STUDENT PROJECT
Regulation:
TITLE Name:
NIM: Faculty of Medicine, Udayana University
2016 1. Introduction Pendahuluan
2. Content Isi sesuai dengan judul paper 3. Summary Ringkasan
4. References Daftar pustaka: Vancouver style 5. Pages: 6-10, Spasi: 1.5, Time New Roman:12
TOPIC Regular Class Class A
GROUP DATE
TIME TITLE
PEMBIMBING FASILITATOR
EVALUATOR
1 Tuesday,
Sept 20
th
2016, 08.30-09.00
Cerebral abses dr. Ni Made
Susilawathi, Sp.S K
2 09.00-09.30
Cerebral toxoplasmosis
3 09.30-10.00
Multi drug
resisten MDR TB
dr. Made Bagiada,
Sp.PD-KP
4 10.00-10.30
Spondilitis TB 5
10.30-11.00 Acute infection
pancreatitis dr. A.A.A. Yuli
Gayatri, Sp.PD- KPTI
6 11.00-11.30
Pes 11.30-12.30
BREAK
7 12.30-13.00
Leishmaniasis dr. Dewi Dian
Sukmawati, Sp.PD
8 13.00-13.30
Tripanosomiasis 9
13.30-14.00 Cytomegalovirus
infection Dr. dr. Ketut
Agus Somia, Sp.PD-KPTI
10 14.00-14.30
Squamous cell carcinoma
associated with HPV infection
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TOPIC
English Class Class B
GROUP DATE TIME
TITLE PEMBIMBING
FASILITATOR EVALUATOR
1 Wednesday,
Oct 5
th
2016, 08.30-09.00
Nasopharyngeal carcinoma
associated with EBV infection
dr. Wayan Gustawan,
Sp.A K
2 09.00-09.30
Hairy leukoplakia associated with EBV
infection
3 09.30-10.00
Korioretinitis dr. Ratih
Karna, Sp.KK 4
10.00-10.30 Carcinoma servik
associated with HPV infection
5 10.30-11.00
Penyakit jantung
rematik dr. Dwi
Lingga Utama, Sp.A
K 6
11.00-11.30 Endoftalmitis
11.30-12.30 BREAK
7 12.30-13.00
Hepatitis C dr. Made
Susila Utama, Sp.PD-KPTI
8 13.00-13.30
Abses payudara 9
13.30-14.00 Epididimitis
Dr. dr. I.B. Fajar
Manuaba, Sp.OG
10 14.00-14.30
Herpes genital tipe 2
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ASSESSMENT METHOD
1. Assessment will be held twice, for infection infectious diseases. Final mark is combination beteween this mark. The time provision is 100 minutes. The number of
MCQ is 100 with passing point 70.
2. Assessment in this block consists of: SGD
: 5 Student Project Paper
: 10 Exam
: 85
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LEARNING PROGRAM
Lecture 1 INTRODUCTION OF BLOCK INFECTION AND INFECTIOUS
DISEASE
Abstract Infections and infectious diseases are a great burden on many societies, including
Indonesia. To reduce that burden an integrated approach is required, combining health promotion, disease prevention and patient treatment. The prerequisite for
success in this fight is the participation of all health care professionals. Should know and understand terminology commonly use in the context of infectious disease.
Infectious diseases are disorders or diseases caused by organisms — such as bacteria, viruses, fungi or parasites. Many organisms live in and on our bodies.
Theyre normally harmless or even helpful, which we called them normal flora; but under certain conditions, some organisms may cause disease. This organisms
called as pathogen as they can produced pathology to the body. Infectious diseases are one of the leading causes of death worldwide. Infectious
diseases can be spread directly or indirectly. Some infectious diseases can be passed from person to person. Some are transmitted by bites from insects or
animals. And others are acquired by ingesting contaminated food or water or being exposed to organisms in the environment.
Many infectious diseases become difficult to control if the infectious agents evolve resistance to commonly used drugs: For example, bacteria can accumulate
mutations in their DNA or acquire new genes that allow them to survive contact with antibiotic drugs that would normally kill them.
Signs and symptoms vary depending on the organism causing the infection, but often include fever and fatigue. Mild infections may respond to rest and home
remedies, while some life-threatening infections may require hospitalization. Many infectious diseases, such as measles and chickenpox, can be prevented by
vaccines but many other still do not have vaccine available. Other prevention mean such as frequent and thorough hand-washing helps protect from most infectious
diseases.
Symptoms Each infectious disease has its own specific signs and symptoms. General signs
and symptoms common to a number of infectious diseases include: fever, fatigue, muscle aches, coughing and diarrhea
Transmission: an infection can be spread through direct and indirect contact Direct contact
An easy way to catch most infectious diseases is by coming in contact with a person or animal who has the infection. Three ways infectious diseases can be spread
through direct contact are: Person to person. A common way for infectious diseases to spread is through the
direct transfer of bacteria, viruses or other germs from one person to another. This can occur when an individual with the bacterium or virus touches, kisses, or coughs
or sneezes on someone who isnt infected. These germs can also spread through
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the exchange of body fluids from sexual contact. The person who passes the germ may have no symptoms of the disease, but may simply be a carrier.
Animal to person. Being bitten or scratched by an infected animal — even a pet — can make you sick and, in extreme circumstances, can be fatal. Handling animal
waste can be hazardous, too. For example, you can acquire a toxoplasmosis infection by scooping your cats litter box.
Mother to unborn baby. A pregnant woman may pass germs that cause infectious diseases to her unborn baby. Some germs can pass through the placenta. Germs in
the vagina can be transmitted to the baby during birth. Indirect contact
Touching: Disease-causing organisms also can be passed by indirect contact. Many germs can linger on an inanimate object, such as a tabletop, doorknob or
faucet handle. When you touch a doorknob handled by someone ill with the flu or a cold, for example, you can pick up the germs he or she left behind. If you then touch
your eyes, mouth or nose before washing your hands, you may become infected. Vectorsinsect bites - Some germs rely on insect carriers — such as mosquitoes,
fleas, lice or ticks — to move from host to host. These carriers are known as vectors. Mosquitoes can carry the malaria parasite or West Nile virus, and deer ticks
may carry the bacterium that causes Lyme disease. Foodwater contamination : disease-causing germs can infect you is through
contaminated food and water. This mechanism of transmission allows germs to be spread to many people through a single source. E. coli, for example, is a bacterium
present in or on certain foods — such as undercooked hamburger or unpasteurized fruit juice.
Risk factors Anyone can catch infectious diseases easier than other people because the body
immune system is not work well. This may occur if there are primary or secondary immune deficiency , such as : Taking steroids or other medications that suppress
immune system, such as anti-rejection drugs for a transplanted organ, certain types of cancer or other disorders that affect the immune system, infection by HIV or
AIDS. In addition, certain other medical conditions may predispose you to infection, including implanted medical devices, malnutrition and extremes of age, among
others.
Complications Most infectious diseases have only minor complications. But some infections —
such as pneumonia, AIDS and meningitis — can become life-threatening. A few types of infections have been linked to a long-term increased risk of cancer:
hepatitis B and C have been linked to liver cancer, human papillomavirus is linked to cervical cancer, Helicobacter pylori is linked to stomach cancer and peptic ulcers
and In addition, some infectious diseases may become silent, only to appear again in the future — sometimes even decades later. For example, someone whos had a
chickenpox infection may develop shingles much later in life.
Diagnosis Diagnosis can be made with clinical symptoms and signs. Because many of
infectious disease have a very similar symptoms and signs, usually laboratory or imaging test would be needed to confirmed the diagnosis
Laboratory tests
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Many infectious diseases have similar signs and symptoms. Samples of body fluids can sometimes reveal evidence of the particular microbe thats causing illness.
Samples can get from blood, urine, throat swabs, stool sample, spinal tap lumbar puncture. A technician obtains a sample with a standard procedure from each.
Imaging scans Imaging procedures — such as X-rays, computerized tomography and magnetic
resonance imaging — can help pinpoint diagnoses and rule out other conditions that may be causing the symptoms.
Biopsies During a biopsy, a tiny sample of tissue is taken from an internal organ for testing.
For example, a biopsy of lung tissue can be checked for a variety of fungi that can cause a type of pneumonia.
Treatment Knowing what type of germ is causing the illness makes it easier to choose
appropriate treatment such as : antibiotics, anti viral, anti fungal, and anti- parasitics.
However, the use of those agents should be use appropriately. The overuse of antibiotics has resulted in several types of bacteria developing resistance to one or
more varieties of antibiotics. This makes these bacteria much more difficult to treat As an alternative medicine, a number of products have been purported to help fend
off common illnesses, such as the cold or flu. Cranberry, echinacea, garlic, ginseng, vitamin C, D and zinc are among other. While some of these substances have
appeared promising in early trials, follow-up studies may have had negative or inconclusive results. More research needs to be done.
Prevention Infectious diseases can be prevented by vaccines but many other still do not have
vaccine available. Prevention to infectious disease transmission with no vaccine available should use another approach. Personal protected equipment such as
gown, masker, google, gloves, and shoes boot. Infectious disease transmitted by vectors should avoid to being bitten by mosquitoes or other insects may be useful,
such as wearing long sleeve shirt, and putting mosquitos repellent. Other prevention means such as frequent and thorough hand-washing helps protect
from most infectious diseases.
Learning tasks:
1. How do we know that a patient in our hospital is suffering from a kind of infectious disease?
2. How he or she can get it? 3. What prevention do we need to do to avoid of getting any infectious
diseases?
Self assessment:
1. Describe all common terminology use in the context of infectious diseases. 2. Describe general clinical manifestation of infectious diseases.
3. Describe pathogenesis of general symptoms of infectious disease.
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Lecture 2 MALARIA
Abstract
Malaria is caused by infection of red blood cells with protozoan parasites of the genus Plasmodium inoculated into the human host by a feeding female
anopheline mosquito. The five human Plasmodium species transmitted from person to person are P. falciparum, P. vivax, P. Ovale two species, P. Malariae and
P. Knowlesi. The first symptoms of malaria are nonspecific and similar to those of a minor systemic viral illness. They comprise headache, lassitude, fatigue, abdominal
discomfort and muscle and joint aches, usually followed by fever, chills, perspiration, anorexia, vomiting and worsening malaise. Disease progression to severe malaria
may take days but can occur within a few hours. Severe malaria usually manifests with one or more of the following: coma cerebral malaria, metabolic acidosis,
severe anaemia, hypoglycaemia, acute renal failure or acute pulmonary oedema. If left untreated, severe malaria is fatal in the majority of cases. All patients with
suspected malaria should be treated on the basis of a confirmed diagnosis by microscopy examination or RDT testing of a blood sample. Management of
uncomplicated malaria using ACT Artemisinine Combination Therapy for 3 days but severe malaria must treated with anti malaria intravenous artesunate.
Learning task
1. Explain clinical symptom and sign of malaria 2. Differentiate between uncomplicated malaria and severe malaria
3. Management uncomplicated malaria and severe malaria
Self assessment Case:
1. Male, 23 years old come to internal medicine clinic with fever for 6 days. Fever was intermittenly every 2 days, fever was followed by chills and
sweathing. He has history travel to Papua. -
How to make diagnosis in this case? -
How to manage this case? 2. Female, 34 years old come to emergency room with severe headache and
fever for 4 days. Physical examination: icterus +, lien S2. Lab examination Hb 4 gdL, bil total 4,3 mgdL and plasmodium falciparum on smear.
- What is the assessment?
- How to manage this case?
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Lecture 3 DENGUE FEVER, DENGUE HEMORRHAGIC FEVER, DENGUE
SHOCK SYNDROME
ABSTRACT
Dengue is mosquito borne viral infection, which causing acute fever and occasionally develops into potential lethal complication. Dengue virus is transmitted
by female mosquitoes mainly of the species Aedes aegypti and, to a lesser extent, Ae. albopictus. This mosquito also transmits Chikungunya, Yellow Fever and
Zika infection. About half of world’ population were at risk, Dengue is widespread throughout the tropics, with local variations in risk influenced by rainfall, temperature
and unplanned rapid urbanization.
There are 4 distinct, but closely related, serotypes of the virus that can cause dengue DEN-1, DEN-2, DEN-3 and DEN-4. Recovery from infection by one
provides lifelong immunity against the particular serotype with partial and temporary cross-immunity to the other serotypes after recovery. Subsequent infections by other
serotypes increase the risk of developing severe dengue.
Dengue should be suspected when a high fever is present, accompanied by 2 of the following symptoms: severe headache, pain behind the eyes, muscle and
joint pains, nausea, vomiting, swollen glands or rash. Symptoms usually last for 2–7 days, after an incubation period of 4 – 5 days range 3 – 14 days after the bite from
an infected mosquito. Severe dengue is a potentially deadly complication due to plasma leakage, fluid accumulation, respiratory distress, severe bleeding, or organ
impairment. Warning signs occur 3–7 days after the first symptoms in conjunction with a decrease in temperature and include: severe abdominal pain, persistent
vomiting, and rapid breathing, bleeding gums, fatigue, restlessness and blood in vomit. The next 24–48 hours of the critical stage can be lethal; proper medical care
is needed to avoid complications and risk of death.
For the purpose of clinical management, WHO classifies dengue illness as i dengue with or without warning signs for progression towards severe dengue and ii
severe dengue. Warning signs of severe dengue include abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleeding,
lethargy or restlessness, liver enlargement of 2 cm, or an increase in Hematocrit concurrent with a rapid decrease in platelet count. Criteria for severe dengue include
any sign of severe plasma leakage leading to shock or fluid accumulation with respiratory distress, severe bleeding, or severe organ impairment.
There is no specific treatment for dengue, maintenance of the patient’s body fluid volume is critical in management of severe dengue. Vaccine for prevention is
now commercially available, Dengvaxia CYD – TDV for use in individual age 9 – 45 years living in area with high burden of disease.
LEARNING TASK Case 1:
IMD, 16 year old male student come to a private clinic with acute onset of high fever. The fever starts abruptly one day before accompanied by nausea and retro orbital
pain. Questions:
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1. What other information needed in anamnesis of this patient? What data should be obtained during physical examination?
2. The evaluation shows vital sign was stabile without any sign of bleeding, the patient able to drink plenty and eat normally. What is the diagnosis of this
patient? How about further plan for this case, including planning for diagnostic, treatment, monitoring and patient and family’s education?
3. The next day, he showed his laboratory evaluation. WBC: 1.03 x 10
3
uL. Hb. 17 gdL. HCT 54 . Plt. 98 x 10
3
uL. What is the diagnosis of this patient? How about further plan for this case, including planning for diagnostic,
treatment, monitoring and patient and family’s education?
Case 2: 25 year old woman, working as a private secretary, come to the clinic with 4 days of
fever. Since morning she also had her menstrual bleeding which comes 2 weeks early. The initial evaluation revealed moderately ill, fully alert. Blood pressure 9076
mmHg. Pulse rate 124 xminutes. Respiratory rate: 22 xminutes. Temperature axillae: 36.7˚C. Hepatomegaly 3 cm below costal arch, tender on palpation, the
acrals were cold. She has her laboratory evaluation: WBC: 3.02 x 10
3
uL; Hb. 16 gdL. HCT: 51.2 . Plt.32 x 10
3
uL 1. What is the diagnosis of this patient? How about further plan for this case,
including planning for diagnostic, treatment, monitoring and patient and family’s education?
2. Is there any indication for platelet transfusion in this case? Why? 3. The patient was then hospitalized, by the third day of her hospital stay, she
complain about shortness of breath and cough if she change position from supine to sitting. The physical evaluation revealed dullness on lower part of
right hemithorax with decreased breath sounds. What kind of complication can be expected in severe dengue cases? How can we establish the
diagnosis?
Self assessment
1. How can we differentiate between dengue fever and dengue hemorrhagic fever? Make a comparison chart on this issue
2. Both DHF grade 3 and 4 are included as DSS. How can we differentiate between the two of them?
3. What is NS1 dengue antigen? When is the best way to use it? 4. How about dengue serology? When IgM anti-Dengue become positive?
When the Ig G anti-dengue become positive? Make the chart on the possible result and its interpretation
REFERENCES:
1. World Health Organization. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control. Geneva, Switzerland: 2009. Available at
http:www.who.inttdr publicationsdocumentsdengue-diagnosis.pdf 2. Messina JP, et al. Global spread of dengue virus types: mapping the 70 year
history. Trends Microbiol. 2014;223:138–146. 3. Guzman MG, et al. Dengue. Lancet. 2015;3859966:453–465.
4. Comprehensive guidelines for prevention and control of dengue and dengue hemorrhagic fever. WHO SEARO 2011
5. Handbook for clinical management of dengue. WHO 2012
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Lecture 4 HOST RESPONSE TO INFECTION
Abstract Infectious diseases are one of the leading causes of death worldwide. Many
infectious diseases become difficult to control if the infectious agents evolve resistance to commonly used drugs, for example, bacteria can accumulate
mutations in their DNA or acquire new genes that allow them to survive contact with antibiotic drugs that would normally kill them. Scientists are currently searching for
new approaches to treat infectious diseases, focusing on exactly how the pathogens change and drug resistance evolves. Understanding and comprehend the host
response to infection is important. Infection process
After invading the body, microorganisms must multiply to cause infection. After multiplication begins, one of three things can happen:
1. Microorganisms continue to multiply and overwhelm the body’s defenses. 2. A state of balance is achieved, causing chronic infection.
3. The body—with or without medical treatment—destroys and eliminates the
invading microorganism.
Defenses Against Infection Host defenses that protect against infection :
– Natural barriers eg, skin, mucous membranes – Nonspecific immune responses eg, phagocytic cells [neutrophils,
macrophages] and their products – Specific immune responses eg, antibodies, lymphocytes
Nonspecific Immune Responses
• Cytokines including IL-1, IL-6, tumor necrosis factor-alpha, and interferon-
gamma are produced principally by macrophages and activated lymphocytes and mediate an acute-phase response that develops regardless of the
inciting microorganism.
• The response involves fever and increased production of neutrophils by the
bone marrow. Endothelial cells also produce large amounts of IL-8, which attracts neutrophils.
• The inflammatory response directs immune system components to injury or
infection sites and is manifested by increased blood supply and vascular permeability, which allows chemotactic peptides, neutrophils, and
mononuclear cells to leave the intravascular compartment.
Specific Immune Responses
• After infection, the host can produce a variety of antibodies complex
glycoproteins known as immunoglobulins that bind to specific microbial antigenic targets. Antibodies can help eradicate the infecting organism by
attracting the host’s WBCs and activating the complement system.
• The
complement system destroys cell walls of infecting organisms, usually
through the classical pathway. Complement can also be activated on the surface of some microorganisms via the alternative pathway.
• Antibodies can also promote the deposition of substances known as opsonins
eg, the complement protein C3b on the surface of microorganisms, which helps promote phagocytosis. Opsonization is important for eradication of
encapsulated organisms such as pneumococci and meningococci.
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Interaction between host and the microbes are depend on factors from the host, the microbes and environment
Host Genetic Factors
• For many pathogens, the hosts genetic make-up influences the hosts
susceptibility and the resulting morbidity and mortality. For example, patients who have deficiencies of the terminal complement components C5 through
C8, perhaps C9 have an increased susceptibility to infections caused by neisserial species.
Factors Facilitating Microbial Invasion Microbial invasion can be facilitated by the
following:
• Virulence factors
• Microbial adherence, biofilm
• Resistance to antimicrobials
• Defects in host defense mechanisms
Defects in Host Defense Mechanisms Two types of immune deficiency states affect the host’s ability to fight infection:
• Primary immune deficiency : are genetic in origin; 100 primary immune
deficiency states have been described. Most primary immune deficiencies are recognized during infancy; however, up to 40 are recognized during
adolescence or adulthood.
• Secondary acquired immune deficiency : are caused by another disease
eg, cancer, HIV infection, chronic disease or by exposure to a chemical or drug that is toxic to the immune system.
Defects in immune responses may involve •
Cellular immunity •
Humoral immunity •
Phagocytic system •
Complement system
Mechanism
• Cellular deficiencies are typically T-cell or combined immune defects. T
cells contribute to the killing of intracellular organisms; thus, patients with T- cell defects can present with opportunistic infections such as Pneumocystis
jirovecii or cryptococcal infections. Chronicity of these infections can lead to failure to thrive, chronic diarrhea, and persistent oral candidiasis.
• Humoral deficiencies are typically caused by the failure of B cells to make
functioning immunoglobulins. Patients with this type of defect usually have infections involving encapsulated organisms eg, H. influenzae, streptococci.
Patients can present with poor growth, diarrhea, and recurrent sinopulmonary infections.
• A defect in the phagocytic system affects the immediate immune response
to bacterial infection and can result in development of recurrent abscesses or severe pneumonias.
• Primary complement system defects are particularly rare. Patients with this
type of defect may present with recurrent infections with pyogenic bacteria eg, encapsulated bacteria, Neisseria sp and have an increased risk of
autoimmune disorders eg, SLE.
Clinical manifestation
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• Most infections increase the pulse rate and body temperature, but others eg,
typhoid fever, tularemia, brucellosis, dengue may not elevate the pulse rate commensurate with the degree of fever.
• Hypotension can result from hypovolemia, septic shock, or toxic shock.
Hyperventilation and respiratory alkalosis are common. •
Alterations in sensorium encephalopathy may occur in severe infection regardless of whether CNS infection is present. Encephalopathy is most
common and serious in the elderly and may cause anxiety, confusion, delirium, stupor, seizures, and coma.
• Infectious diseases commonly increase the numbers of mature and immature
circulating neutrophils. Mechanisms include demargination and release of immature granulocytes from bone marrow, IL-1- and IL-6-mediated release of
neutrophils from bone marrow, and colony-stimulating factors elaborated by macrophages, lymphocytes, and other tissues. Exaggeration of these
phenomena eg, in trauma, inflammation, and similar stresses can result in release of excessive numbers of immature leukocytes into the circulation
leukemoid reaction, with leukocyte counts up to 25 to 30 × 10
9
L. •
Conversely, some infections eg, typhoid fever, brucellosis commonly cause leukopenia. In overwhelming, severe infections, profound leukopenia is often
a poor prognostic sign.
• Characteristic morphologic changes in the neutrophils of septic patients
include Döhle bodies, toxic granulations, and vacuolization. •
Anemia can develop despite adequate tissue iron stores. If anemia is chronic, plasma iron and total iron-binding capacity may be decreased. Serious
infection may cause thrombocytopenia and disseminated intravascular coagulation DIC.
Learning Tasks: A 40 years-old female admitted to hospital with decreased of consciousness. She
suffering from high fever since a week ago, and she also did not eat and drink much as for her weaknesses. She had headache, sometimes vomits and feel
abdominal discomfort.
1. What is the working diagnosis of the patient? 2. What kind of examination do you need to do for this patient?
3. Please explain if there is a possibility of a defective imune response in this
patient?
Self Assessment:
1. Describe the host response to infection in this patient. 2. Based on the pathogenesis, please describe the management of the patient.
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Lecture 5 INFECTION IN PEDIATRIC
1. DENGUE HEMORRHAGIC FEVER References :
