Demam Tifoid Anak & permasalahannya - SEMINAR NASIONAL ...

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275639. 201252. 136088. 255817. 134065. 2000. 2001. 2002. 2003. 2004. Number of Typhoid fever cases yearly. 13. 9.5. 6.4. 12. 6.2. 2000. 2001. 2002. 2003.
Ida Safitri Laksono

Number of Typhoid fever cases yearly 275639 255817 201252 134065

136088

2000

2001

2002

2003

2004

Incidence rate per 10.000 people of Typhoid fever cases yearly 13 12 9.5

Subdit Surveillance Epd Ministry of Health

6.2

6.4

2000

2001

2002

2003

2004

Bulletin WHO 2008

ƒ

Host barriers ƒ Local   : pH, GIT motility , intestinal flora General : 

humoral and sellular immunity ƒ

Organism ƒ Number of microbes ƒ Virulence (serotype)

ƒ

Antibiotic resistance

Intestinal Epithel Lamina propria Multiplication

Plaque Payeri

phagocytocis Inflamation response endotoxin (local, systemic) Local: inflamation Systemic: cytokine

Thoracic Duct Primary bakteremia

circulation Target Organ RES (Liver, spleen, bone marrow)

Secundary bakteremia Other organs (metastatic)

Incubation period Asimptomatic

Invasive period

Typhoid phase

Convalescence

Intermittent fever Headache Malaise Abdominal pain Constipation Diarrhea

Persistent fever Bradicardia Hepatomegaly Splenomegaly Constipation Diarrhea Rose spot

Carrier Relapse

Complication 370C

Day -15

400C

Day 0

Fever

Day 7

Day 21

ƒ ƒ ƒ

Not specific symptoms and signs Fever ≥ 7 days Gastrointestinal symptoms ƒ Vomiting,  ƒ Diarrhea / obstipation,  ƒ Meteorismus

ƒ ƒ

Delirium, decreasing consciousness Adolescent ~ adult ƒ Toxic appearance, dehidrated,  ƒ Typhoid tongue ƒ hepatomegaly, splenomegaly

Sri Rezeki H, Tumbelaka AR, Satari HI. Sari Pediatri 2001;4:182-7 ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ

Fever Chilling Abdominal pain Nausea Vomiting Diarrhea Obstipation Raving Unconsciousness Typhoid tongue Epigastric pain Hepatomegaly Splenomegaly 10

25

50

75

100

Laboratory scheme of typhoid fever

ƒ

Blood counts ƒ leucopenia, aneosinophilia,  ƒ relative lymphocytosis ƒ thrombocytopenia

ƒ ƒ ƒ ƒ

Increasing BSR,  Increasing SGOT/SGPT Serological test : IgM & IgG Culture of Salmonella typhi

Serological test : Widal test,  Tubex – TF, etc DNA probe IgG of outer cells membrane Immunoblotting (Typhi‐dot) PCR (polymerase chain reaction)

Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ 2006;333:78‐82.

ƒ

Widal test, since 1896 ƒ O antibody, established earlier but for short time only (4 ‐ 6 months),  ƒ H antibody, later and stay longer (9 months – 2 years),  ƒ Vi antibody, late (persist in carriers)

ƒ

Interpretation of Widal test should be taken carefully, depend on :  ƒ Disease stadium  ƒ Laboratory methods ƒ Endemicity of disease ƒ Immunisation history Nsutebu EF, Ndumbe PM, Koulla S. Trans R Soc Trop Med Hyg. 2002 Jan-Feb;96(1):64-7.

Advantages of Widal test Olopoenia LA, King, AL. Widal agglutination test - 100 years later: still plagued by controversy. Postgrad Med J 2000;76:80-84.

GROUP

SEROTYPE

ANTIGEN O

ANTIGEN H PHASE I

PHASE II

A

S. paratyphi A

1, 2, 12

a

-

B

S. paratyphi B

1, 4, 5, 12

b

1,2

S. typhimurium

1, 4, 5, 12

i

1,2

S. paratyphi C

6, 7

c

1,5

S. Cholerasuis

6, 7

c

1,5

S. typhi

9, 12, Vi

d

-

S. enteritidis

1, 9, 12

g, m

C D

Out of 103 patients (clinical and cultural proven typhoid), TUBEX pos in  86.4%, Typhidot 74.7%, and Widal 69.9%  ƒ In non typhoid group, Tubex pos in 25%, Typhidot 3.8% and Widal 26,9% ƒ Maximum number of Tubex and Typhidot were positive in patients with 7 – 14 days of fever, while Widal was mostly positive in children with fever of  more than 14 days ƒ Sensitivity, specificity, PPV and NPV for the tests ƒ

Tubex

86.4

84.6

95.7

61.1

Typhidot

74.7

96.1

98.7

49.0

Widal

69.9

73.0

91.1

38.0

Jaffery G, Hussain W, Saeed, Anwer M and Maqbool S. Annual Pathology Conference, 2003, Pakistan and 3rd Scientific Conference of Paediatric Association of SAARC Countries 2004, Lahore

Tubex TF dibandingkan dengan Uji Widal pada  pasien  dengan biakan darah dan/atau PCR  ƒ ƒ ƒ ƒ

RSCM, RS Persahabatan, RS Tangerang , Mei – Oktober 2006  Diperiksa 52 kasus,  27 laki2 dan 25 wanita dengan usia tertua  20 – 30 tahun (53.8 %) Semua pasien telah memenuhi Skor tifoid Nelwan > = 8 dan  klinis memenuhi syarat demam tifoid. Tubex TF dibanding uji Widal terhadap skor itu menghasilkan ƒ Sensitifitas 100% dan 53.1% ƒ Spesifitas 90% dan 65% ƒ Nilai prediksi  positif  94.1% dan  70.8%, prediksi negatif 100% dan 46.4% ƒ Ratio likelihood (+) 10 dan 1.51, Ratio likelihood (‐) 0 dan 0.72 ƒ AUC ROC Tubex 5.91 dan Widal 0.591, sangat berbeda bermakna Surya H, Setiawan B, Shatri H, Sudoyo A dan Loho T. Diunduh dari http:/pacbiotekindo.co.id/tubextf.html, 29.11.2009

Intra intestinal tract

▪ peritonitis,  ▪ bleeding,  ▪ perforation

Outside intestinal  tract

▪ encephalitis ▪ pneumonia ▪ meningitis ▪ osteomyelitis ▪ hepatitis

ƒ

One third of 102 cases develop complications ƒ Anicteric hepatitis, bone marrow supression, paralytic ileus, 

myocarditis, psychosis, cholesystitis, osteomyelitis, peritonitis,  pneumonia, hemolysis, and SIADH ƒ If hepatitis is excluded, the rate of complications is 11 %. ƒ

ƒ

A child with splenomegaly or thrombocytopenia had 1.5 times higher risk, where as a child with leucopenia has 2 times risk to have complications. A child with both splenomegaly and thrombocytopenia  or leukopenia had 2.5 times higher risk. Alam Sher Malik. J of Trop Ped 2002;48:102-8.

ƒ ƒ ƒ ƒ ƒ ƒ ƒ

Irritability Decreasing consciousness (late stadium) Abdominal distension Abdominal pain Defanse musculaire Lowering intestinal sounds Disappearance  of hepatic dullness

ƒ ƒ ƒ ƒ

Clinically difficult to differentiate Need supportive labs Nasogastric and anal tube should be inserted Abdominal x‐ray (3 positions) ƒ Unequal air distribution ƒ Air fluid level ƒ Hepatic area radio lucent  ƒ Free air at abdominal wall 

ƒ

Supportive : ƒ Fluid therapy, dietetic ƒ Electrolyte ƒ Acid base

ƒ

Causal : ƒ Medicamentous  (antibiotics, steroid) ƒ Surgery  (complication therapy)

ƒ

Fluid ƒ Maintenance, D5 : NaCl 0.9% (3:1) ƒ Additional 12.5% for each 10 C increment

ƒ

Dietetic ƒ Solid foods could be given as soon as possible, instead of 

conventional strained food ƒ Less fibers and stimulating food ƒ Not to strict ƒ ƒ

Acid base corrections Electrolyte corrections

Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ 2006;333:78‐82.

Antibiotics

Sensitive

Interme diate

Resistant

Ampicillin

34

10

54

Amoxycillin

28

6

66

Nalidixic acid

64

12

24

Chloramphenicol

46

40

24

Cefixime

80

14

6

Azithromycine

78

22

0

Cotrimoxazole

64

0

36

Ciprofloxacin

84

1

15

E Hartoyo, A Yunanto, L Budiarti. 3rd Congress of Pediatric Infectious Diseases. Cebu City, Philippines, March 2006

ƒ

Chloramphenicol ƒ 100mg/kgBW/day oral, max 2 gram, 10 days ƒ Not recommended for cases with leucocyte count