{\rtf1{\fonttbl{\f2 Times New Roman Bold;}{\f3 Times New Roman;}{\f4 Times New Roman Italic;}{\f5 Times New Roman;}{\f6 Arial Bold;}{\f7 Times New Roman Bold;}{\f8 Times New Roman;}{\f9 Times New Roman Italic;}{\f10 Arial;}{\f11 Arial Bold;}{\f12 Times New Roman;}{\f13 Times New Roman;}{\f14 Arial;}{\f15 Times New Roman;}{\f16 Times New Roman;}{\f1000000 Times New Roman;}}{\colortbl;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;\red0\green0\blue0;}\viewkind1\viewscale100\margl0\margr0\margt0\margb0\deftab80\dntblnsbdb\expshrtn\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg1}{\bkmkend Pg1}\par\pard\ql \li6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb0\sl-276\slmult0 \par\pard\ql\li6062\sb79\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 BAB 2 \par\pard\ql \li4660\sb144\sl-276\slmult0 \up0 \expndtw-5\charscalex100 DEMAM BERDARAH DENGUE \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb268\sl-276\slmult0 \up0 \expndtw-5\charscalex100 2.1 Definisi \par\pard\qj \li2265\ri1512\sb10\sl-414\slmult0\fi720 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf2\f3\fs24 Demam dengue/DF dan demam berdarah dengue/DBD (\ul0\nosupersub\cf3\f4\fs24 dengue haemorrhagic \up0 \expndtw0\charscalex105 fever\ul0\nosupersub\cf2\f3\fs24 /DHF) adalah penyakit infeksi yang disebabkan oleh virus dengue dengan \up0 \expndtw0\charscalex100 manifestasi klinis demam, nyeri otot dan/atau nyeri sendi yang disertai lekopenia, \up0 \expndtw0\charscalex102 ruam, limfadenopati, trombositopeniadan diathesis hemoragik. Pada DBD terjadi \up0 \expndtw0\charscalex100 perembesan plasma yang ditandai oleh hemokonsentrasi (peningkatan hematokrit) \up0 \expndtw0\charscalex100 atau penumpukan cairan di rongga tubuh. Sindrom renjatan dengue (\ul0\nosupersub\cf3\f4\fs24 dengue shock \up0 \expndtw0\charscalex102 syndrome\ul0\nosupersub\cf2\f3\fs24 ) adalah demam berdarah dengue yang ditandai oleh renjatan/syok \up0 \expndtw-3\charscalex100 (Suhendro, Nainggolan, Chen, 2006). \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb264\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 2.2. Etiologi \par\pard\qj \li2265\ri1513\sb31\sl-413\slmult0\fi720 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf2\f3\fs24 Demam dengue dan demam berdarah dengue disebabkan oleh virus dengue, \line \up0 \expndtw-2\charscalex100 yang termasuk dalam genus Flavivirus, keluarga Flaviviridae. Flavivirus merupakan \line \up0 \expndtw-3\charscalex100 virus dengan diameter 30nm terdiri dari asam ribonukleat rantai tunggal dengan berat \line \up0 \expndtw-4\charscalex100 molekul 4 x 10\ul0\super\cf4\f5\fs23 6\ul0\nosupersub\cf2\f3\fs24 . \par\pard\qj \li2265\ri1508\sb406\sl-415\slmult0\fi720 \up0 \expndtw-3\charscalex100 Terdapat 4 serotipe virus tipe yaitu DEN-1, DEN-2, DEN-3, dan DEN-4 yang \line \up0 \expndtw-3\charscalex100 semuanya dapat menyebabkan demam dengue atau demam berdarah dengue keempat \line \up0 \expndtw0\charscalex103 serotype ditemukan di Indonesia dengan DEN-3 merupakan serotype terbanyak. \line \up0 \expndtw-1\charscalex100 Terdapat reaksi silang antara serotype dengue dengan Flavivirus lain seperti \ul0\nosupersub\cf3\f4\fs24 Yellow \line \up0 \expndtw-2\charscalex100 fever, Japanese encephalitis \ul0\nosupersub\cf2\f3\fs24 dan \ul0\nosupersub\cf3\f4\fs24 West Nile virus \ul0\nosupersub\cf2\f3\fs24 (Suhendro, Nainggolan, Chen). \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb28\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf5\f6\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg2}{\bkmkend Pg2}\par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb79\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.3. Epidemiologi \par\pard\qj \li2265\ri1512\sb9\sl-416\slmult0\fi719 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Demam berdarah dengue tersebar di wilayah Asia Tenggara, Pasifik Barat dan \up0 \expndtw0\charscalex100 Karibia. Indonesia merupakan wilayah endemis dengan sebaran di seluruh wilayah \up0 \expndtw-2\charscalex100 tanah air. Insiden DBD di Indonesia antara 6 hingga 15 per 100.000 penduduk (1989 \up0 \expndtw0\charscalex102 hingga 1995); dan pernah meningkat tajam saat kejadian luar biasa hingga 35 per \up0 \expndtw-2\charscalex100 100.000 penduduk pada tahun 1998, sedangkan mortalitas DBD cenderung menurun \up0 \expndtw-3\charscalex100 hingga mencapai 2% pada tahun 1999. \par\pard\qj \li2265\ri1513\sb407\sl-413\slmult0\fi719 \up0 \expndtw0\charscalex100 Penularan infeksi virus dengue terjadi melalui vektor nyamuk genus Aedes \line \up0 \expndtw-3\charscalex100 (terutama \ul0\nosupersub\cf8\f9\fs24 A. aegypti dan A. albopictus\ul0\nosupersub\cf7\f8\fs24 ). Peningkatan kasus setiap tahunnya berkaitan \line \up0 \expndtw0\charscalex104 dengan sanitasi lingkungan dengan tersedianya tempat perindukan bagi nyamuk \line \up0 \expndtw0\charscalex105 betina yaitu bejana yang berisi air jernih \up0 \expndtw0\charscalex104 (bak mandi, kaleng bekas dan tempat \par\pard\ql \li2265\sb121\sl-276\slmult0 \up0 \expndtw-3\charscalex100 penampungan air lainnya). \par\pard\qj \li2265\sb0\sl-400\slmult0 \par\pard\qj\li2265\ri1514\sb62\sl-400\slmult0\fi719 \up0 \expndtw0\charscalex103 Beberapa faktor diketahui berkaitan dengan peningkatan transmisi virus \up0 \expndtw-3\charscalex100 dengue yaitu : \par\pard\ql \li2548\ri1509\sb12\sl-410\slmult0\tx2832\tx2832 \up0 \expndtw-1\charscalex100 1)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Vektor : perkembang biakan vektor, kebiasaan menggigit, kepadatan vektor di \line\tab \up0 \expndtw0\charscalex105 lingkungan, transportasi vektor dilingkungan, transportasi vektor dai satu \line\tab \up0 \expndtw-3\charscalex100 tempat ke tempat lain; \par\pard\qj \li2548\ri1506\sb2\sl-420\slmult0\tx2832 \up0 \expndtw-2\charscalex100 2)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Pejamu : terdapatnya penderita di lingkungan/keluarga, mobilisasi dan paparan \line\tab \up0 \expndtw-3\charscalex100 terhadap nyamuk, usia dan jenis kelamin; \par\pard\qj \li2548\ri1515\sb0\sl-420\slmult0\tx2832 \up0 \expndtw0\charscalex104 3)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Lingkungan : curah hujan, suhu, sanitasi dan kepadatan penduduk (WHO, \line\tab \up0 \expndtw-3\charscalex100 2000). \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb197\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg3}{\bkmkend Pg3}\par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb79\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.4. Patogenesis \par\pard\qj \li2265\ri1507\sb6\sl-420\slmult0\fi719 \up0 \expndtw0\charscalex102 \ul0\nosupersub\cf7\f8\fs24 Patogenesis terjadinya demam berdarah dengue hingga saat ini masih \up0 \expndtw-3\charscalex100 diperdebatkan. \par\pard\qj \li2265\ri1509\sb400\sl-420\slmult0\fi719 \up0 \expndtw0\charscalex105 Berdasarkan data yang ada, terdapat bukti yang kuat bahwa mekanisme \up0 \expndtw0\charscalex103 imunopatologis berperan dalam terjadinya demam berdarah dengue dan sindrom \up0 \expndtw-3\charscalex100 renjatan dengue. \par\pard\ql \li2985\sb0\sl-276\slmult0 \par\pard\ql\li2985\sb243\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Respon imun yang diketahui berperan dalam pathogenesis DBD adalah : \par\pard\ql \li2548\ri1514\sb30\sl-415\slmult0\tx2832\tx2832\tx2832\tx2832 \up0 \expndtw0\charscalex102 a)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Respon humoral berupa pembentukan antibody yang berparan dalam proses \line\tab \up0 \expndtw0\charscalex104 netralisasi virus, sitolisis yang dimeasi komplemen dan sitotoksisitas yang \line\tab \up0 \expndtw0\charscalex100 dimediasi antibody. Antibody terhadap virus dengue berperan dalam \line\tab \up0 \expndtw-1\charscalex100 mempercepat replikasi virus pad monosit atau makrofag. Hipotesis ini disebut \line\tab \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf8\f9\fs24 antibody dependent enhancement \ul0\nosupersub\cf7\f8\fs24 (ADE); \par\pard\ql \li2548\ri1513\sb7\sl-413\slmult0\tx2832\tx2832\tx2832 \up0 \expndtw-2\charscalex100 b)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Limfosit T baik T-helper (CD4) dan T sitotoksik (CD8) berepran dalam respon \line\tab \up0 \expndtw0\charscalex105 imun seluler terhadap virus dengue. Diferensiasi T helper yaitu TH1 akan \line\tab \up0 \expndtw0\charscalex100 memproduksi interferon gamma, IL-2 dan limfokin, sedangkan TH2 \line\tab \up0 \expndtw-3\charscalex100 memproduksi IL-4, IL-5, IL-6 dan IL-10; \par\pard\ql \li2548\ri1512\sb0\sl-420\slmult0\tx2832\tx2832 \up0 \expndtw0\charscalex104 c)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Monosit dan makrolag berperan dalam fagositosis virus dengan opsonisasi \line\tab \up0 \expndtw0\charscalex103 antibodi. Namun proses fagositosis ini menyebabkan peningkatan replikasi \line\tab \up0 \expndtw-3\charscalex100 virus dan sekresi sitokin oleh makrofag; \par\pard\qj \li2548\ri1510\sb0\sl-420\slmult0\tx2832 \up0 \expndtw0\charscalex102 d)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Selain itu aktivitasi komplemen oleh kompleks imun menyebabkan \line\tab \up0 \expndtw-3\charscalex100 terbentuknya C3a dan C5a. \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb179\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840{\shp{\*\shpinst\shpleft2180\shptop2540\shpright10640\shpbottom8800\shpwr3\shpfblwtxt0\shpbxpage\shpbypage\shpz213\shplid3{\sp{\sn shapeType}{\sv 75}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn pib}{\sv 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Pg4}{\bkmkend Pg4}\par\pard\ql \li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb0\sl-230\slmult0 \par\pard\ql\li4771\sb129\sl-230\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf11\f12\fs20 Secondary heterologus dengue infections \par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb21\sl-230\slmult0\fi1439\tx6772 \up0 \expndtw-3\charscalex100 Virus replication\tab \up0 \expndtw-3\charscalex100 Anamnestic antibody response\par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb1\sl-230\slmult0\fi2615 \up0 \expndtw-3\charscalex100 Virus antibody complex\par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb226\sl-230\slmult0\fi719\tx5851\tx8481 \up0 \expndtw-3\charscalex100 Platelet aggregation\tab \up0 \expndtw-3\charscalex100 Coagulation activation\tab \up0 \expndtw-3\charscalex100 Complement activation\par\pard\li2419\sb0\sl-230\slmult0\par\pard\li2419\sb6\sl-230\slmult0\fi0\tx4713\tx7795 \up0 \expndtw-3\charscalex100 Impaired platelet\tab \up0 \expndtw-3\charscalex100 Platelet factor\tab \up0 \expndtw-3\charscalex100 Plasmin\par\pard\li2419\sb29\sl-230\slmult0\fi0\tx4713\tx6067\tx8899 \up0 \expndtw-3\charscalex100 function\tab \up0 \expndtw-3\charscalex100 III release\tab \up0 \expndtw-3\charscalex100 Activated Hagemen\tab \up0 \expndtw-3\charscalex100 Anaphylatoxi\par\pard\li2721\sb0\sl-230\slmult0\par\pard\li2721\sb0\sl-230\slmult0\par\pard\li2721\sb2\sl-230\slmult0\fi0 \up0 \expndtw-3\charscalex100 Platelet removal by RES\par\pard\li2721\sb0\sl-230\slmult0\par\pard\li2721\sb1\sl-230\slmult0\fi2577\tx7458 \up0 \expndtw-3\charscalex100 Consumptive\tab \up0 \expndtw-3\charscalex100 Klinin\par\pard\li2721\sb230\sl-230\slmult0\fi417\tx7458 \up0 \expndtw-3\charscalex100 Thrombocytopeni\tab \up0 \expndtw-3\charscalex100 Kini\par\pard\li2721\sb1\sl-230\slmult0\fi2576\tx8432 \up0 \expndtw-3\charscalex100 Clotting factors\tab \up0 \expndtw-3\charscalex100 Vascular permeablity\par\pard\li5297\sb0\sl-230\slmult0\par\pard\li5297\sb226\sl-230\slmult0\fi0\tx7457 \up0 \expndtw-4\charscalex100 Excessive\tab \up0 \expndtw-4\charscalex100 FDP\par\pard\li5297\sb1\sl-230\slmult0\fi3752 \up0 \expndtw-4\charscalex100 Shock\par\pard\li2265\sb0\sl-276\slmult0\par\pard\li2265\sb127\sl-276\slmult0\fi0\tx9979 \up0 \expndtw0\charscalex102 \ul0\nosupersub\cf6\f7\fs24 Gambar 2.1. \ul0\nosupersub\cf7\f8\fs24 Hipot esis \ul0\nosupersub\cf8\f9\fs24 secondary heterologus infections\ul0\nosupersub\cf7\f8\fs24 (Sumber: Suvatt\tab \up0 \expndtw0\charscalex101 1977-\par\pard\li2265\sb2\sl-276\slmult0\fi0 \up0 \expndtw0\charscalex101 dikutip dari Sumarmo, 1983).\par\pard\ql \li2985\sb261\sl-276\slmult0\tx5227 \up0 \expndtw0\charscalex103 Halstead pada tahun \tab \up0 \expndtw0\charscalex101 1973 mengajukan hipotesis \ul0\nosupersub\cf8\f9\fs24 secondary heterologous \par\pard\qj \li2265\ri1509\sb34\sl-410\slmult0 \up0 \expndtw-1\charscalex100 infection \ul0\nosupersub\cf7\f8\fs24 yang menyatakan bahwa DHF terjadi bila seseorang terinfeksi ulang virus \up0 \expndtw0\charscalex103 dengue dengan tipe yang berbeda. Re-infeksi menyebabkan reaksi anamnestik \up0 \expndtw-3\charscalex100 antibodi sehingga mengakibatkan konsentrasi kompleks imun yang tinggi. \par\pard\qj \li2265\sb0\sl-412\slmult0 \par\pard\qj\li2265\ri1513\sb17\sl-412\slmult0\fi719 \up0 \expndtw0\charscalex106 Kurang dan Ennis pada tahun 1994 merangkum pendapat Halstead dan \line \up0 \expndtw0\charscalex102 peneliti lain; menyatakan bahwa infeksi virus dengue menyebabkan aktivasi \line \up0 \expndtw-4\charscalex100 makrofag yang me-fagositosis kompleks virus-antibody non netralisasi sehingga virus \line \up0 \expndtw0\charscalex100 bereplikasi di makrofag. Terjadinya infeksi makrofag oleh virus dengue \line \up0 \expndtw0\charscalex100 menyebabkan aktivasi T helper dan T sitotoksik sehingga diprosuksi limfokin dan \line \up0 \expndtw-2\charscalex100 interferon gamma. Interferon gamma akan mengaktivasi monosit sehingga disekresi \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb39\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg5}{\bkmkend Pg5}\par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb79\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24 berbagai mediator inflamasi seperti TNF-\u945?, IL-1, PAF (\ul0\nosupersub\cf8\f9\fs24 platelet activating factor\ul0\nosupersub\cf7\f8\fs24 ), IL-\par\pard\qj \li2265\ri1509\sb54\sl-410\slmult0 \up0 \expndtw0\charscalex103 6 dan histamine yang mengakibatkan terjadinya disfungsi sel endotel dan terjadi \up0 \expndtw-2\charscalex100 kebocoran plasma. Peningkatan C3a dan C5a terjadi melalui aktivasi oleh kompleks \up0 \expndtw-3\charscalex100 virus-antibodi yang juga mengakibatkan terjadinya kebocoran plasma. \par\pard\ql \li2985\sb121\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Trombositopenia pada infeksi dengue terjadi melalui mekanisme : \par\pard\ql \li2548\sb124\sl-276\slmult0 \up0 \expndtw-4\charscalex100 1)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Supresi sumsum tulang, dan \par\pard\ql \li2548\sb144\sl-276\slmult0 \up0 \expndtw-5\charscalex100 2)\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Destruksi dan pemendekan masa hidup trombosit. \par\pard\qj \li2265\sb0\sl-412\slmult0 \par\pard\qj\li2265\ri1511\sb40\sl-412\slmult0\fi719 \up0 \expndtw0\charscalex103 Gambaran sumsum tulang pada fase awal infeksi (45% dari total leukosit) disertai adanya limfosit plasma \line\tab \up0 \expndtw-4\charscalex100 biru \up0 \expndtw0\charscalex109 (LPB) > 15% dari jumlah total leukosit yang pada fase syok akan \line\tab \up0 \expndtw-3\charscalex100 meningkat. \par\pard\ql \li2548\sb141\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Trombosit: umumnya terdapat trombositopenia pada hari ke 3-8. \par\pard\ql \li2548\ri1508\sb17\sl-430\slmult0\tx2832\tx2832 \up0 \expndtw0\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Hematokrit: Kebocoran plasma dibuktikan dengan ditemukannya peningkatan \line\tab \up0 \expndtw0\charscalex104 hematokrit \u8805? 20% dari hematokrit awal, umumnya dimulai pada hari ke-3 \line\tab \up0 \expndtw-4\charscalex100 demam. \par\pard\ql \li2548\ri1508\sb27\sl-410\slmult0\tx2832\tx2832 \up0 \expndtw0\charscalex103 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Hemostasis: Dilakukan pemeriksaan PT, APTT, Fibrinogen, D-Dimer, atau \line\tab \up0 \expndtw-2\charscalex100 FDP pada keadaan yang dicurigai terjadi perdarahan atau kelainan pembekuan \line\tab \up0 \expndtw-4\charscalex100 darah. \par\pard\ql \li2548\sb141\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Protein/albumin: Dapat terjadi hipoproteinemia akibat kebocoran plasma. \par\pard\ql \li2548\sb144\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 SGOT/SGPT (serum alanin aminotransferase): dapat meningkat. \par\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Ureum, Kreatinin: bila didapatkan gangguan fungsi ginjal. \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb182\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg8}{\bkmkend Pg8}\par\pard\ql \li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb79\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Elektrolit: sebagai parameter pemantauan pemberian cairan. \par\pard\qj \li2548\ri1515\sb46\sl-420\slmult0\tx2832 \up0 \expndtw0\charscalex108 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Golongan darah: dan \ul0\nosupersub\cf8\f9\fs24 cross\ul0\nosupersub\cf7\f8\fs24 macth (uji cocok serasi): bila akan diberikan \line\tab \up0 \expndtw-3\charscalex100 transfusi darah atau komponen darah. \par\pard\ql \li2548\sb119\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Imuno serologi dilakukan pemeriksaan IgM dan IgG terhadap dengue. \par\pard\qj \li2832\ri1512\sb26\sl-420\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf6\f7\fs24 IgM\ul0\nosupersub\cf7\f8\fs24 : terdeksi mulai hari ke 3-5, meningkat sampai minggu ke-3, menghilang \up0 \expndtw-3\charscalex100 setelah 60-90 hari. \par\pard\qj \li2832\ri1510\sb17\sl-400\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf6\f7\fs24 IgG\ul0\nosupersub\cf7\f8\fs24 : pada infeksi primer, IgG mulai terdeteksi pada hari ke-14, pada infeksi \up0 \expndtw-3\charscalex100 sekunder IgG mulai terdeteksi hari ke-2. \par\pard\qj \li2548\ri1509\sb40\sl-400\slmult0\tx2832 \up0 \expndtw-1\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Uji III: Dilakukan pengambilan bahan pada hari pertama serta saat pulang dari \line\tab \up0 \expndtw-3\charscalex100 perawatan, uji ini digunakan untuk kepentingan surveilans. (WHO, 2006) \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb267\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.6.2. Pemeriksaan radiologis \par\pard\qj \li2265\ri1512\sb34\sl-410\slmult0\fi719 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Pada foto dada didapatkan efusi pleura, terutama pada hemitoraks kanan tetapi \up0 \expndtw0\charscalex102 apabila terjadi perembesan plasma hebat, efusi pleura dapat dijumpai pada kedua \up0 \expndtw-2\charscalex100 hemitoraks. Pemeriksaan foto rontgen dada sebaiknya dalam posisi lateral dekubitus \up0 \expndtw-3\charscalex100 kanan (pasien tidur pada sisi badan sebelah kanan). Asites dan efusi pleura dapat pula \up0 \expndtw-4\charscalex100 dideteksi dengan pemeriksaan USG. (WHO, 2006) \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb265\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.7. Diagnosis \par\pard\qj \li2265\ri1512\sb6\sl-420\slmult0\fi719 \up0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 Masa inkubasi dalam tubuh manusia sekitar 4-6 hari (rentang 3-14 hari), \up0 \expndtw-3\charscalex100 timbul gejala prodormal yang tidak khas seperti : nyeri kepala, nyeri tulang belakang \up0 \expndtw-4\charscalex100 dan perasaan lelah. \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb123\sl-276\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.7.1. Demam Dengue (DD). \par\pard\qj \li2265\ri1511\sb6\sl-420\slmult0\fi719 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Merupakan penyakit demam akut selama 2-7 hari, ditandai dengan dua atau \up0 \expndtw-3\charscalex100 lebih manifestasi klinis sebagai berikut: \par\pard\ql \li2548\sb119\sl-276\slmult0 \up0 \expndtw0\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Nyeri kepala. \par\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Nyeri retro-oebital. \par\pard\ql \li2548\sb144\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Mialgia / artralgia. \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb82\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg9}{\bkmkend Pg9}\par\pard\ql \li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb0\sl-276\slmult0 \par\pard\ql\li2548\sb79\sl-276\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Ruam kulit. \par\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Manifestasi perdarahan (petekie atau uji bending positif). \par\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \expndtw0\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Leukopenia. \par\pard\qj \li2265\ri1515\sb6\sl-420\slmult0 \up0 \expndtw0\charscalex103 dan pemeriksaan serologi dengue positif, ayau ditemukan pasien DD/DBD yang \up0 \expndtw-3\charscalex100 sudah dikonfirmasi pada lokasi dan waktu yang sama. \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb263\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.7.2. Demam Berdarah Dengue\ul0\nosupersub\cf7\f8\fs24 \ul0\nosupersub\cf6\f7\fs24 (DBD). \par\pard\qj \li2265\ri1508\sb6\sl-420\slmult0\fi719 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Berdasarkan kriteria WHO 1997 diagnosis DBD ditegakkan bila semua hal ini \up0 \expndtw-5\charscalex100 di bawah ini dipenuhi : \par\pard\ql \li2548\sb119\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Demam atau riwayat demam akut, antara 2-7 hari, biasanya bifasik. \par\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Terdapat minimal satu dari manifestasi perdarahan berikut : \par\pard\ql \li2692\sb144\sl-276\slmult0 \up0 \expndtw-2\charscalex100 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Uji bendung positif. \par\pard\ql \li2692\sb124\sl-276\slmult0 \up0 \expndtw-3\charscalex100 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Petekie, ekimosis, atau purpura. \par\pard\li2692\sb157\sl-276\slmult0\fi0\tx5222 \up0 \expndtw0\charscalex103 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Perdarahan mukosa\tab \up0 \expndtw0\charscalex103 (tersering epistaksis atau perdarahan gusi), atau\par\pard\li2692\sb137\sl-276\slmult0\fi283 \up0 \expndtw0\charscalex103 perdarahan dari tempat lain.\par\pard\ql \li2692\sb118\sl-276\slmult0 \up0 \expndtw-2\charscalex100 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Hematemesis atau melena. \par\pard\ql \li2548\sb164\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \u8226?\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Trombositopenia (jumlah trombosit 20% dibandingkan standar sesuai dengan umur dan \line\tab \up0 \expndtw-4\charscalex100 jenis kelamin. \par\pard\ql \li2692\ri1508\sb0\sl-420\slmult0\tx2975 \up0 \expndtw0\charscalex102 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Penurunan hematokrit >20% setelah mendapat terapi cairan, dibandingkan \line\tab \up0 \expndtw-3\charscalex100 dengan nilai hematokrit sebelumnya. \par\pard\ql \li2692\sb99\sl-276\slmult0 \up0 \expndtw-3\charscalex100 -\ul0\nosupersub\cf9\f10\fs24 \ul0\nosupersub\cf7\f8\fs24 Tanda kebocoran plasma seperti : efusi pleura, asites atau hipoproteinemia. \par\pard\qj \li2265\ri1514\sb286\sl-420\slmult0\fi359 \up0 \expndtw0\charscalex103 Dari keterangan di atas terlihat bahwa perbedaan utama antara DD dan DBD \up0 \expndtw-3\charscalex100 adalah pada DBD ditemukan adanya kebocoran plasma. (WHO, 1997) \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb187\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840\pard\sb0\sl-240{\bkmkstart Pg10}{\bkmkend Pg10}\par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb79\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.8. Diagnosis Banding \par\pard\qj \li2265\sb0\sl-420\slmult0 \par\pard\qj\li2265\ri1508\sb6\sl-420\slmult0\fi719 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Diagnosis banding perlu dipertimbangkan bilamana terdapat kesesuaian klinis \up0 \expndtw-4\charscalex100 dengan demam tiroid, campak, influenza, chikungunya dan leptospirosis. \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb243\sl-276\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf6\f7\fs24 Sindrom Syok Dengue\ul0\nosupersub\cf7\f8\fs24 \ul0\nosupersub\cf6\f7\fs24 (SSD). \par\pard\qj \li2265\sb0\sl-420\slmult0 \par\pard\qj\li2265\ri1492\sb26\sl-420\slmult0\fi719 \up0 \expndtw0\charscalex106 \ul0\nosupersub\cf7\f8\fs24 Seluruh kriteria di atas untuk DBD disertai kegagalan sirkulasi dengan \up0 \expndtw-2\charscalex100 manifestasi nadi yang cepat dan lemah, tekanan darah turun (\u8804? 20 mmHg), hipotensi \up0 \expndtw-2\charscalex100 dibandingkan standar sesuai umur, kulit dingin dan lembab serta gelisah. (Suhendro, \up0 \expndtw-3\charscalex100 Nainggolan L, Chen K, Pohan, 2006) \par\pard\ql \li2265\sb0\sl-276\slmult0 \par\pard\ql\li2265\sb263\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf6\f7\fs24 2.9. Derajat penyakit infeksi virus dengue \par\pard\qj \li2265\ri1511\sb6\sl-420\slmult0\fi719 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 Untuk menentukan penatalaksanaan pasien infeksi virus dengue, perlu \up0 \expndtw-3\charscalex100 diketahui klasifikasi derajat penyakit seperti tertera pada tabel 1. \par\pard\ql \li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb0\sl-230\slmult0 \par\pard\ql\li8187\sb47\sl-230\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf10\f11\fs20 Universitas Sumatera Utara \par\pard\sect\sectd\fs24\paperw12240\paperh15840{\shp{\*\shpinst\shpleft2020\shptop9660\shpright10940\shpbottom9820\shpwr3\shpfblwtxt0\shpbxpage\shpbypage\shpz909\shplid10{\sp{\sn shapeType}{\sv 75}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn pib}{\sv 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