eli173 slide elektif infeksi
ELEKTIF INFEKSI
DEPARTMENT PARASITOLOGY
MEDICAL FACULTY OF USU
A 16 year old female student came to Community
Health Centre with complaints of swelling of right
leg from thigh to toes. The swelling occurred once
every 5-6 months. It started 4 years ago along with
hardness and swelling of inguinal lymph nodes. She
also developed chills and fever. About 4-5 days later
the fever stopped, but the swelling of the leg
increased. At this stage she had chills with severe
pain in the right leg. This lasted for 10-12 days, after
which the pain subsided. During this time she had
ulcers on the swollen leg with bleeding and a yellow
discharge. This remained for 2 days. Later the
swelling decreased and the ulcers started healing.
10/31/2010
DEWI M DARLAN
2
10/31/2010
DEWI M DARLAN
3
HOW IS THE MECHANISME OF DISEASE?
HOW IS THE TREATMENT?
HOW IS THE PROGNOSIS?
10/31/2010
DEWI M DARLAN
4
Pathogenesis
Inflammation occurs when worms die, either drug-induced or
spontaneously.
Granulomas arise around those worms, characterized by macrophages which
develop into giant cells: as plasma cells, eosinophils and neutrophils.
Clinical symptom is filarial fever starting when the worm death and leads to
retrograde lymphangitis (painful with swelling), and lymphadenitis, which
lasts for ± 1 week .
Lymph vessels dilation, not obliteration, is probably the early event
following antigenic stimulation, which spring larvae are being released. These
larvae are degenerate and will be taken up by phagocytic cells.
These accompanied by triggering of the innate immune system, release proinflammatory cytokines and molecules that promote lymphangiogenesis
10/31/2010
DEWI M DARLAN
5
The enlarge lymph vessels become less efficient at transporting lymph
from the periphery, which in the legs is always oriented against gravity,
more vulnerable to exogenous microorganisms.
Insufficient fluid transport will lead to fluid extravasations, particularly in
the lower limbs, and eventually to lymphedema.
L3 preferentially stimulate IL-4 and IK-13 release from basophils as well
as histamine release (King 2001). In addition, basophils comprise
approximately 1% of cells in PBMC and their contribution to the
observed cytokine production can be substantial. Therefore mast cells
and basophils may plan an important role in regulating the host
response to filarial infection by affecting T cell differentiation, local
blood flow, lymphocyte proliferation or by release of histamine or other
prostanoids
10/31/2010
DEWI M DARLAN
6
10/31/2010
DEWI M DARLAN
7
10/31/2010
DEWI M DARLAN
8
PENGOBATAN
• Dietyl Carbamazyn Citrat (DEC): 6 mg/Kg BB/ hari selama12 hari.
Pemberian dapat diberikan dibagi 3 dosis/hari: sesudah makan.
• Obat ini dapat membunuh mikrofilaria, cacing dewasa pada
pengobatan jangka panjang.
• Untuk membunuh mikrofilaria dapat menggunakan dosis di atas;
tetapi untuk membunuh cacing dewasa harus diulang beberapa
kali siklusnya.
• Untuk program eliminasi filariasis melalui pengobatan masal di
daerah endemis (prevalensi 1%), menggunakan kombinasi DEC 6
mg/kgBB dan albendazole400mg yang diberikan setiap tahun
selama 5-10 tahun pada penduduk di atas 2 tahun
• Ivermectin : dosis tunggal 400µg/kgBB (setiap 6 bulan sekali)
atau kombinasi dengan DEC (1 thn sekali).
• Antibiotik dan antimikotik jika dijumpai infeksi sekunder
10/31/2010
DEWI M DARLAN
9
Lymphedema care treatment
10/31/2010
DEWI M DARLAN
10
10/31/2010
DEWI M DARLAN
11
10/31/2010
DEWI M DARLAN
12
10/31/2010
DEWI M DARLAN
13
10/31/2010
DEWI M DARLAN
14
10/31/2010
DEWI M DARLAN
15
10/31/2010
DEWI M DARLAN
16
10/31/2010
DEWI M DARLAN
17
PROGNOSIS4
10/31/2010
• Pengobatan akan memberikan kesembuhan
pada penderita mikrofilaremia, stadium
akut, lymphedema std 1-2, chyluria dan std
dini elephantiasis.
• Bila sudah sampai stadium hydrochele dan
elephantiasis lanjut maka diperlukan
pembedahan.
• Pengobatan DEC pada filariasis akan
membunuh parasit sehingga keluar
Wolbachia (bakteri) menyebabkan efek
samping pengobatan.
• Sehingga menambahkan antibiotik
tetrasiklin dan doksisiklin dapat membunuh
Wolbachia.
DEWI M DARLAN
18
EFEK SAMPING
PENGOBATAN4
10/31/2010
• Bersifat respons terhadap kematian parasit;
terdapat dua reaksi:
• Reaksi sistemik: demam, berupa sakit kepala,
sakit pada berbagai tubuh, sendi-sendi,
pusing, anoreksisa, lemah, hematuria
transien, reaksi alergi, muntah, serangan
asma; Hal ini terjadi beberapa jam setelah
pemberian DEC (< 3 hari).
• Reaksi Lokal: limfadenitis, abses, ulserasi,
transien, lymphedema, hidrokel, funikulitis
dan epididimitis.
• Efek samping bancroftian filariasis lebih ringan
daripada brugian filariasis; hal ini disebabkan
kemampuan DEC membunuh filaria lbh lambat
pada W.bancrofti
DEWI M DARLAN
19
DEPARTMENT PARASITOLOGY
MEDICAL FACULTY OF USU
A 16 year old female student came to Community
Health Centre with complaints of swelling of right
leg from thigh to toes. The swelling occurred once
every 5-6 months. It started 4 years ago along with
hardness and swelling of inguinal lymph nodes. She
also developed chills and fever. About 4-5 days later
the fever stopped, but the swelling of the leg
increased. At this stage she had chills with severe
pain in the right leg. This lasted for 10-12 days, after
which the pain subsided. During this time she had
ulcers on the swollen leg with bleeding and a yellow
discharge. This remained for 2 days. Later the
swelling decreased and the ulcers started healing.
10/31/2010
DEWI M DARLAN
2
10/31/2010
DEWI M DARLAN
3
HOW IS THE MECHANISME OF DISEASE?
HOW IS THE TREATMENT?
HOW IS THE PROGNOSIS?
10/31/2010
DEWI M DARLAN
4
Pathogenesis
Inflammation occurs when worms die, either drug-induced or
spontaneously.
Granulomas arise around those worms, characterized by macrophages which
develop into giant cells: as plasma cells, eosinophils and neutrophils.
Clinical symptom is filarial fever starting when the worm death and leads to
retrograde lymphangitis (painful with swelling), and lymphadenitis, which
lasts for ± 1 week .
Lymph vessels dilation, not obliteration, is probably the early event
following antigenic stimulation, which spring larvae are being released. These
larvae are degenerate and will be taken up by phagocytic cells.
These accompanied by triggering of the innate immune system, release proinflammatory cytokines and molecules that promote lymphangiogenesis
10/31/2010
DEWI M DARLAN
5
The enlarge lymph vessels become less efficient at transporting lymph
from the periphery, which in the legs is always oriented against gravity,
more vulnerable to exogenous microorganisms.
Insufficient fluid transport will lead to fluid extravasations, particularly in
the lower limbs, and eventually to lymphedema.
L3 preferentially stimulate IL-4 and IK-13 release from basophils as well
as histamine release (King 2001). In addition, basophils comprise
approximately 1% of cells in PBMC and their contribution to the
observed cytokine production can be substantial. Therefore mast cells
and basophils may plan an important role in regulating the host
response to filarial infection by affecting T cell differentiation, local
blood flow, lymphocyte proliferation or by release of histamine or other
prostanoids
10/31/2010
DEWI M DARLAN
6
10/31/2010
DEWI M DARLAN
7
10/31/2010
DEWI M DARLAN
8
PENGOBATAN
• Dietyl Carbamazyn Citrat (DEC): 6 mg/Kg BB/ hari selama12 hari.
Pemberian dapat diberikan dibagi 3 dosis/hari: sesudah makan.
• Obat ini dapat membunuh mikrofilaria, cacing dewasa pada
pengobatan jangka panjang.
• Untuk membunuh mikrofilaria dapat menggunakan dosis di atas;
tetapi untuk membunuh cacing dewasa harus diulang beberapa
kali siklusnya.
• Untuk program eliminasi filariasis melalui pengobatan masal di
daerah endemis (prevalensi 1%), menggunakan kombinasi DEC 6
mg/kgBB dan albendazole400mg yang diberikan setiap tahun
selama 5-10 tahun pada penduduk di atas 2 tahun
• Ivermectin : dosis tunggal 400µg/kgBB (setiap 6 bulan sekali)
atau kombinasi dengan DEC (1 thn sekali).
• Antibiotik dan antimikotik jika dijumpai infeksi sekunder
10/31/2010
DEWI M DARLAN
9
Lymphedema care treatment
10/31/2010
DEWI M DARLAN
10
10/31/2010
DEWI M DARLAN
11
10/31/2010
DEWI M DARLAN
12
10/31/2010
DEWI M DARLAN
13
10/31/2010
DEWI M DARLAN
14
10/31/2010
DEWI M DARLAN
15
10/31/2010
DEWI M DARLAN
16
10/31/2010
DEWI M DARLAN
17
PROGNOSIS4
10/31/2010
• Pengobatan akan memberikan kesembuhan
pada penderita mikrofilaremia, stadium
akut, lymphedema std 1-2, chyluria dan std
dini elephantiasis.
• Bila sudah sampai stadium hydrochele dan
elephantiasis lanjut maka diperlukan
pembedahan.
• Pengobatan DEC pada filariasis akan
membunuh parasit sehingga keluar
Wolbachia (bakteri) menyebabkan efek
samping pengobatan.
• Sehingga menambahkan antibiotik
tetrasiklin dan doksisiklin dapat membunuh
Wolbachia.
DEWI M DARLAN
18
EFEK SAMPING
PENGOBATAN4
10/31/2010
• Bersifat respons terhadap kematian parasit;
terdapat dua reaksi:
• Reaksi sistemik: demam, berupa sakit kepala,
sakit pada berbagai tubuh, sendi-sendi,
pusing, anoreksisa, lemah, hematuria
transien, reaksi alergi, muntah, serangan
asma; Hal ini terjadi beberapa jam setelah
pemberian DEC (< 3 hari).
• Reaksi Lokal: limfadenitis, abses, ulserasi,
transien, lymphedema, hidrokel, funikulitis
dan epididimitis.
• Efek samping bancroftian filariasis lebih ringan
daripada brugian filariasis; hal ini disebabkan
kemampuan DEC membunuh filaria lbh lambat
pada W.bancrofti
DEWI M DARLAN
19