toms o& ence!ha$itis may very 'ide$y de!ending
on the cause and severity" They range &rom no sym!toms in very mi$d cases, to
more severe sym!toms, inc$uding musc$e 'ea2ness 9unsteadiness standing u! or
troub$e 'a$2ing;, headache, &atigue, &ever, nec2 !ain, sti&& nec2, nausea and
vomiting, a &ou$ mood, irritabi$ity, aversion to $ight 9s-uinting;, seizures,
c$umsiness, menta$ con&usion, dro'siness, and a coma 9in severe cases;" :ost
!eo!$e in&ected 'ith an arthro!od*borne virus do not deve$o! ence!ha$itis"
35
3n&ection is usua$$y does not !roduce sym!toms 9ca$$ed asym!tomatic; or causes
&$u*$i2e sym!toms such as &ever, headache, and ma$aise"
3n this case, the diagnosis is estab$ished based on historica$ ta2ing and c$inica$
e/amination that $ead to ence!ha$itis" 4istorica$ ta2ing gained an unconsciousness
that has been e/!erienced by the !atient since $ast 2 days" Fever 'as &ound 'ith
the tem!erature around (H,) *(F,)O7" This !atient been having seizure H days in a
ro' be&ore admitted, &re-uency K( times !er day &or L0*20 minutes, rigid hand
'as &ound" 6ther then that, the !hysio$ogy re&$e/es o& this !atient are higher then
usua$"
To con&irm the diagnosis a doctor 'i$$ as2 &or a b$ood sam!$e and order a $umbar
!uncture, in 'hich a need$e is inserted into the $o'er bac2 and a sma$$ amount o&
&$uid 9ca$$ed 7SF or cerebra$*s!ina$ &$uid; is ta2en &rom the s!ina$ cana$" Some
hos!ita$s are a$so e-ui!!ed to ta2e a bio!sy, 'here a tiny amount o& tissue is ta2en
&rom the brain 'hi$e the !atient is under genera$ anaesthesia" Doctors a$so
&re-uent$y order a 7T scan or :agnetic ?esonance 3mage 9:?3;, in 'hich
com!uterized images o& the brain are obtained that sho' the e/tent o& the s'e$$ing
and damage to the brain" %nother test sometimes used to he$! con&irm a diagnosis
is an e$ectroence!ha$ogram 900>;, 'hich records e$ectrica$ events in the brain"
For this !atient 'e had done severa$ !rocedures such as LFT, .$ood cu$ture,
Lumbar Puncture, mantou/ test, Q*ray, 00>, and 4ead 7T scan" The resu$t &or
the $umbar !uncture is L7S ana$ize 'ithin norma$ $imits" The resu$t &or 00> is
norma$" For radio$ogy the resu$t is norma$ and :antou/ test 'as negati&" Fina$$y
4ead 7T resu$t are atro&i cerebra$ corte/, hidrose&a$us comunicans, ischemic, and
in&ar2 bi$atera$occi!ita$ $obes e"c meningitis"
Treatment &or vira$ ence!ha$itis a$so inc$udes !a$$iative care" There is no cure &or
arbovira$ ence!ha$itis and the goa$ o& treatment is to re$ieve sym!toms 9!a$$iative;"
Pa$$iative care may inc$ude intravenous &$uids 9to !revent dehydration;, antibiotics
9to !revent secondary in&ections;, and other medications 9to !revent
com!$ications;" Diuretics 9e"g", &urosemide, mannito$; may be administered to
36
reduce intracrania$ !ressure and benzodiaze!ines 9e"g", $oraze!am D%tivanCE; may
be administered to !revent seizures"
The !atient 'as given o/ygen, 38FD D)+ Na7$ 0,22)+, 3nA" 7e&ota/ime, inA"
%m!ici$$in, inA" Phenytoin, 3nA" :anito$, Paracetamo$ tab$et, ?is!eridon tab$et, and
7etrizine tab$et"
(.2. Summ)ry
3t has been re!orted a case o& a boy, year and J months years o$d 'ith
ence!ha$itis" The diagnosis 'as estab$ished based on anamnesis, c$inica$ sign,
sym!toms, and !hysica$ e/amination" The !rognostic o& this !atient 'as not good"
Fina$$y, the !atient !assed a'ay on the J
th
o& march 200 at H") 'ith cause o&
death being metabo$ic asidosis"
RE'ERENCES
"
2" N$iegman, 5enson, :arcdante, .ehrman 200G, 0ssentia$s o& !ediatrics,
Fi&th edition, 4 : ,F(*,FG, SteF00, Phi$ade$!hia"
3. Le'is, P" >$aser, 7%, Pediatrics in revie', 0nce!ha$itis" 6&&icia$ 5ourna$
6& The %merican %cademy 6& Pediatrics" 200)"
4. %nonim JF), 0nse&a$itis da$am 4asan ?", 3$mu Nesehatan %na2, h : G22*
G2,, Fa2u$tas Nedo2teran 1niversitas 3ndonesia" 5a2arta"
5. >ondim, F%%" 6$iveira, >" Thomas, FP" 8ira$ 0nce!ha$itis D cited 200F
6ctober ,E" %vai$ab$e &rom: 1?L:
htt!://emedicine"medsca!e"com/artic$e/GG,JF*overvie'"
%ccessed 6ctober 2), 200
6. Ne$son, d22" :eningoense&a$itis 8irus, 3$mu Nesehatan %na2 Ne$son, h :
FF2*FF," 07>" 5a2arta
37
7. %nonim 2000, 0nse&a$itis da$am %ri& :, Na!ita Se$e2ta Nedo2teran, 0disi
(, 5i$id 2, h: G0*GG, :edi2 %escu$a!ius FN 13, 5a2arta"
F" Nem!e, 7"4", JF2, 3n&ections, bacteria$ and S!irochaeta$ 3n 5erry L" 0$$er,
7urrent Pediatric Diagnosis and Treatment, H ed", ! : H(2*H((, Lange
:edica$ Pub$ications, Los %t$os, 7a$i&ornia"
38