rheumatic fever indonesia
TRANSCRIPT
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RHEUMATIC FEVER
Current Diagnosis And Secondary Prevention Strategy
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Tn. Rio Widyatmoko , 18 thn
No CM : 01795901
Alamat : Yogyakarta
Pendidikan : SMU
Pekerjaan : Swasta
Suku : Jawa
Agama : Islam
Dirawat di : bugenvil 5
Dokter Jaga : dr. Sari
Dokter bangsal : dr. Rico
Indikasi rawat inap : Diagnosis dan Terapi
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RPS :
• Laki-laki, usia 18 tahun, rujukan dari RSUD Temanggung dengan demam rematik
• Demam sejak 14 hari disertai nyeri sendi di kedua lutut, pergelangan kaki, siku, sendi bengkak (+), gerakan terbatas (+) sampai
sulit berjalan
• Nyeri tenggorokan (+), batuk (-), nyeri dada (-), berdebar debar (-), sesak (-), ruam kulit (-)
• Keluhan serupa dialami 4 tahun yang lalu di lutut kanan, kambuh-kambuhan setiap tahunnya, dan memberat sejak 3 bulan yang
lalu.
• Os pengobatan di RSU Temanggung dikatakan radang sendi, mendapat terapi anti nyeri diklofenak jika nyeri sendi dan ranitidin
• Nyeri tenggorokan berulang ketika SD.
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Pemeriksaan Fisik
KU : sedang, CM, gizi cukup
TB 169 cm, BB 65 kg, IMT 22.76 kg/m²
VS : TD 120/70 mmHg, tidur, manset di lengan kanan, large adult cuff
N 90 x/menit, irama teratur, isi dan tekanan cukup
R 20 x/menit, irama teratur, tipe pernapasan thorakoabdominal
T° 38,3 °C, suhu aksila
Kepala : Insp. : konj. pucat (-), sklera ikterik (-)
Palp. : tidak ada nyeri tekan, tak teraba massa
orofaring : hiperemis (+)
Leher : Insp. : JVP tak meningkat
Palp. : lnn ttb
Thorax :
Pulmo : Insp. : simetris, KG (-),
retraksi (-)
Palp. :
stem fremitus kanan = kiri
Perk. :
sonor (+)
Ausk. :
vesikuler (+) RBK (-) RBB (-) Wheezing (-)
Cor : Insp. :
IC tak tampak
Palp. :
IC teraba di SIC V LMCS
Perk. :
kardiomegali (-), kesan konfigurasi dbn
Ausk. : S1-
2 murni reguler, bising (-)
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Pemeriksaan Fisik
Abdomen : Insp. : datar
Ausk. : peristaltik (+) N
Perk. : timpani di seluruh regio
Palp. : NT (-), H/L ttb
Extremitas : Insp. : edema − −
− −
Palp. : akral hangat, tidak ada nyeri tekan
nyeri sendi + +
+ +
Gerakan terbatas terbatas
terbatas terbatas
St.lokalis R.genu dekstra et sinistra, R. Cubiti dekstra et sinistra :
bengkak (+), teraba hangat (+), nyeri tekan (+), gerak terbatas karena nyeri (+), krepitasi (-)
Kulit : eritema marginatum (-), nodul subcutan (+) di regio antebrachii sinistra
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Foto klinis
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Foto klinis
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Foto klinis
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Pemeriksaan Penunjang
Darah rutin
Hb 12
AL 28.79
AT 529
AE 4.41
Hmt 36.4
S 84.9
L 9.1
M 4.5
E 1.3
B 0.2
MCV 82.5
MCH 27.2
CRP >150 mg/L (normal = < 5)
ASTO (+)
Procal 0.59
LED 98 mm/1jam (normal = 0-10)
g/dl
.103/μL
.103/μL
.106/μL
%
%
%
%
%
%
fL
pg
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EKG 24/12/16 : Sinus Rythm, heart rate 90 kali/menit, normoaksis
PR interval = 0,12 s
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Ro thorax 24/12/16 :
• pulmo tak tampak kelainan, besar cor normal
• Diafragma dextra letak tinggi suspek proses infradiafragma
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Re-assesment• Reccurent acute rheumatic fever
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Terapi :• Inf. NaCl 0.9% 20 tpm
• Inj ampicillin 1gram/6jam iv
• Inj Metilprednisolon 62.5mg/24jam
• Inj. PPI 1A/24jam
• Paracetamol 3x500mg
Plan:• Lacak swab faring
• Echocardiografi
• Evaluasi CRP
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PEMBAHASAN
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DEFINISI
• Acute rheumatic fever adalah penyakit inflamasi sistemik pasca infeksi group A streptococcus
• Menyerang pada connective tissue (joint, jantung, jaringan subkutan, CNS)
• Usia : 5 – 15 tahun• Low risk population (Eropa, USA)
– ARF incidence ≤ 2/1000 at school age– RHD incidence ≤ 1/1000 at all age
• high risk population (Australia, New Zeland, Turkey, Africa, Asia selatan dan pada negara negara berkembang)– ARF incidence > 2/1000 at school age– RHD incidence > 1/1000 at all age
Luiza G, et al, 2016Ayse et al., 2016
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“ARF licks the joints and BITES THE HEART”
• Carditis Manifestasi terbanyak kedua setelah artritis (pada anak) Pada dewasa carditis > artritis
• Melibatkan endocardium dan valvular• ARF = penyebab tersering acquired heart disease pada anak dan usia
muda• Insidensi ARF 500,000 per tahun kasus baru • 280,000 RHD• 233,000 dead
“PENTINGNYA SCREENING DAN PREVENSI RHD PADA PASIEN ARF”
Luiza G, et al, 2016
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CLINICAL CARDITIS
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Michael et al, AHA, 2015
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“screening subclinical carditis”
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“pentingnya prevensi sekunder untuk mencegah progresi ke RHD terutama pada awal penyakit”
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“pentingnya prevensi tersier untuk mencegah komplikasi RHD terutama pada awal penyakit”
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STRATEGI PREVENSI KOLONISASI FARING DAN FARINGITIS
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Management Of Acute Rheumatic Fever
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MONITORING
• Evaluasi klinis– Artritis biasanya respon dengan aspirin (6 minggu stop obat)
• Cek CRP 2 x seminggu (pada minggu I), lalu setiap 1-2 minggu sekali, biasanya kembali normal setelah 1 bulan
• Echocardiografi minimal diulang setiap bulan• Discharge planning
– Pada ARF ringan (tanpa carditis atau mild carditis) biasanya 2 minggu
– Dengan carditis berat rawat inap lebih lama
Luiza G, et al, 2016Ayse et al., 2016
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Antibiotics appear to be effective in reducing the incidence of acute rheumatic fever following
an episode of suspected GAS pharyngitis. This effect may be achieved at relatively low cost if a
single intramuscular penicillin injection is administered.
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AMPICILLIN ON RHEUMATIC FEVER TREATMENT
• NO EVIDENCE AVAILABLE
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Antiinflamasi (Croticosteroid dan NSAID) mengurangi LOS tapi tidak berefek pada outcome
cardial
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Secondary Prevention And Rheumatic Heart Disease
Control Programs
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Recommended routine review and structured care planning
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TAKE HOME MESSAGE
• Diagnosis dini RHD pada pasien ARF menentukan prognosis dan terapi (pentingnya echocardiografi sebagai screening)
• Optimalisasi terapi antibiotik sesuai guideline
• Antiinflamasi (Croticosteroid dan NSAID) mengurangi LOS tapi tidak berefek pada outcome cardial
• Prevensi sekunder perlu diberikan pada pasien ini dengan pemberian penicillin V 2x250mg (perhatikan kepatuhan)
• Monitoring berkala perlu dikerjakan sesuai guideline
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THANK YOU....
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