INTERESTING CASE

Saturday, 13th June

2015

Riski, Lea, Erni, Eni, Sarah, Dicky, Putu, Restu, Rini

Putu

PATIENT IDENTITY

Name : an. FFF

Age : 14 months old
Sex : Male
Address : Bojong, Wonolelo, Pleret
Admission date : Saturday, June 13th 2015

Chief complaint : Seizure (referred from

Nur Hidayah Hospital).

HISTORY

23
DBA

11 DBA

Putu

Fever for 1 days, seizure one times, duration

= 5 minutes, whole body tense, brought to
Nur Hidayah Hospital, seizure stop with
diazepam suppositories. After seizure, the
patient crying. Inpatient for 5 days.
Diagnosed as febrile seizure. Patient were
given anti-seizure and paracetamol when
discharged
Diarrhea 10-20 times a day. @Volume = 1
table spoon~1/4 of drinking glass. No blood,
no mucus. Admitted to Rajawali Citra
Hospital, diagnosed as acute watery
diarrhea with dehydration. Patient were
discharged after 4 days. Diarrhea stop. No
seizure during inpatient.

HISTORY

Day of
Admission

Putu

4 hours before admission : Seizure

without febrile, duration = 5 minute,
whole body tense, stop
spontaneously, after seizure, the
patient crying
3 hours before admission (13.00) :
seizure without febrile, duration +/45 minutes. Brought to Nur Hidayah
Hospital.
13.45 diazepam rectally 5 mg
13.50 diazepam rectally 5 mg
14.00 phenytoin 150 mg (18,8
mg/kgbb/x)
14.30 phenobarbital 150 mg (18,8
mg/kgbb/x)
Seizure stop after phenobarbital
injection,

History Taking

Putu

Patient was born from G2P1A0 mother,

gestational age 10 months, spontaneous
delivery, with induction. Body weight of
newborn = 3750 gram. Spontaneously
crying after delivery.
No history of jaundice
No history of seizure
No history of head trauma
History of febrile seizure in older sister and
father
Complete immunization according to

Developmental History
Gross Motor
Fine Motor
Speech
Personal
Social
No developmental delay

Putu

Crawl 6 months
Standing 12 months
Walking 1-2 steps without support 14 months
Pass object from one hand to another : 6 months
Pinching : 9 months
Dringking from glasses : 12 months
Speak simple sound ma : 6 months
Word mamak, bapak, emoh, mimik, maem, nenek :
12 months

Wave goodbye : 9 months

Ci luk ba : 12 months

Physical examination

Putu

General condition: look weak, under sedation

VS: HR: 130 x/min, RR 29 x/min, t: 37,0oC, SpO2 98% (room air),
Neck
: Neck Stiffness (-)
Thorax
: symmetric, no retraction, abdomino thoracal
respiratory
Cor : normal heart sound. Pulmo : vesicular +/+, rales -/-, no
crepitation, no wheezing
Abdomen : normal bowel sound, normal turgor and elasticity, no
tenderness
Hepar: not palpable, Lien: not palpable
Ext: warm extremities, strong pulse, good perfusion, CRT < 2s
Head: anemic conjungtiva -/- , Ikteric sclera -/-, erythema pharynx
N N
eu eu
(-)
Not
valid
Power
Not valid Tonus
Movement
Trof
Neuromuscular
:
assessed examination
assessed
eu eu
N N Meningeal Sign
:
Neck stiffneess
Physiologic N N Pathologic
(-)
al
al
Clonus
N N
Brudzinski sign I
reflexes
reflexes
(-)
Brudzinski sign II
(-)

- - -

- -

NUTRITIONAL STATUS
Body weight : 8,0 kg
Height : 73 cm
UAC : 11,5 cm
WAZ : -2<z < 0 SD
HAZ : -2<z < 0 SD
WHZ : 0 < SD < 1SD
Normal weight
Normal Height
Good nutritional status

LABORATORY FINDING

Putu

(Sardjito Hospital)
13/6/2015
Hemoglobin (g/dL)
Hematocrite (%)
Eritrocyte (. x
106/uL)
Leucocyte (. /uL)
Neutrophil (%)
Lymphocyte (%)
Monocyte (%)
Eosinophil (%)
Basophil (%)
Thrombocyte (./uL)
MCV
MCH
MCHC

10,4
29,8%
4,47 x106 /uL
9.6x 103 /uL
80,1%
15,6%
2,1%
0%
0,2%
411 X 103 /uL
66,5
23,2
34,8

Reference range
9,5-14,0 g/dL
36% - 46%
4-5 x 106 /uL
10 26 x 103 /uL
40-60%
45-65%
2-8 %
0-1%
0-1%
150-450 X103 /uL
80-99
27-32
32-36

LABORATORY FINDING

Putu

(Sardjito Hospital)
13/5/15

Reference range

Natrium
Kalium
Chloride
Ca

143
4,73
106
2,18

136 - 145
3.50 5.10
98 107
2,15-2,55

GDS

119

80-140

DATA LIST

Putu

GA: looks weak, E3V5M6, somnolent (under

sedation)
Seizure 2 times, > 30 minutes, seizure stop with
diazepam, phenytoin and phenobarbital.
No fever, no head trauma, no electrolyte imbalance,
no hypoglycemia
Neurologic status: free movement at 4 extremities,
strength: 5 at 4 extremities, physiologic reflexes
within normal limit, no pathologic reflexes, clonus (-),
no meningeal sign.

Status epilepticus overcome

DATA LIST

Seizure without provocation

Generalized Tonic-Clonic type seizure

Epilepsy susp

Putu

ANTROPOMETRI
Normal weight
Body weight : 8,0 kg
Normal Height
Height : 73 cm
Good nutritional
UAC : 11,5 cm
Head circumference : 43 status
Microcephaly
cm

WAZ : -2<z < 0 SD

HAZ : -2<z < 0 SD
WHZ : 0 < SD < 1SD
Nellhaus : z<-3 SD

No data on mother CMV

status

Putu

DATA LIST
13/6/2015
Hemoglobin (g/dL)
Erythrocyte
MCV
MCH
MCHC

10,4
4,47 x106 /uL
66,5
23,2
34,8

Reference range
9,5-14,0 g/dL
4-5 x 106 /uL
80-99
27-32
32-36

Milk as main source of food from birth to 12 months

old
Food seldom contain red meat or liver
No history of iron supplementation
No organomegaly
Anemia microcytic hypochromic
Mentzer index : 14,8 (>13)

Putu

WORKING DIAGNOSIS

Status epilepticus overcome

Epilepsy susp
Microcephal susp congenital infection
Anaemia microcytic hypochromic susp IDA

INTEGRATED
PLANNING
Problems
Patient
needs
Planning

Date
13/6

Epilepsy

No seizure
Establish
diagnosis

Putu
& Goal

Phenobarbital maintenance
dose 10 mg/kgbw/day ~ 40
mg/12 hours
EEG
Head CT scan without contrast
IgM, IgG anti-CMV

13/6

Microcephal
susp
Congenital
infection

Establish the
diagnosis

13/6

Anaemia
microcytic
hypochromi
c susp IDA

Normal
hemoglobin
level

Elemental iron 3
mg/kgBW/day~25 mg/day
MDT
Iron panel

FOLLOW UP

Condition this morning

S : no seizure, no fever
O: GA: looks active, E4V5M6
HR: 106x/m
RR: 26x/m
T: 37,5 SpO2: 99% (room
air)
Neurologic status:
meningeal sign (-)
Movement

F F
F F

Meningeal Sign :
(-)

Power

Asessment :
Epilepsy susp
Microcephal susp
congenital infection
Anaemia microcytic
hypochromic susp IDA
Plan
Phenobarbital
maintenance dose 10
mg/kgbw/day ~ 40 mg/12
hours
Head CT Scan without
contrast
EEG
IgM, IgG anti CMV

Condition this Morning

Physical examination

Putu

General condition: look weak, under sedation

VS: HR: 130 x/min, RR 29 x/min, t: 37,0oC, SpO2 98% (room air),
Neck
: Neck Stiffness (-)
Thorax
: symmetric, no retraction, abdomino thoracal
respiratory
Cor : normal heart sound. Pulmo : vesicular +/+, rales -/-, no
crepitation, no wheezing
Abdomen : normal bowel sound, normal turgor and elasticity, no
tenderness
Hepar: not palpable, Lien: not palpable
Ext: warm extremities, strong pulse, good perfusion, CRT < 2s
Head: anemic conjungtiva -/- , Ikteric sclera -/-, erythema pharynx
N N
eu eu
(-)
Power
Movement
Tonus
Trof
Neuromuscular examination :
eu eu
N N Meningeal Sign
:
Neck stiffneess
Physiologic N N Pathologic
(-)
al
al
Clonus
N N
Brudzinski sign I
reflexes
reflexes
(-)
Brudzinski sign II
(-)

- - -

- -

THANK YOU

Status
Epilepticus

Putu

Types of Epilepsy

Putu

Generalized epilepsies have no defned area in the brain from which

the seizures originate. There are two varieties of generalized epilepsies:
Idiopathic, in which the brain behaves normally between seizures and
the cause of seizures is unknown; and
Symptomatic, in which there is a clear structural abnormality that
contributes to the seizures.
The seizures caused by generalized epilepsy include:
Absence, or petit mal, seizures
Tonic-clonic, or grand mal, seizures
Tonic seizures
Myoclonic seizures
Atonic seizures

Types of Epilepsy

Putu

Partial (focal) epilepsy involve seizures that begin in a region of the

most highly developed part of the brains hemispheres. While the seizures
sometimes are localized, they can spread to become generalized seizures.
The seizures caused by these epilepsies, which may spread and become
generalized, include:
Complex partial seizures (psychomotor attacks)
These seizures often begin with an aura, or a neurological warning, such
as a sense of fear, an unpleasant smell, or change in perception. After
the aura, consciousness may be altered; speech may stop and the person
may perform automatic repetitive movements such as chewing,
swallowing, hand fdgeting, or purposeless movement from place to
place.
Simple partial seizures
These seizures typically affect the motor or sensory areas of the brain,
causing jerking movements in the hand or facial muscles, or sensory
symptoms such as flashing lights or a buzzing sound, but without altering
consciousness.

Putu

Putu

CMV congenital

Putu

Microcephaly and seizures are common

manifestations of congenital cytomegalovirus
infection.
Microcephaly and seizures result from brain
damage due to meningoencephalitis in the
developing brain.
Cytomegalovirus meningoencephalitis produces
damage to the fetal brain due to its destructive
effects on the proliferating and migrating
neurons.
Babies with symptomatic congenital CMV disease
can have sensorineural hearing loss,
microcephaly, motor defects, mental retardation,

Infeksi CMV

Putu

Pada keadaan sosial ekonomi yang jelek, atau di

negara berkembang, lebih dari atau sama dengan
80 - 90% masyarakat terinfeksi oleh CMV.
Infeksi CMV kebanyakan asimtomatis. Penelitian
Listiani (2004) pada 395 orang tanpa keluhan:
344 menunjukkan IgG-anti CMV positif (7 dari 344
penderita disertai IgM-anti CMV positif), dan 3
penderita hanya menunjukkan hasil IgM-anti CMV
positif). Total seluruhnya 347 orang atau 87,8 %
menunjukkan seropositif.

Transmisi CMV

Putu

Transmisi intrauterus: apabila terjadi sebelum

usia kehamilan 16 minggu akan menimbulkan
gejala yang berat pada janin.
Transmisi perinatal : terjadi karena sekresi
melalui saluran genital atau air susu ibu.
Transmisi postnatal: saliva, mainan anak-anak
misalnya karena terkontaminasi dari vomitus,
kontak seksual, transfusi darah, transplantasi
organ.
Penyebaran endogen di dalam diri individu:
dari sel ke sel melalui desmosom yaitu celah di
antara 2 membran atau dinding sel yang
berdekatan.

Sel terinfeksi CMV

Replikasi DNA virus dan pembentukan
kapsid terjadi di dalam nukleus sel inang.
Sel-sel terinfeksi CMV dapat berfusi satu
dengan yang lain, membentuk satu sel
besar dengan nukleus yang banyak.

Endothelial giant cells (multinucleated

cells) dapat dijumpai dalam sirkulasi
selama infeksi CMV menyebar. Sel berinti
ganda yang membesar ini sangat berarti
untuk menunjukkan replikasi virus, yaitu
apabila mengandung inklusi intranukleus
berukuran besar seperti mata burung
hantu (owl eye).

Putu