BAGIAN NEUROLOGIBAGIAN NEUROLOGI FK UNDIP / RSUP DR KARIADI SEMARANGFK UNDIP / RSUP DR KARIADI SEMARANG DAFTAR MATA KULIAH DAN DOSEN DAFTAR MATA KULIAH DAN DOSEN PENGAMPUPENGAMPU
NO NO MATA KULIAHMATA KULIAH DOSEN PENGAMPU DOSEN PENGAMPU
11 Infeksi Susunan Saraf PusatInfeksi Susunan Saraf Pusat Dr Aris Catur Bintoro, SpsDr Aris Catur Bintoro, Sps
22 StrokeStroke Dr Dodik Tugasworo, SpS(K)Dr Dodik Tugasworo, SpS(K)
33 EpilepsiEpilepsi Dr Endang Kustiowati, SpS(K)Dr Endang Kustiowati, SpS(K)
44 Nyeri Kepala & VertigoNyeri Kepala & Vertigo Dr Herlina Suryawati, SpSDr Herlina Suryawati, SpS
55 Gangguan Gerak & Trauma Kepala Gangguan Gerak & Trauma Kepala Prof Dr Amin Husni, MSc, Prof Dr Amin Husni, MSc, SpS(K) SpS(K)
66 Nyeri muskuloskeletal & nyeri Nyeri muskuloskeletal & nyeri neuropatikneuropatik
Dr Dani Rahmawati, SpS(K)Dr Dani Rahmawati, SpS(K)
77 NeuropatiNeuropati Prof Dr Widiastuti, MSc, SpS(K)Prof Dr Widiastuti, MSc, SpS(K)
88 Neurogeriatri & tumor serebriNeurogeriatri & tumor serebri Dr Soetedjo, SpS(K)Dr Soetedjo, SpS(K)
99 Neurobehaviour & NeuropediatriNeurobehaviour & Neuropediatri Dr Hexanto Muhartomo, MKes, Dr Hexanto Muhartomo, MKes, SpSSpS
1010 NeuroemergensiNeuroemergensi Dr Retnoningsih, SpS, KIC Dr Retnoningsih, SpS, KIC
1111 Rehabilitasi MedikRehabilitasi Medik Dr Rudy Handoyo, SpRMDr Rudy Handoyo, SpRM
1212
INFEKSI SUSUNAN SARAF PUSAT
Dr Aris Catur Bintoro, SpS
BUKU ACUAN
• Gilroy : Basic neurology
• RT Johnson: Current therapy in neurologyc disease
• Adam & Victor : Principle of neurology
• Priguna Sidharta & Mahar Margono :
-Neurologi klinis dasar
-Neurologi dalam praktek umum
-Tatacara pemeriksaan neurologi
TUJUAN PENDIDIKAN
• TIU : Setelah menyelesaikan perkuliahan mahasiswa mampu mendiagnosis dan mengelola pasien infeksi SSP dengan
benar
• TIK : Mahasiswa mampuMenyebutkan etiologiMenjelaskan patologi / patogenesis Menjelaskan gejala & tandaMenegakkan diagnosisMelakukan terapi
INFEKSI SUSUNAN SARAF PUSAT
LOKASI
MeningitisEncephalitis Meningoencephalitis
CerebritisBrain abscess Cranial epidural abscessSubdural empyema
Myelitis transversa
KLASIFIKASI MENINGITIS
Penyebab (infeksi SSP) :Bakteri ProtozoaVirus Cacing Jamur
Cairan serebrospinal :-Piogenik-Non Piogenik (Aseptik)
Lapisan : Pakimeningitis (duramater)
Leptomeningitis (araknoid & piamater)
MENINGITIS MENINGITIS BAKTERIAL AKUTBAKTERIAL AKUT
DEFINISI
Infeksi cairan serebrospinal disertai
radang yang mengenai araknoid, piamater dan
derajat ringan bagian superfisial jaringan otak &
medulla spinalis
EPIDEMIOLOGI>> Negara berkembang, sosek tak mampu
Indonesia : data minimal
ETIOLOGI
Neonatus - 3 bl : E. coli (-), Strept group B (+), Listeria (+), Staph aureus (+)
3 bl – 6 th: H.Influenzae (-), N.Meningitidis (-), S.Pneumoniae (+)
6 – 20 th : N.Meningitidis, S.Pneumoniae, H. Influenzae
> 20 th : S.Pneumoniae, N.Meningitidis, Streptococcus, Staphylococcus
17%
6%
17%
5%2%3% 4%
25%
29%
Haemophilus
Neisseria
Strep Pn.
Other Strep.
Listeria
Staph.
Mycobact
E. Coli
Others
PATOGENESIS
I)I) Kolonisasi Kuman nasofaringsKolonisasi Kuman nasofarings
Invasi lokal Invasi lokal (I : Mucosal invasion)(I : Mucosal invasion)
Bakteriemia Bakteriemia (II : intravascular survival)(II : intravascular survival)
Melekat pada endotel pleksus khoroid / endotel vaskular otakMelekat pada endotel pleksus khoroid / endotel vaskular otak
Kerusakan sel endotelKerusakan sel endotel
Invasi selaput otak Invasi selaput otak (III: crossing BBB)(III: crossing BBB)
Replikasi bakterial di LCS + inflamasi Replikasi bakterial di LCS + inflamasi (IV: Survival in CSF)(IV: Survival in CSF)
MeningitisMeningitis
1.1. Luka terbuka dikepalaLuka terbuka dikepala2.2. Penyebaran langsung dari :Penyebaran langsung dari :
a. Infeksi telinga bag. tengah (OM)a. Infeksi telinga bag. tengah (OM)b. Sinus paranasalisb. Sinus paranasalisc. Kulit kepala - mukac. Kulit kepala - mukad. Benda asing terinfeksi (shunting)d. Benda asing terinfeksi (shunting)
3.3. SepsisSepsis4.4. Thromboplebitis kortikalThromboplebitis kortikal5.5. Abses sub/ekstra dural Abses sub/ekstra dural 6.6. Lamina cribosa os ethmoidalis dan rhinorheaLamina cribosa os ethmoidalis dan rhinorhea7.7. Pungsi lumbalPungsi lumbal
Jalur Kuman mencapai Leptomening dan Subarachnoid Jalur Kuman mencapai Leptomening dan Subarachnoid
PATOLOGI
-Pneumokokus & H Influenza : eksudat di konveksitas-N.Meningitidis : eksudat di basal
-Lapisan Pia-Araknoid menebal dan adesi ganggu aliran LCS Hidrosefalus
-Reaksi inflamasi & fibrosis meningen dapat mencakup radix nn kranialis paresis n kranialis VII & disfungsi n VIII
PATOLOGI (Lanjutan)
-Inflamasi arteri & vena (vaskulitis) trombosis – infark hemiparesis, afasia, serebelar sign
-Kasus akut fulminan meninggal sebelum terjadi perubahan patologi di SSP
CLINICAL FEATURES
Early : -Fever-Irritability-Headache-Stiffneck
-Relative preservation of mental status-Lack of major focal neurological signs-No papil edema
CLINICAL FEATURES
Later SeizuresCranial nerve palsies (VII,VIII)Lethargy and stuporFocal neurological signs
CARACTERISTIC’S OF ETIOLOGYCARACTERISTIC’S OF ETIOLOGY
ETIOLOGY EPIDEMIOLOGY CLINICAL FEATURES
MORTALITY
S PneumoniaS Pneumonia Adult, head trauma, Adult, head trauma, anemia, alcoholicanemia, alcoholic
Cough, blood Cough, blood culture (+) 56% culture (+) 56%
20-60%20-60%
N Meningitidis
Youth, epidemics, spring /winter
Sore throat, petechiae, purpura
6-7 %
H InfluenzaeH Influenzae Child, winterChild, winter Earache, (+) blood Earache, (+) blood culture 79%culture 79%
7-8%7-8%
Streptococcus group B
Neonates, premature rupture of membrane
40-80%
E ColiE Coli Neonates, head Neonates, head trauma, neurosurgerytrauma, neurosurgery
Urinary tract Urinary tract infection 40%infection 40%
50%50%
Stap. aureus Neonates, elderly, head tr., neurosurgery
Listeria Listeria monocytogenmonocytogen..
Renal transplant, Renal transplant, Neonates, Neonates,
Absence of nuchal Absence of nuchal rigidity rigidity
DIAGNOSIS
Pemeriksaan LCS -Tekanan : > 180 mmH2O
-Warna : keruh – purulen-Sel : PMN, 200 – 10.000-Protein : > 75 mg/100 ml-Gula : < 40%-Pengecatan -Jumlah kuman -Kultur-Antigen : RIA, EIA, Latex
CAIRAN SEREBROSPINAL NORCAIRAN SEREBROSPINAL NORMALMAL
Warna : jernih
Tekanan : 70 – 180 mm H20
Sel : 0 – 5 / mm3 , MN
Glukosa : 45 – 80 mg%
Protein : 15 – 45 mg%
PUNGSI LUMBALPUNGSI LUMBAL INDIKASI Konfirmasi diagnosis (infeksi, perdarahan,blok subaraknoid) Identifikasi organisme Memasukkan zat kontras (myelografi) Pengobatan (injeksi intra thecal)
KONTRA INDIKASI Infeksi pada daerah suntikan Adanya TIK meningkat Abses / tumor fossa posterior
KOMPLIKASI Nyeri kepala Herniasi otak Perdarahan spinal subdural/epidural/subaraknoid Lain2 : iritasi radikuler, infeksi
DIAGNOSIS
• Pemeriksan darah tepi • Cel reactive protein • Kultur dan sensitivitas sumber infeksi• X foto • CT scan kepala (+kontras) • EEG
TERAPI
UMUM
• Prinsip 5B• Cairan, infus dalam jumlah cukup• Panas, diturunkan• Kejang, diatasi dengan inj. Diazepam iv• TIK meningkat, diturunkan : inj.
Kortikosteroid, drip manitol 20% • Hidrosefalus, dilakukan shunting• Fisioterapi pasiv - aktiv
KHUSUS
Prinsip antibiotika :Bersifat bakterisidKonsentrasi tinggi di LCSObati infeksi parameningealJenis AB tergantung : kultur, kepekaan,
usia
Antibiotika dosis tinggi IV : Antibiotika dosis tinggi IV :
Kadar bakterisidal dalam LCS 10 - 20 x konsentrasi bakterisidal minimal organisme
Sifat antibiotika ideal :Sifat antibiotika ideal :Larut dalam lemak menembus BBBAktif dalam LCS purulen dan asam
Antibiotika tepat : Antibiotika tepat :
• LCS steril dalam 24 - 36 jam
Lama pemberian :Lama pemberian :• Pneumokok : 10 - 14 hari• H. Influenza : 10 hari• Meningokok : 7 hari• Gram ( - ) : 21 hari• Umumnya hingga bebas panas 7 hari
Empiric Antibiotic therapy of Bacterial MeningitisEmpiric Antibiotic therapy of Bacterial Meningitis
Patient GroupPatient Group AntibioticAntibiotic
NeonatesAmpicillin + Aminoglycoside or Ampicillin + Cefotaxime
Infants (1-3 mo) Ampicillin + Cefotaxime
Children (3 mo - 6 yr) Ampicillin + CefotaximeOlder Children, adults (no
spesific risk factors)Penicillin G or third generation cephalosporin
Immunocompromised patient
Third generation cephalosporin + Ampicillin (+Aminoglycoside)
Neurosurgery, head trauma patients
Third generation cephalosporin + Nafcillin (+ Aminoglycoside)
Chronic CSF fistulaThird generation cephalosporin + Nafcillin
Bacterial Pathogens
OrganismOrganism Antibiotic*Antibiotic*
H. InfluenzaeH. InfluenzaeThird generation cephalosporin, Ampicillin (if sensitive), Chloramphenicol
S. pneumoniaeS. pneumoniaePenicillin G, third generation cephalosporin, Chloramphenicol
Reduced penicillin Reduced penicillin sensitivesensitive
Third generation cephalosporin
Penicillin resistantPenicillin resistantThird generation cephalosporin or Vancomycin
N. meningitidisN. meningitidis Penicillin G, Chloramphenicol
S. agalactiaeS. agalactiae Penicillin or ampicillin
OrganismOrganism Antibiotic*Antibiotic*
L. monocytogenesL. monocytogenesAmpicillin (plus aminoglycoside) or
trimethoprim-sulfamethoxazole
EnterobacteriaceaeEnterobacteriaceaeThird generation cephalosporin with or
without aminoglycoside
P. aeraginosaP. aeraginosaCeftazidime + aminoglycoside or
fluroquinolone (eg. Ciprofloxacin)
S. aureusS. aureus Nafcillin
* Third generation cephalosporins : Third generation cephalosporins : Cefotaxime ; Ceftriaxone; CeftizoximeCefotaxime ; Ceftriaxone; Ceftizoxime For penicillin allergic patientFor penicillin allergic patient
Dosage of Antibiotics Commonly Used in the Dosage of Antibiotics Commonly Used in the Therapy of Bacterial MeningitisTherapy of Bacterial Meningitis
AntibioticAntibiotic Children (>1 mo)Children (>1 mo) AdultsAdults
NafcillinNafcillin 50 mg/kg q6h50 mg/kg q6h 1.5 g q4h1.5 g q4h
GentamycinGentamycin 11--2 mg/kg iv q8h2 mg/kg iv q8h
Penicillin GPenicillin G 50.000 U/kg q4h50.000 U/kg q4h 3 3 -- 4 MU q4h4 MU q4h
Dose and dosing intervalDose and dosing interval
AmpicillinAmpicillin 100 mg/kg q8h100 mg/kg q8h 2 g q4h2 g q4h
CefotaximeCefotaxime 50 mg/kg q6h50 mg/kg q6h 22--3 g q6h3 g q6h
CeftriaxoneCeftriaxone 50 mg/kg q12h50 mg/kg q12h 2 g q12h2 g q12h
CeftazidimeCeftazidime 50 mg/kg q6h 2 g q8h50 mg/kg q6h 2 g q8h
ChloramphenicolChloramphenicol 25 mg/kg q6h25 mg/kg q6h 1.5 g q6h1.5 g q6h
VancomycinVancomycin 10 mg/kg q6h10 mg/kg q6h 0.5 g q6h0.5 g q6h
COMPLICATIONS
Common SeizuresPersistent FeverHearing lossFocal neurological signsIncreased intracranial pressureSIADH : Na < 130 mEq/L (serum)
Na & osmolality (urin)Subdural effusion
COMPLICATIONS
Less common ShockDICComaHydrocephalusSubdural empyemaBrain abscess
PENCEGAHAN
Anak 1-12 th: Rifampisin 10 mg/kgBB/12 jamDiatas 12 th : “ 600 mg, 1xH Influenzae, pemberian 4 hariN Meningitidis, pemberian 2 hari
VaksinasiH Influenzae type B infants efektifMeningococcus. S Pneumonia belum terbukti
PROGNOSIS
Tergantung : -Umur -Virulensi-Kedinian pengobatan-Jenis & dosis AB
A.A. Non kontrast CT scan menunjukkan adanya edema cerebri ( E ).Non kontrast CT scan menunjukkan adanya edema cerebri ( E ).
B.B. CECT menunjukkan adanya penyerapan kontrast pada girus.CECT menunjukkan adanya penyerapan kontrast pada girus.
C.C. NCMRI T1W pada penderita yang sama, tak jelas menunjukkan adanya kelainan.NCMRI T1W pada penderita yang sama, tak jelas menunjukkan adanya kelainan.
Meningitis supurativa dengan edema atau infark kortex
D. T2W menunjukkan adanya edema multiple pada daerah gyrus cortex cerebri. ( panah terbuka )
E. Dengan pemberian kontrast, tampak adanya penyerapan kontrast pada meningen.
Meningitis supurativa dengan edema atau infark kortex
MENINGITIS TUBERKULOSA
PATOGENESIS -Aktivasi infeksi laten mycobacterium TB-Aktivasi infeksi laten mycobacterium TB
-Kuman di respiratory tract -Kuman di respiratory tract via via hematogen hematogen
ke mening & permukaan otak ke mening & permukaan otak Tuberkel, Tuberkel,
pecah, masuk ke subaraknoid pecah, masuk ke subaraknoid Meningitis Meningitis TBTB
PATOLOGI-Eksudat di basal sisterna, >>MN-Hidrosefalus obstruktif-Arteritis, infark serebri
GAMBARAN KLINIK
Stadium I : sadar, rangsang meningeal, demam Stadium II: kesadaran, ggn. neurologik fokal Stadium III: stupor – koma
Bayi : rewel, fontanella menonjol Orang tua : demam (-), kesadaran, timbul kaku kuduk secara perlahan Kelainan neurologik fokal :
Paresis n VI, oftalmoplegi, hemiparesis
DIAGNOSIS
Pemeriksaan LCSwarna jernih/ santokromtekanan sel 50-500, >>MN, pada awalnya PMNprotein > 100mg/dlglukosa < 20 mg/dlpengecatan, biakan kuman
Tes antigen : darah & LCSPemeriksaan darah tepi; LEDPCRX foto torakCT scan kepala
Diagnosis berdasar: -Klinis & laboratorium-Ditemukan kuman TB dari LCS
DIAGNOSIS BANDING
Meningitis ok. Sifilis , jamurMeningitis bakterial dg pengobatan tak sempurna
TERAPI Daya tembus OATB pada meningen berbeda
OBAT INFLAMASI NON INFLMS
STREPTOMISINSTREPTOMISIN Baik Buruk
INH Baik Baik
RIFAMPISINRIFAMPISIN Baik Buruk
PIRAZINAMID Baik Baik
ETAMBUTOLETAMBUTOL Baik Buruk
Kombinasi : 4 macam obat2 bulan I : R + I + P + E (+S)7 bulan II : R + I
OBATOBAT DEWASADEWASA ANAKANAK
INH 400 mg/hari 10-20 mg/kg/hari
RIFAMPISIN 600 mg/hari 15-25 mg/kg/hari
PIRASINAMID 1500 mg/hari 20-35 mg/kg/hari
ETAMBUTOLSTREPTOMISIN
500 mg/hari750 mg, im 20 mg/kg/hari
KORTIKOSTEROID
Indikasi :
Kesadaran makin memburuk
gejala fokal progresifgejala gangguan batang otak, MS,
radik
Dosis : inj. Deksametason 4x 1-2 amp 1 minggu tappering of hingga 3 minggu.
Meningitis Tuberculosa
A. CT Scan tanpa kontras.B. CT Scan dengan kontras menunjukkan adanya
penyerapan kontras pada daerah tentorium dan spatium subarachnoid.
C. CT Scan dengan kontras.D. Hari ke 3 setelah CT Scan A-C; tampak
terjadinya infark cerebri.
Pre C Post C Post C
Meningoencephalitis TB dengan multiple tuberculoma dan kalsifikasi. Untuk melihat adanya kalsifikasi CT lebih baik
daripada MRI
Encephalitis dan Ventrikulitis, kesan : TBC
MRI Nn. D.I.S. 16 th .
ABSES OTAK
PATOGENESIS
Penyebaran kuman langsungPenyebaran kuman langsung
- telinga, sinus, mastoid, gigi- telinga, sinus, mastoid, gigi
- trauma kepala, tindakan bedah- trauma kepala, tindakan bedah
Penyebaran kuman hematogenPenyebaran kuman hematogen
- paru, saluran cerna, jantung- paru, saluran cerna, jantung
Lokasi : -substansia alba Lokasi : -substansia alba
-substansia alba – grisea junction-substansia alba – grisea junction
Perkembangan absesPerkembangan abses : :
Early cerebritisEarly cerebritis (hari 1-3)(hari 1-3)
Late cerebritisLate cerebritis (hari 4-9)(hari 4-9)
Early capsulated formation (hari 10-Early capsulated formation (hari 10-14)14)
Late capsulated formationLate capsulated formation (> 14 (> 14 hari)hari)
ETIOLOGY
Chronic ear inf.Chronic ear inf. Aerob and anaerob streptococci,Aerob and anaerob streptococci, Temporal lobe or 15 % Temporal lobe or 15 %B Fragilis, EnterobacteriaceaeB Fragilis, Enterobacteriaceae cerebellar hem. cerebellar hem.
Frontal or Frontal or Staphylococcus aureus, streptococci, Frontal lobe 20%Staphylococcus aureus, streptococci, Frontal lobe 20%Ethmoid sinusitisEthmoid sinusitis B fragilis, haemophilusB fragilis, haemophilus
Periodontal inf.Periodontal inf. Mixed flora, streptococciMixed flora, streptococci Frontal lobe Frontal lobe 15% 15%
Pulmonary inf.Pulmonary inf. Mixed flora, B fragilis,Mixed flora, B fragilis, parietal and other 15% parietal and other 15%Streptococci, nocardiaStreptococci, nocardia lobes (often multiple) lobes (often multiple)
EndocarditisEndocarditisMixed flora, S aureusMixed flora, S aureus multiple, small multiple, small
Cranial truma orCranial truma or Staphylococcus pyrogens/aureusStaphylococcus pyrogens/aureus adjacent to site of 5% adjacent to site of 5%SurgerySurgery Streptococci, enterobacterStreptococci, enterobacter injury injury
GAMBARAN KLINIS
Tergantung dari letak lesi dan akibat Tergantung dari letak lesi dan akibat kenaikan TIKkenaikan TIK
-Nyeri kepala -Nyeri kepala 65%65%
-Mual, muntah-Mual, muntah 50%50%
-Kejang fokal / umum -Kejang fokal / umum 65%65%
-Gangguan kesadaran -Gangguan kesadaran 50%50%
bersifat progresifbersifat progresif
-Bila di serebelum :-Bila di serebelum : -ataksia-ataksia
-nistagmus-nistagmus
-edema papil-edema papil
LABORATORIUM
-Darah :-Darah : lekosit 40% normallekosit 40% normal
LED LED 75% meningkat75% meningkat
-LCS : -LCS : tak memberi informasi, bahayatak memberi informasi, bahaya
-CT scan (+kontras) : “ring enhancement”-CT scan (+kontras) : “ring enhancement”
-MRI-MRI
-EEG-EEG
DIAGNOSISBerdasar temuan klinis dan laboratorium (CT Berdasar temuan klinis dan laboratorium (CT scan)scan)
TERAPI
-Terbaik kombinasi antibiotika dan -Terbaik kombinasi antibiotika dan kraniotomikraniotomi
-Antibiotika yang menembus BBB-Antibiotika yang menembus BBB
-Kuman -Kuman AerobAerob : -Penicillin G, Ampicillin, : -Penicillin G, Ampicillin,
Chloramfenicol, Cefotaxim, Chloramfenicol, Cefotaxim, CeftriaxoneCeftriaxone
-Kuman -Kuman AnaerobAnaerob : : MetronidazoleMetronidazole
-Kortikosteroid-Kortikosteroid ::
(+) kurangi edema(+) kurangi edema
(-) efek resistensi kuman >> (-) efek resistensi kuman >>
Antibiotic IV Dosage **Penicillin G 3 milliion units, q4hNafcillin 2g, q4hVancomycin 1g, q8hMetronidazole 500 mg, q6hChloramphenicol 1.5 g, q6hCeftriaxone 2 g, q12hCeftazidime 2g, q8hCefotaxime 2g, q6hGentamycine 1.5 mg/kg, q8h
For suspected Toxoplasmosis Gondii abcess :Sulfadiazine 4 g, q6hPyrimethamine 75 mg, q8h ***
*Dosing for infants, children, and adults who weigh less than 60 kg must be done on a per kilogram basis according to published guidelines. Adjustments in doses must also be made if renal functions is impaired
** Standard i.v adult dosage *** Folinic acid must be administered concurrently, 10 mg per day
Antibiotics Dosing Schedules Useful in theTreatment of Brain Abcess and Parameningeal Infections of Adults*
PROGONOSIS
-Antibiotika + kraniotomi -Antibiotika + kraniotomi mortalitas mortalitas 8%8%
-Penyebab kematian :-Penyebab kematian :
Kenaikan TIKKenaikan TIK
Abses pecahAbses pecah
Diagnosis terlambatDiagnosis terlambat
Cerebritis dan Abses cerebri
CT Scan kepala dengan kontrast menunjukkan adanya sinusitis frontalis (panah tertutup), cerebritis (Ce) dan abses lobus frontalis (panah terbuka).
Cerebritis dengan AbsesCT Scan an. D. 8 th.
Tanpa kontrast Dengan kontrast
INFEKSI VIRUS
PATOLOGI
Virus menyebar ke sistem saraf via Virus menyebar ke sistem saraf via hematogen hematogen menembus sel menembus sel endotel & pleksus koroideus endotel & pleksus koroideus
Infiltrasi limfosit perivaskular dan Infiltrasi limfosit perivaskular dan proliferasi mikroglia daerah proliferasi mikroglia daerah subkorteksubkortek
GAMBARAN KLINIK
Awal : demam, nausea, nyeri kepala
Lanjut : - gangguan kesadaran- kejang fokal / umum- defisit neurologis- rangsang meningeal
(Meningoensefalitis)
Lokasi Predileksi
Eneterovirus : sel meningeal
Mumps virus : sel ependym nyeri kepala, kaku kuduk
Polio virus: motor neuron paralisis flaksid Rabies : sistim Limbik hiperaktif, agresif
LABORATORIUM
Pemeriksaan LCS; -Tekanan : N / -Sel limfosit : < 1000, MN-Protein : N / -Glukosa : N /
Titer antibodiPCRCT scan / MRIEEG
DIAGNOSISDIAGNOSISPemeriksaan fisik & hasil laboratorium
TERAPI
Simtomatik : - kebutuhan cairanSimtomatik : - kebutuhan cairan
- turunkan demam- turunkan demam
- atasi kejang- atasi kejang
- kurangi edema otak- kurangi edema otak
Antivirus :Antivirus :
-Acyclovir : 10 mg/kg,q8h,iv 14d (H -Acyclovir : 10 mg/kg,q8h,iv 14d (H simplex)simplex)
5 mg/kg,q8h,iv, 5 d (H 5 mg/kg,q8h,iv, 5 d (H zooster)zooster)
SIGN OF TESTSIGN OF TEST BACTERIAL M.BACTERIAL M. VIRAL M. VIRAL M.
Clinical FeaturesClinical Features SeveritySeverity Often severeOften severe Often mild Often mild High Fever High Fever CommonCommon UncommonUncommon Shaking chillsShaking chills CommonCommon UncommonUncommon CourseCourse Untreated course worsens Untreated course worsens Seldom worsens Seldom worsens
after after first day first day
Systemic signsSystemic signs May have upper respiratorMay have upper respiratory y May have May have parotitis, or parotitis, or tract infection or otitis mediatract infection or otitis media diarrheadiarrhea
Previous healthPrevious health May be poor or have May be poor or have Often healthy Often healthyimmunodeficienciesimmunodeficiencies
CSF examinationCSF examination CellsCells Predominantly neutrophilsPredominantly neutrophils Pred. Pred.
lymphocyteslymphocytes GlucoseGlucose usually lowusually low Usually normal Usually normal ProteinProtein ElevatedElevated N or N or
slightly elevatedslightly elevated Gram stainGram stain Often bacteria seenOften bacteria seen No bacteria seen No bacteria seen Bacterial antigensBacterial antigens Often detectedOften detected Absent Absent
Blood TestBlood Test White blood cell countWhite blood cell count usually elevatedusually elevated Often Often
normalnormal Blood cultureBlood culture Positive greater than 60%Positive greater than 60% Sterile Sterile
INFEKSI HIV-AIDS
ETIOLOGY
Human immunodeficiency virus type 1 (HIV-1)
Characterized : Opportunistic infections Malignant neoplasms Variety of neurologic disturbances
Transmission : Sexual activity Contaminated blood or blood products
Classification of HIV Infection
LABORATORY category
1. CD4 lymphocyte count > 500 cell/mm3
2. CD4 “ “ 200 – 499 cell/mm3
3. CD4 “ “ < 200 cell/mm3
CLINICAL Category
HIV and the brain
o Meningitis• HIV itself• TB • Cryptococcal• Syphilitic
o Space occupying lesions• Toxoplasmosis• Tuberculomas• Lymphoma
HIV and the brain
o EncephalitisEncephalitis– HIV dementiaHIV dementia– Progressive multifocal leukoencephalopathy Progressive multifocal leukoencephalopathy
(PML)(PML)– CMV, HSV, HZV encephalitisCMV, HSV, HZV encephalitis– ToxoplasmosisToxoplasmosis
o Strokes and intracerebral haemorrhageStrokes and intracerebral haemorrhage
HIV and the spinal cord
o Vacuolar myelopathyVacuolar myelopathyo SyphilisSyphiliso HZV, HSV, CMV, HTLV-1HZV, HSV, CMV, HTLV-1o TBTBo LymphomaLymphoma
Usually subacute over weeks
Headache 50%Fever 45%Behaviour changes 40%Confusion 15-52%Focal signsSeizures 24-29%
TOXOPLASMOSIS, Clinical features
Reactivation of latent infectionReactivation of latent infectionToxo seroprevalence 12-46% Toxo seroprevalence 12-46%
LaboratoryLaboratory : CD4 > 200 virtually excludes Toxo : CD4 > 200 virtually excludes Toxo Over 80% have CD4 < 100Over 80% have CD4 < 100
CT/MRICT/MRI : Typically multiple ring enhancing lesions : Typically multiple ring enhancing lesions
TreatmentTreatment : :- Sulphadiazine and Pyrimethamine is first - Sulphadiazine and Pyrimethamine is first choicechoice- Co-trimoxazole (80/400mg) 4 tablets BD x - Co-trimoxazole (80/400mg) 4 tablets BD x 4/52,4/52, then 2 tablets BD x 8/52then 2 tablets BD x 8/52
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