INFEKSI RABIES PADA SUSUNAN SARAF PUSAT

I Wayan Tunjung, dr. Sp.SBAGIAN NEUROLOGIRSU KOTA MATARAM

PENDAHULUANRABIES ZOONOTIC DISEASE.

MASALAH KESEHATAN SERIUS DI NEGARA BERKEMBANG.

BERSIFAT FATAL.

Mortality Rate of Rabies Cases (Thomas E, 2007)

Tahun 1884 pada kuda Tahun 1889 pada anjingKasus thn 1894 pada manusiaEpidemiologi Rabies di Indonesia

Kondisi SekarangWilayah endemisWilayah bebas historisWilayah bebas karena tindak pemberantasan

Wilayah EndemisSumatera NADSumatera UtaraSumatera Barat Jambi RiauBengkulu Sumatera SelatanLampungSulawesi Gorontalo, Sulawesi Utara Sulawesi Tengah Sulawesi Selatan Sulawesi TenggaraPulau Kalimantan Kalimantan Tengah Kalimantan SelatanKalimantan Timur Pulau FloresMalukuKota Ambon Pulau SeramBali (?)

Karakteristik Virus RabiesOrdo MononegaviralesFamily Rhabdoviridae bullet shapedGenus LyssavirusSpecies Rabies virusGambar dari Centers for Disease Control and Preventionwww.cdc.gov/ncidod/dvrd/rabies

Genom beruntai tunggal, tidak bersegmen dan berbentuk peluru Selubung luar diliputi oleh penonjolan duriKelompok Ribonukleokapsid genomic RNA

struktur spt peluru nonsegmen Negatif strand RNA 12 Kb dgn inti berupa pita helik RNA dengan protein NRP yang dikelilingi oleh amplop lipid bilayer.5 protein utamaRibonucleoprotein (RNP) Core:Nucleocapsid protein (N)Nucleocapsid phosphoprotein (NS or P)RNA polymerase (L)Matrix protein (M)Glycoprotein (G)

RNAM proteinEnvelope (membrane bilayer)RNPCross SectionalIlustrasi dari Centers for Disease Control and Preventionwww.cdc.gov/ncidod/dvrd/rabiesG proteinRabies Virus

PATOGENESISTransmisi: Utama: Gigitan (saliva)Lainnya: scratch, oral, aerosol, transplantasi kornea (iatrogenik)Virus rabies tidak dapat penetrasi ke kulit yang tidak terlukaVirus tidak menyebar melalui pembuluh darahWaktu inkubasi bervariasi antar individu dan spesies (minggu bulan tahun)

PATOGENESISPenyebaran menuju SSP.Penyebaran di dalam SSP.Penyebaran dari SSP.

Diadaptasi dari Jubb, Kennedy, and Palmers, 2007 dan http://pathmicro.med.sc.edu/virol/route.jpg

VARIASI MASA INKUBASILatar belakang genetik inangStrain virus yang terlibatKonsentrasi reseptor virus pd sel inangJumlah inokulumBeratnya laserasiJarak tempuh virus ke SSP

PENATALAKSANAAN

RISK ASSESMENTTAKING A FULL HISTORYPAYING ATTENTION TO THE EXACT CIRCUMSTANCES OF THE BITETHE BITTING ANIMALS BEHAVIOURWETHER THE BITE WAS PROVOKED OR UNPROVOKEDWETHER FROM A WILD OR PET ANIMALTHE SITE OF THE BITEINITIAL TREATMENT OF THE WOUND

MANIFESTASI KLINISAvindra, 2003Masa inkubasi (30-90) hari, variasi 4 hari tahun.Gejala prodromal : (2-10) hari.Gejala neurologi akut : (2-7) hari.Koma kematian : (0-14) hari.

CLINICAL DIAGNOSIS IN HUMANEARLY CLINICAL SYMPTOM ARE NON SPECIFIC

LOCAL NEUROLOGIC SYMPTOMS :PARESTHESIAPAINITCHING AT THE ENTRANCE SITE

USUALLY WITHIN ONE WEEK OF SYMPTOM ONSET,DEVELOPES COMA

CLINICAL DIAGNOSIS IN HUMANSPECIFIC CLINICAL SIGN OF HYDRO- OR AEROPHOBIA

CLASSICAL SIGN OF BRAIN INVOLVMENT : SPASM IN RESPONS TO TACTILE, AUDITORY, VISUAL OR OLFACTORY STIMULI

CLINICAL DIAGNOSIS IN HUMANALTERNATING WITH PERIODS OF LUCIDITYAGITATIONCONFUSION SIGN OF AUTONOMIC DYSFUNCTIONSPASMS OCCUR AT SOME TIME IN ALMOST ALL RABID PATIENTS, EXCITATION IS PROMINENT

CLINICAL DIAGNOSIS IN HUMANSPONTANEOUS INSPIRATORY SPASM USUALLY OCCUR CONTINOUSLY UNTIL DEATH

THEIR PRESENCE OFTEN FASILITATES CLINICAL DIAGNOSIS

EXCITATION IS LESS EVIDENT IN PARALYTIC RABIES

PARALYTIC RABIESEARLY STAGESPHOBIC SPASMS APPEAR IN ONLY 50%

MYOEDEMA AT PERCUSSION SITE, REGION OF THE CHEST, DELTOID MUSCLE AND THIGH

PILOERECTION

MRI : hiper signal ringan T2 meliputi batang otak, hipokampus, hypothalamus.

LABORATORY DIAGNOSISDEFINITE DIAGNOSIS OF RABIES CAN ONLY BE OBTAINED BY LABORATORY INVESTIGATIONS

HistopatologySel saraf normal tanpa negri bodySel saraf yang terinfeksi negri bodiDIAGNOSIS

FAT

FAT PositifFAT Negatif

Hasil PCRHasil amplifikasi gen N pada yang divisualisasi dgn elektroforesis pada agarose gel 0.8 %

Line 1 kontrol positifLine 2 kontrol negatifLine 3 - 13 Sampel rabies Indonesia

LABORATORY DIAGNOSISBIOSAFETY CONSIDERATIONSTRANSPORT OF SPECIMENSSAMPLING FOR INTRA VITAM DIAGNOSISSAMPLING FOR POSTMORTEM DIAGNOSIS

TREATMENT OF RABIESTHE FOLLOWING MEASURES HAVE BEEN ASSESED IN CLINICAL RABIES, BUT WITHOUT ANY EVIDENCE OF EFFECTIVINESS

SINGLE AGENT : RIBAVIRIN OR IFN_a

TREATMENT RABIESCOMBINATION THERAPY : RABIES VACCIN (MULTIPLE-SITE INTRADERMAL ROUTE)HIRG (INTRAMUSCULER)RIBAVIRIN (IV AND INTRAVENTICULER)IFN_a (IV AND INTRATHECAL)KETAMIN (INTRAVENOUS INFUSION)

MANAGEMENTSUPPORTIVE TREATMENTSedativeAnalgetik narkotikaAntikonvulsanNeuromuskuler bloker

PREVENTION

RECOMMENDATION FOR SAFE CLINICAL MANAGEMENTBECOME ISOLATED BECAUSE OF THE PERCEIVED RISK OF TRANSMISSION OF THE VIRUS THROUGH CONTACT

STAFF SHOULD WEAR GOWNS, GOGGLES, MASK AND GLOVES

THIS IS IMPORTANT WHEN INTUBATION AND SUCTIONING ARE PERFORMED

POSTMORTEM MANAGEMENTGENERALLY SMALL RISK TRANSMISSIONBLOOD DOES NOT CONTAIN VIRUSEMBALMING SHOUD BE DISCOURAGEDINSTRUMENT MUST BE AUTOCLAVED OR BOILED AFTER USEEARLY DISPOSAL OF THE BODY BY CREMATION OR BURIAL IS RECOMMENDED

WOUND TREATMENTRabies virus easy killed by sunlight, soap

Transmission can be almost completely prevented by local wound treatment given within the first 3 hours after exposure

Post-exposure prophylaxisThe aim : Is to neutralise inoculated virus before it can enter the nervous system of the patients

PENCEGAHANVaksinasi sesudah paparanDosis VAR pada anak dan dewasa sama.Hari 0 : 0,5ml deltoid kanan dankiri.Hari 7 : 0,5ml IM di deltoidHari 21 : 0,5ml IM di deltoid

Pemberian bersama SAR, diberi VAR 0,5ml pada hari ke 90.

PENCEGAHAN SETELAH TERPAPARDapat dgn VAR saja atau (VAR+ SAR).VAR saja bila : Luka tidak berbahaya (jilatan, ekskoriasi/lecet) terletak di tangan/kaki. (VAR + SAR) bila :Luka berbahaya jilatan/luka pada mukosa terletak di atas bahu (muka, kepala, leher).

CARA PEMBERIAN SARSerum heterolog :Tes kulit terlebih dahulu.Infiltrasi pada luka sebanyak-banyaknya, sisanya disuntik IM.Dosis : 40 IU/kgBB

CARA PEMBERIAN SARSerum homologInfiltrasi pada luka sebanyak-banyaknya, sisanya disuntikkan secara IM.Dosis : 20 IU/kgBB.Pemberian hari pertama kunjungan.

VAKSINASI SEBELUM PAPARANHari 0: 0,5 ml.IMHari 28: 0,5 ml.IM Vaksin ulangan setelah 1 tahun diulangi seterusnya setiap 3 tahun.

Injeksi di area deltoid pada dewasa, di area paha anterolateral pada anak

*********Herbivora dan manusia adalah dead-end hosts.Aerosol transmission under natural condition is rare. However, laboratory infections and infections in bat caves by aerosol are known to occur.Human to human transmission has been only documented in cases of corneal transplantation where rabies had not been diagnosed as the cause of death of donor (Zoonoses 3rd Ed, 2003).

The incubation period varies considerably from 10 days to 3 months and up to years. The shortest reported incubation period is 5 days, and the longest was 2 years. The closer the bite is to the CNS and the deeper it is, the shorter the incubation period is (Zoonoses, 3rd Ed. 2003)*********************