LAPORAN KASUS TOXOPLASMOSIS CEREBRI PADA HIV.docx

LAPORAN KASUS

causa Toxop T oxoplasm lasmosi osiss cere cerebri  bri  pada Penurunan Kesadaran Struktural et causa Pasien HIV AIDS

Disusun Oleh: Chita Annisha 1102015049

Pembimbing: dr. Didiet Pratignyo, Sp.PD, FINASIM

DISUSUN DALAM RANGKA TUGAS KEPANITERAAN KLINIK SMF ILMU PENYAKIT DALAM RSUD CILEGON FAKULTAS KEDOKTERAN UNIVERSITAS YARSI PERIODE 8 APRIL  –  22  22 JUNI 2019

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DAFTAR ISI

Pendahuluan .......................................................................................... 3 Identifikasi Kasus .................................................................................. 5 Follow up ............................... ................ ............................... ................................ ............................... .............................. ............... 12 Analisa Kasus ...................................................................................... 16 Tinjauan Pustaka ................................................................................. 21 Daftar Pustaka ..................................................................................... 26

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PENDAHULUAN  Human immunodeficiency virus (HIV) merupakan patogen yang menyerang sistem imun manusia, terutama semua sel yang memiliki penanda CD4+ di permukaannya seperti makrofag dan limfosit T. Sementara acquired immunodeficiency syndrome (AIDS) merupakan suatu kondisi (sindrom) imunosupresif yang berkaitan erat dengan berbagai infeksi opotunistik, neoplasma sekunder, serta manifestasi neurologic tertentu akibat infeksi HIV. Toxoplasmosis merupakan penyebab terbanyak dari lesi fokal pada penderita AIDS dan biasanya berlokasi pada basal ganglia. Toxoplasmosis pada penderita HIV timbul dalam onset subakut dan mengalami manifestasi seperti perubahan status mental, sakit kepala, dan deman dengan defisit fokal neurologi. Infeksi yang lebih lanjut memicu kebingungan (confusion), confusion), mengantuk (drowsiness ( drowsiness), ), kejang, hemiparesis, hemianopsia, aphasia, ataxia, dan cranial nerve palsy. Kelemahan motorik dan gangguan bicara juga dapat terjadi pada tahapan lebih lanjut2. Pemeriksaan serologi dan imaging merupakan pilihan terbanyak yang digunakan dalam mendiagnosis toxoplasmosis. CT Scan dan MRI merupakan pemeriksaan imaging yang dipilih, pada pemeriksaan tersebut menghasilkan tanda target asimetrik dengan sebuah cincin. Sedangkan untuk pemeriksaan serologi dapat menggunakan antitoxoplasma antibodi yaitu serum IgG dan IgM. Namun pemeriksaan patologi dari spesimen biopsi otak merupakan diagnosa definitif pada penderita toxoplasma cerebri, karena cukup invasif biopsi hanya direkomendasikan bila diagnosis meragukan atau pasien tidak berespon atau memburuk terhadap pengobatan empirik 2. Kesadaran dapat digambarkan sebagai kondisi awas-waspada, hal ini berarti bahwa seseorang menyadari seluruh asupan dari panca indera dan mampu bereaksi secara optimal terhadap seluruh rangsangan baik dari luar maupun dari dalam tubuh. Penurunan kesadaran mempunyai berbagai derajat, derajat kesadaran ditentukan oleh banyak neuron penggerak. Unsur fungsional utama neuron-neuron ialah kemampuan untuk dapat digalakkan sehingga menimbulkan potensial aksi 1. Kesadaran memerlukan interaksi yang terus menerus dan efektif antara hemisfer otak dan formatio retikularis di batang otak. Selain itu didiukung juga oleh proses-proses yang

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IDENTIFIKASI KASUS I.

II.

Identitas Pasien

 Nama

: Tn. D

Jenis Kelamin

: Laki-laki

 Nomor CM

: 10-XX-XX

Usia

: 37 tahun

Berat Badan

: 50 kg

Alamat

: Cibeber

Agama

: Islam

Suku Bangsa

: Sunda

Status Pernihakan

: Menikah

Status Pekerjaan

: Tidak bekerja

Tanggal Masuk

: Selasa, 16 April 2019

Tanggal Keluar

: Kamis, 25 April 2019

Ruangan

: Nusa Indah (Kamar 1)

Anamnesis

-

Autoanamnesis, dilakukan hari Senin, 22 April 2019, sudah menggunakan bahasa isyarat (instruksi mata berkedip untuk jawaban Ya, dan tidak berkedip untuk  jawaban Tidak) tetapi pasien tetap tidak responsif.

-

Alloanamnesis, dilakukan hari Selasa, 23 April 2019, tetapi keluarga kurang informatif.

1. Keluhan Utama

Penurunan kesadaran 2. Riwayat Penyakit Sekarang

Pasien dibawa ke Instalasi Gawat Darurat RSUD Cilegon oleh keluarga dengan keluhan pasien ditemukan di kamar mandi dalam keadaan tidak sadarkan diri sejak 3 jam sebelum masuk rumah sakit (SMRS). Pasien terlihat kelojotan selama 3-5 menit di bagian tubuh kiri sejak 2 jam SMRS, terdapat luka kepala dan tangan kiri. Tidak ada muntah, dan demam. Pasien tidak mau makan.

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-Riwayat B20 + riwayat Toxo terakhir kontrol Januari 2018, pengobatan yang digunakan Tenofovir 1 x 300mg, Lamivudin 2 x 150mg , Evafirenz 1x 600mg. -Riwayat epilepsi + vertigo Juni 2017. -Riwayat bronkitis Juli 2017. Riwayat pengobatannya kotrimoksazol 1 x 960 mg 4. Riwayat Kebiasaan

Pasien adalah perokok aktif sejak SMA. Dalam satu hari pasien dapat menghabiskan 1 bungkus rokok. 5. Riwayat Penyakit Keluarga

Tidak ada keluhan yang serupa pada keluarga pasien, tidak ada keluarga yang memiliki riwayat penyakit jantung maupun metabolik. 6. Riwayat Alergi

Pasien tidak memiliki alergi baik pada makanan, obat, maupun alergen lain. 7. Anamnesis Sistem Organ

1. Kulit

: sawo matang, dan dalam batas normal

2. Kepala

: normocephal

3. Mata

: Sklera ikterik (-/-), konjungtiva anemis (-/-)

4. Wajah

: dalam batas normal

5. THT

: dalam batas normal

6. Mulut

: dalam batas normal

7. Leher

: dalam batas normal

8. Thoraks

: vesikuler (+/+), rhonki (+/+), wheezing (-/-)

9. Abdomen

: supel, nyeri tekan (-), bising usus (+)

10. Saluran kemih atau kelamin : dalam batas normal 11. Saraf dan otot

: lateralisasi ke kiri, kesan kiri tertinggal  pada bagian kiri

12. Ekstremitas

: luka pada tangan kiri, dan lemas pada tangan dan kaki kiri

III.

Pemeriksaan Fisik 

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

GCS

: 4 (E1, M3, V1)



Tekanan Darah

: 90/60 mmHg

 Nadi

: 88x/ menit



Respirasi

: 24x/ menit



Suhu Tubuh

: 37 oc



Kepala

: bentuk kepala normal, pertumbuhan



rambut normal tapi sedikit kotor,  bentuk wajah simetris, pupil bulat isokor, konjungtiva anemis (-/-), sklera ikterik (-/-), eksoftalfmus (-/-), RCL (+/+), RCTL(+/+) 

Leher

: pembesaran tiroid (-), pembesaran KGB (-), deviasi trakea (-)



Cor : -Inspeksi

: dada terlihat simetris

- Palpasi

: letak iktus cordis pada ICS V linea midclavicularis sinistra

- Perkusi

: batas jantung normal, batas kanan atas ICS II parasternalis dextra, batas kanan  bawah ICS IV parasternalis dextra,  batas kiri atas ICS II parasternalis sinistra, batas kiri bawah ICS IV midclavicularis sinistra

- Auskultasi 

: S1 S2 reguler, murmur (-), gallop (-).

Pulmo : - Inspeksi

: pengembangan dinding dada kanan = kiri



- Perkusi

: sonor

- Palpasi

: fremitus normal

- Auskultasi

: Vesikuler +/+, Ronkhi +/+,wheezing -/-

Abdomen :

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- Perkusi

: terdengar timpani di keempat kuadran, shifting dullness (-)

- Palpasi

: hepatomegali (-), pembesaran lien (-), nyeri tekan (-)



Ekstremitas

: akral hangat (+), edema ekstremitas superior (-), edema ekstremitas inferior (-), luka pada tangan kiri, lemah pada ekstremitas bagian kiri.

IV.

Pemeriksaan Penunjang

a. Hematologi 

: 15 April 2019

Darah Rutin :

-

Hemoglobin

: 14,6 g/dL

-

Hematokrit

: 41,0 %

-

Eritrosit

: 4,91 106/μL

-

MCV/VER

: 83,5 fL

-

MCH/HER

: 29,7 pg

-

MCHC/KHER

: 35,6 g/dL

-

Leukosit

: 13,40 103/ μL

-

Trombosit 

: 121

103/ μL

Kimia Klinik :

-

SGOT (AST)

: 130 U/L

-

SGPT (ALT)

: 40 U/L

-

Ureum

: 42 mg/dL

-

Kreatinin

: 2,14 mg/dL

-

GDS

: 72 mg/dL

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Intrepetasi Intrepetasi EKG

-

Reguler

-

Sinus

:

c. Rontgen Toraks COR

: 15 April 2019

: CTR 350 sel/mm 3 dan ≤500 sel/mm3 tanpa melibatkan stadium klinis

-

Tanpa melihat hitung CD4+ ; pasien HIV dengan TB aktif, pasien HIV dengan koinfeksi hepatitis B dengan  penyakit hati kronis, perempuan HIV yang sedang

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(pemeriksaan kreatinin serum dan urinalisis), terapi  NVP (pemeriksaan SGPT pada minggu ke-2, 4, 8, dan 12 setelah terapi), terapi d4T (deteksi kejadian asidosis laktat) 7,12. 

Sindrom Pulih Imun (immune ( immune reconstitution syndrome/ syndrome/ IRIS): Merupakan perburukan kondisi klinis akibat respons inflamasi  berlebihan saat pemulihan respons imun im un pascapemberian terapi

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kronik persisten yang asimptomatik, namun pada immunocompromised akan terjadi reaktivasi sehingga menimbulkan gejala klinis. Penularan terhadap manusia terutama terjadi apabila tertelan daging babi atau domba yang mengandung kista jaringan atau apabila menelan sayuran yang terkontaminasi dan dimasak tidak matang. Jika kista jaringan yang mengandung bradizoit atau ookista tertelan pejamu, maka parasit akan terbebas dari kista dalam proses pencernaan1,4,5. Bradizoit ini resisten terhadap efek dari pepsin dan menginvasi traktus gastrointestinal

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Toksoplasmosis cerebri merupakan salah satu kasus emergensi neurologi pada HIV,

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