LAPSUS 2 POLIKLINIK
24/12/2013
Wanita 34 tahun dengan Rubella
Anugerah
Pembimbing:
Dr. Rivan D, Sp.S, M.Kes.
11
IDENTITAS PENDERITA






Nama
Umur
Jenis kelamin
Pekerjaan
Agama
Alamat
Tgl Pemx
 No. RM

:
:
:
:
:
:
Ny. S P
34 tahun
Wanita
Karyawati
Islam
Ngasem, Colomadu
: 17 Desember 2013 pk. 10.00 WIB
: 01199130
2
I. ANAMNESIS
Keluhan Utama
Nyeri kepala sebelah kanan
Keluhan Yang Menyertai
Kelemahan anggota gerak sebelah
kanan
3
Riwayat Penyakit Sekarang





Keluhan utama : nyeri kepala
Penderita merasa nyeri kepala sejak 3 tahun ini. Nyeri
kepala sebelah kanan, dari mata kanan sampai kepala
bagian belakang. Nyeri seperti di remas-remas, hingga
mengeluarkan air mata. Nyeri di rasakan terus
menerus. Nyeri tidak disertai mual atau pun muntah.
Juga disertai pandangannya semakin lama semakin
kabur, terutama mata sebelah kanan. Pada jarak 1
meter penderita bisa melihat jari tangan, tetapi kabur.
Bulu mata penderita juga rontok.
Disertai pandangan dobel dalam 6 bulan ini.
Tidak pernah bengkak atau benjolan di daerah telinga
atau tempat lainnya.
4
Riwayat Penyakit Sekarang
 Sudah
pernah di rawat di RS
Swasta 2 kali.
◦ Pertama pada tahun 2010
menderita sakit kepala biasa.
◦ Tahun 2011 : keluhan yang sama.
:
 CT Scan : terkena stroke

Derajat nyeri dari awal sampai
sekarang, dirasakan sama.
5
Riwayat Penyakit Sekarang
Bulan April 2012 : periksa Laboratorium
Toxo dan Rubella  Ig G Rubella (+)
 Berobat di poliklinik RSDM mulai bulan Juni
2013, nyeri kepala sebelah kanan, saat itu
juga disertai badannya sebelah kanan
gringgingan, dan kekuatan anggota gerak
sebelah kanan sedikit menurun. Mudah lelah.
Kemudian disarankan rawat inap. Menjalani
pemeriksaan DSA  hasil pemeriksaan
disimpulkan vaskulitis cerebral.

6
Riwayat Penyakit Dahulu
Riwayat sakit sendi
 Riw. pembesaran kelenjar
 Riwayat sakit tenggorokan
 Riw. ISPA
 Riwayat perdarahan
 Riw. demam lama
 Riwayat mondok
 Riw. Hipertensi
 Riwayat cedera kepala

: (-)
: (-)
: (-)
: (-)
: (-)
: (-)
: (+)
: (-)
: (-)
7
RIWAYAT PENYAKIT
KELUARGA
Riwayat penyakit yang sama : (-)
8
 Keadaan
sosial ekonomi
Pasien : seorang karyawati, (bekerja di pabrik
pewarna celana jeans dan sepatu) status janda,
satu anak. Berobat dengan fasilitas Jamkesmas.
 Riwayat
Kebiasaan dan Gizi
 Riwayat olahraga
: jarang
 Memelihara hewan
: (-)
 Keadaan gizi
: kesan cukup
9
II. PEMERIKSAAN FISIK
Status Interna :

Kesan Umum
:
Kompos mentis
gizi kesan cukup
Tanda Vital
:
TD : 120/70 mmHg
N : 80 x/mn
VAS : 4
RR : 20 x/mnt
T : 36,5°C
Kepala
: dbn
Leher
: KGB (-), JVP ≠ ↑
Ketiak&lipatan paha : pembesaran KGB (-)
10
Status Interna :
Jantung
:I
:P
:P
:A
: iktus cordis tidak tampak
: iktus kordis tidak kuat angkat
: kesan batas jantung tidak melebar
: BJ I-II reguler, bising(-)
Paru
:I
:P
:P
:A
: pengembangan simetris
: fremitus raba kiri = kanan
: sonor / sonor
: vesikuler ( +/+ ),
suara tambahan ( - / - )
11
Status Interna :
Abdomen : I : cembung, vena kolateral (-)
: P : supel, hepar & lien tidak teraba
: P : tympani
: A : bising usus (+)
Status Psikiatri :
-
Emosi
Proses berpikir
Kecerdasan
Perhatian
: dbn
: dbn
: dbn
: dbn
12
Status Neurologis
Kesan Umum & Fungsi luhur
Kepala
: dbn
Kesadaran
: komposmentis, E4 V5 M6
Cara berbicara
: dbn
Fungsi psikosensorik : agnosia sensorik (-)
agnosia motorik (-)
Fungsi psikomotorik :dbn
13
Status Neurologis
Meningeal Sign







Kaku kuduk
Tanda Laseque
Tanda Kernig
Tanda Brudzinski I
Tanda Brudzinski II
Tanda Brudzinski III
Tanda Brudzinski IV
: (-)
: (-)
: (-)
: (-)
: (-)
: (-)
: (-)
14
Status Neurologis
Kolumna Vertebralis
 Kelainan bentuk
 Nyeri tekan / ketok
 Tanda Patrick
 Tanda Kontrapatrick
 Gerak V. Cervikal
 Gerak tubuh
: (-)
: (-)
: (-)
: (-)
: dbn
: dbn
15
Status Neurologis
(Saraf Otak )
Nervus I (Olfaktorius)
Anosmia
Parosmia
Halusinasi
:
:
:
-
/
/
/
-
Nervus II (Optikus)
Visus
Kacamata
Lapang Pandang
Warna
Funduskopi
:
:
:
:
:
Kanan
>3/60
(-)
dbn
dbn
dbn
Kiri
>3/60
(-)
dbn
dbn
dbn
16
Status Neurologis (Saraf Otak)
Nervus III, IV, VI
Kanan
Kiri
Celah mata
: Simetris
Simetris
Posisi bola mata
: Ditengah
Ditengah
Gerak bola mata
: dbn
dbn
Pupil : ukuran
Bentuk
- R. cahaya langsung
: 3 mm
: Bulat
: (+)
3 mm
Bulat
(+)
- R. cahaya tak langsung
- Konvergensi
- Akomodasi
: (+)
(+)
-
: dbn
: dbn
17
Status Neurologis (Saraf Otak )
Nervus V






Sensorik I
Sensorik II
Sensorik III
Otot kunyah
Refleks masseter
Refleks kornea
:
:
:
:
:
:
Kanan
↓
↓
↓
dbn
dbn
+
Kiri
dbn
dbn
dbn
dbn
dbn
+
18
Status Neurologis (Saraf Otak )
Nervus VII










Otot dahi
Tinggi alis
Sudut mata
Sudut mulut
Lipatan nasolabial
Memejamkan mata
Meringis
Sekresi air mata
Pengecap lidah
Hiperakusis
:
:
:
:
:
:
:
:
:
:
Saat diam
Saat gerak
simetris
simetris
simetris
simetris
simetris
simetris
simetris
simetris
simetris
simetris
simetris
simetris
simetris
simetris
kanan
kiri
dbn
dbn
- / -
kanan
kiri
19
Status Neurologis (Saraf Otak )
Nervus VIII



Pendengaran
Vertigo
Nistagmus
:
:
:
Kanan
dbn
(-)
(-)
kiri
dbn
(-)
(-)
20
Status Neurologis (Saraf Otak )
Nervus IX dan Nervus X







Kanan
Kiri
Refleks muntah :
dbn
dbn
Pengecapan
:
dbn
dbn
Posisi uvula
:
ditengah
Arkus faring
:
dbn
Menelan
:
dbn
Bersuara
:
dbn
Fenomena Vernet Rideau:
simetri
21
Status Neurologis (Saraf Otak )
Nervus XI



Bentuk otot
Mengangkat bahu
Berpaling
:
:
:
Kanan
dbn
dbn
dbn
Kiri
dbn
dbn
dbn
22
Status Neurologis (Saraf Otak )
Nervus XII






Atrofi lidah
Kekuatan
Fasikulasi
Posisi diam
Posisi dijulurkan
Gerak spontan
:
:
:
:
:
:
Kanan
(-)
dbn
(-)
di tengah
ditengah
dbn
Kiri
(-)
dbn
(-)
23
Status Neurologis (Sistem Koordinasi)
Kanan








Gerakan abnormal
Uji jari-jari tangan
Uji jari hidung
Uji pronasi dan supinasi
Uji hidung-jari-hidung
Uji tumit lutut
Cara berjalan
Uji Romberg
:
:
:
:
:
:
:
:
Kiri
(-)
dbn
dbn
dbn
dbn
dbn
dbn
(-)
dbn
dbn
dbn
dbn
dbn
(-)
24
Status Neurologis (Sistem Sensorik )
Lengan
Kanan
Kiri
Tungkai
kanan
kiri
Rasa eksteroseptif
Rasa nyeri superfisial
Rasa suhu
Rasa raba ringan
:
:
:
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
Rasa proprioseptif
Rasa getar
Rasa tekan
Rasa nyeri tekan
Rasa gerak dan posisi
:
:
:
:
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
25
Status Neurologis (Sistem Sensorik )
Rasa kortikal
Stereognosis
Barognosis
:
:
:
Pengenalan 2 titik (atas)
(bawah) :
kanan
kiri
dbn
dbn
dbn
dbn
dbn
dbn
dbn
dbn
26
Status Neurologis (Sistem Otonom)




Miksi
: dbn
Defekasi : dbn
Salivasi : dbn
Sekresi keringat : dbn
27
Status Neurologis
Sistem Motorik & Refleks
Ekstremitas Superior
Lengan
Atas
Kanan
Pertumbuhan :
Tonus
:
Kekuatan
Fleksi
Ekstensi
:
:
kiri
N
N
Reflek patologis
Hoffman
: (Tromner
: (+
kanan
N
N
4+
4+
Reflek fisiologis
Bisep
: +3
Trisep
: +3
bawah
5
5
/
/
/
/
N
N
4+
4+
tangan
kiri
kanan
N
N
5
5
kiri
N
N
N
N
4+
4+
5
5
+2
+2
-)
-)
28
Status Neurologis
Sistem Motorik & Refleks
Ekstremitas Inferior
Tungkai
atas
bawah
Kanan kiri
Pertumbuhan :
Tonus
:
N
N
Kekuatan
Fleksi
Ekstensi
:
:
4+
4+
Klonus
Lutut
Kaki
:
:
(-)
(-)
N
N
5
5
kanan
kiri
N
N
N
N
4+
4+
kaki
kanan
N
N
5
5
kiri
N
N
4+
4+
5
5
29
Status Neurologis
Sistem Motorik & Refleks
Refleks Fisiologis & Patologis
Kanan
Refleks
Refleks
Reflkes
Refleks
Refleks
Refleks
Refleks
Refleks
Patella
Achilles
Babinski
Chaddock
Openheim
Gordon
Schaeffer
dinding perut
:
:
:
:
:
:
:
:
+2
+2
(-)
(-)
(-)
(-)
(-)
(-)
Kiri
+2
+2
(-)
(-)
(-)
(-)
(-)
(-)
30
Status Neurologis
Sistem Motorik & Refleks
Refleks Primitif




Refleks memegang
Refleks snout
Refleks menghisap
Refleks palmo-mental
: (-)
: (-)
: (-)
: (-)
31
III. PEMERIKSAAN PENUNJANG









Pemeriksaan CT Scan Kepala polos (5/4 2012)
Tampak lesi hipodens pada genu capsula interna
kanan kiri dan lobus frontalis kiri
Sulkus kortikalis region basal fisura serta sisterna
sedikit menyempit
System ventrikel normal
Tak tampak midline shifting
Tak tampak kelainan pada batang otak dan cerebellum
KESAN :- Gambaran oedem cerebri ringan
- Suspek infark cerebri lakunar pada genu
kapsula interna kanan kiri dan lobus
frontalis kiri
- Tak tampak tanda tanda SOL intrakranial
32
33
34
35
DSA tgl 26 Juni 2013







RCCA injeksi : normal, tidak ada stenosis di
bifurkasio
RICA injeksi : tampak normal aliran kontras
sampai fase vena
LCCA injeksi : normal, ada stenosis di
bifurkasio
LICA injeksi : tampak normal aliran kontras
sampai fase vena.
Tampak hipervaskularisasi arteriole dan venule
yang menyokong gambaran inflamasi.
Kesimpulan : Cerebral DSA menyokong
gambaran vaskulitis cerebral
Saran
: Terapi di lanjutkan
36
37
IV. RESUME
Anamnesis







Nyeri kepala 3 tahun
Nyeri kepala bagian kanan. Nyeri seperti di remas
remas, kadang kadang sampai mengeluarkan air
mata. Nyeri di rasakan terus menerus.
Derajat nyeri dari awal penderita merasakan nyeri
sampai sekarang, dirasakan sama.
Pandangan double
Kelemahan anggota gerak kanan
Gringgingan pada badan sebelah kanan
Tidak ada riwayat trauma
38
IV. RESUME
Pemeriksaan Fisik
 Status interna
 Status neurologis
 Kesadaran
 Fungsi sensoris
 Fungsi motorik
 Reflek fisiologis
 Reflek patologis
 Nervi craniales
: dalam batas normal
:
: GCS E4V5M6, compos mentis
: hemihipestesi dextra
: hemiparese dextra
: meningkat pada lengan kanan
: Tromer (+) pada bagian kanan
: N V. Hemihipestesi dextra
39
IV. RESUME
Pemeriksaan Penunjang

CT Scan : Suspek infark cerebri lakunar pada
genu kapsula interna kanan kiri dan
lobus frontalis kiri

Laboratorium : Anti Rubella IgG (+)
126,00 IU/ml

DSA
:Vaskulitis Cerebral
40
V. DIAGNOSIS
Diagnosis Neurologis
Diagnosis klinis : Chepalgia kronik, diplopia,
hemiparese dekstra, hemihipestesi
dextra.
 Diagnosis topis : Subcortex sinistra
 Diagnosis etiologi: Rubella dengan Vaskulitis Cerebral
 Diagnosis lain : Stroke Infark

41
VI. PENATALAKSANAAN
A. Pengobatan medikamentosa
Aspilet 80 mg 1x1
B comp 2x1
Na diklofenak 2x25 mg
Parasetamol 300mg,amitriptilin
6,25mg,diazepam 1mg  caps 2x1
42
VII. KONSULTASI /
RAWAT BERSAMA
Bagian Mata tgl 17 Des 2013
Jawaban :
 Visus : OD: 6/6
OS : 6/6
 Papil oedem : tidak ditemukan
 Ptosis ringan
43
44
45
TERIMA KASIH
46
47
Rubella Disease


20-50% of infections are asymptomatic
Prodrome

Rash

Other symptoms
◦ Rare in children
◦ Adolescents/adults: low grade fever, malaise,
lymphadenopathy, upper respiratory symptoms lasts15 days
◦ Maculopapular
◦ Begins on face and head
◦ Usually persists 3 days
◦ Lymphadenopathy: postauricular, posterior cervical, and
suboccipital
◦ Conjunctivitis
48
Congenital Rubella Syndrome

Infection in pregnancy, most dangerous <12 weeks
gestation

May lead to fetal death or premature delivery

Hearing impairment, cataracts, heart defects, microcephaly,
developmental delay, bone alterations, liver and spleen
damage

Organ specificity generally related to stage of gestational
infection
49
Three day measles; German measles or
Rubella is an infectious
disease transmitted by the
rubella virus. The signs of
the disease are: swelling of
lymph nodes in the neck and
a skin rash which first
appears on the face and then
rapidly spreads to other
parts of the body. The
complications of rubella
include encephalitis and joint
pain. Infection with rubella
during pregnancy can cause
serious damage to the child,
including cataracts,
deafness, heart defects and
mental retardation.
There is no drug therapy for
rubella. However, the
disease can be prevented by
immunization.
50
The disease is caused by a virus that is spread through the air or by close
contact. It can also be transmitted to a fetus by a mother with an active
infection. The disease is usually mild and may even go unnoticed. Children
may have few symptoms, but adults may experience a prodrome (warning
symptom) of a fever, headache, malaise, runny nose, and inflamed eyes that
lasts from 1 to 5 days before the rash appears. A person can transmit the
disease from 1 week before the onset of the rash until 1 week after the rash
disappears. The disease is not as contagious as rubeola (measles),
therefore many people are not infected during childhood. Lifelong immunity
to the disease follows infection. Epidemics may occur at about 6- to 9-year
intervals. The risk factors are the unimmunized individuals.
The disease is potentially serious because of the ability to produce defects
in a developing fetus if the mother is infected during early pregnancy. As
many as 10 to 15% of women in their childbearing years are susceptible to
infection. Congenital rubella syndrome occurs in 25% or more of infants
born to women who acquired rubella during the first trimester ofpregnancy.
Defects are rare if the infection occurs after the 20th week of pregnancy. One
or more defects may occur in an infected fetus and include deafness,
cataracts,microcephaaly,mental retardation,congenital heart defects and
other defects. A miscarriage or stillbirth may occur.
Risk factors include lack of immunization and exposure to an active case of
rubella.
51
Rubella syndrome, or congenital rubella, is a group of physical
abnormalities that have developed in an infant as a result of maternal
infection and subsequent fetal infection with rubella virus. It is characterized
by rash at birth, low birth weight, small head size, heart abnormalities, visual
problems and bulging fontanelle.
52
The first shot is recommended at 1215 months. Because the first shot
may not provide adequate lifetime
immunity to some individuals, a
second MMR is recommended prior
to school entry at 4-6 years or prior
to entry into junior high at 11-13
years. Some states require a second
MMR at kindergarten entry
VACCINE INFORMATION
The MMR vaccine is a "3-in-1" vaccine
that protects against measles, mumps,
and rubella. Although single antigen
(individual) vaccines have been
developed for each component of the
MMR, they are not readily available and
usually used only for very specific
situations. An example of such a
situation would be if an outbreak of
either measles, mumps, or rubella was
occurring in a specific community and
public health officials deemed it
necessary to immunize infants 6 to 12
months old. Single antigen vaccines
might be used because they pose less
risk to children younger than the
recommended age of 12 months for the
MMR. For children 12 months or older
and adults, the risks of giving the single
antigen vaccine are presumed to be the
same as giving the MMR.
53
Rubella Pathogenesis

Respiratory transmission of virus

Replication in nasopharynx and regional lymph
nodes

Viremia 5-7 days after exposure with spread
to tissues

Placenta and fetus infected during viremia
54
Rubella Clinical Features

Incubation period 14 days (range 12-23 days)

Prodrome of low grade fever

Lymphadenopathy in second week

Maculopapular rash 14-17 days after
exposure
55
Rubella Complications
Arthralgia or arthritis
children
adult female
Thrombocytopenic
purpura
Encephalitis
Neuritis
Orchitis
rare
up to 70%
1/3000 cases
1/5,000+ cases
rare
rare
56
Rubella Laboratory Diagnosis

Isolation of rubella virus from clinical
specimen (e.g., nasopharynx, urine)

Significant rise in rubella IgG by any
standard serologic assay (e.g., enzyme
immunoassay)

Positive serologic test for rubella IgM
antibody
57
Rubella Epidemiology

Reservoir
Human

Transmission
Respiratory
Subclinical cases may
transmit

Temporal pattern

Communicability 7 days before to 5-7 days
after rash onset
Infants with CRS may shed
virus for a year or more
Peak in late winter and spring
58
Rubella Vaccine

Composition
Live virus (RA 27/3 strain)

Efficacy
95% (Range, 90%-97%)

Duration of
Immunity
Lifelong

Schedule
1 Dose

Should be administered with measles and mumps as
MMR
59
Eye pain on lateral and upward eye movement (a particularly
troublesome complaint)
 Conjunctivitis
 Sore throat
 Headache
 General body aches
 Low-grade fever
 Chills
 Anorexia
 Nausea
 Tender lymphadenopathy (particularly posterior auricular and
suboccipital lymph nodes)
 Forchheimer sign (an enanthem observed in 20% of patients
with rubella during the prodromal period; can be present in
some patients during the initial phase of the exanthem;
consists of pinpoint or larger petechiae that usually occur on
the soft palate)

60
Temperature
 Fever is usually not higher than 38.5°C
(101.5°F).
Lymph nodes
 Enlarged posterior auricular and suboccipital
lymph nodes are usually found on physical
examination.
Mouth
 The Forchheimer sign may still be present on
the soft palate.
61
Salt and pepper retinopathy
http://www.kellogg.umich.edu/theeyeshave
it/congenital/retinopathy.html
Courtesy
http://phil.cdc.gov/phil_images/2003072
4/28/PHIL_4284_lores.jpg
Courtesy: Jonathan Trobe, M.D. - University
of Michigan Kellogg Eye Center
Content Providers(s): CDC Creation
Date: 1976
62
DIFFERENTIALS

Drug Eruptions
Erythema Infectiosum (Fifth Disease)
Measles, Rubeola
Mucocutaneous Lymph Node Syndrome
(Kawasaki Disease)
Roseola Infantum
Scarlet Fever

63
Lab Studies
If the diagnosis is in doubt, a rising titer of
immunoglobulin M (IgM) antibody over a
2-week period indicates a recent
infection.
 A WBC count, if performed, may be lower
than normal, as in many viral infections,
with increased percentages in the
lymphocyte count. In those very rare
cases where encephalitis is present,
lymphocytes are present in the
cerebrospinal fluid (CSF).

64
Rubella virus can be isolated from the
nasopharynx, the blood, the urine, and
CSF.
 Now, newer tests with a higher
specificity (eg, latex agglutination,
fluorescence immunoassay, passive
hemagglutination, hemolysis in gel,
enzyme immunoassay tests) are
available. From a public health
standpoint, attempting to confirm a
rubella infection in a pregnant woman or
a newborn or an infant is important.

65
A pregnant woman exposed to rubella
should be tested immediately for a
rubella-specific antibody. The presence
of rubella-specific immunoglobulin G
(IgG) is evidence that the patient is
immune.
 If the test result is negative, repeat the
test again in 3-4 weeks, and also repeat
the test on the first specimen. If an
antibody is present in the second test
and not in the first test, an infection has
occurred.

66

An infant with CRS will show the IgG
antibody from the mother, which
disappears in a few months and an
elevated IgM antibody level because of
antibody production by the infant. The
presence of the IgM antibody usually
indicates recent infection because IgM
does not cross the placenta from the
mother as does IgG
67
TREATMENT
Medical Care: No specific treatment
of rubella exists.
 The disease is usually self-limited.
 Rest and oral fluids are appropriate.
 Individuals may remain contagious
for 7 days after the onset of the
rash, and they should be
appropriately isolated from work,
school, or other public settings.

68
Medication

No specific medication is available
for rubella, except that given for
symptomatic relief.
69
70
71
Rare cases of vasculitis have similarly been
reported
following
rubella
virus,
adenovirus,echovirus,
coxsackievirus,
parainfluenza virus, herpes simplex
viruses, and hepatitis A virus infections.
72
Pathology vaskulitis


Perivascular cellular infiltration is a common histological
finding in many disease entities, but for a definitive
diagnosis of vasculitis, the presence of vascular damage,
particularly in the form of fibrinoid degeneration, is
necessary.
Vasculitis may involve blood vessels of varying calibers
and this feature forms the basis of a useful pathological
classification of vasculitis. An infiltrate, composed of a
variety of cell types, like neutrophils, lymphocytes, and
histiocytes may invade the vessel wall and the
surrounding tissue. Extravasation of red cells is a
prominent feature in many vasculitides. Granulomatous
inflammation with giant cell formation is a characteristic
finding in some types.
73
ICHD 3
74
75
76
Humoral and cell-mediated immunity develop following
a rubella infection. IgG and IgM antibodies are observed
about 14-18 days after rubella infection, at about the
time when the rash appears (Figure 6). Rubella IgM
antibodies wane quickly and are usually undetectable
after 2 months, whereas rubella IgG antibodies persist. A
rubella-specific cell-mediated lymphocyte response
begins 1 week after the humoral response and persists
for a lifetime.
 Although natural rubella infection generally confers
lifelong immunity, rare cases of serologically confirmed
re-infections after earlier infection (or immunization)
have been reported. There have also been cases of CRS
following re-infection in pregnant women with natural
or vaccine-induced immunity, but this is extremely rare.
Maternal rubella antibodies provide protection against
rubella for the first months of life and may affect the
immune response if vaccination occurs at an early age. 77

78
79
80
81