Michelle Audrey Darmadi1, Gurmeet Singh2
1 Mahasiswa Fakultas Kedokteran Universitas Indonesia
2 Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia /
Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo

Abstract

Background: Community-acquired pneumonia (CAP) is a common, yet serious infection as it is associated with high mortality and morbidity. Rather than microorganism proliferation, inflammatory response of the host itself seems to be the responsible trigger for the clinical manifestations of pneumonia. Corticosteroid or glucocorticoid is the most potent and commonly used anti-inflammatory known to date. However, evidence of the benefit of corticosteroid use remains controversial and there are risk of side effects. It is expected that corticosteroid use as adjuvant therapy can help reduce mortality in patient with severe CAP.
Methods: Literature search was conducted using 4 databases, namely PubMed, Cochrane, Scopus, and Clinical Key with the keywords corticosteroid, severe pneumonia, and mortality. We obtained 6 articles and critical appraisal were done for each article using the criteria validity, importance, and applicability
Results: We reviewed 2 randomized clinical trial (RCT) articles and 4 meta-analysis articles. According to the study we gathered, it is suggested that corticosteroid use seem to reduce mortality in severe CAP, but not so in less severe CAP. However, interpretation of each study gathered must be taken with caution. Steroid use is also considered to be an acceptable treatment in Indonesia.
Conclusion: Studies suggest the use of corticosteroid as an adjuvant therapy might reduce mortality in severe CAP patients, but until recently, there is still no strong evidence to support it. Therefore, a larger study might be needed to obtain stronger evidence.
Keywords: severe pneumonia, corticosteroid, mortality, adjuvant therapy
ABSTRAK
Latar Belakang: Pneumonia komunitas (PK) adalah penyakit infeksi yang umum namun bersifat serius dan diasosiasikan dengan mortalitas dan morbiditas yang tinggi. Dibanding proliferasi mikroorganisme, respon inflamasi dari inanglah yang memicu manifestasi klinis dari pneumonia. Kortikosteroid atau glukokortikoid adalah obat anti-inflamasi yang paling efektif dan paling banyak digunakan. Namun bukti manfaat penggunaan kortikosteroid masih kontroversial dan terdapat risiko efek samping.Diharapkan penggunaan kortikosteroid sebagai terapi adjuvan dapat menurunkan mortalitas pasien dengan pneumonia komunitas berat.
Metode: Pencarian literatur dilakukan pada 4 database internet yaitu PubMed, Cochrane, Scopus, dan Clinical Key dengan menggunakan kata kunci corticosteroid, severe pneumonia, dan mortality. Hasil pencarian akhir didapatkan 6 artikel dan dilakukan telaah kritis menurut aspek validity, importance, dan applicability.
Hasil: Didapatkan 2 artikel randomized clnical trial dan 4 artikel meta-analisis. Berdasarkan studi yang terkumpul, secara garis besar, penggunaan kortikosteroid tampak menurunkan mortalitas pada pneumonia komunitas berat, tetapi tidak pada derajat kurang berat.Namun demikian, interpretasi hasil dari setiap studi yang dikumpulkan perlu dilakukan secara hati-hati.Penggunaan steroid juga termasuk sebagai pengobatan yang tergolong aplikabel untuk dilakukan di Indonesia.
Kesimpulan: Penggunaan kortikosteroid sebagai terapi adjuvan cenderung dapat menurunkan mortalitas pada pasien PK berat, namun hingga kini belum terdapat bukti yang cukup kuat untuk mendukung hal tersebut. Dibutuhkan studi yang lebih besar untuk mendapatkan bukti yang lebih kuat.
Kata Kunci: pneumonia berat, kortikosteroid, mortalitas, terapi adjuvant

Puji Astuti Tri K1, Anak Agung Arie1, Cleopas Martin Rumende2
1)Internal Medicine Department, Cipto Mangunkusumo National General Hospital-Faculty of Medicine, Universitas Indonesia
2)Division of Respirology and Critical Care, Internal Medicine Department, Cipto Mangunkusumo National General Hospital-Faculty of Medicine, Universitas Indonesia

Abstract
Systemic Sclerosis (SSc) is achronic tissue disorder characterized by immune dysfunction, microvascular injury, and fibrosis. Organ involvement in patients with SSc is variable; however, pulmonary involvement occurs in up to 90% of patients with SSc. Interstitial lung disease (ILD) is a majorcomplication in SSc and has ahigh mortality rate. The SSc-ILD therapy is basically consistent with the progress of scleroderma pathophysiology. In this case, we examine a case of 59-years-old female patientwith a blackened ulcer on her left hand ring finger with disappearing of her distal finger segment, and also a chronic white phlegm cough followed by dysnea in exertion. Clinical examination and evaluation explored that she had a scleroderm, accompanied with ILD. Her complaint did not improve, so she got an immunosuppresant and supportive therapy to control the worsening of her disease.
Keywords: systemic sclerosis, interstitial lung disease

Yohanes Susanto1, Patrice Ginting2, Ruddy Hardiansyah3
1General Practitioner, Metta Medika Hospital, Sibolga, North Sumatera
2Internist, Metta Medika Hospital, Sibolga, North Sumatera
3Anesthesiologist-Intensivist, Metta Medika Hospital, Sibolga, North Sumatera

Abstract

Acute dyspnea after pregnancy is a rare presentation and a number of important conditions may accompany it. Pulmonary embolism, amniotic fluid embolism, pneumonia, aspiration, and pulmonary edema are some of the potential causes that must considered. Pulmonary edema complicates around 0,05% of low-risk pregnancies but may develop in up to 2,9% of pregnancies complicated by preeclampsia, with 70% of cases occurring after birth. The most common contributing factors include peripartum cardiomyopathy, underlying cardiac disease, preeclampsia, administration of tocolytic agents and iatrogenic fluid overload. Here we report a case of 34-year-old woman of 1st postpartum day following lower uterine cesarean section presented with acute progressive dyspnea from her first pregnancy who was admitted in intensive care unit with history of preeclampsia. Clinical examination and relevant investigations explored that it was a case of acute pulmonary edema. Patient was kept in ventilator and was treated with intravenous diuretic and calcium channel blocker. After diuresis, considerable improvement was observed in her respiratory status. The day after, the patient became hemodynamically stable and was weaned off the ventilator. After seven days, she was discharged in stable condition.
Keywords: post-partum, pulmonary edema, preeclampsia
ABSTRAK
Dispnea akut setelah kehamilan merupakan keadaan yang jarang terjadi serta seringkali disertai kondisi-kondisi penting lainnya. Emboli paru, emboli air ketuban, pneumonia, aspirasi, dan edema paru, adalah penyebab dispnea yang perlu dipikirkan. Edema paru terjadi pada 0,05% pada kehamilan dengan risiko rendah, tetapi dapat meningkat menjadi sebesar 2,9% pada kehamilan dengan preeklampsia, dengan 70% terjadi setelah persalinan. Faktor pendukung lainnya adalah kardiomiopati peripartum, adanya penyakit jantung, preeklampsia, pemberian obat tokolitik, dan kelebihan pemberian cairan. Berikut ini adalah sebuah kasus pada seorang perempuan berusia 34 tahun post partum 1 hari dengan riwayat sectio caesarea dan preeklampsia yang mengalami dispnea akut progresif sehingga dirawat di ICU. Pemeriksaan fisik dan pemeriksaan lainnya menunjukkan bahwa kasus ini merupakan sebuah kasus edema paru akut. Pasien menggunakan ventilator dan mendapat terapi diuretik intravena serta penyekat kanal kalsium. Setelah mendapat terapi diuresis, kondsi pasien membaik. Setelah tujuh hari perawatan, pasien dipulangkan dengan kondisi stabil
Kata kunci: post-partum, edema paru, eklampsia

Dedi Suyanto1, Ii Sariningsih2, Basti Andriyoko3, Prayudi Santoso4
1Tim Tuberkulosis RSHS
2Klinik TB MDR Instalasi Rawat Jalan RSHS
3Divisi Biomolekuler Departemen Patologi Klinik RSHS 4Ketua Tim TB-MDR RSUP dr. Hasan Sadikin

Abstr act
Latar Belakang: RSUP Dr. Hasan Sadikin ditunjuk sebagai pusat rujukan penanganan pasien tuberkulosis resisten obat (TB MDR) di Jawa Barat sejak tahun 2012 dan sampai bulan Februari 2015 tercatat sebanyak 1982 suspek TB MDR yang diperiksakan dahaknya. Dari suspek sebanyak itu sebanyak 384 didiagnosis sebagai (TB MDR). Namun ternyata dari 384 pasien yang didiagnosis sebagai TB MDR, hanya sebanyak 338 pasien yang sudah mendapatkan pengobatan. Masih ada sebanyak 47 pasien TB MDR yang belum memulai pengobatan dengan berbagai alasan.
Tujuan: Penelitian ini bertujuan untuk mengetahui karakteristik pasien serta faktor-faktor yang menghambat pemberian OAT MDR pada pasien yang sudah didiagnosis TB MDR di RSHS.
Metode: Penelitian ini menggunakan data primer berupa hasil wawancara menggunakan kuesioner yang diisi oleh subjek penelitian (responden), dengan mengunjungi tempat tinggal pasien (home visit). Jika subjek penelitian tidak berhasil ditemukan, atau telah meninggal dunia, maka data kuesioner diisi melalui wawancara dari keluarga atau petugas puskesmas setempat.
Hasil: Dari hasil pengumpulan data didapatkan bahwa dari 47 subjek penelitian, sebanyak 21 pasien (44%) tidak berhasil dilacak dengan berbagai sebab seperti pindah alamat, pulang kampung, tidak ada di alamat yang tertera, atau alamat tidak ditemukan (fiktif). Hal ini menyebabkan tidak didapatkannya informasi mengenai alasan mereka belum memulai pengobatan. Sisanya sebanyak 26 pasien (55%) berhasil didapatkan informasi mengenai alasan yang membuat mereka belum memulai pengobatan. Dari 26 pasien, 13 (50%) diantaranya menolak diobati, 6 pasien (23%) meninggal, 3 pasien (11%) terkendala administrasi BPJS, 2 pasien (7%) terlambat mendapatkan informasi, 1 pasien (3%) terkendala biaya, serta 1 pasien (3,85%) diobati di tempat lain. Dari 13 pasien yang menolak diobati, 7 pasien (53%) menolak dengan alasan yang tidak jelas, 2 pasien (15%) menolak karena takut efek samping, 2 pasien (15%) lebih memilih pengobatan alternatif, 1 pasien (7%) menolak karena tidak bisa meninggalkan pekerjaan, dan 1 pasien (7%) menolak karena merasa sehat.
Simpulan: Pasien yang menolak pengobatan antara lain disebabkan karena takut efek samping, tidak bisa meninggalkan pekerjaan, memilih obat alternatif, atau merasa dirinya sehat.
Kata kunci: TB MDR, belum pengobatan

IvanaPurnama Dewi1,2, Kristin Purnama Dewi1, Rizaldy Pinzon1, BagusAndi Pramono2
1Faculty of Medicine, Duta Wacana Christian University, Yogyakarta
2Cardiology and Vascular Division, PanembahanSenopati Hospital, Bantul

Abstract
Acute heart failure (AHF) defined as a sudden gradual onset of heart failure symptoms. Acute heart failure commonly occur after acute onset of ST-segment elevation myocardial infarction (STEMI). ST-segment Elevation Myocardial Infarction can lead to a sudden impairment in systolic and diastolic function, resulting in a decreased cardiac output, elevated filling pressures, and the development of cardiogenic pulmonary edema with rapid fluid accumulation in the lungs that potentially fatal cause of acute respiratory distress. ST-segment Elevation Myocardial Infarction-Acute Heart Failure patients require hospitalization and if possible cardiac catheterization and revascularization. The main treatment goals in the hospitalized patient are to restore euvolemia and to minimize adverse events. Here we report the clinical findings of anAHF case in post STEMI with thrombolytic therapy patient. This case has good prognosis after intensive pharmacology combination therapy.
Keywords: STEMI, Acute Heart Failure, Management

Suhendro Suwarto1, Zahra Farhanni Suhardi2, Amin Soebandrio3,4
1Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia.
2 Faculty of Medicine Universitas Indonesia.
3Eijkman Institute for Molecular Biology, Jakarta, Indonesia.
4Department of Microbiology, Faculty of Medicine Universitas Indonesia.

Abstract

Background: The laboratory marker of leucocytes, neutrophils and procalcitonin (PCT) are elevated in Gram-negative-infected patients. Salmonella species, a cause of typhoid fever, are also a type of Gram-negative bacteria. We investigated the laboratory marker of bacterial infection levels in Salmonella and Gram-negative bacteremias.
Methods: This retrospective study was conducted in Jakarta, Indonesia. Sixty-one patients with positive blood cultures of Salmonellaor Gram-negative bacteria who were admitted to the hospital from April 2014 through May 2017 were included. Twenty-seven patients (44,3%) had Salmonella, and 34 patients (55,7%) had Gram-negative bacteremias. The following laboratory parameters were recorded: leucocyte count, neutrophil count, and PCT levels. Bivariate analysis was used to analyze the differences in the laboratory marker between Salmonella and Gram-negative bacteremias.
Results: Gram-negative bacteremia was significantly associated with an elevated leucocyte count (p<0.001), neutrophil count (p<0,001) and PCT levels (p<0,001). The leucocyte count cut-off of ≥10.5x103/μL, a neutrophil countcut-off of ≥80,9% and a PCT level cut-off of ≥1,18 ng/ml were significantly higher in the Gram-negative bacteremia group compared with the Salmonella group (p<0,001 for each variable).
Conclusion: Leucocyte, neutrophil counts, and PCT levels in Gram-negative bacteremia were higher than inSalmonella bacteremia.
Keywords: Gram negative bacteremia,leucocyte, neutrophils cells counts, procalcitonin, Salmonella bacteremia.

MirnawatiMappiare, Abdul Hakim Alkatiri, Peter Kabo
Department of Cardiology, Faculty of Medicine, University of Hasanuddin, Makassar, Indonesia

Abstract
Background: Epicardial adipose tissue (EAT) is a visceral adipose tissue surrounding the heart. Correlation of EAT with coronary artery disease (CAD) in Indonesia is unknown. To address this issue, we evaluate the capacity of EAT thickness measured by transthoracic echocardiogram (TTE) to predict the severity of coronary lesion.
Methods: In this cross sectional study conducted in Wahidin Sudirohusodo Hospital, Makassar, Indonesia, 127 stable CAD patients were enrolled. EAT was identified as an echo-lucent area on the free wall of the right ventricle of the two-dimensional TTE at end diastole in the parasternal long-axis view. Coronary angiograms were analyzed for severity of CAD using modified Gensini score. Accordingly, we classified the study population into two angiographic groups: patients with non-severe CAD (score ≤13; n=73) and severe CAD (score >13; n=54).
Results: There were no significant differences between the groups with respect to body mass index and waist circumference (p=0,562 and 0,659, respectively). There was a positive linear relationship between EAT thickness and modified Gensini score for the entire subjects (R2=21.4%). EAT thickness was significantly greater in patients with severe CAD than in those with non-severe CAD (8,4±2,1 mm vs6,1±2.5 mm, p<0,001). EAT thickness of >7,0 mm had 79,6% sensitivity and 71,2% specificity (ROC area of 0,812, p<0,001)for predicting severe CAD.
Conclusion: Our results could help identify severe CAD by readily available and relatively inexpensive TTE, thereby indicating whether early invasive coronary angiography and timely interventions should be performed.
Keywords: epicardial adipose tissue, echocardiography, coronary artery disease, Indonesia.

Adrina Vanyadhita1, Dian Kusumadewi2
1Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
2Department of Community Medicine, University of Indonesia, Jakarta, Indonesia
Abstract
Introduction: Tuberculosis infection remains a global problem especially in developing countries. In 2013, approximately 9 million of people were diagnosed with tuberculosis and 1.5 million died from tuberculosis. The association between tuberculosis and malnutrition is well established that tuberculosis can cause malnutrition and an individual with malnutrition is susceptible to tuberculosis.
Therefore, low body mass index (BMI) as seen in patients with tuberculosis is often present at the time of diagnosis.
Aim: to assess the role of body mass index in predicting the negative sputum conversion in patients with tuberculosis
Methods: Searching was carried out using the database of Pubmed, Cochrane Central Register of Clinical Trials and Science Direct on 20th March 2015. The search strategy included following keywords and combinations “body mass index AND pulmonary tuberculosis AND sputum conversion”. Three articles was included in the critical appraisal.
Results: A study conducted by Putri FA et al revealed severely low BMI (BMI < 16 kg/m2) is significantly associated with longer negative sputum conversion (HR 0.56, 95%CI 0.38–0.81 and lower probability of conversion before 4 months (aRR 0.67, 95%CI 0.56–0.93). A study by Kenangalem E et al showed that in patients with pulmonary tuberculosis, the time to predict the accomplishment in negative conversion of sputum culture by lower body mass index is not significant with p value of 0.91 and hazard ratio of
0.99 (95%CI 0.85-1.16). A study by Hesseling AC et al revealed low body mass index (BMI <18 kg/m2) is not significantly associated with sputum culture conversion after 2 months of treatment but it significantly predicted a tuberculosis recurrence within 24 months after the completion of treatment.
Conclusion:Based on the critical appraisal of three studies, the predictor factor of sputum conversion in patients with pulmonary tuberculosis by body mass index is not significant and needs further study.
Keywords: tuberculosis, body mass index, sputum conversion

Indah Pratiwi1, Hasrayati Agustina2,Erwan Martanto3 1Faculty of Medicine Universitas Padjadjaran 2Departement of Pathology Anatomy,UniversitasPadjadjaran/Dr. HasanSadikin General Hospital Bandung 3Departement of Cardiology and Internal Medicine, UniversitasPadjadjaran/Dr. HasanSadikin General Hospital Bandung

Abstract

Background: Pericardial effusion is a common condition in clinical practice. Manifestation of effusion depends on its causes and the underlying diseases as well as influenced by patient’s characteristics and geographical location. This study was conducted to determine the characteristic of pericardial effusion patient based on age, gender, cytological and clinical diagnosis. Method: The study was conducted using descriptive retrospective method. The data collected was medicalrecord ofpericardial effusion patients for 5 years from 1st January 2009 to 31st December 2013. This study was conducted in SMF Pathology Anatomy Dr. HasanSadikin General Hospital Bandung. Fifty four cases were collected as samples through total sampling technique. The variables were age, gender, cytological diagnosis and clinical diagnosis. Results: Pericardial effusion mostly occurred in 21-30 years old. Pericardial effusion is more common in man than woman. Based on the type of cytology, the most common pericardial effusion was non-specific inflammation. The most common clinical features of patients is tuberculous infection. Conclusions: Pericardial effusion frequently occurred in 21-30 years old. Based on gender, pericardial effusion is not significantly distributed between male and female. Basesd on cytological diagnosis, pericardial effusion is mostly diagnosed as nonspesific inflammation type. The manjority of clinical feature of pericardial effusion is tuberculosis infection.

Keywords: age, clinical diagnosis, gender, pericardial effusion, type of cytological diagnosis

Anna Uyainah ZN,Gurmeet Singh Divisi Respirologi dan Perawatan Penyakit Kritis Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia/Rumah Sakit Cipto Mangunkusumo

Abstract

Tes bronkodilatasi adalah tes untukmelihat responsivitas saluran nafas terhadap bronkodilator.Spirometri merupakan pemeriksaan yang sangat penting dalam menilai derajat obstruksi saluran nafas pasien. Di samping data-data lain seperti riwayat penyakit, rekam medis sebelumnya, riwayat keluarga dan pekerjaan, pemeriksaan fisik, dan kesan klinis, data spirometri juga memiliki andil dalam menentukan diagnosis dan terapi pasien.

Kata kunci: tes bronkodilatasi

Zulkifli Amin Divisi Respirologi dan Perawatan Penyakit Kritis Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia/ Rumah Sakit Cipto Mangunkusumo

Abstract

The smoking habit give many bad effects, especially in health and economy aspect. In Indonesia, most people still have this habit. Quit smoking is beneficial. Clinicians have an important role in helping patients to quit their smoking habit. Keywords; quit, smoking Kebiasaan merokok memberikan dampak yang buruk, terutama pada hal kesehatan dan ekonomi. Di Indonesia sendiri, masih banyak penduduk yang memiliki kebiasan merokok. Berhenti merokok memberikan keuntungan yang banyak. Dokter memiliki peranan penting dalam membantu pasien mengehentikan kebiasaan merokoknya.

Kata kunci: berhenti merokok

Gurmeet Singh, Stephanie Gita Wulansari Respirology and Critical Illness Division, Internal Medicine Department Cipto Mangunkusumo Hospital/ Faculty of Medicine Universitas Indonesia

Abstract

Introduction: Cytomegalovirus (CMV) is a double-stranded DNA virus and a member of the Herpesviridae family. Cytomegalo- virus infection is one of the important causes of mortality and morbidity in immunocompromised patients. This is a case report of 72 year-old immunocompromised male patient with worsening cough needing an intubation despite previous adequate antibiotic administration. Further examination showed positive CMV infection. The patient showed improvement after administration of ganciclovir.

Keywords: cytomegalovirus, immunocompromised, reactivation, pneumonitis

Ian Huang1, Raymond Pranata2,Novita3 1General Practitioner, Siloam Hospitals Buton, Baubau, Indonesia 2Faculty of Medicine, UniversitasPelitaHarapan, Tangerang, Banten, Indonesia 3Internist, Siloam Hospitals Buton, Baubau, Indonesia

Abstract

Introduction: Acute upper back pain as one of the atypical symptoms of acute myocardial infarction (AMI) is more frequently encountered in women, elderly, diabetics, and patients with prior stroke or heart failure.1 Failure to recognize atypical clinical presentation of AMI conveys to delayed diagnosis, which are associated with increased morbidity and mortality.2 Abstract : Acute upper back pain as one of the atypical symptoms of acute myocardial infarction (AMI) is more frequently encountered in women, elderly and diabetics. Failure to recognize atypical clinical presentation of AMI conveys to delayed diagnosis, which are associated with increased morbidity and mortality. Herein we report a case of 46 yearsold male presenting with a sudden onset of severe acute upper back pain 6 hours prior to hospital admission. Diagnosis of AMI was delayed until 12 hours later after typical ischemic chest pain manifested and ECG reading showed evolution of ST-Elevation Myocardial In- farction (STEMI). Due to the atypical clinical presentation, diagnosis of AMI in this patient was delayed. Vigilant observation and low threshold for acute coronary syndrome (ACS) work-up are obligatory to prevent delayed diagnosis and management. Keywords: back pain, STEMI, atypical presentation, ACS, myocardial infarction

Abstrak

Nyeri punggung atas adalah salah satu gejala atipikal dari infark miokard akut (IMA) yang lebih sering ditemukan pada perempuan, lanjut usia dan penderita diabetes. Kegagalan untuk mengenali presentasi atipik dari IMA menyebabkan telatnya diagnosis yang dihubungkan dengan meningkatnya mortalitas dan morbiditas. Dalam kasus ini kami melaporkan seorang laki-laki berusia 46 tahun datang dengan keluhan nyeri punggung atas yang berat dan mendadak sejak 6 jam sebelum masuk rumah sakit. Diagnosis IMA tertunda hingga 12 jam kemudian ketika nyeri dada tipikal dirasakan dan EKG menunju- kan evolusi dari STEMI. Karena presentasi klinis yang atipikal, diagnosis IMA pada pasien ini tertunda. Pemantauan yang jeli danpemeriksaan lanjutanuntuk sindrom koroner akut (SKA) wajibdilaksanakan untuk mencegah tertundanya diagnosis dan tatalaksana yang sesuai.

Kata Kunci: nyeri punggung, STEMI, presentasi atipikal, SKA, infark miokard

Telly Kamelia
Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, RSUPN Cipto Mangunkusumo, Jakarta
ABSTRACT
Liver abscess is an inflammatory lesions of the liver that can spread into the pleural cavity resulting in empyema and lung abscess. One of the causes of spread to the pleural cavity is due to hepatopleura fistulas. In this case, a man, 43 years old, came with complaints of shortness of breath that became heavier since one week ago, accompanied by upper abdominal pain, bleeding cough one time, stomach felt enlarged, and history of smoking, promiscuity, and drinking alcohol. On physical examination, it was found the right lung left behind during inspiration, vocal fremitus decreased, dull percussion, and vesicular sounds decreased in the right lung field and hepatomegaly. IDT amoeba was 1,92 and pleural fluid examination showed an exudate. Massive pleural effusion was found on chest X-ray. In hepatology ultrasound was found liver abscess, hepatomegaly, and right pleural effusion. In thoracic ultrasound examination obtained the right loculated pleural effusion. Thoracic CT scan with contrast showed cavity with air-fluid level in the right hemithorax and hepatic lesions in 4th,5th segments. The results of the liver abscess fluid analysis obtained microbiological examination did not find germs, acid-fast bacilli (AFB) smear was negative, culture examination is not find microorganisms and anaerobes, pathological examination showed colored brown viscous fluid, and microscopic examination obtained the necrotic mass and fibrous connective tissue.
Key words : liver abscess, empyema, lung abscess, hepatopleural fistula

Herikurniawan, Anna Uyainah ZN
Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia-RSUPN Dr. Cipto Mangunkusumo
ABSTRACT
Background: Heat stroke is an emergency condition that become one of the main cause of morbidity and mortality during pilgrimage in the summer. Old age, comorbid diseases, high temperature (>45oC), and heavy physical activity are the risk factors for heat stroke. Heat stroke can be prevented by awareness of early sign and symptom, people who has susceptibility, and the predisposition situation.
Method: This study was a cross sectional study with consecutive sampling method among Indonesian hajj pilgrims in 2016 who got heat stroke in Arafah and Mina. Diagnosis of heat stroke and heat exhaustion was made based on: 1. fever/hyperpirexia 2. pale skin/dry skin 3. decrease of consciousness/confusion, and 4. no sign of infection Results: There were 41 Indonesian hajj pilgrims had heat stroke, consists of 16 persons had heat stroke and the rest had heat exhaustion. The majority of subjects were males (63,4%). Most of subjects were > 70 years old (29,3%) There were 14,6% subjcts that had diabetes mellitus and 12,2% had hypertension. There were 78% heat stroke condition occured in Arafah and 22% occured in Mina.There were 68,5% subjects that recovered, and 29,3% got hospitalizad. Conclusion: Most of heat stroke victim was above 70 years old. Major comorbid were diabetes mellitus and hypertension. Most of heat stroke condition occured in Arafah.
Keywords: heat stroke, heat exhaustion, Indonesian hajj pilgrims

Zen Ahmad1, Diah Syafriani2, Merianson2
1Sub Bagian Pulmonologi FK UNSRI/RSMH-Palembang
2 PPDS SP2 IPD Bidang Ilmu Pulmonologi FK UNSRI/RSMH-Palembang
ABSTRACT
Multi Drug Resistant Tuberculosis (MDR TB) is tuberculosis caused by Mycobacterium tuberculosis that resistant to rifampicin and isoniazid. The diagnosis of MDR TB is made based on clinical symptoms, physical examination, radiologic finding, acid fast bacilli examination, and TB culture. It is a case about female, 36 years old, diagnosed with MDR TB who underwent intensive phase and had sputum conversion. However, after underwent the continuation phase, the sputum examination showed reversion. The point of this case is the importance to decide whether continue or discontinue the treatment of MDR TB, because the treatment was considered to be failed
Keywords: Multi Drug Resistant Tuberculosis, conversion, reversion

Telly Kamelia
Divisi Respirologi dan Perawatan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, RSUPN Cipto Mangunkusumo, Jakarta
ABSTRACT
Introduction: Obstructive sleep apnea (OSA) is a breathing disorder that commonly occur during sleep. OSA occurs due to upper airway collapse either totally or partially. Polysomnography examination level 3 still often performed by the clinician because the examination is easy and not expensive.
Objective: Assess the accuracy diagnosis of obstructive sleep apnea with level 3 portable sleep monitor test.
Method: The literature search conducted using PubMed and the Cochrane database, obtained 37 articles. The selection of articles and critical study of systematic review is based on validity, importance, and applicability standardized by the Centre of Evidence Medicine University of Oxford British and critical analyzes articles diagnosis standardized by the British Medical Journal (BMJ).
Results: a systematic review and meta-analysis by Shayeb et al. (2014) found that the examination of level 3 portable sleep monitor test has moderate to high heterogeneity (I2 value of 53% -85%), the sensitivity and specificity (0,79-0,97 and 0,60-0,93). A cohort studies by Garg et al. (2014) showed that examination of level 3 at home had a sensitivity of 0,96, specificity of 0,43, 0,79 PPV, and NPV 0,82.
Conclusion: Examination level 3 with a portable monitor in the house has a good degree of accuracy and is recommended for high-risk OSA patients without comorbid.
Keywords : obstructive sleep apnea, polysomnography, level 3 portable sleep monitor test, sensitivity, specificity

Triyanti Kurniasari Ananta Putri Sudibyo, Eko Budiono
Bagian Ilmu Penyakit Dalam, Universitas Gajah Mada
ABSTRACT
Introduction: Orbital TB is an uncommon condition. Lacrimal gland TB or dacryoadenitis is a type of orbital TB condition that uncommon, even in endemic country.
Case presentation: A woman, 48 years old, came with diplopia. There was a gradual swelling with no pain at palpebra. There was no history of fever or lung disease. The histopathological examination showed granulomatous inflammation with giant cell of Datia Langhans that came from lacrimal gland. Microbiological study to find acid fast bacilli showed negative result. Patient gave good response after underwent TB treatment. Conclusion: Lacrimal gland TB can not be diagnosed easily because it is commonly not accompanied with TB at other site. However, consideration for this diagnosis is still important, especially in endemic areas such as Indonesia.
Keywords: tuberculosis, lacrimal gland, histopathology

Try Nirmala Sari1, Sumardi2, Heni Retnowulan2, Barmawi Hisyam2, Bambang Sigit Riyanto2, Eko Budiono2, Ika Trisnawati2
1 Resident of Department of Internal Medicine, FK UGM/RSUP Dr. Sardjito Yogyakarta
2Division of Pulmonology, Department of Internal Medicine, FK UGM/RSUP Dr. Sardjito Yogyakarta
ABSTRACT
Background: Second line anti tuberculosis drug in MDR-TB patients is notorious for having several side effects. Ethionamide is anti tuberculosis drug that is used as a second line therapy in MDR-TB patient management. Hypothyroid is an important side effect in ethionamide administration. Cycloserine is in the fourth group of second line therapy that acts as bacteriostatics. Psychiatric side effects such as anxiety, hallucination, depression, euphoria, habit alteration, and suicide are reported in 9,7%-50% of patients in cycloserine therapy. Case Presentation: A 46 year-old lady with MDR-TB started her second line anti TB drugs therapy since January 2016. Her regimen included levofloxacin, cycloserine, ethionamide, pyrazinamide, ethambutol and PAS (Para- Aminosalicylic Acid). Therapy evaluation in the first month control founded fatigueness, reduced communication, self-secluding, and behaviour alteration. Patient often felt sad, desperate, and had a lot of thought on her illness. Patient also had thoughts of suicide. Patient was then hospitalized and was diagnosed by psychiatry department with TB drugs -possibly cycloserine-induced depression episode. Then, cycloserine therapy was stopped. And at the same time, laboratory result showed an increase in TSH without hypothyroid symptoms. Levothyroxin 1x100 mcg was administered. In the third month of therapy, patient returned with a much higher TSH level, then ethionamide was stopped for 3 months. Evaluation was conducted post ethionamide cessation and found well-controlled TSH level. Ethionamide was then continued with titration doses per month.
Conclusion: In MDR-TB therapy, potential complication of ethionamide administration should be considered carefully. Severe neurotoxicity caused by cycloserine can be managed by delaying the drug use temporarily. It is also worth considered that hypothyroid state can exhibit depression symptoms therefore careful monitoring of the side effects of anti TB drug therapy is needed.
Keywords: Multi drug resistant, tuberculosis, drug-induced hypothyroid, drug-induced psychosis.

Zulkifli Amin1, Martin Winardi2
1Division of Respirology and Critical Care, Department of Internal Medicine,
Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Indonesia 2Department of Internal Medicine, Faculty of Medicine,
Universitas Indonesia, Cipto Mangunkusumo Hospital, Indonesia

ABSTRACT
Background: Decreased oxygen supply due to acute physiological deterioration may increase mortality risk, particularly in critically ill patients with inadequacy to compensate such changes. The aim of the study was to evaluate peripheral oxygen saturation (SpO2) at admission in predicting mortality of emergency patients with critical conditions at Cipto Mangunkusumo Hospital (CMH), the national referral hospital in Indonesia. Methods: We performed a retrospective cohort study of emergency patients with critical conditions at Emergency department (ED), CMH from October to November 2012. SpO2 was meassured within 15 minutes after patients’ arrivals. Subjects were divided into two groups: group 1 consisted of subjects with SPO2 more or equal to 95% and subjects with SpO2 less than 95% were in group 2. Primary outcome measured was in-hospital mortality. Log-rank test was used to analyze survival between groups. Risk of in-hospital mortality was analyzed with Cox proportional hazard model.
Results: In-hospital mortality rate was observed in 69 (40.1%) from 172 patients. Patients with SpO2 less than 95% had a significantly lower survival rate (mean survival 21.3 vs 28.6 days, log-rank p = 0.011). The hazard ratio of mortality was 1.8 (95% CI 1.13 to 2.90) in patients whose SpO2 fell below 95%.
Conclusions: Peripheral oxygen saturation below 95% at admission was significantly associated with increased risk of in-hospital mortality. Given the ease of its measurement, SpO2 should be considered as a predictor of mortality in emergency patients with critical conditions.
Keywords: Peripheral oxygen saturation, critical conditions, emergency, mortality

Riska A Ambarwati1, Rudy Putranto2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Psikosomatis, Departemen Ilmu Penyakit Dalam FKUI/RSCM

PENDAHULUAN
Perawatan paliatif adalah pendekatan medis yang bertujuan untuk meningkatkan kualitas hidup pasien dan keluarga yang sedang menghadapi penyakit yang mengancam nyawa melalui pencegahan dan mengurangi penderitaan dengan identifikasi dini, penilaian masalah yang tepat, serta pengelolaan nyeri dan masalah fisik lain, psikososial, dan spiritual.1 Pelayanan ini dimulai ketika pasien terdiagnosis dan diberikan bersamaan dengan terapi spesifik.2
Konsensus American Thoracic Society (ATS) mendefinisikan dispnea sebagai
pengalaman subjektif berupa rasa tidak nyaman yang terdiri atas sensasi kualitatif yang bervariasi intensitasnya. Dispnea adalah salah satu dari gejala yang paling sering dijumpai pada pasien dengan kanker paru stadium lanjut, fibrosis kistik, fibrosis interstisialis, maupun penyakit paru obstruktif kronis (PPOK) yang mengakibatkan hendaya dan relatif sulit diatasi. 2,4
Makalah ini akan membahas mengenai penggunaan opioid sebagai salah satu cara untuk mengurangi dispnea pada pasien paliatif terutama pasien yang refrakter terhadap terapi primer. Meskipun banyak klinisi yang mempertimbangkan mengenai keamanan penggunaan opioid pada pasien karena efek depresi pernapasan yang dapat terjadi, penggunaan opioid secara tepat relatif aman.5-7

Kartika Anastasia Kosasih1, Zulkifli Amin2, Astrid Priscilla Amanda3
1Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
2Division of Respirology and Critical Illness, Department of Internal Medicine Universitas Indonesia, Jakarta, Indonesia 3Assistant Researcher, Division of Respirology and Critical Illness, Department of Internal Medicine Universitas Indonesia, Jakarta, Indonesia

ABSTRACT
Introduction: Tuberculosis (TB) is a leading cause of death worldwide alongside with HIV. Globally, there were an estimated 9.6 million new TB cases and 1.5 million deaths from TB in 2014. Tuberculosis-destroyed lung is a complication of severe pulmonary tuberculosis that can causes various respiratory symptoms and pulmonary dysfunction. Destroyed lung can seriously compromises long-term survival, so it is imperative to do the surgery. Objective: to determine the chance of survival in patients with tuberculosis-destroyed lung who underwent pulmonary resection.
Method: Literature searching on PubMed, Cochrane Library, ProQuest, EBSCOHost, Science Direct and ClinicalKey was conducted on March 15th, 2016. Three articles were included to be appraised for its validity and relevance using several aspect based on Center of Evidence-Based Medicine, University of Oxford for prognostic study. Result: Study by Byun CS. et al showed operative mortality of 6.8%, SE 2.9%, 95% CI (3.9% to 9.7%). The post- operative mortality rate in 5 years is 11.1%, SE 3.7%, 95% CI (7.4% to 14.8%) and 23.8%, SE 5%, 95% CI (18.8% to
28.8%) in 10 years. Rifaat A. et al revealed post-operative mortality rate of 7.1%, SE 6.8%, 95% CI (0% to 20.3%). Bai
L. et al presented post-operative mortality rate of 5.8%, SE 1.8%, 95% CI (4% to 7.6%).
Conclusion: Pulmonary resection for tuberculosis-destroyed lung patients can be achieved with low overall mortality rate (operative and post-operative).
Keywords: destroyed lung, mortality, resection, surgery, tuberculosis

Tim Editor
PENDAHULUAN
Saat Perang Dunia I, banyak pasien dengan trauma non-torakal, pankreatitis berat, transfusi masif, sepsis, dan kondisi terdeteksi dengan tanda-tanda distres pernapasan, infiltrat difus paru, dan gagal napas. Ashbaugh dkk (1967) mendeskripsikan 12 pasien yang ditangani olehnya dengan kondisi seperti diatas dan kemudian ia definisikan sebagai adult respiratory distress syndrome (ARDS).
DEFINISI
Acute respiratory distress syndrome (ARDS) merupakan perlukaan inflamasi paru yang bersifat akut dan difus, yang mengakibatkan peningkatan permeabilitas vaskular paru, peningkatan tahanan paru, dan hilangnya jaringan paru yang berisi udara, dengan hipoksemia dan opasitas bilateral pada pencitraan, yang dihubungkan dengan peningkatan shunting, peningkatan dead space fisiologis, dan berkurangnya compliance paru.

Sofian K. Marsawidjaya1; Ujainah ZN2; Aries Perdana3; Murdani A4
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Respirologi dan Penyakit Kritis, Departemen Ilmu Penyakit Dalam, FKUI/RSCM 3Departemen Anestesiologi FKUI/RSCM
4 Departemen Ilmu Penyakit Dalam, FKUI/RSCM

ABSTRACT
Background: Postoperative pulmonary complication had important effect in increasing morbidity, mortality as well as length of stay. Several factors contributing to those such as patient’s health status, type of operation and type anaesthesia used. There were risk score developed by Arozullah that can be used to predict the possibility of respiratory failure and postoperative pneumonia. Due to the differences of the characteristic population, the study needed internal validation to discover the performance of the Arozullah score.
Objectives: To assess the performance of calibration and discrimination of Arozullah’s model risk score in predicting complications of respiratory failure and pneumonia postoperative in patients undergoing non-cardiac surgery in Cipto Mangunkusumo General Hospital (RSCM)
Methods: A cohort retrospective study was conducted in patients undergoing non-cardiac surgery in RSCM from January to December 2015. Considered variables were type of surgery, age, emergency surgery, history of Chronic Obstructive Pulmonary Disease (COPD), serum albumin, ureum, functional status, weight loss, history of smoking, alcohol use, blood transfusions pre surgery, general anaesthesia, history of cerebrovascular disease , acute impaired sensorium, chronic steroid use. Outcomes assessed were complications of respiratory failure and pneumonia in 30 days post-operative. Performance calibration were assessed with Hosmer-Lemeshow test and performance discrimination were assessed with area under the curve (AUC).
Result: There were 403 subjects met the inclusion criteria with 74 of subjects had pulmonary complications (18.4 %). Ther are 52 subjects had respiratory failure, 34 subjects had pneumonia post operative, and 12 subjects had both complication. Hosmer-Lemeshow test on the complications of respiratory failure showed p =0.333 and the AUC value is 0.911. While pneumonia complications showed p =0.617 and AUC value is 0.789.
Conclusion: Arozullah score perioperative had good performance in predicting respiratory failure and pneumonia 30-days postoperative in RSCM.
Keywords: respiratory failure, pneumonia, non-cardiac surgery, validation, risk index score perioperative Arozullah

Reza Nugraha Yulisar1, Telly Kamelia2
1Departemen Ilmu Penyakit Dalam FKUI/RSCM
2Divisi Respirologi dan Penyakit Kritis, Departemen Ilmu Penyakit Dalam FKUI/RSCM

PENDAHULUAN
Hemoptisis atau batuk darah merupakan gejala yang tidak jarang ditemukan pada praktek sehari-hari dan berpotensi menyebabkan kematian. Kasus hemoptisis ini bervariasi, dapat berupa batuk darah yang self limiting sampai ke hemoptisis masif yang mengancam nyawa. Mortalitas dari hemoptisis masif ini berkisar antara 50%, dengan prevalensi sekitar 5% dari seluruh kasus hemoptisis.1 Sedangkan mortalitas dari hemoptisis itu sendiri antara 7-30%.2 Kematian pada hemoptisis dapat terjadi akibat banyaknya darah pada saluran pernafasan sehingga menyebabkan asfiksia dan diikuti oleh gagal sistem kardiovaskular. Di Indonesia, prevalensi hemoptisis pada pasien rawat inap di RSP tahun 2007 dan 2008 sebesar 30.99% dan 34.68%.3 Etiologi dari hemoptisis ini beragam, di antaranya adalah penyakit parenkimal, penyakit saluran nafas, dan penyakit vaskuler. Namun dari beberapa penelitian, 3-42% pasien dengan hemoptisis etiologinya tidak dapat diketahui dan dapat disebut sebagai kriptogenik.3 Pasien dengan hemoptisis masif sebaiknya selalu dianggap kondisi yang mengancam nyawa yang memerlukan terapi yang cepat, tepat, dan efektif. Pada makalah ini, akan dibahas mengenai diagnosis dan tatalaksana dari hemoptisis non masif dan hemoptisis masif.