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ASPECT NEUROLOGY

TETANUS, RABIES,
MALARIA, TBC
THYPOID, HIV

Anwar Wardy W

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FKK.UNIVERSITAS MUHAMMADIYAH

TETANUS

Tetanus toxin:

Patient number in Canada


After antitoxin vaccine
1941-1995

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For lecture only Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Tetanus Epidemiology
Uncommon in the US but not worldwide

1 million cases worldwide per year

Mortality rate of 20-50%

Highestprevalence in developing
countries
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Epidemiology
Fewer than 50 cases per year in the US

Majority of cases in temperate climates (Texas,


California, and Florida)
Indonesia is same (Bali, Manado and North
Sumatra)
Mortality rate of 11%

Most who develop it have an inadequate


immunization history

Only 27% of Americans older than age 70 have


adequate immunity to tetanus
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Pathophysiology
Wound contamination with Clostridium
tetani

Motile,
nonencapsulated, anaerobic,
gram positive rod

Spore
forming and ubiquitous in soil and
animal feces
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Pathophysiology
Usually introduced in the spore forming
state, then germinates to the toxin
producing vegetative form

Requires decreased tissue oxygen tension to


germinate

Vegetative state produces two exotoxins


Tetanolysin
Tetanospasmin
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Toxins: affect on nerve-muscle transmission

Block the release of ACH

sthetik-Forum Berlin
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Toxins
Tetanolysin
clinically insignificant
Tetanospasmin

Neurotoxin responsible for the clinical


manifestations of tetanus
Reaches peripheral nerves by
hematogenous spread and retrograde
intraneuronal transport
Does not cross blood brain barrier
Reaches CNS by retrograde transport

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Tetanospasmin
Acts on the motor end plates of
skeletal muscle, in the spinal cord, and
in the sympathetic nervous system

Prevents release of inhibitory


neurotransmitters glycine and
gamma-aminobutyric acid (GABA)

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Clinical Features
Tetanospasmin responsible for generalized
muscular rigidity, violent muscular
contractions, and instability of the ANS.

Typical wound is a puncture, but no wound is


identified in up to 10%

Other routes are surgical procedures, otitis


media, abortion, umbilical stump and drug
abusers
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Four Clinical Forms


Local

Generalized

Cephalic

Neonatal

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Local Tetanus
Rigidityof the muscles in proximity to
the site of injury

Usually resolves completely in weeks to


months

May develop into generalized

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Generalized Tetanus
Most common form

Mostcommon presenting complaint is


pain and stiffness of the masseter
muscles (Lockjaw)

Shortaxon nerves affected initially


therefore starts in the face, then neck,
trunk, and extremities

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Generalized Tetanus
Muscle stiffness leads to rigidity

Trismus and characteristic sardonic smile


develops (risus sardonicus)

Reflex convulsive spasms and tonic muscle


contraction create dysphasia, opisthotonos
(arching of back and neck), flexing arms,
clenching fists, and lower extremity extension
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Trismus and Sardonic Smile

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Opisthotonos

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Generalized Tetanus
Autonomic nervous system
Hypersympathetic state
Usually in the second week
Tachycardia
HTN
Diaphoresis
Increased urinary catecholamines
Significant morbidity and mortality

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Cephalic Tetanus
Resultsfrom an injury to the head or
otitis media

Cranial
nerves affected most commonly
the seventh

Poor prognosis

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Neonatal Tetanus
400,000 worldwide deaths annually

Results
from inadequately immunized
mothers

Frequent after unsterile treatment of


the cord stump

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Neonatal Tetanus
Signs

Weakness

Irritability

Inability to suck
Presents in the 2nd week of life
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Diagnosis
Clinical diagnosis

No laboratory confirmatory tests

Wound cultures not very useful as C.


tetani may be recovered without tetanus

Immunization history usually unknown or


inadequate

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Tetanus Ddx
Strychnine Peritonitis
poisoning
Meningeal irritation
Dystonic reaction
Rabies
Hypocalcemic
tetany TMJ

Peritonsillar abscess
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Treatment
Admit to ICU

Be prepared for intubation with


neuromuscular blockade as respiratory
compromise may develop

Minimal environmental stimuli to avoid


reflex convulsive spasms

Initial wound debridement to improve


oxygenation
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Treatment
Tetanus Immunoglobulin (TIG)
Neutralizes wound and circulating
tetanospasmin
Does not neutralize toxin already bound to
the nervous system
Does not improve clinical symptoms
Decreases mortality

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Treatment
TIG

Usual dose is 3,000 to 6,000 units


Administered IM opposite side as Td given
Give before wound debridement

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Treatment
Antibiotics

Questionable utility but usually given


Metronidazole
antibiotic of choice
Avoid penicillin
it is a GABAA antagonist and may worse symptoms

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Treatment
Muscle relaxants
Tetanospasmin
prevents neurotransmitter release at
inhibitory interneurons and therapy of
tetanus is aimed at restoring balance
Midazolam
preferred agent as it is water soluble
Baclofen
specific GABAB agonist that has also been
used

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Treatment
Neuromuscular blockade
Blockade often required to allow respiration
and to prevent fractures and rhabdomyolysis
Succinylcholine
recommended for initial airway management
Vecuronium
treatment of choice for long term blockade

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Treatment
ANS dysfunction treatment
Labetalol
useful for treatment due to combined alpha
and beta activity
Magnesium sulfate
inhibits the release of epinephrine and
norepinephrine from the adrenal glands
Clonidine
central alpha receptor agonist for cardiac
stability

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Immunization
Disease does not confer immunity so those
that recover must undergo immunization

Tetanus toxoid
0.5 cc IM at presentation, 6 weeks, and 6 months
Local reactions are common
Less common serous reactions include urticaria,
anaphylaxis, or neurologic complications

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Immunization and TIG guide


Clean,
Minor All other
wounds wounds
History of
Td Doses Td TIG Td TIG
Unknown or
<3 Yes No Yes Yes
Three or
more
Td dose: 0.5cc IM No No Yes No
TIG dose: 250 U IM
DPT given if under 7, Td given if over 7

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

RABIES
Family Rhabdoviridae
Genus Lyssavirus (Greek root lyssa)
Infeksi melalui darah mammalia, termasuk
pada manusia.
Causes encephalitis of the central nervous
system
Results in death of the host

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

TRANSMISSION OF
RABIES
Is zoonotic, meaning is transmitted
from animal-animal or animal-human.
Rabies is most commonly contracted
from the bite of an animal that is
infected with the virus.
The virus is found in the saliva of the
infected animal.
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

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PARAMYXOVIRUS Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
TRANSMISSION OF RABIES

Can also enter via any mucous membrane,


such as the eye, nose or mouth.
Handling and skinning of infected animal
carcasses.
Few cases of human to human
transmission.
Can be transmitted via aerosol, but thats
also uncommon.
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

TRANSMISSION OF
RABIES
Inside the Jakarta/Java, important
reservoirs for the transmission of the
disease are wild animals such as
raccoons, skunks, foxes, bats, and
coyotes.
The time it takes for rabies to affect the
animal averages 1-3 months.
Sometimes may only be a few days, and
rarely longer than a year after exposure.
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

THE RABIES INFECTION AND THE


SYMPTOMS THAT ACCOMPANY IT IS
1. IncubationBY
CLASSIFIED (1-3FIVE
months)
STAGES:
2. Prodromal, where first symptoms
occur
3. Acute neurological phase
4. Coma
5. Death or recovery

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

TRANSMISSION OF
RABIES
1 Acute Neurological Stage, continued
Aerophobia
Sensitivity to lights, sounds and smells
Respiratory spasms.
2. Coma
Spasms decrease because paralysis occurs
Heart arrhythmias and irregular heartbeat persist
Cerebral encephalitis causes major organs to collapse
Fixed pupils that are unresponsive to light
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

DEATH OR RECOVERY
1. - Death results from encephalitis of
the brain.
2. - Heart failure along with major
organ failure are the main causes of
death.
3. - Only four known cases of human
recovery, and they were permanently
brain damaged.
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Anwar Wardy W
Pathophysiology
FKK.UNIVERSITAS MUHAMMADIYAH

Histologically resembles other encephalitis


Monocellular infiltration with focal hemorrhage
Demyelination
Perivascular gray matter
Basal ganglia
Spinal cord
Negri bodies
Eosinophilic intracellular lesions in cerebral
neurons
Highly specific for rabies
Present in 75% of rabies cases
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Negri bodies

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Epidemiology
Primarily a disease of animals
Human cases reflect the prevalence in
animals and degree of human contact with
them
Major vectors include
Dogs
Foxes
Raccoons
Skunks
Coyotes
Mongooses
bats

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Epidemiology
7,369 cases of animal rabies in the US in 2000
(Other World is some)
Domestic animals

Wild animals (93%) (7%)


Raccoons (37.7%) Cats (3.4%)
Skunks (30.2%) Dogs (1.6%)
Bats (16.8%) Cattle (1.1%)
Horses, donkeys,
Foxes (6.2%) mules (0.71%)
Others (2.2%) Sheep, goats, camels
(0.15%)
Others and ferrets
(0.06%)
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Epidemiology
Dogs
Less than 5% of animal cases in US, Canada and
Europe
Greater than 90% of animal cases in developing
countries
Very rare documented rabies in:
Squirrels, hamsters, guinea pigs, gerbils,
chipmunks, rats, mice, domesticated rabbits and
other small rodents
Almost never requires post exposure prophylaxis

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Epidemiology
Transmission

Saliva though bite of an rabid animal most


common
Aerosolized in bat caves
Mucus membrane transmission also
reported
Bites and scratches
Risk of developing rabies dependant on the
location injury, depth, an number of bites

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Infection Risk
Risk of infection
Multiple bites around the face 80-
100%
Single bite 15-40%
Superficial bite on the extremity 5-10%
Contamination of open wound by 0.1%
saliva
Transmission via fomites (e.g. 0%
tree branch, or animal)
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Epidemiology
32 cases reported from 1980 to 1996
in the US
7 had a known animal bite
6 dog bites in a foreign country
1 bat bite
Animal contact identified in 12
8 with a bat
2 with a dog
1 with a cow
1 with a cat
No identifiable source in the other 13
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Preexposure Prophylaxis
Prophylaxis

Individuals with occupations or recreation


that place them at risk should receive the
series
4 shot series with booster shots required
Does not eliminate need for postexposure
prophylaxis
No need for HRIG and less doses of vaccine

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Postexposure Prophylaxis
Indicated for all persons possibly exposed to
a rabid animal
Exposure is a bite, scratch, abrasion, open
wounds, or mucous membrane exposure
Contact alone, and contact with blood, urine, or
feces does not constitute and exposure

Cleansing wound with 20% soap and water


has been show in experimental animals to
markedly reduce the rate of infection
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Bats
Increasinglyimportant wildlife vectors of
transmission of rabies

Allcases of possible bat bites the bat


should be collected and tested for rabies

Bat unavailable
Begin postexposure prophylaxis
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Dogs, Cats, and Ferrets


Observation

CDC recommends 10 days of observation of


a healthy dog, cat, or ferret after a bite
Normal behavior
No action needed
Unusual behavior
Sacrifice animal, test for rabies, and initiate HRIG
and vaccine
Positive Complete course of vaccine
Negative Discontinue course
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Postexposure Prophylaxis
Course

HRIG (human rabies immune globulin)


One dose initially
May be given up to 7 days after an exposure
Infiltrate as much as possible around wound
Give on the opposite side as the vaccine
Vaccine
5 doses over 28 days

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Postexposure Prophylaxis
Vaccine reactions
Minor reaction
Erythema, swelling, pain
30-74%
Systemic reaction
Headache, nausea, abdominal pain, muscle
aches
5-40%
Anaphylaxis and neurological symptoms
Rarely reported
Vaccine should not be stopped for
minor
fkk umj
or systemic reactions
anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Special Circumstances
Prior rabies immunization
Either prior preexposure course or full
postexposure course
No HRIG
Course shortened to 2 doses
One dose on presentation
One dose three days later

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Special Circumstances
Immunocompromised patient
HRIG and vaccine usual course
Safe
Vaccine is inactivated so no danger of contracting
Stop all immunosuppressives if possible
Measure antibody titers to assure appropriate
response

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Special Circumstances
Travelers

Preexposure prophylaxis
Recommended if prevalence and possible
exposure
Veterinarians, animal handlers, spelunkers, certain
lab workers
Non-FDA postexposure prophylaxis
If initiated in another country contact health
department for recommendations

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Special Circumstances
Pregnancy

No adverse effects of the vaccine or HRIG


Follow usual course in pregnancy if indicated

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Special Circumstances
Children

Vaccine
Same dose and same course
HRIG
Dose is based on weight
If quantity of HRIG not sufficient to infiltrate all
wounds may be diluted with saline

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Clinical Disease
Incubation period
20 to 90 days
4 days up to 19 years have been reported
Greater than 1 year is well documented
Prodrome
Fever, sore throat, chills malaise, headache, N/V,
weakness
May report limb pain, weakness, and paresthesias
Nonspecific neurologic conditions such as anxiety,
agitation, irritability or psychiatric disturbances

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Clinical Disease
Acute neurologic phase
Furious 80%
Hyperactivity, disorientation, hallucinations,
bizarre behavior
Symptoms may alternate with calm
Autonomic dysfunction
Hydrophobia with pharynx spasms in 50%
Paralytic 20%
Paralysis in the extremity, diffuse or ascending
Fever and nuchal rigidity
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Clinical Disease
Coma

Almost always present within 10 days


Death

Occurs from complications such as pituitary


dysfunction, seizures, respiratory dysfunction,
cardiac dysfunction, ANS dysfunction, ARF, or
infection
Outcome almost always fatal
No person without post-exposure prophylaxis in
the US has survived since 1980

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Diagnosis
Rabiesshould be in the differential of
any acute encephalitis

May be confused with poliomyelitis,


Guillain-Barre syndrome, transverse
myelitis, postvaccinial
encephalomyelitis, CVA, atropine-like
poisoning, other viral encephalitis
fkk umj anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Diagnosis
Lab testing
No one test is completely informative
Test serum, CSF, and skin for antibodies in a
non-vacinated person
Nuchal skin biopsy most sensitive early
PCR from saliva also useful

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Treatment
Limited

No specific treatment exists for clinical


course
Treatment directed at the clinical
complications

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Malaria

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Protozoan infection
Falciparum malaria- most common virulent type
Cerebral malaria-obstruction of small blood vessels
in the brain
Rupturingof red blood cells
Relapses can occur

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Brief history of malaria


Basic biology of
Plasmodium
Epidemiology of
malaria, malaria & HIV

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Malaria in Indonesia
Malaria was quite prevalent in
the rural South
It was eradicated after World
War II in an aggressive
campaign using, treatment,
vector control and exposure
control (along with overall
improvement of living
conditions)
Eradication of malaria in
Indonesias initial mission

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Pathogenesis of
severe falciparum
malaria
Drugs used to
treat malaria and
the development
of drug resistance

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

9-14 day incubation


period
Fever, chills,
headache, back and
joint pain
Gastrointestinal
symptoms (nausea,
vomiting, etc.)

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Symptoms intensify
Irregular high fever
Anxiety, delirium and other
mental problems
Sweating, increased pulse
rate, severe exhaustion
Worsening GI symptoms
Enlarged spleen and liver

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Malaria the disease


3 Severe manifestations

Cerebral malaria Severe anemia Renal failure

Irritability, loss of reflexes, Progressive severe drop Dwindling urine, high urea
neurological symptoms of hematocrit, poor oxygen Level in serum, hyperventilation
similar to menigitis, coma Supply for organs and Coma, poor prognosis
20% fatality fkk umj tissues anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Pathogenesis of
malaria
In highly endemic areas: high
mortality among children due to
severe anemia, children who
survive beyond the first years
show decreasing parasitemia and
disease (this immunity is not
sterile and depends on constant
exposure)
In areas with less infection
pressure: malaria is an epidemic
disease with varying intensity.
Adults and children are equally
susceptible and death in adults is
mostly due to cerebral malaria

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Pathogenesis of
malaria

Parasitemia

Anemia Cerebral malaria

Age
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Development of malaria consist of an asexual phase
(carried out in the human) and a sexual phase (carried
out in the mosquito).

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The life and transmission of Plasmodium Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Features of malaria.

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

DIAGNOSIS OF MALARIA
1. HISTORY AND CLINICAL
FEATURES
* LOCALITY , TRAVEL
HISTORY
* FEVER
* SPLENO-HEPATOMEGALY
* PRESENCE OF
COMPLICATIONS
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

* DRUG HISTORY
* ANTI MALARIALS
* BLOOD TRANSFUSION
HISTORY OF
- HAEMOGLOBINOPATHY
- DIABETES
- ALCOHOLISM/ JAUNDICE
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Specifically ask / look for


- fever with duration
- headache
- vomiting, diarrhoea
- urine output and colour
- cough / dyspnoea/ bleeding
- altered sensorium / seizures
- pregnancy

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

CLINICAL EXAMINATION
PALLOR, ICTERUS
BLEEDING SIGNS
EARLY SIGNS OF PULM
OEDEMA
CONSOLIDATION
ARRHYTHMIA
HEPATOSPLENOMEGALY
UTERUS
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

CNS Examination
Sensorium /coma score
- Glasgow coma score
- Blantyre coma score
- decerebration
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

LABORATORY DIAGNOSIS
Microscopy

Immunological tests
Antigen capture tests

Antibody detection tests

QBC test

DNA probe

PCR
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

MENINGITIS TBC
(TUBERCULOSE)

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Balita / anak (3 bulan - 6 thn);


Haemophilus influenzae
Neisseria meningitidis
Streptococcus pneumoniae
Staphylococcus aureus
Mycobacterium TBC
"Normal" Dewasa (6-21 years)
Neisseria meningitidis
Streptococcus pneumoniae
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
H o s t: Bakteri:
Eukaryote Prokaryote
Nukleus mengandung Tidak ada nukleu,
material genom material genom bebas

Banyak kromosom Satu kromosom


linear sirkuler.
Ribosome besar Ribosome kecil
Multiseluler Sel tunggal.
Reproduce by binary
Reproduce sexually
fission
Pernapasan Respire aerobically or
O2(aerobic)
fkk umj anaerobically
anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

PATHOGENESIS.
Kebanyakan infeksi bakteri
menyerang melalui; mucosa,
darah, dan bakteri tumbuh dengan
cepat di dalam cairan serebro
spinal; sehingga tanda klinik yang
khas adalah, demam, kaku kuduk
dan kejang pada penderita
meningitis.
fkk umj anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Mekanisme Patogenik Bakteri dan Respon Tubuh


Host Defense Bacterial Evasion
Pathogenic Event
Mechanism

Colonization and 1. Secretory IgA IgA protease secretion


mucosal invasion, 2. Cellular cilia activity Ciliostasis
3.Mucosal epithelium Adhesive pili

Survivalintheblood ActivationofComplement BlockageofAlternative


stream Pathways ComplimentPathwayby
Mechanismsonthecell
surface
Crossingtheblood-brain Cerebralendothelium Passagethroughtight
barrier junctionsbetweencells,

SurvivalwithintheCSF Pooropsonicactivity Rapidbacterialreplication


fkk umj
mechanism unknown
anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Invasi Bakteri

Bakteri dalam jumlah yang banyak berpotensi dapat


melewati BBB sampai di gyrus,
Terjadi vaskulitis disertai dengan deposit fibrin
karena kerusakan pembuluh arteri yang kecil; serta
petichae akan terlihat pada lapisan piamater.
Terjadi eksudat disertai dengan granulasit dan fibrin
dalam sulkus-sulkus hemisfer.
Pada beberapa penderita terjadi ventrikulitis; hal ini
menyebabkan mudah terjadinya ensefalitis dan bisa
difus pada kedua parenkhim-hemisfer.
fkk umj anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Foki MeningoEnsefalitis

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Antibiotik

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Thypoid
Transmission Disease Prevention

cholera, thyphoid, improve water quality, prevent casual use


waterborne
bacillas, hepatitis of polluted source

trachoma, scabia,
water washed improve water access, hygiene control
dysentery

schistomaisis,
water based snail control, filtration
guinea worm

malaria, sleeping
water vector surface water management
sickness
fkk umj http://www.arts.mcgill.ca/152-497b/h2o/water/gwater/death.htm
anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Water Related Diseases in poor countries


(000s)

Infection Infections Deaths Cases of Disease

Diarrheas 5,000,000 10,000 5,000,000


Malaria 800,000 1,200 150,000
Polio 80,000 10-20 2,000
Typhoid 1000 25 500

Whipworm 500,000 low 100

http://www.arts.mcgill.ca/152-497b/h2o/water/gwater/death.htm
fkk umj anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Meningococcemia

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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Human immunodeficiency virus
(HIV)
Viralinfection
Acquired immunodeficiency syndrome (AIDS)

Infects helper T cells (CD4 receptor)

Latency

Therapy

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

AIDS is a cluster of symptoms associated with


the initial infection of HIV.

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
HIV have specific glycoprotein receptors that bind to CD4
receptors of T cells.

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
HIV infects, undergoes latency, and eventually replicates
and lyses the host T cell.

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Primary sources and possible routes of infection by HIV.

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
New HIV infections based on gender, risk group, and race.

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Nucleoside analogs, protease inhibitors, and integrase
inhibitors are effective therapies used to treat HIV
infections.

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH
Features of HIV infections and AIDS.

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

MINIMUM DIAGNOSTIC EVALUATION

5. Cultures of blood, urine


and other normally sterile compartments if
clinically indicated, e.g. joints, pleura, cerebrospinal fluid
6. Chest radiograph
7. Abdominal (including pelvic) ultrasonography
8. Autoantibodies
ANA, ANCA, Reuma factor, etc.
9. Tuberculin skin test
10. Serological tests directed by local epidemiological data
. Knockaert DC et al: Fever of unknown origin in adults: 40 years on. J
fkk umj Intern
anwar Med. 2003;253:263-75. Review.
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Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

PENICILLINS
Pharmacokinetics:
A: Oral and parenteral

D: Variable: no CNS entry except w/meningitis

M: Not extensively metabolized

E: Filtration and secretion: Short life: 1-2 hr.


Probenicid prolongs actions: blocks secretion
fkk umj anwar wardy w
Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

PENICILLIN TOXICITY
REMARKABLY NON-TOXIC

RENAL: Dose-related

I.T. INJECTIONNeurotoxicity

HYPERSENSITIVITY----Death

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Lifestyle Factors
Genes load the gun.
Lifestyle pulls the trigger
Dr. Elliot Joslin

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

Readings

Fundamental Neuroscience 1st Ed. Chapters 7 and 8


(for Neurochem also), 2nd Ed. Chapters 7 and 8.
Molecular Biol. Of the Cell 4th Ed. Chapter 13.
Harold L. Atwood & Shanker Karunanithi
Diversification of synaptic strength: presynaptic
elements. Nature Reviews Neuroscience 3, 497 -516
(2002). Advanced review comprehensive.
T. Galli, V. Haucke, N. R. Gough, Synaptic vesicle
fusion followed by clathrin-mediated endocytosis. Sci.
STKE 2003, tr3 (2003) shockwave animation of ves.
fusion.
Ref. Text book Of Clinical Neurology, Gilroy. 2001, 2006

fkk umj anwar wardy w


Anwar Wardy W
FKK.UNIVERSITAS MUHAMMADIYAH

WASSALAM, WR, WBR.........

Thank You

fkk umj anwar wardy w


Anwar Wardy W