SUCTION PUMP ASSIST DEVICE IN CARDIOGENIC SHOCK

Lukman H. Makmun, Telly Kamelia, Ryan Ranitya, Zuswayudha Samsu

• Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
• Respirology and Critical Illness Divison, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

ABSTRACT

 

 

Background: Cardiogenic shock is a critical condition where the heart fails to pump blood effectively, lead- ing to high mortality rates. Mechanical circulatory support can temporarily reduce the heart’s workload while maintaining systemic perfusion. This paper in- troduces the Suction Pump Assist Device, an early mechanical support system patented in 1979.

Aim: To present the design, working principle, and clinical relevance of the Suction Pump Assist Device and compare it to the modern standard, Extracorpo- real Membrane Oxygenation (ECMO).

Method: The working principle of the suction pump assist device was analyzed and compared to ECMO, which has been the standard of care for cardiogenic shock since 2016.

 

Results: The Suction Pump Assist Device operates on a principle similar to VA-ECMO, where venous blood is oxygenated externally and returned to the arterial system, thereby reducing cardiac workload and ensur- ing systemic oxygenation. While ECMO has evolved significantly with technological advancements, the fundamental concept remains consistent.

Conclusion: The Suction Pump Assist Device repre- sents an early innovation in mechanical circulatory support for cardiogenic shock, sharing key principles with modern ECMO systems.

Keywords: Cardiogenic shock, Mechanical circula- tory support, ECMO, Suction pump assist device

Validation of Clinical PROMISE Score in Predicting 3-Month Mortality in Malignant Pleural Effusion Patients

 

Dita Gemiana¹, Cleopas Martin Rumende², Ikhwan Rinaldi³, Robert Sinto⁴ , Aida Lydia⁵, Rudy Hidayat⁶, Noto Dwimartutie⁷, Nadia Ayu Mulansari³

¹ Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

² Respirology and Critical Illness Divison, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

³ Hematology and Medical Oncology Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

⁴ Tropical and Infectious Diseases Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

⁵ Nephrology Divison, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

⁶ Rheumatology Divison, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

⁷ Geriatric Divison, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

 

Corresponding Author: Dita Gemiana

Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Email: dita.gemiana91@ui.ac.id, Phone 081319100857

 

Abstract

Background: Pleural effusion is a frequent complication of malignancy. Malignant pleural effusion accounts for 15% to 35% of all pleural effusion cases and the incidence rate reaches 660 people per 1 million population globally. Several prediction models have been evaluated to predict mortality in malignant pleural effusion patients. The PROMISE score is a prediction model for 3-month mortality in patients with malignant pleural effusion.

Methods: A retrospective cohort study was conducted on patients with malignant pleural effusion registered in 2015-2022 at Cipto Mangunkusumo National Central General Hospital. A three-month mortality assessment was carried out. The collected data was analyzed using the Hosmer-Lemeshow goodness-of-fit test to determine the calibration performance and creation of a Receiver Operating Curve (ROC) curve to determine the discrimination performance of the Clinical PROMISE score on three-month mortality outcomes.

Results: A total 120 subject were included in the study. The majority of subjects were women (73.3%), mean age 55 years and other types of cancer (78.3%). The Clinical PROMISE score had good calibration performance (p = 0.230, coefficient of correlation r = 0.945). The discrimination performance of the Clinical PROMISE score was good with an AUC of 0.849 (95% CI 0.776 –0.922).

Conclusion: The calibration and discrimination performance of Clinical PROMISE score to predict 3-month mortality of malignant pleural effusion is good.

Keywords: Malignant pleural effusion, mortality, Clinical PROMISE score.

Unexpected Tension Pneumothorax Complicated by Double-Lumen Catheter Insertion in Patient with Mechanical Ventilator: A Case Report

 

Arif Himmawan, Rullyano Hardian, Fitriah Sherly Marleen

Khidmat Sehat Afiat General Hospital of Depok

Koresponden: himmawan89@gmail.com

 

 

Abstract

 

Introduction: Tension pneumothorax is an emergency situation with a high mortality rate which can be caused by trauma/iatrogenic. We report a case of tension pneumothorax observed after insertion of a double-lumen cetheter in a patient on a mechanical ventilator.

Case: A 70 year old man with a mechanical ventilator was designed to install a double-lumen catheter in preparation for hemodialysis. After insertion of a double-lumen catheter, the patient’s saturation decreased, breath sounds from the right hemithorax decreased. A chest X-ray shows a collapsed right lung and flattened diaphragm. A needle thoracocentesis was performed at the 2nd ICS, the right mid-clavicular line, and continued with the installation of a WSD at the 5th ICS, the right anterior axilla line. The result is a clinical improvement.

Discussion: Tension pneumothorax is not an uncommon complication in mechanical ventilated patient, but its occurance immediately after insertion of a double-lumen cetheter is extremely rare. Subsequent decline in respiratory and cardiovascular function can be life-threatening if not detected early enough and managed properly. With the needle thoracocentesis and insertion of a WSD tube, the patient’s clinically condition significantly improved.

Conclusion: Tension pneumothorax is an emergency situation with a high mortality rate which can be caused by trauma/iatrogenic. With the needle thoracocentesis and insertion of WSD tube, a clinical improvement in the patient’s condition was evident.

 

Keywords: tension pneumothorax, double-lumen catheter, mechanical ventilator

 

 

ANALYSIS OF DEMOGRAPHIC PROFILE AND CHARACTERISTICS OF ACUTE CORONARY SYNDROME PATIENTS: AN OBSERVATIONAL STUDY

 

Muhammad Perdana Airlangga^1*, Irma Kartikasari², Juliana Juliana³, Saski Yasmin Alfina⁴, Frida Nur Rohmatin⁵,

^1,2 Faculty of Medicine, Muhammadiyah Surabaya University, Indonesia

³ General Practitioner, Siti Khodijah Muhammadiyah Sepanjang Hospital, Indonesia

^4,5 Internship doctor, Siti Khodijah Muhammadiyah Sepanjang Hospital, Indonesia

                                                  * Correspondence Author: angga.cardio@gmail.com                

 

ABSTRACT

Cardiovascular disease (CVD) is the leading cause of death globally. Based on the 2018 Indonesia Basic Health Research data, the prevalence of heart disease in Indonesia reached 1.5% including Acute Myocardial Infarction (AMI). Blockage or total occlusion of the coronary arteries in ST-Elevation Myocardial Infarction (STEMI) patients requires immediate reperfusion (Percutaneous Coronary Intervention (PCI) or fibrinolytic therapy). Based on data from the Sidoarjo Health Office in 2023, there was 3968 cases of AMI. This study aims to identify the profile of Acute Coronary Syndrome (ACS) patients in Sidoarjo, This is a descriptive observational study with a retrospective cohort study design. This study used secondary data from the medical records with an inclusion and exclusion criteria. There were 150 samples which predominantly males (85%) with aged 50-60 years (47%).  The most  systolic blood pressure was  ≤120 mmHg (55%). The result of PCI in patients showed that the most was Coronary Artery Disease (CAD) triple vessel disease (44%). A total of 67 of 150 patients experienced occlusion, 36 were chronic total occlusion (CTO) and 31 others were acute total occlusion. The location of the most common cause of blockage was in the Left Anterior Descendens (LAD) artery, which was 121 patients. This study showed that the most PCI patients were male, aged 51-60 years, systolic blood pressure <120 mmHg, multi vessel disease, chronic total occlusion, the most arterial blockage was located in the LAD artery, and had normal creatinine serum.

Keywords: Acute coronary syndrome, cardiovascular diasease, chronic total occusion

Latent Tuberculosis Treatment in HIV-Positive Patients: What’s New? Is It Overtreatment? Which One Is Preferred?

Arya Marganda Simanjuntak¹, Ellya Catharine Lumbantoruan², Merlinda Veronica³, Heri Ginting⁴, Anwar Sholeh⁴, Dani Rosidana⁴

¹ Research Intern, Department of Internal Medicine, Faculty of Medicine, Universitas Riau, Arifin Achmad General Hospital

² Faculty of Medicine, Universitas Tanjungpura, Pontianak, Indonesia

³ Tropical Infection Division, Department of Internal Medicine, Faculty of Medicine, Universitas Riau, Arifin Achmad General Hospital, Pekanbaru, Riau, Indonesia

⁴ Pulmonary and Critical Medicine Division, Department of Internal Medicine, Faculty of Medicine, Universitas Riau, Arifin Achmad General Hospital, Pekanbaru, Riau, Indonesia

 

Corresponding Author : Arya Marganda Simanjuntak, Dept of Internal Medicine, Faculty of Medicine, Universitas Riau, Arifin Achmad General hospital. arya.marganda@gmail.com

 

ABSTRACT

Latent Tuberculosis Infection (LTBI) is a focus especially in HIV-seropositive patients because immunocompromise increases the risk of reactivation of LTBI into active TB. Therefore, LTBI therapy was developed to prevent the TB from becoming active. However, several issues have been questioned regarding LTBI therapy in HIV patients as an overtreatment and potentially dangerous because both drugs in TB and HIV have the same profile of hepatotoxicity. This review comprehensively discusses existing regimens and current evidence on the management of LTBI in HIV patients.  This should be taken into consideration, but we also see from recent studies that if a patient has TB activation in HIV, it will decrease treatment success and also increase morbidity and mortality. Therefore, LTBI therapy has been developed up to the latest prevention guideline in 2024 with fewer treatment regimens than Active TB with 3HP or 3 HR. While it can be argued that LTBI therapy in HIV patients is necessary and not overtreatment, measures have also been developed to reduce the rate of hepatotoxicity that may occur.

 

Keywords : HIV, Latent Tuberculosis, Pharmacotherapy,  Tuberculosis, Treatment

Glucocorticoid-Induced Immunosuppression and Immunocompromised Host Pneumonia

Mira Yulianti, Department of Internal Medicine, Division of Respirology and Critical Illness, Faculty of Medicine Universitas Indonesia – Dr. Cipto Mangunkusumo General Hospital

Dwitya Wilasarti, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia – Dr. Cipto Mangunkusumo General Hospital

 

Corresponding author: Dwitya Wilasarti, Dr Cipto Mangunkusumo Hospital, Jl Pangeran Diponegoro no 71, Central Jakarta, dwitya.w@gmail.com

Abstract:

Glucocorticoid is still a mainstay therapy in numerous diseases despite advances in novel chemotherapy and biologic immunomodulators. Estimated prevalence of glucocorticoid exposure is 1% in the general population. Glucocorticoid affect the immune system through various pathways, rendering those exposed to glucocorticoid immunocompromised. Studies have found that even at lower doses and short-term prescription, infection risk is increased in this population. Pneumonia is one of the leading causes of infection in the immunocompromised population, and based on the latest ATS/IDSA workshop report regarding immunocompromised-host pneumonia (ICHP), diagnosis and the etiologic workup differs compared to the community acquired pneumonia in immunocompetent patients. Approach to admission to inpatient care also differs due to the higher possibility of rapid deterioration of initially stable patients. Empirical treatment targets core respiratory pathogens but must be followed up to an attempt to determine causative pathogen according to clinical predisposition and imaging findings.

Abstrak:

Glukokortikoid tetap menjadi opsi pengobatan penting untuk berbagai penyakit, meskipun telah ada kemajuan dalam kemoterapi dan terapi biologis. Sekitar 1% dari populasi umum diperkirakan terpapar glukokortikoid, yang mempengaruhi sistem kekebalan tubuh melalui berbagai jalur, sehingga meningkatkan risiko infeksi. Secara khusus, penelitian menunjukkan bahwa bahkan dosis rendah dan penggunaan jangka pendek dapat meningkatkan risiko infeksi. Pneumonia menjadi salah satu infeksi utama pada individu dengan imunitas menurun. Pedoman terbaru dari ATS/IDSA menekankan bahwa diagnosis dan pemeriksaan etiologis pneumonia pada pasien dengan imunitas menurun (ICHP) berbeda dari pneumonia yang didapat di masyarakat pada pasien yang imunokompeten. Keputusan untuk merawat inap pasien pada populasi tersebut juga sangat bergantung pada keputusan klinis karena memiliki risiko lebih tinggi untuk mengalami perburukan kondisi dengan cepat walau datang dengan klinis stabil. Pengobatan empiris biasanya menargetkan patogen pernapasan umum, tetapi penting untuk memperbaiki pendekatan ini berdasarkan temuan klinis dan pencitraan untuk secara efektif mengidentifikasi organisme penyebabnya.

Keywords: immunocompromised host pneumonia, glucocorticoid

Factors Influencing the Survival of Patients with Pleural Effusion Without Clear Etiology

Bellinda Magdalena¹, Gurmeet Singh², Lisnawati³, Dicky L. Tahapary⁴

 

¹Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

²Div of Respirology and Critical Care, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

³Departmen of Anatomic Pathology, Dr. Cipto Mangunkusumo National General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

⁴Division of Endocrinology and Metabolism, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

 

*Corresponding author: Bellinda Magdalena

Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia

E-mail: bellindamagdalena@gmail.com

 

 

 

 

Abstract

BACKGROUND: Undiagnosed pleural effusion is a common cause of respiratory distress worldwide and contribute to morbidity and mortality. OBJECTIVE: The aim of this study is to evaluate factors affecting mortality and determine the 30 day and 90 day survival of patients with pleural effusion undergoing medical thoracoscopy. METHODS: This prospective study was conducted on patients with pleural effusion of unknown etiology who were over 18 years old and underwent medical thoracoscopy in Dr. Cipto Mangunkusumo National General Hospital, a tertiary care hospital in Jakarta, Indonesia. The study included 57 patients with pleural effusion who underwent medical thoracoscopy from January 2023 to May 2024. Patients were monitored up to 90 days after medical thoracoscopy. Kaplan-Meier and Cox proportional hazard analysis was used to analyze the data. RESULTS: The 90-day survival rate was 74.63% (CI 66.36-82.88). Analysis using the cox proportional hazard showed male gender [HR 2.108 (CI 0.732-6.076), p=0.167)] and poor ECOG PS [HR 3.822 (CI 0.863-16.928), p=0.077] were factors directly influencing the 90-day mortality of patients with pleural effusion of unknown etiology undergoing medical thoracoscopy. CONCLUSION: The 90-day survival rate of patients with pleural effusion with unknown etiology undergoing medical thoracoscopy is 74.63% (CI 66.36-82.88). Patients with pleural effusion of unknown etiology undergoing medical thoracoscopy who were male and with worse ECOG PS were associated with a higher risk of mortality within 90 days post procedure. 

Keywords:  Pleural effusion, medical thoracoscopy, survival, mortality

EFEKTIVITAS TINDAKAN BRONHOALVEOLAR LAVAGE DALAM PENEGAKAN DIAGNOSIS TUBERKULOSIS PARU PADA PASIEN YANG KESULITAN MENGELUARKAN SPUTUM

Ade Yudisman¹, Prayudi Santoso², Arto Yuwono Soeroto²

¹Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran/ RSUP Dr Hasan Sadikin Bandung

²Divisi Respirologi dan Penyakit Kritis Respirasi, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran/ RSUP Dr Hasan Sadikin Bandung

 

 Corresponding Author:

Ade Yudisman. 1Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran/ RSUP Dr Hasan Sadikin Bandung Jl Pasteur No. 38, Bandung, 10430, Indonesia. E-mail: yudismanade@yahoo.com

Abstrak

Latar belakang: Pemeriksaan Bakteri Tahan Asam (BTA) dan Test Cepat Molekular (TCM) pada penegakkan diagnosis TB Paru memerlukan specimen sputum. Penegakkan diagnosis menjadi sulit, bila sputum tidak didapatkan. Hal ini dapat menimbulkan overdiagnosis atau overtreatment serta undertreatment, terutama pada kasus terduga TBC resisten obat atau TB paru kasus kambuh dengan gejala klinis dan hasil interpretasi foto toraks yang menggambarkan TB namun tidak berhasil mendapatkan hasil bakteriologis. Pada kasus pasien tersebut, maka sputum untuk pemeriksaan bakteriologis bisa didapat melalui prosedur Bronhoalveolar Lavage (BAL) dengan menggunakan bronkoskopi.  Hasilnya dapat membantu klinisi untuk tidak ragu-ragu memberikan terapi TB paru sensitif atau resisten obat, bahkan mungkin pasien tidak diberikan Obat anti Tuberkulosa (OAT) sama sekali. Metode: Penelitian kohort-retrospektif data primer yang diperoleh dari rekam medis dalam rentang januari 2023 sampai november 2024 di RSUD Cibabat. Subjek penelitian adalah pasien presumptive TB kasus baru dan kambuh dengan gejala klinis dan interpretasi gambaran toraks TB paru. Spesimen yang digunakan adalah hasil BAL menggunakan bronkoskopi fleksibel sebanyak > 5 cc. Spesimen dilakukan pemeriksaan BTA dengan pewarnaan Ziehl Neelsen (ZN), dan pemeriksaan TCM Ultra. Hasil: Dari 122 pasien presumptive TB baru, hasil dengan TCM positif 115 (94,3%), dan 7 (5,7%) yang negatif. Pada 34 pasien presumptive TB kambuh, subjek dengan hasil BTA positif adalah 4 (11,7%), sekaligus kesemuanya mendapatkan hasil TCM positif pula. Kesimpulan: BAL efektif untuk mendapatkan sputum bagi pasien yang tidak dapat mengeluarkan sputum spontan atau dengan kualitas buruk, sehingga menghindari keterlambatan diagnosis, mencegah overdiagnosis dan undertreatment. TCM sangat sensitif untuk kasus baru namun butuh hasil BTA positif pada diagnosis TB paru kasus kambuh.

Kata kunci: tuberkulosis paru, bronchoalveolar lavage, TCM, BTA, Brokoskopi

Abstract

Background: Bacteriological examinations of Acid-Fast Bacilli (AFB) and the Molecular Rapid Test (Xpert MTB/RIF test) for diagnosing pulmonary tuberculosis (TB) require sputum specimens. Diagnosis becomes challenging when sputum is unavailable, potentially leading to overdiagnosis, overtreatment, or undertreatment, particularly in cases of drug-resistant TB or recurrent pulmonary TB with clinical symptoms and chest radiographs suggestive of pulmonary TB but without bacteriological confirmation. In patients who have difficulty expectorating sputum, a specimen for bacteriological examination can be obtained through Bronchoalveolar Lavage (BAL) using bronchoscopy. The results can assist clinicians in making precise decisions, such as initiating therapy for drug-sensitive or drug-resistant pulmonary TB, or even refraining from administering Anti-Tuberculosis Drugs (ATDs) altogether. Methods: This retrospective cohort study utilized primary data collected from medical records between January 2023 and November 2024 at Cibabat General Hospital. The study subjects were presumptive new and recurrent pulmonary TB cases with clinical symptoms and chest X-ray interpretations suggestive of pulmonary TB, as reported in the Tuberculosis Information System of the Ministry of Health of the Republic of Indonesia. Specimens were obtained through BAL using flexible bronchoscopy, collecting >5 mL into sputum containers. The specimens were examined for AFB using Ziehl-Neelsen (ZN) staining and Xpert MTB/RIF test Ultra testing, including rifampicin resistance detection. Results: Among the group of presumptive new pulmonary TB cases, 115 (94.3%) of 122 subjects tested positive by Xpert MTB/RIF test, while only 7 (5.7%) were negative. In the group of presumptive recurrent pulmonary TB cases, 4 (11.7%) of 34 subjects tested positive for AFB, and all of these also tested positive by Xpert MTB/RIF test. Conclusion: BAL is a viable solution for obtaining sputum samples for bacteriological examination in patients unable to produce spontaneous or high-quality sputum. This approach can prevent delays in tuberculosis diagnosis, avoid overdiagnosis, and reduce undertreatment. Furthermore, MTB detection through BAL can identify drug resistance and assess the high risk of transmission. This facilitates timely diagnosis, appropriate therapy, and rapid contact investigation measures. While Xpert MTB/RIF test is highly sensitive for diagnosing new cases, positive AFB results remain critical for diagnosing recurrent pulmonary TB cases.

Keywords: pulmonary tuberculosis, bronchoalveolar lavage, AFB, bronchoscopy

Pendekatan Tatalaksana dan Pengawasan Efek Samping Pemanjangan Masa QT Interval dalam Pengobatan Tuberkulosis Resisten Obat

 

Raden Fidiaji Hiltono Santoso*, Herikurniawan**, Mira Yulianti**

*Divisi Kardiologi, Departemen Ilmu Penyakit Dalam RS Cipto Mangunkusumo

**Divisi Pulmonologi, Departemen Ilmu Penyakit Dalam RS Cipto Mangunkusumo

 

ABSTRACT

Tuberculosis (TB) is one of the deadliest infectious diseases in the world. A major challenge in its treatment is the long duration of therapy, which often leads to low patient adherence to medication. This can result in incomplete treatment, therapy failure, and the development of drug resistance.

Drug-resistant tuberculosis (DR-TB) occurs when TB bacteria no longer respond to first-line anti-TB drugs such as rifampicin and/or isoniazid. In the treatment of DR-TB, the use of combination therapy that includes bedaquiline has been shown to yield better outcomes. However, it is also associated with an increased risk of cardiac side effects, particularly arrhythmias caused by QT interval prolongation.

QT interval prolongation can trigger dangerous arrhythmias and increase the risk of sudden death. Therefore, it is crucial to conduct thorough risk assessments and monitor the side effects of DR-TB treatment, especially for drugs that carry a risk of QT prolongation. Additionally, a good understanding of emergency management for arrhythmias is essential to ensure patient safety and treatment success.

Keywords: Tuberculosis, DR-TB, MDR-TB, QT Interval Prolongation, Arrhythmia.

Katrin Wilentina Siahaan1, I Gede Ketut Sajinadiyasa2
1Program Studi Pendidikan Dokter Spesialis Penyakit Dalam, Fakultas Kedokteran Universitas Udayana/ RSUP. Prof. I.G.N.G. Ngoerah Denpasar,
Bali, Indonesia.
2Departemen/KSM Penyakit Dalam, Fakultas Kedokteran Universitas Udayana/
RSUP. Prof. Prof. I.G.N.G. Ngoerah Denpasar, Bali, Indonesia

ABSTRACT
Chylothorax is a rare cause of pleural effusion, secondary to accumulation of lymph in the pleural space. Diagnosis is based on the triglyceride and cholesterol content of pleural fluid obtained with thoracentesis. Chylothorax is usually described as traumatic or nontraumatic. Causes of nontraumatic chylothorax include a wide range of differential diagnoses. Thoracic malignancies and lymphoma are the most common causes and are responsible for chylothorax by extrinsic compression or invasion of the thoracic duct. One of the causes of nontraumatic chylothorax is lung cancer. The main cause of chylothorax is traumatic, typically postsurgical, secondary to iatrogenic direct puncture of the thoracic duct during thoracic surgery. Chylothorax is associated with significant morbidity and mortality if left untreated. The etiology, clinical presentation, and diagnosis and the management of chylothorax must be well understood to diagnose and provide appropriate therapy to patients.
Keyword: Chylothorax, Nontraumatic Chylothorax, Lung cancer

 

Elcia Melisa Dwisari Simatupang1*, Fransiscus Ginting2,
Elvando Tunggul Mauliate Simatupang3
1Public Health Center of Uluan Sub-District, Government of Toba District, Province of North Sumatera
2Department of Internal Medicine, Haji Adam Malik Central General Hospital, Medan,
Province of North Sumatera
3Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Riau University, Pekanbaru, Province of Riau

ABSTRACT
Diabetes mellitus (DM) is a challenge in controlling Pulmonary Tuberculosis (PTB) cases. The increase in DM cases is one of the reasons that Indonesia is the second highest contributor of PTB cases in the world. The relationship between these two diseases impacts morbidity and mortality globally. This condition is based on the role of each individual’s immune system against Mycobacterium tuberculosis (Mtb) infection. Impairment of the innate and adaptive immune system in eliminating Mtb infection influences the increase of PTB cases with DM. Early prevention is important in the interaction of DM and PTB.
Keywords: Diabetes Mellitus, Tuberculosis,
Interaction, Risk Population

Physical Medicine and Rehabilitation Management of Patient With Bilateral Lung Bullar: a Case Report

 

Tresia Fransiska Uliana Tambunan¹, Dinna Yulistya Ningrum², Dave Nicander Kurnain³

¹Cardiorespiration Division, Physical Medicine and Rehabilitation Department, University of Indonesia, Jakarta

²Physical Medicine and Rehabilitation Resident University of Indonesia, Jakarta

³Faculty of Medicine, Tarumanagara University, Jakarta

 

Correspondent:

Tresia Fransiska UT, Cardiorespiratory division, Physical Medicine and Rehabilitation department, University of Indonesia, Jakarta.

Email: fransiska_ut@yahoo.com.au   

Phone: +62 816-1976-762

Abstract

Lung bullae are defined as air spaces in the lungs, measuring more than 1 cm in diameter when distended, while giant bullae occupy at least 30% of the hemithorax. Bullae are thought to be in contact with the bronchial tree; they are preferentially filled during inspiration, causing collapse of the adjacent normal lung parenchyma. Clinical manifestations of giant bullae include cough, dyspnea, and chest pain, but in some cases, the condition may be asymptomatic. Although the diagnosis of infected bullae has been reported, tuberculosis as a causative pathogen is rare. This case Present a 27 year old male patient came to the medical rehabilitation department of feeling easily tired when walked more than 8 meters. The patient was initially diagnosed with pulmonary tuberculosis 14 months ago, and completed 12 months of antituberculosis treatment. He underwent a thoracotomy decortication wedge resection of the right superior lobe of lung and another thoracotomy to evacuate the haematoma and control the bleeding two weeks before admision. From the physical examination, he had forward head posture, rounded shoulders, and slight hyperkyphotic posture. Respiromotor status showed decreased chest expansion and asymmetrical movement during respiration. Two weeks after rehabilitation program consist of breathing control, chest expansion exercise, airway clearance technique, and aerobic exercises, the patient shows improvement.

Key words: Lung Bullae, Rehabilitation, Thoracotomy, Tuberculosis.

Abstrak

Bula paru didefinisikan sebagai ruang udara di paru-paru, berukuran diameter lebih dari 1 cm saat menggembung, sedangkan bula besar menempati setidaknya 30% hemithorax. Bula diperkirakan bersentuhan dengan cabang bronkial; yang terisi selama selama inspirasi, menyebabkan kolapsnya parenkim paru normal. Manifestasi klinis dari bula besar meliputi batuk, dispnea, dan nyeri dada, namun pada beberapa kasus, kondisi ini mungkin tidak menunjukkan gejala. Meskipun diagnosis bula yang terinfeksi telah dilaporkan, tuberkulosis sebagai patogen penyebab jarang terjadi. Laporan kasus ini melaporkan seorang laki-laki berusia 27 tahun datang ke bagian rehabilitasi medis dengan perasaan mudah lelah jika berjalan lebih dari 8 meter. Pasien awalnya terdiagnosis tuberkulosis paru 14 bulan yang lalu, dan menyelesaikan pengobatan antituberkulosis selama 12 bulan. Dia menjalani reseksi dekortikasi torakotomi pada lobus paru superior kanan dan torakotomi lainnya untuk mengevakuasi hematoma dan mengontrol pendarahan dua minggu sebelum datang ke rumah sakit. Dari pemeriksaan fisik didapatkan postur kepala ke depan, bahu membulat, dan postur sedikit hiperkimfosis. Status respiromotor menunjukkan penurunan ekspansi dada dan gerakan asimetris saat respirasi. Dua minggu setelah program rehabilitasi yang terdiri dari kontrol pernapasan, latihan ekspansi dada, teknik pembersihan jalan napas, dan latihan aerobik, pasien menunjukkan perbaikan.

Kata kunci: Bula paru, Rehabilitasi, Torakotomi, Tuberkulosis.

 

 

A Rare Extrapulmonary Tuberculosis, Hepatic Tuberculosis: A Case Report

Ghea Arifah Shabrina¹, Telly Kamelia²

1Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

2Pulmonary and Respiratory Medicine Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

 

 

 

ABSTRACT

Introduction:

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, a disease that attacks the lung parenchyma and can infect other organs. Tuberculosis is a significant health problem and is highly prevalent in developing countries. Abdominal Tuberculosis (TB) is a rare variant of TB, and hepatic tuberculosis is the most infrequent manifestation of tuberculosis infections.

 

Case Illustration:

A 44-year-old female patient complained of abdominal pain since one year ago. Abdominal pain felt in the lower right abdomen, sometimes spreading to the back side. Abdominal pain felt intermittent, not affected by eating or defecation. There were no complaints of fever, cough, shortness of breath, chest pain, and palpitations. The patient denied weight loss, loss of appetite, night sweats, or fluctuating fever. There was no prior history of tuberculosis. These patients have normal liver function and elevated alkaline phosphatase. Multiple calcified hypodense lesions appear in segments VII-VIII of the liver in a Computed Tomography (CT) Scan. A liver biopsy showed clusters of epithelioid cells accompanied by multinucleated giant cells. There was also necrosis resembling caseous necrosis with negative Acid-Fast Bacteria staining. The histological conclusion was following granulomatous inflammation, the possibility of tuberculosis infection could not be ruled out, and no malignant tumor cells were found in the preparations. The stage of fibrosis is around F2-F3. The patient was then diagnosed with hepatic tuberculosis and received anti-tuberculosis therapy. Obtained resolution of abdominal pain improvement and assessment of liver function remained normal after this 2-week treatment.

 

Conclusion:

Hepatic TB is a manifestation of extrapulmonary TB, which is rarely found. Anamnesis, physical examination, and supporting examinations are carried out to diagnose hepatic TB. Investigations such as imaging and liver biopsy can help diagnose this type of TB. The treatment given for hepatic TB is given according to the same regimen as other extrapulmonary TB.

 

Keywords: Hepatic Tuberculosis, Extrapulmonary Tuberculosis, Diagnosis, Management

Bronchial Thermoplasty in Severe Asthma Patients: A Literature Review

Yosua Kevin Hermawan¹, Ida Ayu Ika Wari Utami²

¹ Department of Pulmonology and Respiratory Medicine, Wangaya General Hospital, Denpasar, Indonesia
² Department of Pulmonology and Respiratory Medicine, Wangaya General Hospital, Denpasar, Indonesia

 

Abstract

Severe asthma is caused by chronic inflammation in the airway. Several treatments have been proposed to treat severe asthma. Bronchial thermoplasty is part of management that has been proposed to treat severe asthma. The treatment has been mentioned in asthma guidelines released by Global Initiative for Asthma (GINA) as an interventional management option in uncontrolled severe asthma. Bronchial thermoplasty is approved for patients with the age of at least 18 years old. The treatment is focus on airway smooth muscle by delivering radiofrequency ablation using bronchoscopy. Airway remodeling is an important feature in the disease course of asthma. There are three large randomized trial that has been done for bronchial thermoplasty. The trials recorded an increase in quality of life from asthma patients that have been treated and reduce in exacerbation frequency in long term follow up. The trials also show increased in emergency departments visit and asthma exacerbation for within a certain period after the procedure. Long term follows up of the patients that has undergone the procedure show no deterioration in terms of lung function, indicating a persistent effect of the bronchial thermoplasty. Better understanding in mechanisms of the procedure in the airway and more trials about safety and efficacy is still needed.

Keywords: Bronchial Thermoplasty, Airway smooth muscle, Interventional

Terapi Inhalasi Konvensional Pada Pasien Dewasa

 

Fatih Anfasa¹, Gurmeet Singh²

 

 

1 Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo

2 Divisi Respirologi dan Penyakit Medis Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia, Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo

Alamat korespondensi: Dr. dr. Gurmeet Singh, SpPD, K-P. Departemen Ilmu Penyakit Dalam FKUI-RSCM. Jl Diponegoro No. 71, Jakarta Pusat.

Alamat email: gurmeetsingh10@yahoo,com

 

Abstrak

Terapi inhalasi konvensional merupakan salah satu terapi penting pada berbagai penyakit saluran nafas, terutama asma dan penyakit paru obstruktif kronik (PPOK). Pemberian obat melalui inhalasi memberikan berbagai keuntungan dibandingkan pemberian obat melalui jalur lainnya terutama untuk penyakit yang melibatkan organ pernapasan. Meskipun demikian, keefektifan terapi akan berkurang jika pasien tidak dapat menggunakan alat inhalasi dengan tepat. Kesalahan pemakaian alat inhalasi berhubungan dengan menurunnya kontrol penyakit asma, prognosis PPOK yang buruk, serta meningkatkan morbiditas dan mortalitas. Sari pustaka ini bertujuan untuk menjabarkan mekanisme terapi inhalasi konvensional dan berbagai modalitas terapi yang ada untuk pasien dewasa.   

Kata Kunci: terapi inhalasi, pasien dewasa

 

 

Abstract

Conventional inhalation therapy is an important therapy for various respiratory diseases, especially asthma and chronic obstructive pulmonary disease (COPD). Administering drugs via inhalation provides various advantages compared to other routes, especially for diseases involving the respiratory organs. However, the effectiveness of therapy will be reduced if the patient cannot use the inhalation devices correctly. Incorrect use of inhalation devices is associated with decreased asthma control, poor COPD prognosis, as well as increased morbidity and mortality. This article aims to describe the mechanism of conventional inhalation therapy and various therapeutic modalities available for adult patients.

Keywords: inhalation therapy, adult patients

Faktor Risiko Kejadian Tuberkulosis Paru di Berbagai Wilayah Indonesia

 

Alya Humaida Avy¹, Balqis Permata Hutami², M. Zhafran Alfalah³, Syeri Febriyanti⁴

 

Fakultas Kedokteran dan Ilmu Kesehatan Universitas Bengkulu

 

 

Abstract

Background: Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis that attacks the lung organs. This disease can lead to many complications and deaths if not treated properly. Tuberculosis in Indonesia remains a major challenge and requires the attention of all parties. Moreover, Indonesia is currently in the second place with the largest number of cases of pulmonary tuberculosis in the world. The aim of this study is to evaluate the risk factors of lung tuberculosis in various regions of Indonesia.

Method: The method used is the study of literature by searching for scientific articles from online databases.

Results: The results of the study show that there are several risk factors that influence the incidence of pulmonary tuberculosis in Indonesia. The risk factors obtained have much in common in different regions of Indonesia. Each of these risk factors exacerbates and increases the potential for pulmonary TB by generating OR values for each variable. According to the research journal, the six most important risk factors in the incidence of pulmonary tuberculosis in various regions of Indonesia are smoking habits, poor nutritional status, contact with the patient, knowledge level, population density, and poor ventilation of the house.

Conclusion: In this study we highlighted six risk factors for lung tuberculosis in various regions of Indonesia, namely smoking habits, poor nutritional status, contact with the affected, knowledge level, population density, and poor ventilation of the home.

 

Keywords: Pulmonary Tuberculosis, Risk Factor, regions of Indonesia

Abstrak

Latar belakang: Tuberkulosis (TB) adalah suatu penyakit infeksi menular yang disebabkan oleh Mycobacterium tuberkulosis  yang menyerang organ paru. Penyakit ini bisa mengakibatkan banyak komplikasi dan berujung kematian apabila tidak tepat penanganannya. Penyakit Tuberkulosis di Indonesia masih menjadi tantangan besar yang dihadapi dan memerlukan perhatian semua pihak. Terlebih, Indonesia saat ini berada di urutan kedua dengan kasus TB paru terbanyak di dunia. Tujuan dari kajian ini adalah untuk mengevaluasi faktor risiko dari Tuberkulosis paru di berbagai wilayah Indonesia.

Metode: Metode yang digunakan adalah studi literatur dengan mencari artikel ilmiah dari database online.

Hasil: Hasil kajian menunjukkan bahwa ada beberapa faktor risiko yang berpengaruh terhadap kejadian Tuberkulosis paru di Indonesia. Faktor – faktor risiko yang didapat memiliki banyak kesamaan di berbagai wilayah Indonesia. Masing – masing dari faktor risiko tersebut memperberat dan meningkatkan potensi kejadian TB paru dilihat dari nilai OR untuk setiap variabel. Berdasarkan jurnal penelitian, didapatkan 6 faktor risiko yang paling berperan dalam angka kejadian TB paru di berbagai wilayah Indonesia, yaitu  kebiasaan merokok, status gizi buruk, kontak dengan penderita, tingkat pengetahuan, kepadatan hunian, dan ventilasi rumah yang kurang baik.

Kesimpulan: Pada kajian ini, kami menyoroti terdapat 6 faktor risiko kejadian Tuberkulosis paru di berbagai wilayah Indonesia, yaitu kebiasaan merokok, status gizi buruk, kontak dengan penderita, tingkat pengetahuan, kepadatan hunian, dan ventilasi rumah yang kurang baik.

 

Keyword : Tuberkulosis Paru , Faktor Risiko, Wilayah Indonesia

KORELASI NYERI DENGAN AGITASI PADA PASIEN YANG TERINTUBASI DI ICU RUMAH SAKIT UMUM PUSAT HAJI ADAM MALIK MEDAN

 

 

Muhammad Syakur1 ,  Tasrif Hamdi ^{2  ,} Andriamuri Primaputra Lubis²

 1Program Studi Magister Kedokteran Klinik / Program Studi Anestesiologi dan Perawatan Intensif, Fakultas Kedokteran, Universitas Sumatera Utara-Rumah Sakit Umum H. Adam Malik Medan, Indonesia

2Program Studi / Departemen Anestesiologi dan Perawatan Intensif, Fakultas Kedokteran, Universitas Sumatera Utara-Rumah Sakit Umum H. Adam Malik Medan, Indonesia

 

ABSTRAK

Latar Belakang: Agitasi umum terjadi pada pasien ICU dan dapat disebabkan oleh faktor-faktor seperti lingkungan baru, paparan obat, kondisi medis, dan kondisi kesehatan mental. Nyeri juga banyak dialami oleh pasien yang diintubasi di ICU yang menerima perawatan medis seperti suctioning ETT, pemasangan kateter urin, nasogastrik, dan tindakan perawatan pasien rutin sehari-hari dapat memperburuk agitasi. Dalam perawatan ICU, penting untuk mempertimbangkan hubungan antara agitasi, nyeri, delirium, dan faktor-faktor lain untuk mengelola dan mengatasi kondisi pasien secara efektif.

Tujuan: Untuk menganalisis korelasi antara nyeri menggunakan CPOT dan agitasi menggunakan RASS pada pasien intubasi di ICU Rumah Sakit Umum Haji Adam Malik.

Metode: Desain penelitian adalah analitik observasional dengan studi cross sectional menggunakan skala CPOT dan RASS sebagai alat ukur selama periode Oktober 2023.

Hasil: Semua data karakteristik (usia, jenis kelamin, BMI, durasi perawatan ICU, dan durasi penggunaan ventilator) tidak menemukan perbedaan dan korelasi (p>0,05) antara kelompok non-bedah dan bedah. Ada perbedaan yang signifikan secara statistik (p<0,001) antara pengukuran pagi dan sore di semua penilaian hemodinamik. Diketahui ada korelasi positif yang signifikan (p<0,001) antara CPOT dan RASS pada pagi hari dengan tingkat korelasi sedang (r = 0,516) dan arah korelasi positif. Tidak ada korelasi yang signifikan secara statistik yang ditemukan antara CPOT malam dan RASS malam. Diketahui bahwa perbedaan nilai CPOT pagi dan RASS pagi dan sore hari signifikan secara statistik (p<0,05), tetapi pada CPOT malam hari tidak ada perbedaan yang signifikan antara kelompok dosis. Diketahui ditemukan perbedaan nilai CPOT pagi pada Golongan 2 dengan 3 (p<0,001) dan Golongan 1 dengan Golongan 3 (p<0,001). Pada pagi hari ditemukan nilai RASS pada Kelompok 2 dengan 3 (<0,001) dan Kelompok 1 dengan Kelompok 3 (<0,001). Pada malam hari RASS, perbedaan signifikan ditemukan pada Kelompok 2 dan Kelompok 3 (p = 0,037).

Kesimpulan: Terdapat korelasi yang signifikan (p<0,001) antara nyeri dan agitasi pada pasien yang diintubasi di ICU Rumah Sakit Umum Adam Malik dengan tingkat korelasi sedang. CPOT dianggap memiliki manfaat untuk digunakan di ICU.

Kata kunci: agitasi, nyeri, ICU, RASS, dan CPOT

Biomarker of Post-COVID-19 Lung Fibrosis: A Systematic Review and Meta-Analysis of Cohort Studies

Gede Ari Mahendra Mardaningrat¹*, Putu Andrika², Isabella Soerjanto Putri¹, I Putu Hendri Aryadi¹

¹ Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia

² Division of Pulmonary and Critical Care, Department of Internal Medicine, Udayana University/Prof. dr. I.G.N.G Ngoerah Hospital, Denpasar, Bali, Indonesia

 

Abstract

Introduction: The World Health Organization (WHO) labeled COVID-19 as a pandemic. On January 7, 2024, an estimated 774,075,242 confirmed cases of COVID-19 had occurred, resulting in 7,012,986 deaths. Pulmonary fibrosis is commonly observed as a consequence of COVID-19 infection, with a reported prevalence of up to 83.3% in individuals who have recovered from the disease. Pulmonary fibrosis that develops after a COVID-19 infection arises from the immune system's reaction to the virus, resulting in inflammation and lung damage.

Objective: This systematic review and meta-analysis were conducted to determine the laboratory biomarker findings in patients with post-COVID-19 lung fibrosis.

Methods: Systematic review and meta-analysis adhering to the PRISMA and MOOSE guidelines. We conducted a literature search on PubMed, EMBASE, and Web of Science from January 1, 2020, to January 31, 2024.

Results: Nine eligible studies, including 1,406 patients, were identified. The research results showed that several biomarkers had statistically significant values such as lymphocytes (MD: -0.35; 95% CI: -0.49; -0.21), CRP (MD: 40.73; 95% CI: 27.78; 53.69), D-dimer (MD: 0.76; 95% CI: 0.18; 1.34), lactate (MD: 38.43; 95% CI: 19.73; 57.13), and interleukin-6 (MD: 16.97; 95% CI: 2.57; 31.37). Meanwhile, for biomarkers such as white blood cells (MD: 0.14; 95% CI: -0.54; 0.81) and neutrophils (MD: 3.71; 95% CI: -3.80; 11.23), the values were not statistically significant for the occurrence of lung fibrosis.

Conclusion: The diagnosis of pulmonary fibrosis is generally established using biopsy or CT scans. However, in some hospitals with limitations on healthcare resources and equipment such as CT scans, these biomarkers can be used in diagnosing pulmonary fibrosis, especially in patients after experiencing COVID-19 infection.

 

Keywords: Biomarker, COVID-19, Lung Fibrosis, Sars-Cov2

FACTORS CORRELATED WITH INCREMENTAL SHUTTLE WALK TEST DISTANCE IN SEDENTARY HEALTHY ADULTS

 

Astrid Priscilla Amanda¹, Nury Nusdwinuringtyas¹, Tresia Fransiska Ulianna Tambunan¹, Dewi Friska²

¹Physical Medicine and Rehabilitation Department, Cipto Mangunkusumo Hospital,

Faculty of Medicine, Universitas Indonesia

²Community Medicine Department, Faculty of Medicine, Universitas Indonesia

 

 

Abstract

Background: In carrying out daily activities, it is influenced by a person’s physical fitness. A person’s functional capacity can be assessed by exercise testing distance. One of the exercise tests that currently being applicated nowadays is incremental shuttle walk test (ISWT). There are various factors that affect cardiorespiratory fitness, as well as demographic and anthropometric characteristics such as age, gender, body height, and body weight. This study focused on demographic and anthropometric factors.

Objective: The aim of this study was to determine the factors that correlate with ISWT distance in sedentary healthy adults

Material and Methods: This study was a cross-sectional study conducted on 85 subjects. Subjects performed ISWT twice, with the greatest distance was included in analysis. The independent variables (age, gender, body height, body weight) were analyzed using bivariate analysis to see the correlation with ISWT distance. Furthermore, multivariate analysis was done to see the most influential variable.

Results: Sixty women were participated in this study. Among four variables, multivariate analysis showed gender, body height, and body weight correlated with ISWT distance (p<0,05)

Conclusion: Gender, body height, and body weight correlated with ISWT distance in sedentary healthy adults.

 

Keywords: Incremental shuttle walk test, distance, sedentary, healthy, field test

Low Alveolar Macrophages Function, Low BALF IL-6 Level and High BALF CD4 Cell Count is Associated with Successful Extubation and Survival in Severe Pneumonia Patients: Prospective Cohort Study

 

Gurmeet Singh^1,2, Cleopas Martin Rumende¹, Iris Rengganis³, Zulkifli Amin¹, Tonny Loho⁴, Emmy Hermiyanti Pranggono⁵, Kuntjoro Harimurti⁶, Heri Wibowo⁷, Nova Bornida Fauzi¹, Sudirman Fakhruddin Masse¹, Laila Fakhriyatuz Zakiyah¹

 

¹Division Respirology and Critical Illness, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

²Doctorate Program Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.

³Division of Allergy and Clinical Immunology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

⁴Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

⁵Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr Hasan Sadikin Hospital Bandung, Bandung, Indonesia.

⁶Department of Internal Medicine, Faculty of Medicine Universitas Indonesia – Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.

⁷Head of Integrated Laboratory, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.

A case of concurrent tuberculous pleural effusion and peritonitis

Vanya Utami Tedhy1 , Nurhidayat Mohammad1, Lie Khie Chen2, Mira Yulianti3
1Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia
2Division of Tropical Disease and Infection, Department of Internal Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
3Division of Respirology and Critical Illness, Department of Internal Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
Introduction: Extrapulmonary tuberculosis accounted for about 16% of 7.5 million tuberculosis cases worldwide in 2019 with lymph nodes, pleura, and gastrointestinal system as its most common sites of infection.
Case description: A 36 year-old female patient presented with dyspnea and abdominal distention due to unilateral pleural effusion and ascites. She had accompanying symptoms of weight loss and night sweat since 6 months prior to her presentation. The patient’s medical history was unremarkable, but she had positive contact with tuberculosis patients. Diagnostic approach was taken. Both pleural fluid and ascitic fluid were analysed, revealing exudative fluid with lymphocyte predominance. ADA for both pleural and ascitic fluid was elevated. Abdominal CT scan showed para-aortic lymphadenopathy, omental thickening, and complex ascites. Pleural fluid culture for Mycobacterium was positive for M. tuberculosis. Diagnosis of tuberculous pleural effusion and peritonitis was made and anti-tuberculous treatment was initiated.
Conclusion: The variable manifestation of extrapulmonary TB can make diagnosis difficult, but this diagnosis should always be considered especially in the setting of high TB prevalence. Confirmatory diagnosis with microbiological examination should always be attempted, but clinical feature highly suspicious of TB supported with biological marker can aid in the diagnosis of extrapulmonary TB.
Keywords: tuberculous pleural effusion, tuberculous peritonitis, extrapulmonary tuberculosis

ABSTRA CT
Introduction: Extrapulmonary tuberculosis accounted for about 16% of 7.5 million tuberculosis cases worldwide in 2019 with lymph nodes, pleura, and gastrointestinal system as its most common sites of infection.
Case description: A 36 year-old female patient presented with dyspnea and abdominal distention due to unilateral pleural effusion and ascites. She had accompanying symptoms of weight loss and night sweat since 6 months prior to her presentation. The patient’s medical history was unremarkable, but she had positive contact with tuberculosis patients. Diagnostic approach was taken. Both pleural fluid and ascitic fluid were analysed, revealing exudative fluid with lymphocyte predominance. ADA for both pleural and ascitic fluid was elevated. Abdominal CT scan showed para-aortic lymphadenopathy, omental thickening, and complex ascites. Pleural fluid culture for Mycobacterium was positive for M. tuberculosis. Diagnosis of tuberculous pleural effusion and peritonitis was made and anti-tuberculous treatment was initiated.
Conclusion: The variable manifestation of extrapulmonary TB can make diagnosis difficult, but this diagnosis should always be considered especially in the setting of high TB prevalence. Confirmatory diagnosis with microbiological examination should always be attempted, but clinical feature highly suspicious of TB supported with biological marker can aid in the diagnosis of extrapulmonary TB.
Keywords: tuberculous pleural effusion, tuberculous peritonitis, extrapulmonary tuberculosis

Seorang Laki-Laki 49 Tahun Dengan Tuberkulos Monoresisten Isoniazid (Hr-TB) : Kasus Pertama  Hr-TB di RSUP dr.Kariadi Semarang

Arif Wicaksana1, Fathur Nur Kholis2, Banteng Hanang Wibisono2
1Resident of Internal Medicine, Department of Internal Medicine, Faculty of Medicine, Diponegoro University
2 Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine,
Diponegoro University
Introduction : Drug Resistance Tuberculosis still become one of biggest burden on Global TB Control. Isoniazid Resistance Tuberculosis (Hr-TB) is one form of Drug Resistance TB. Although Hr-TB cases is commonly found worldwide, yet this case is the first case to be reported in Kariadi Hospital Semarang.
Case Illustration : A 49-year-old male come with productive cough, sub-febris fever and weight loss within 1 month with history of Complete Drug Sensitive TB treatment 10 years ago. Patient had decreasing of vesicular sound and crackles in lower part of right lung. On chest radiographic evaluation found consolidation on lower base of right lung and image of tuberculosis. Sputum evaluation found Acid-fast Bacteria with Nucleic acid amplification tests (NAAT) detected M. Tuberculosis with rifampicin sensitive, Line Probe Assay (LPA) stated resistance of Low Dose and High Dose Isoniazid. Patient was given treatment regimen of 6RHZE-Lfx. Evaluation was done in second month of treatment that given no identification of Acid-fast bacteria, improvement on chest radiographic, and bodyweight.
Discussion : Hr-TB was found in 156 countries from 2003 until 2017, prevalence of Hr-TB is 7.6% of Newly Diagnosed TB and 11.4% of patient TB on treatment. Mechanism of resistance in Hr-TB are identified the mutation of katG ang inhA that decrease the antimicrobial function of Isoniazid. Diagnostic of Hr-TB based on WHO guideline is using NAAT and LPA to rule out resistance of INH and other line of regimen. WHO 2017 recommendation for Hr-TB treatment is RHZE-Lfx for 6 months. Addition of Fluoroquinolone to the regimen for Hr-TB strengthen treatment regimens since bactericidal effect of Isoniazid replaced by Lfx and became core drug for Drug Resistance TB. Adding Lfx shows improvement on results, and there is no evidence of including Isoniazid on regimen giving poor outcome on therapy.
Conclusion : Hr-Tb need to be identified on high-risk group to have proper diagnosis and therapy and give better prognosis and improve TB elimination.
Keyword : Tuberculosis, Isoniazid, Resistance
ABSTRAK
Pendahuluan : Tuberkulosis resisten obat masih menjadi salah satu permasalahn pada ELiminasi TB secara global. Tuberkulosis mnoresisten isoniazid (Hr-TB) adalah salah satu bentuk TB Resisten Obat. Walaupun kasus Hr-TB banyak ditemukan secara global, tetapu kasus ini adalah kasus pertama yang dilaporkan di RSUP dr. Kariadi Semarang
Ilustrasi Kasus : Seorang laki-laki 49 tahun dating dengan batuk produktif, demam sub febris dan penurnan berat badan dalam 1 bulan dengan Riwayat pengobatan TB Sesitif Obat lengkap 10 tahun yang lalu. Pada pasien ditemukan penurunan suara vesikuler pada dan ronki kasar pada basal paru kanan. Pada pemeriksaan ronsen thoraks didapatkan konsolidasi pada basal paru kanan dan gambaran yang mendukun tuberculosis. Pada pemeriksaan dahak ditemukan BTA dan TCM mendeteksi M. Tuberkulosis dengan sensitive rifampisin. PEmeriksaan Line Probe Assay (LPA) menyatakan resisten dari Isoniazid dosis rendah dan dosis tinggi. Pasien diberikan regimen pengobatan ^RHZE-Lfx. Evaluasi dilakukan pada bulan kedua dari pengobatan dan didapatkan BTA negative dan perbaikan pada ronsen thorakas dan berat badan.
Diskusi : Hr-TB ditemukan pada 156 negara dari 2003 hingga 2017, prevalensi dari Hr-TB adalah 7.6% dari TB kasus baru dan 11.4% pada pasien yang sedang pengobatan TB. MEkanisme reistensi dari Hr-TB diidentifikasi pada mutasi gen katG dan inhA yang menurunkan fungsi antimicrobial dari Isoniazid. Diagnosis dari Hr-TB berdasarkan Guideline WHO menggunakan TCM dan LPAuntuk menemukan adanya resistensi Isoniazid dan regimen lain. Rekomendasi WHO 2017 untuk pengobatan Hr-TB adalah RHZE-Lfx untuk 6 bulan. Penambahan FLuoroquinolon pada regimen untuk Hr-TB memperkuat efek bakterisidal dan menggantikan efek bakterisidal dari Isoniazid dan menjadi core drug untuk TB Resisten Obat. PEnambahan Lfx menunjukan perbaikan pada hasil dan melibatkan Isoniazid pada terapi tidak membuktikan perburukan luaran dari terapi.
Kesimpulan : Hr-TB perlu diidentifikasi pada kelompok resiko tinggi dan mendapatkan diagnosis dan tatalaksana yang tetap untuk mendapatkan prognosis yang lebih baik dan meningkatkan angka eliminasi TB.
Kata Kunci : Tuberkulosis, Isoniazid, Resitensi

Hubungan Penyakit Komorbid dan Faktor Prognostik dengan Mortalitas pada Pasien COVID-19 Critical ill Bulan Juni - Desember 2021 di Ruang Intensive Care RSUP Prof. DR. I.G.N.G Ngoerah Denpasar

Ni Wayan Eka Satyawati1, Putu Andrika2
1Program Studi Spesialis Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Udayana/RSUP Prof. Dr. I.G.N.G. Ngoerah Denpasar, Bali, Indonesia
2Staf Divisi Pulmonologi dan Penyakit Kritis, Departemen/KSM Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Udayana/ RSUP Prof. Dr. I.G.N.G. Ngoerah Denpasar, Bali, Indonesia

Background : Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV2). The spread of COVID-19 occurs globally and designated as a pandemic with clinical manifestations of COVID-19 mainly affect the respiratory system. COVID-19 there is often an increase in inflammatory response, thrombosis, coagulopathy, and the presence of comorbid chronic diseases which is associated with increased degree of disease severity, morbidity and mortality. In this study, aimed that there will be a relationship between the presence of comorbid diseases (Diabetes Mellitus, hypertension, and chronic kidney disease) as well as prognostic factors (platelet levels, neutrophil lymphocyte ratio (NLR), procalcitonin and D-dimer) with mortality in critically ill COVID-19 patients in the Intensive Care Unit (ICU) Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar.
Methods : This research is an analytical study with a retrospective approach using secondary data from medical records with a purposive sampling method. The population was all medical record data for critically ill COVID-19 patients in the ICU Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar period June - December 2021 as many as 397 patients. The analysis performed was univariate and bivariate analysis with the Chi-Square statistical test using the SPSS 26.0 application for windows.
Results : In this study, based on data from patients critical ill period June - December 2021 were treated in the ICU Prof. Dr. I.G.N.G Ngoerah Hospital Denpasar obtained that the predominant age was 45-59 years for 214 patients (53.9%), with a mortality rate of 133 patients (50.6%). The gender factor was more in males, 229 patients (57.7%) with a mortality rate of 154 patients (58.6%) The bivariate test results found no significant relationship between age and mortality and between gender and mortality in critically ill COVID-19 patients, with a p-value of 0.148 and 0.62. In the comorbid factor data, more patients with hypertension were found, namely 154 patients (38.8%), while type II DM was 141 patients (35.5%) and chronic kidney disease 84 patients (21.2%). Based on the results of the bivariate test, there was no significant association with mortality in critically ill COVID-19 patients with comorbid factors, with p-values of 0.31 and 0.67, respectively. Whereas in the comorbid factors of chronic kidney disease, the results of bivariate tests found a significant relationship with mortality in critically ill COVID-19 patients, p-value 0.03. In terms of platelet levels, there were more platelets with normal platelet levels, namely 308 patients (77.6%) with bivariate test results, there was no significant relationship with mortality in critically ill COVID-19 patients, p-value 0.23. The factor of NLR levels was higher with an increase in NLR in 365 patients (91.9%), procalcitonin levels was higher with increased procalcitonin in 283 patients (71.3%), D-dimer levels with increased D-dimer levels in 370 patients (93.2%), with the results of bivariate tests there is a significant relationship with mortality in critically ill COVID-19 patients, p-value 0.001 for NLR, p-value 0.000 for procalsitonin and p-value 0.013 for D-dimer.
Conclusion : In this study it was found that the age and gender factors did not have a significant relationship with mortality in critically ill COVID-19 patients who were treated in the June-December 2021 period at Prof. Dr. IGNG Ngoerah Denpasar. While the comorbid factors studied were mostly hypertension, followed by type II DM and chronic kidney disease. However, comorbid chronic kidney disease has a significant relationship with mortality in critically ill COVID-19 patients. As for the levels of routine investigations carried out in patients with COVID-19, they are a complete blood count (in this study including NLR and platelet values) as well as procalcitonin and D-dimer levels. In this study it was found that elevated NLR, procalcitonin and D-dimer levels had a significant relationship with mortality in critically ill COVID-19 patients.
Keyword : COVID-19 critical ill, comorbid, D-Dimer, procalcitonin

Diagnostic Accuracy and Prediction of COVID-19 Outcome Using Artificial Intelligence Based on Radiological Data, Clinical and Laboratory Parameter at Dr. Sardjito General Hospital, Yogyakarta

Harik Firman Thahadian 1 Ika Trisnawati1 Eko Budiono1 Bambang Sigit Riyanto 1 Heni Retnowulan1 Nur Rahmi Ananda1 Sarah Ulfa 1 Tani Prima Auladina1 Imam Manggalya Adhikara 1 Sumardi
1 Department of Internal Medicine of Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada Yogyakarta
Introduction: The application of the “color heat-map” method through identifying and analyzing chest X-ray images transferred into AI (artificial intelligence) to generate scores. The aim of this research to was to evaluate the diagnostic accuracy of artificial intelligence scores of Chest X-Ray for predicting the clinical outcome of COVID-19 patients and establishing a scoring system using predictor variables based on AI scoring data based on chest X-rays, clinical parameters, and laboratories of COVID-19 patients.
Methods: A retrospective study collected data from hospitalized COVID-19 patients in Dr. Sardjito General Hospital, Yogyakarta, between 2020 and 2022. The data collected is clinical, laboratory parameters, patient outcomes, and values from AI Chest X-Ray readings. Artificial intelligence was used to detect radiographic abnormalities using CAD4COVID-Xray software (Thirona, Nijmegen, Netherlands). Receiver operator curve (ROC) to evaluate the predictive value of the AI probability score and AI Affected Lung Area score. Multiple logistic regression analysis selected some variables to develop the scoring model.
Results: Four hundred forty-nine (449) patients were included in the study: 237 males (52,8%), median age 56 years (IQR = 45-65). ROC analysis shows that the AI probability score (AUC = 0.875, CI 95% 0.801-0.948) and AI ALA score (AUC = 0.836, CI 95% 0.766-0.906) have sufficient discrimination ability to determine the degree of disease severity of COVID-19 confirmed subjects. Multiple logistic regression analysis from clinical, laboratory, and clinical outcomes showed that this scoring system uses seven variables (5 clinical and two laboratory variables) and has a good prognostic ability to predict the severity of COVID-19 patients. Based on the stratification of scoring results, we found that the scoring value of low-risk patients (1-2 points) had a mortality proportion of 7.8.%, moderate risk ((3-5) points) had a mortality proportion of 38.7%, and high-risk ((6-9) points) had a mortality proportion of 76.9%.
Discussion: Using an AI-based score derived from radiographic, clinical, and laboratory parameters may be beneficial to estimate prognosis in confirmed COVID-19 patients.

Thymoma Presenting as Superior Vena Cavaa Syndrome
Putri Indah Permata1, Fauzar2, Roza Kurniati2 Eifel Faheri3
1. Peserta Program Pendidikan Dokter Spesialis Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Andalas,
RSUP Dr. M. Djamil Padang, Indonesia
2. Divisi Pulmonologi, Program Studi Penyakit Dalam, Fakultas Kedokteran Universitas Andalas RSUP Dr. M. Djamil Padang, Indonesia
3. Divisi Hematologi Onkologi Medik, Program Studi Penyakit Dalam, Fakultas Kedokteran Universitas Andalas
RSUP Dr. M. Djamil Padang, Indonesia
Pendahuluan
Timoma adalah neoplasma yang jarang terjadi yang berasal dari sel epitel timus dengan prevalensi 0,5-1,5% dari semua keganasan di Amerika Serikat. Pada 2018-2023 ditemukan 20 kasus pasien timoma yang dirawat di RSUP M Djamil. Gejala klinis dapat berupa nyeri dada, dispnea, batuk, atau sindrom vena kava superior akibat efek pendesakan pada organ yang berdekatan.
Ilustrasi Kasus
Laki-laki, 28 tahun dirawat di Bagian Penyakit Dalam RSUP Dr. M. Djamil Padang mengeluhkan sesak nafas yang hebat sejak 3 hari sebelum masuk RS disertai dengan bengkak pada leher, wajah, dan tangan kanan. Pemeriksaan fisik didapatkan keadaan umum berat, takipneu, dan pemberton sign positif. Pada pemeriksaan laboratorium didapatkan hasil dalam batas normal. Pemeriksaan CT Scan thoraks dengan kontras didapatkan tumor mediastinum anterior yang menekan vena kava superior. Dilakukan pemberian kortikosteroid dan radioterapi cito untuk keadaan emergency sindroma vena kava superior (SVKS). Setelah sesak berkurang, dilakukan pemeriksaan transthoracic needle aspiration (TTNA) dan trans thoracic biopsy (TTB) dengan hasil timoma. Selanjutnya pada pasien dilakukan kemoterapi sebagai terapi primer timoma karena massa tumor yang non-resectable.
Diskusi
Kasus ini menarik karena keberhasilan terapi pada pasien. Radioterapi dapat memberikan perbaikan klinis pada pasien SVKS kemudian dilakukan kemoterapi menggunakan regimen cisplatin, doxorubicin, siklofosfamid karena tumor non-resectable. Pada follow up setelah kemoterapi didapatkan perbaikan klinis dan pengecilan massa tumor pada pasien secara radiologis.
Kesimpulan
Timoma adalah tumor yang jarang dengan mortalitas tinggi. Pengobatan timoma harus dilakukan oleh tim multidisiplin untuk menentukan strategi perawatan yang tepat. Pilihan pengobatan kemoterapi memberikan perbaikan klinis pada pasien dengan massa yang non-resectable
Kata kunci: timoma, SVKS, radioterapi, kemoterapi