FAKULTAS KEDOKTERAN

UNIVERSITAS MUSLIM INDONESIA MAKASSAR, 10 JULI 2018

LAPORAN KELOMPOK PBL

“MODUL IMUNOLOGI”
BLOK IMUNOLOGI DAN HEMATOLOGI

Pembimbing : dr. Rachmat Faisal Syamsu, M.Kes

Disusun oleh Kelompok 15 :

Andi Azizah Nur F.S 11020170030 Siti Alzavira Chairunnisa 11020170095

Rahmi Utami 11020170024 Jihan Rana Mardhiyah 11020170115
Ari Savira Alda 11020170044 M. Ilhamsyah Dandung 11020170008
Muhammad Fakhri 11020170069 Adibah Afriastini Wenni 11020170133
M. Avizena Ilhami. S 11020170078 Afifah Syahbani Zainal 11020170110

FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA
MAKASSAR
2018
SCENARIO
A 48-year-old man came to the puskesmas complaining of red spots on both hands and feet.
Experienced since 2 days ago. 5 days earlier it looks like a mosquito bite in the right arm,
which then enlarges and extends into both arms, folding elbows and knees and legs. Itching
feels especially in the afternoon or when sweating so patients often scratch it. There was no
pus in the scratch. Patients also feel dry skin. Previous history of the same disease does not
exist. No history of allergies. The same history of the disease in the family is unknown. The
history of treatment with itchy powder is present but the itch decreases temporarily and
reappears.

KEYWORDS
• 48-year-old man
• Reddish spots on both hands and feet
• 5 days earlier looks like mosquito bites
• Itching in the afternoon
• No pus
• Dry skin
• No allergies
• The same family history of the disease is unknown

QUESTION
1. Explain the anatomy of histology and immune matter on the skin!
2. What causes the patient to experience itching, dry skin and redness?
3. Why 5 days ago the skin had symptoms as appropriate
scenario!
4. The association of no history of allergy with symptoms of the patient's natural
5. Differential diagnosis related to the scenario!
6 .The management of the symptoms in the scenario!
7. How in the perspective of Islam?
Answer

1. Explain the anatomy of histology and immune matter on the skin!

a. Anatomy of skin histology
I. Anatomy of the skin

Sistem imun Penyebab

spesifik infeksi

Sistem imun Pertahanan

non spesifik eksternal

Jaringan kulit
Epidermis,
Dermis, dan
Hipodermis
 Tissue information

Epidermis Contains four types of resident cells, Melanocytes, creatinocytes,

Langerhans cells, and Granstein cells plus T lymphocytes that
spread throughout the epidermis and dermis.
Kreationsit, secretes IL-1 (a product secreted by macrophages),
which affects T cell maturation.
Langerhans cells, antigen review cells, Skin also warns the
lymphocyte of the soul of a barrier violated by microorganisms.
Langerhans cells, presenting antigens to T cells and accelerating
cell responsiveness to skin-related antigens.
Dermis Many elastin fibers and collagen fibers as well as many blood
vessels.
Hipodermis Subcutaneous tissue, a loose connective tissue layer. Filled by
adipose tissue.

II. Skin Histology

I. EPIDERMIS

The epidermis is primarily the epithelial epithelium of berkreatin called creatinocyte.

epidermis presents the main difference between the thick skins found in the palms of the
hands and feet, with thin skins found on other body parts. Three types of epidermal cells that
are fewer in number are also found, among others: melanocytes, Langerhans cell antigen
presenter, and Merkel cells

The epidermis consists of five layers of creatinocytes, the five layers of thick skin

a) The basal layer (basal basal) consists of a layer of cuboid cell or basophilic columnar
located above the basement membrane on the epidermis-dermis border. Hemisdesmosomes,
which are present in the basmalema of basal and desmosomes, increase these coated cells
together at the top and lateral surfaces. Stratum basale is characterized by high mitotic
activity and is responsible for the joints with the early part of the next layer on the production
of epidermal cells in conjunction.

All creatinocytes in the basal stratum contain a 10 nm diameter filament consisting of keratin.
b) Spinosa layer (stratum spinosum), normally the thick paaling layer of the epidermis
consists of cuboid or somewhat flat cells with a central nucleus and a cytoplasm that actively
synthesizes keratin. The keratin filament forms a beam and looks microscopically, called
converging tonofibrils and ends in a number of desmosomes that connect cells together
strongly to avoid friction.

c) Granular layer (stratum granulosum), is 2 or 3 layers of flat cells with coarse grained
cytoplasm and there is a core of them. These coarse grains consist of keratohyalin. Mucosa
usually does not have this layer. Stratum granulosum is also visible in the palms of the hands
and feet.

d) Startum Lusidum, found only in thick skin, and consists of a very thin layer of
transuscinate eucinophilic cells. The organelles and nuclei have disappeared and the
cytoplasm is almost entirely composed of solid keratin filaments imprinted in an electron-
solid matrix. Desmosomes are still visible between adjacent cells.

e) Stratum Corneum, horn layer. The outermost layer of skin and consists of several layers of
dead, non-core, and protoplasmic cells have been transformed into keratin (horn)

II. DERMIS

The dermis is the connective tissue that supports the epidermis and binds it to the
subcutaneous tissues. The thickness of the dermis varies, depending on the body area, and
reaches a maximum thickness of 4 mm in the back area. The surface of the dermis is very
irregular and has many protuberances (dermal papilla) that interlock with epidermal stretches
(epidermal rounds). Papilla dermis is more prevalent in the skin that often experience
pressure, where this papilla strengthens the dermis-epidermis link.

The dermis consists of two layers with unreal borders, an outer papillary layer and a deeper
reticular layer.

a) A thin Papillar layer composed of loose connective tissue, with fibroblasts and other
connective tissue cells, such as mast cells and macrophages. Leukocytes coming out of the
vessels are also present. From this layer, the inhibiting fibrils of type VII collagen slip into
the basal lamina and bind the dermis to the epidermis. \

b) The reticular layer is thicker, consisting of an irregular solid connective tissue (especially
type I collagen), and has more fibers and fewer cells than the papillary layer. Elastin fiber
tissue is also found which results in skin elasticity. The space between collagen and elastin
fibers is filled with proteoglycans rich in sulfate dermatics.

Dermis is a place of epidermal derivatives in the form of hair follicles and glands. There are
many nerve fibers in the dermis. The effector nerve that runs into the dermis structure is a
symbiotic ganglia pascaganglionik sympathetic, there is no parasympathetic innervation.
Sensory afferent nerve fibers form a braid in the dermal papilla and around the hair follicle,
which ends in epithelial tactile cells, on the sensory receptors in the dermis, and part of the
nerve endings (unlike) between the epidermal cells

III. SUBKUTAN

The subcutaneous layer consists of a loose connective tissue in the lower organs, which
allows the skin to shift above it. The layer, also called hypodermis or facia superficialis, often
contains fat cells whose numbers vary according to the body area and sizes that vary
according to nutritional status. Extensive vascular supply in the subcutaneous layer increases
the rapid uptake of insulin and drugs injected into this tissue.

IV. SKIN GLANDS

a) The sebaceous glands, which are the holocrin glands, are drowned in varying dermis
ranging from 100 to 900 per centimeter square. The sebaceous gland is a branched acinar
gland with a number of asini that empties into the short duct and usually ends at the top of the
hair follicle. Asini consists of a basal layer of undifferentiated flat epithelial cells located
above the basal lamina. These cells berpoliferasi and shift toward the mid-acinus, which
undergoes terminal differentiation in the form of large lipid-producing lipids with cytoplasm
filled with small fat droplets. The point gradually furrows and undergoes autophagi along the
other organelles and near the duct, separated cells and lipids undergo a holocrin secretion.
The result of the process is sebum, which gradually moves to the surface of the skin along the
duct or follicle.

b) Sweat glands, is an epithelial derivate embedded in the dermis that opens onto the surface
of the skin or into the hair follicle. The eccrine sweat glands and apocrine sweat glands differ
greatly. The eccrine sweat gland, a cylindrical tubular gland curled up with a duct that
empties into the skin surface. The duct is unbranched and has a smaller diameter than its
secretory section of 0.4 mm. there are two kinds of mioepithelial cells that surround the part
of the skeeter, the dark cells containing secretory granules and bright cells that do not contain
the secretory granules. Apocrine sweat glands, have a larger size (3-5 mm) of eccrine sweat
glands. This gland is immersed in

2. What causes the patient to experience itching, dry skin and redness?

Symptoms on the scenario:

1. Reddish Patomechanism

Because of the emergence of redness, red (erythema) due to changes in vascular changes in
the caliber and blood vessel flow. This change begins after a temporary vasoconstriction (a
few seconds), arterial vasodilation occurs, resulting in increased blood flow and localized
blockage (hyperemia) in subsequent capillary blood flow. Dilation of these blood vessels is
the cause of the red color (erythema)

2. Patomekanisme Itching and Pain

Itching is a perception due to the arousal of the mechanoreceptor fibers. Usually impulse
starts from the stimulation of the surface, for example in the propagation of lice, irritant
materials, insect bites. The itching sensation is usually followed by a scratching reflex that
aims to give sufficient pain sensation so that the itching signal on the spinal cord can be
suppressed. The cause of itch is very diverse, among others

• Allergic reactions (hypersensitivity type 1)

• Establishment of complement system

• Inflammation

• Physical exposure

• Stress

• Autoimmun

• Systemic disease

• Malignancy

• Irritant materials

• Drugs
Each cause factor has different pathomechanism pathways, but in the end all mechanisms will
be associated with histamine release as an inflammatory mediator causing pruritus ataugatal.
Histamine is formed by tissue mast cells and basophils. The release is stimulated by the
antigen-antibody complex (IgE), allergicone I, activation of complement (C3a, C5a), burning,
inflammation, and some drugs. Histamine through H1 receptors and elevated cellular Ca2 +
concentrations in the endothelium will cause endothelias to release NO, which is an arterial
and venous dilator. Through histamine H2 receptors also causes dilation of small blood
vessels that are independent of NO. Histamine increases protein permeability in capillaries.
Thus, plasma proteins are filtered under the influence of histamine, and the oncotic pressure
gradient passing through the capillary wall will decrease resulting in edema.

When a mast cell produces histamine, it can immediately sensitize the end of the C fibers
located in the superficial part of the skin. The C nerve includes an unmyelial nerve that also
acts as an amorous receptor. After the impulse is received by the C, the impulse is continued
by the absurdity of the predictor and then proceeded to the spinal cord. Padakomisura anterior
medulla spinalis impulse crossed kekolumna alba anterolateral opposite side. Then up the
brain stem or thalamus to be interpreted as an itching sensation. This sensation then
stimulates the reflex scratching to provide sufficient pain sensation to then suppress the itchy
signal on the spinal cord.

3. Dry skin

The skin is the outermost layer of the body covering which functions as a barrier to all
forms / kinds of trauma from outside both physical, mechanical and chemical. In addition, as
well as cover the body of aesthetic value with a look that looks smooth, soft and shiny. In
certain circumstances the skin looks rough dry scaly that looks dull, no longer interesting.

Dry skin or xerosis is defined to describe the loss or decrease in stratum corneum
(SC) moisture content. The skin looks and feels healthy when the outer layer contains 10%
water. Increased tranepidermal water loss (TEWL) that causes dry skin due to a skin disorder
that causes a lot of water to evaporate into the atmosphere.

An important dry skin process is the balance between water evaporation and the
ability of the skin to retain water, the function of the skin barrier also plays a role. Therefore
it is important to maintain a healthy skin and improve dry skin to keep the skin looking
beautiful. The basic mechanism for restoring dry skin is by increasing binding and storage of
water by application of water-fastening agents or moisturizers, lubricants or emollients and
leather covers or conditioners. Under normal circumstances, water flows by diffusion from
the dermis to the epidermis through its two ways through the stratum corneum (sc) and
intercellular space. Therefore normal water will come out of the body through the epidermis,
the condition is known as trans epidermal water loss (TEWL). Normal TEWL ranges from
0.10.4 mg / cm2 per hour. The passive diffusion process occurs because of differences in the
water content of the basal stratum (60-70%), stratum granulosum (40-60%) and stratum
corneum less than 15% so that water flows from the stratum basaliske stratum corneum.
Thus, SC is a hydration barrier that is very important in maintaining skin moisture. In the sick
skin as in psoriasis daneczemal (there are epidermal abnormalities), the skin barrier is
weakened so that TEWL fat increases 10 times greater than normal. On the other hand, SC
consists of non-nucleated cells containing protein (profilaggrin, filaggrin and keratohyalin
garnules) and intercellular space containing lipids and SC membranes (ceramide, FFA and
cholesterol) and natural moisturizing agents (NMF ) that has a very strong water binding
ability. In addition, enzymes, enzymes present in the intercellular space can also cause
changes in the intercellular lipid composition that may affect TEWL.

Ceramide is a major component of the SC intercellular lipids and contains many

acidicloyds. The bond between ceramide and water will form a smooth emulsion so that it
looks smooth and soft. In certain circumstances, low-temperature weather with relatively low
humidity, the bond between ceramide and water will crystallize so that the skin becomes dry
rough and dull. In the SC aging process is still intact but the function of the barrier has
decreased. This is due to the low number of natural moisturizing factors causing a decrease in
water binding capacity of approximately 75% of normal, consequently TEWL increases.

Patients with dry skin are usually itchy and will scratch. On physical examination, this patient
will show secondary changes of thickening or lichenification, erosion and super infection
with moisture, melting and crusting lesions.

In the aging process will occur drought due to the ability of stratum corneum bind water is
reduced, sehinggakulkulkenpapers appear, shrink and hard.
3. Why 5 days ago the skin experience the symptoms according to such a scenario!

In because the previous 5 days the patient exposed to antigen so that our immune system
from innate to adaptive to do its work where to cause homeostasis or to eliminate bacteria or
cells that have been infected with antigen (sick cells) will cause some symptoms of
inflammation where it can cause redness, itching, and dry skin. Which is where the
mechanism has been described in the number 2.

4. The association of no history of allergy with symptoms of the patient's natural!

Here in the scenario it is explained that the patient has no history of allergies, where the
allergy is usually common in the body by the body's excessive response to an object or food
containing allergens. while patients do not have a history of allergies and get symptoms such
as exposed to allergies, it can be caused by the antigens that enter into our body where our
immune system will fight so as to cause inflammatory reactions that cause itching and other,
but it also itch and others can be caused by the stress in the patient's natural where When the
patient is under stress, the body will react. Stress stimulates chemical reactions in the body
that make the patient's skin more sensitive. In addition, there are many nerve endings of
patients connected to the skin so that if the patient's central nervous system reads any
disturbance due to stress, the patient's skin will also react. This condition can also make the
patient's skin more difficult to cure if you are experiencing problems or certain skin diseases.
The problem is, sometimes even the patients themselves are unaware that the patient is under
stress or being overworked. So when the patient experiences a sudden itch, the patient feels
that the cause is unclear. Stress is usually followed by other symptoms such as excessive
sweat production. However, if you are in a hot, humid environment, or the air circulation is
not fluid, sweat actually gets trapped in the skin layer and can not evaporate. This will then
cause prickly heat on the skin that itch. Prickly heat is not harmful, but until it completely
disappears from the surface of the skin you usually need at least two weeks.
5. Differential diagnosis related to the scenario!

There are a number of inflammatory skin diseases, immunodeficiency, genetic diseases,

infectious diseases, and infestations that have similar symptoms and signs with atopic
dermatitis. Atopic dermatitis is diagnosed in comparison with seborrheic dermatitis, contact
dermatitis, numular dermatitis, scabies, ichthyosis, psoriasis, herpetiformis dematitis,
Sezary's syndrome and Letterer-Siwe disease. In infants, it can also be diagnosed as
appealing to the Wiskott-Aldrich syndrome and hyper IgE1 syndrome

6 .The management of the symptoms in the scenario!

a systematic approach is required, including skin hydration, pharmacological therapy, and the
identification and elimination of precipitating factors such as irritants, allergens, infections,
and emotional stressors.
 Systemic therapy

Systemic steroids

Cyclosporine

potent immunosuppressive drugs that work

primarily on T cells by suppressing cytokine

transcription.

Giving:

- Cream or ointment of corticosteroids can reduce the rash and control the itching.

- Antihistamines (diphenhydramine, hydroxyzine) can control the itching, especially

with its sedative effects

7. How in the perspective of Islam?

َ ‫اح ِميْن‬ َّ ‫ت أ َ ْر َح ُم‬

ِ ‫الر‬ َ ‫ض ُّر َوأ َ ْن‬
ُّ ‫ي ال‬ َّ ‫ب أ َ ِنِّى َم‬
َ ‫س ِن‬ ِ ِّ ‫َر‬
Meaning:

"O my Lord! Lo! I have been afflicted with sickness, and Thou art the Most Merciful
of all merciful." (Surat al-Anbiya: 83)
REFERENCE:

1. FKUI. 2012. Kamus Kedokteran FKUI. Jakarta: FKUI.

2.Rengganis, Iris. 2014. Imunologi Dasar FKUI. Jakarta: FKUI.

3.FKUI. ilmu penyakit kulit dan kelamin FKUI edisi V. Jakarta: FKUI

4.Mescher L. Anthony. Histologi Dasar IUNQUEIRA Teks & Atlas edisi 12 : EGC

5.Leung DYM, Eichenfield LF, Boguniewicz M. 2008. Atopic Dermatitis (Atopic

Eczema). In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, David J.
Leffell DJ, editors. Fitzpatrick’s Dermatology in General Medicine, VII ed. New
York: McGraw-Hill

6.Djuanda A, Hamzah M, Aisah S. 2007. Ilmu Penyakit Kulit dan Kelamin, edisi
kelima. Jakarta: Balai Penerbit FKUI.

7.Freddberg IM, Elsen AZ, Wolff K. 2003. et al: Fitzpatrick’s Dermatology General
Medicine, 6th edition. New York: McGraw-Hill.

8.Buku karangan Prof.Dr.dr.M.Athuf Thaha, SpKK.