Kelompok B13

7/30/2019 Kelompok B13

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Lembar 1

-Seorang anak perempuan, usia 7 tahun, yang datang

dibawa ibunya ke puskesmas dengan keluhan

demam yang dialaminya 2 hari ini, demam tinggi.Ruam kulit muncul 1 hari setelah demam, awalnya

terlihat di wajah, dan semakin menyebar ke seluruh

tubuh


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Lembar 2

- Sebelumnya pasien mengalami gelembung pada

kulit yang sebagian berisi cairan dan lainnya berisi

darah. Yang kemudian pecah dan meninggalkanbekas. Dijumpai juga bekas ruam yang mengelupas.

Ruam disertai nyeri dan gatal. Riwayat kontak

dengan penderita yang sama, yaitu abang pasien,

dijumpai 2 minggu yang lalu. Sejak 6 bulan yanglalu pasien telah didiagnosis dengan leukimia oleh

dokter di rumah sakit kabupaten dan saat ini sedang

menjalani pengobatan.


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Lembar 3

-Pada pemeriksaan fisik dijumpai;

Berat badan 20 kg, panjang badan 118cm, sadarcompos mentis, temperature 38.7 C

Kepala : vesikel (+), vesikel hemoragik (+), pustule(+), erosi (+). Toraks : simetriks fusiformis tidakdijumpai retraksi, vesikel (+), vesikel hemoragik(+), pustule (+), erosi (+),denyut jantung 88x/min,

regular, tidak dijumpai desah, pernafasan22x/min, regular, konki (-).Abdomen : vesikel (+),vesikel hemoragik (+), pustule (+), erosi (+).Extremitas: vesikel hemoragik (+), pustule (+),erosi (+).


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Diagnosis banding demam dengan ruam kulit.

Jenis-jenis ruam kulit.

Patogenesis varicella.

Patofisiologi varicella.

Faktor resiko varicella hemoragik

Manifestasi klinis varicella

Kompliksi varicella.


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Non farmakologi varicella

Farmakologi varicella tanpa komplikasi.

Farmakologi varicella hemoragik

Pencegahan varicella


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Measles

-8-12 days. Fever, cough, coryza and

conjuntivitis. Duration: 3-4 days.

-Rash: maculopapular, confluent. Extends fromthe face to the trunk and limbs. Colour: red-

purpura. Duration: 5-6 days.

-Furfuraceous. Palms and soles do not present

desquamation. Kplik spots in oral mucosa.


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Rubella

- 16-18 days. Malaise, low-grade fever, coryza,

conjuntivitis. Duration: 1-5 days

- Rash: maculopapular, non-confluent. Extendsfrom face to trunk and limbs. Colour: red-

pink. Duration: 2-3 days

- Characteristic sign in rubellas patient :

Lymphadenopathy (retroauricular andsuboccipital) , arthritis and arthralgias

(adult)


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Erythema infectiosum

- 5-10 days. No prodormal period.

- Indurated erythema in cheeks. Rash:

symmetrical maculopapular rash in theextensor face of upper and lower limbs.

Colour: red-violet. Duration: 5-10 days

(recurrences).

- Characteristic signs : erythema in cheeks.


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Infectious mononucleosis

- 4-6 weeks.

- Prolonged fever. Duration: 6-10 days.

- Rash: may manifest in various forms. Morefrequent after taking ampicillin.

- Characteristic signs; Membranous tonsillitis,

lymphadenopathy and hepatosplenomegaly.


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Macule

- A macule (Lat. macula = spot) is a small ( 1cm) papule (4).

Vesicle (Blister)

- A vesicle (Lat. vesicula = small bladder) is a small (< 1cm)circumscribed, fluid-filled elevation within the upper skin layer(epidermis). It has a thin wall, and is often translucent .

Bulla

- A bulla (Lat. bulla = bubble) is a vesicle that exceeds 1cm insize.

Pustule

- A pustule (Lat.pustula = inflamed sore) is a pus-filled vesicle.

Crust

- A crust is rough, flat or bumpy, fragile, dried secretion of theoil glands, ruptured fluid-filled skin lesions, or dried blood. It isusually red, brown or yellowish, and falls off the skin in fewdays or weeks in one or several pieces.


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Little is known about the route and the source oftransmission of the virus. VZV is certainly transmissiblethrough the airborne route and does not require closepersonal contact. The skin lesions are certainly full ofinfectious virus particles whilst in contrast, it is almostimpossible to isolate virus from the upper respiratory

tract. It is possible that aerial transmission originates fromsymptomless oral lesions.

The virus is thought to gain entry via the respiratory tractand spreads shortly after to the lymphoid system. After anincubation period of 14 days, the virus arrives at its maintarget organ, the skin. The virus probably spreads to other

organ systems in the body without any ill effect. However,in immunocompromised individuals and neonates,dissemination can cause serious infection of the lungs andbrain. Recovery from infection is thought to result inlifelong immunity.


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Following the primary infection, the virus remains latent inthe cerebral or posterior root ganglia. In 10 - 20% ofindividuals, a single recurrent infection occurs afterseveral decades. The virus reactivates in the ganglion andtracks down the sensory nerve to the area of the skininnervated by the nerve, producing a varicellaform rash in

the distribution of a dermatome. The failure of the hostdefense mechanisms to contain the virus in the gangliaafter such prolonged periods of time is not understood.

In immunocompetent individuals, it is probably due to thedecline effectiveness of previously acquired immunity withadvancing age. Herpes zoster also appears in increasing

frequency in immunocompromised individuals such asthose with Hodgkin's disease and AIDS, who have defectiveCMI. Also disseminated herpes zoster is more likely tooccur in such people.


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VZV reactivation causes inflammation in thedorsal root ganglion, accompanied byhemorrhagic necrosis of nerve cells. Theresult is neuronal loss and fibrosis. The

distribution of the rash corresponds to thesensory fields of the infected neurons withina specific ganglion.

The anatomic location of the involved

dermatome often determines the specificmanifestations (eg, herpes zosterophthalmicus [HZO], causing ocularcomplications, when the trigeminal ganglionis involved).


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Pasien yang imunokompromais

Keganasan

Pasien yang diterapi dengan kortikosteroid dosis

tinggi Mendapat transplantasi ginjal dan bone marrow

Mekanisme:

- Defisit respon imun seluler terhadap varicella-zoster-virus

- Respon limfosit lambat


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The incubation period is 7 - 23 days (mean = 2 weeks). Ashortened incubation period can be especially encounteredin immunocompromised patients. In children, the illnessbegins with the characteristic rash but in adults, aprodrome resembling an influenza-like illness commonlypresents a few days earlier. Neck lymphadenopathy is

commonly present. The rash is characteristically centripedal in distribution

and is seen mainly in areas not exposed to pressure, suchas the flank, shoulder blades, and in the axillae. The skinlesions progress rapidly through the stages of macules topapules to vesicles which rapidly break down with crust

formation. The lesions appear in a series of crops so thatall stages in their genesis can be seen at any one time.Patients with varicella are generally considered to beinfectious 2 days before the appearance of the rash and 7days after onset, when the vesicles have crusted.


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Secondary bacterial infection is by far the most commoncomplication of varicella. Bacterial infection of the skin does not

increase the risk of scarring. Secondary bacterial pneumonia can

occur but is very uncommon.

Haemorrhagic chickenpox - haemorrhagic symptoms sometimesoccur during the course of varicella and usually present 2 - 3 days

after the onset of the rash. Haemorrhage into the skin, epitaxis,

malaena or haematuria may be present. The haemorrhagic

chickenpox may be so severe as to be life threatening.

Viral pneumonia - It is mainly seen in immunocompromisedindividuals but can occur in normal people. The chest X-ray

usually reveals scattered areas of consolidation typical of a viral

pneumonia. It may be difficult to distinguish this condition from

bacterial pneumonia unless a biopsy is taken. Patients may

recover completely or be left with permanent fibrosis of thelungs.


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Encephalitis - it is not known how often the CNS isinvolved in varicella, minor degrees of CNS involvement isprobably common as isolated paralysis of occulomotormuscles has often been noted following varicella. Typicalcases of encephalitis that proceed to coma are rarely seenand are certainly less common than the encephalitisassociated with measles. CNS involvement occurs muchmore frequently in immunocompromised patients.

Other complications - other neurological disorders such asmeningitis, cerebella ataxia and Guillain-Barre syndrome

have been reported. Reyes syndrome, which consists of anoften fatal encephalopathy secondary to liver damage, islinked with several viral infections of which varicella issecond on the list after influenza. Other manifestationsthat have been reported include arthritis, myocarditis,renal and ureteric damage has been reported.


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Symptomatic ; acetaminophen for high fever,

oral antihistamine may help control the

itching. Fingernails should be kept short and

clean in attempt to minimize secondary skin

infections. For same reason, daily bathing

also recommended during chickenpox


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Asiklovir

-Diberikan segera setelah ruam muncul

-Secara intravena

-Dosis;

< 1 tahun : 10 mg/kg/dosis diberikan setiap 8 jam sebagai

infus 1 jam

>1 tahun : 500 mg/m/dosis diberikan setiap 8 jam sebagai

infus 1 jam

Lama pengobatan : 7 hari atau tidak ada lesi yang munculselama 48 jam

Kerja obat : memeutuskan pemebentukan DNA virus dan

mengurangi pembentukan lesi


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Varicella-Zoster Virus Vaccination

-Vaccination recommendations consist of 1 dose for healthychildren aged 12-18 months and 2 doses, in a 4- to 8-week

interval, in susceptible persons older than 13 years

-Adverse effects of the vaccination include pain and

erythema at the site of injection, allergic reactions to gelatin,and the development of a localized chickenpox. Vaccine-

induced herpes zoster infection in immunocompetent and

immunocompromised populations has also been reported,

though it is a rare phenomenon. Rarer still is thetransmission of vaccine-associated virus from vaccinated

individuals to susceptible contacts.

Documents

Kelompok B13