TUBERCULOSIS (TB)

<div style="text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div style="text-align: justify;"><b style="font-family: georgia; text-align: left;"><br /></b></div><div style="text-align: justify;">Tuberculosis (TB) is a disease that has long been recognized by humans. Mycobacterium tuberculosis causes tuberculosis germ has been discovered by Robert Koch in 1882. Although already known for so long and have long found the drug - a potent antituberculosis drugs, today TB is still a major health problem throughout the world. Last decade of the 20th century, the number of new TB cases increased throughout the world, 95% of cases occurring in developing countries. In Indonesia, tuberculosis is still a prominent problem. Even globally, Indonesia was ranked third as the world's largest contributor of cases. </div><div style="text-align: justify;">Increasing the number of TB cases in many places at this time thought to be caused by many things, namely (1) incorrect diagnosis, (2) inadequate treatment, (3) prevention program is not implemented properly, (4) infection endemic human immuno - deficiency virus (HIV), (5) migration of population; (6) treat yourself (self-treatment); (7) increasing poverty; (8) inadequate health services. </div><div style="text-align: justify;"><div class="separator" style="clear: both; text-align: center;"></div>Tuberculosis child has special problems that are different from adults. In tuberculosis of children, the problems faced is the problem of diagnosis, treatment, prevention, and tuberculosis in HIV infection. </div><div style="text-align: justify;">The difficulty of diagnosing TB in children, often followed over diagnosis overtreatment. On the other hand, under diagnosis and under treatment was also found. This happens because the source of the spread of TB are usually adults with sputum positive acid-fast bacilli, so that TB control is emphasized in the treatment of adult tuberculosis. As a result, TB treatment of children less attention. </div><div style="text-align: justify;">WHO is making efforts by making a consensus diagnosis in many countries. Given this consensus, the diagnosis of TB is expected to be enforced child the possibility of overdiagnosis or underdiagnosis sehinggan can be minimized and the exact prevalence known. </div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b><span style="color: #bf9000;">1. Symptoms of Tuberculosis (TB)</span></b> </div><div style="text-align: justify;">a. Main symptoms, persistent cough and phlegm for 3 (three) weeks or more </div><div style="text-align: justify;">b. Additional symptoms that are common: bloody sputum, coughing up blood, shortness of breath and chest pain, body weakness, decreased appetite, weight loss, body discomfort (malaise), night sweats, although no activity, fever fever for more than a month , there is a reddish reaction immediately after injection of BCG (within 3-7 days), there are common symptoms of TB </div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b><span style="color: #bf9000;">2) Common symptoms of TB in children </span></b></div><div style="text-align: justify;">- Weight down for 3 months in a row for no apparent reason and does not rise within 1 month despite treatment with good nutrition (failure to thrive). </div><div style="text-align: justify;">- No appetite (anorexia) with failure to thrive and weight does not go up (failure to thrive) with adequately. </div><div style="text-align: justify;">- Fever long / repetitive for no apparent reason (not typhoid, malaria or acute respiratory infection) can be accompanied by night sweats. </div><div style="text-align: justify;">- Enlargement of superficial lymph nodes are not ill usually the most frequent multiple armpit and neck area groin (inguinal). </div><div style="text-align: justify;">- The symptoms of respiratory tract such as cough for more than 30 days (after excluded other causes of cough), signs of chest fluid, and chest pain. </div><div style="text-align: justify;">- The symptoms of recurrent gastrointestinal tract such as diarrhea that are not cured by treatment of diarrhea, lump (period) in the abdomen and signs of fluid in the abdomen. </div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b><span style="color: #bf9000;">3) Specific Symptoms </span></b></div><div style="text-align: justify;">These symptoms usually depend on which body part affected for example: </div><div style="text-align: justify;">- TB Skin / skrofuloderma </div><div style="text-align: justify;">- Tuberculosis of bones and joints: </div><div style="text-align: justify;">- Spine (spondylitis): gibbus </div><div style="text-align: justify;">- Pelvis (koksitis): lame swelling in the hip </div><div style="text-align: justify;">- Bone knee: a limp and / or swelling </div><div style="text-align: justify;">- Foot and hand bones </div><div style="text-align: justify;">- TBC Brain and Nervous: meningitis, with symptoms iritabel vomiting, stiff neck and decreased consciousness </div><div style="text-align: justify;">- Symptoms of eye </div><div style="text-align: justify;">- Conjunctivitis fliktenularis </div><div style="text-align: justify;">- Choroid tubercles (only visible by funduscopic) </div><div style="text-align: justify;">- Other</div>

By  Deden Sura Agung Tuberculosis (TB) is a disease that has long been recognized by humans. Mycobacterium tuberculosis causes tuberculosis ...

PREGNANCY SEROTINUS

<div style="text-align: justify;"><b style="color: #bf9000;"><span style="color: black; font-family: georgia; font-weight: 400; text-align: left;">By </span><b style="color: black; font-family: georgia; text-align: left;">Deden Sura Agung</b></b></div><div style="text-align: justify;"><b style="color: #bf9000;"><b style="color: black; font-family: georgia; text-align: left;"><br /></b></b></div><div style="text-align: justify;"><b style="color: #bf9000;">DEFINITION</b></div><div style="text-align: justify;">Pregnancy serotinus is a pregnancy that lasted 42 weeks (294 days) or more, calculated from the first day of last menstrual cycle 28 days or 280 days (40 weeks) from day of conception. Another term often used is overdue pregnancy, postmaturitas, delayed pregnancy, postdatism or postdates. Approximately 10% of pregnancies continue until 42 weeks, 4% continued until the age of 43 weeks.</div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><span style="color: #bf9000;">DIAGNOSIS</span></div><div style="text-align: justify;">Determination of gestational age based on the formula Naegele, calculated from the first day of last menstrual period and based on the menstrual cycle (estimated delivery is 280 days or 40 weeks from the first day of last menstrual cycle 28 days or 266 days after ovulation). So to determine the pregnancy gestation serotinus must be known precisely. Naegele formula is still commonly used, but must keep in mind the various factors that may affect / result in errors of calculation, namely:</div><div style="text-align: justify;">1. Determination of gestational age based on the first day of last period is often not easy because the mother could not remember the date of the first day of last menstrual period with certainty.</div><div style="text-align: justify;">2. Determining the time of ovulation is not easy.</div><div style="text-align: justify;">3. Factors that affect the calculation, such as menstrual cycle variations, the calculation error by the mother, and so forth.</div><div style="text-align: justify;">Apart from menstruation, pregnancy age determination can be assisted by a clinical re-evaluate the age at first pregnancy from mother to come. The earlier a pregnancy examination performed, gestational age has come closer to the truth. Clinicians also need to ask when was the movement of children or take measurements in serial fundus uteri. Examination of high serial fundus uteri in pregnancy serotinus will show a decline, because the fetus is not growing larger while the amniotic fluid began to decrease. Mother also felt fetal movement decrease the frequency and intensity.</div><div style="text-align: justify;">Ultrasound examination is very helpful estimated gestational age. With the ultrasound gestational age can be determined more accurately by the deviation is only more or less a week. But there is also a problem in multiple pregnancies / twins because each fetus will be smaller than in normal singleton pregnancies.</div><div style="text-align: justify;">In Indonesia, the diagnosis of pregnancy serotinus very difficult because many mothers do not know the date of the last menstrual period properly. A good diagnosis can only be made if the patient checked out since the beginning of pregnancy.</div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b><span style="color: #bf9000;">ETIOLOGY</span></b></div><div style="text-align: justify;">Experiments on animals show that pregnancy causes serotinus is a combination of maternal and child factors. Factors that affect pregnancy serotinus, namely:</div><div style="text-align: justify;">1. Factors placenta: placental sulfatase deficiency of the enzyme</div><div style="text-align: justify;">2. Factors children: adenokortikotropik hormone deficiency (ACTH)</div><div style="text-align: justify;">3. Maternal factors. Although there is no obvious explanation, there are several factors that allegedly associated with pregnancy serotinus, such as age, parity, state serotinus seosioekonomi and history of previous pregnancies. According to the study, the incidence of pregnancy serotinus increased from 10% to 27% in women with a history of pregnancy serotinus before and to 39% in women with two previous serotinus pregnancy history.</div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b style="color: #bf9000;">CLINICAL</b></div><div style="text-align: justify;">Postmaturitas syndrome is a term used to describe the clinical state of infants who showed more months of pregnancy. This situation occurs in 30% of pregnancies serotinus and 3% pregnancy term.</div><div style="text-align: justify;">Signs serotinitas:</div><div style="text-align: justify;">1. Disappearance of subcutaneous fat</div><div style="text-align: justify;">2. Dry skin, wrinkles or cracks</div><div style="text-align: justify;">3. Meconium staining of the skin, umbilicus and amniotic membrane</div><div style="text-align: justify;">4. Nails and long hair</div><div style="text-align: justify;">5. Lazy baby</div><div style="text-align: justify;">6. Face looked old and worried-looking</div><div style="text-align: justify;">In some cases even exceed 42 weeks gestational age, placental function remains good, resulting in a large baby (> 4000 grams). The incidence in pregnancy is 37-41 weeks was 1.4% and increased to 2.2% at 42 weeks gestation or more.</div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b style="color: #bf9000;">COMPLICATION</b></div><div style="text-align: justify;">Complications that can occur is the death of the fetus in the uterus (due to placental insufficiency) and neonatal mortality. The fetus also can suffer from hypoxia, hypovolemia, acidosis, breathing distress syndrome, hypoglycaemia or adrenal hipofungsi.</div><div style="text-align: justify;">Placental function peaking at gestational age 38-42 weeks, then decreased after 42 weeks, seen from the decreasing levels of estrogen and placental laktogen. Also occur placental spiral arteries spasm. As a result of supply disruption could occur oxygen and nutrients to live and intrauterine fetal growth and development. Circulation uteroplasenta reduced to 50%. By histopathology, placental abnormalities found were calcification, villous edema, pseudohiperplasia on sinsitium, degeneration of fibroids in placental villi and mikroinfark. The volume of amniotic fluid also decreases because the absorption is taking place. These circumstances are conditions that are not good for the fetus.</div><div style="text-align: justify;">Asphyxia is a major cause of neonatal mortality and morbidity. In neonates with serotinus autopsy found the petekie the pleura and pericardium, which is a sign of hypoxia and found the existence of particles of meconium in the lungs.</div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b style="color: #bf9000;">ASSESSMENT ANTEPARTUM</b></div><div style="text-align: justify;">Given the high morbidity and mortality in pregnancy serotinus, an assessment of the risk of antepartum dismaturitas must be done to decide whether the fetus was still allowed to stay in the womb (waiting for spontaneous labor) or to be born.</div><div style="text-align: justify;">Assessment of fetal well-being can be done by:</div><div style="text-align: justify;">1. Evaluation of amniotic fluid by amniocentesis or ultrasound (also for checking biometric).</div><div style="text-align: justify;">2. Monitor changes in fetal heart rate with no load (nonstress test) or with a load (contraction stress test). Test with a load no-load test performed if non rektif. If the result is unsatisfactory or suspicious, the test was repeated 24 hours later.</div><div style="text-align: justify;">3. Determine the biophysical profile scoring obtained from the NST and ultrasound examination to see the fetal heart rate, fetal breathing, fetal tone, fetal movement and the amount of amniotic fluid. It must be remembered that there is no way of monitoring fetal well-being of the most ideal, so it must be a combination of different ways.</div><div style="text-align: justify;">In addition to fetal welfare assessment, inspection also needs to be done to assess the degree of maturity of the cervix, using the Bishop score. It is necessary to determine further action.</div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b style="color: #bf9000;">TREATMENT</b></div><div style="text-align: justify;">1. Ekspektatif, therefore induction of labor associated with the incidence of uterine inertia, long deliveries, cervical trauma, cesarean section deliveries made and, in some cases, particularly with the immature cervix, ekspektatif care needs to be done, provided that good fetal condition. This is based on:</div><div style="text-align: justify;">    a. 60% of pregnancies will end in spontaneous labor at gestational age 40-41 weeks and 80% at 43 weeks gestation.</div><div style="text-align: justify;">    b. With the advancement of medical technology for monitoring the welfare of the fetus, the fetus can still be retained in the uterus during the situation is still good.</div><div style="text-align: justify;">2. Active, without seeing the state of the cervix, induction should be performed on fetuses that have a risk for experiencing postmaturitas syndrome or when the pregnancy reaches 308 days of age (44 weeks). Pregnancy should also be immediately terminated if the biophysical profile scoring 0-2, found oligohydramnios (<2 cm in greatest sac or amniotic fluid index <5), variable decelerations encountered in no-load test, load test results with positive, ripe cervix (Bishop score > 6), there PJT or patients with complications such as preeclampsia or diabetes mellitus.</div><div style="text-align: justify;">Genesis long obstructed labor, uterine inertia hypotonic and fetal distress during labor will increase, so that the induction of pregnancy serotinus intrapartum monitoring should be more stringent. Induction can be performed with oxytocin by intravenous drip or by the use of prostaglandin preparations.</div><div style="text-align: justify;">In some cases even exceed 42 weeks gestational age, placental function remains good, resulting in a large baby (> 4000 grams) that can complicate delivery. In this case the action performed cesarean section.</div><div style="text-align: justify;">At the time of delivery, amniotic fluid state is considered important. If meconium staining has occurred or even coagulation with blackish green, so baby born resuscitation should be done immediately. Ideally directly performed tracheal intubation and rinsing</div>

By  Deden Sura Agung DEFINITION Pregnancy serotinus is a pregnancy that lasted 42 weeks (294 days) or more, calculated from the first day of...

MENSTRUATION DISORDERS

<div style="text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div style="text-align: justify;"><b style="font-family: georgia; text-align: left;"><br /></b></div><div style="text-align: justify;">Abnormalities of menstruation is most reason for women to visit obstetricians and gynecologists, and menorrhagia are the most common cause in women with iron deficiency anemia in the western world. Menstrual abnormalities that were found to be abnormalities of the amount of blood removed or duration of bleeding that occur each cycle. Menstrual disorders that can be encountered is amenorrhoea, oligomenorrhoea, menorrhagia and dysmenorrhoea.</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>AMENORRHOEA</b></div><div style="text-align: justify;">A symptom of ovarian dysfunction and reproductive systems are usually associated with infertility problems. Definition is the state does not obtaining menstruation more than 6 months (not in a state of pregnancy). Amenorrhoea can be divided into: </div><div style="text-align: justify;">1. Primary Amenorrhoea, if a woman never gets menstruation until the age of 16 years. </div><div style="text-align: justify;">2. Secondary Amenorrhoea is the absence of menstruation for more than 6 months in women who usually get a regular menstrual cycle or can be up to 12 months in women who usually experience oligomenorrhoea.</div><div style="text-align: justify;">The successful management of amenorrhoea depends on the accuracy of diagnosis and assessment of patient needs. Patients should be given an explanation of fertility problem, hirsutism, delayed secondary sexual development and protection against osteoporosis. Besides anamnesis and thorough physical examination, investigation is also needed, particularly those leading to endocrine disorders. Here is the algorithm evaluation in women with amenorrhoea.</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>THERAPY </b></div><div style="text-align: justify;">Women with ovarian disorders require sex steroid hormone therapy with estrogen and progesterone are periodic. Estrogen hormone deficiency may be detrimental to bone and blood vessels, and therefore there is a suspicion in women with Turner syndrome was not optimal bone growth and higher risk for fracture. In addition, replacement hormone therapy can improve fertility in patients with ovarian disorders. In women with low gonadotropin concentrations are needed ovulation induction with gonadotropin therapy.</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>MENORRHAGIA</b></div><div style="text-align: justify;">Are spending too much blood and is usually accompanied by blood clots during menstruation, occurs on a regular menstrual cycle. Normal amount of menstrual blood are removed each is about 50 ml, but the upper limit of normal menstrual bleeding is 80 ml. Causes of menorrhagia can be divided into 4 categories: A coagulation disorder, incidence of menorrhagia is closely linked to conditions such as thrombocytopenic purpura and von Willebrand's disease. In women with thrombocytopenia, excessive menstrual blood can be attributed to the low number of platelets that is when menstruation occurs. In these circumstances, splenectomi known to reduce the amount of blood that comes out with a significant. However, the discharge of excessive menstrual blood can also be found in the normal state of coagulation system. Two dysfunctional uterine bleeding (PUD) is abnormal bleeding from the uterus (long time, frequency, amount) that occurs within and outside the menstrual cycle, with no organ abnormalities, hematological and pregnancy, and is the process of hypothalamic disorders - pituitary - ovarian. PUD can be divided into 2 PUD, PUD ovulation and anovulation.</div><div style="text-align: justify;"> - PUD ovulation, is an idiopathic bleeding. Found that there are some products that alter endometrial vasoconstriction and the effect on the amount of bleeding when menstruation.</div><div style="text-align: justify;">- PUD anovulation, usually due to an inadequate signal, for example in polycystic ovarian disease or in the premenopausal state. Could also be due to an interruption in such a positive feedback system in children.</div><div style="text-align: justify;">3 suspected menorrhagia associated with uterine fibroids, pelvic infections, endometrial polyps, foreign bodies such as the intrauterine device in the uterus, myometrial hypertrophy and vascular abnormalities. 4 medical disorders, menorrhagia associated with various endocrine disorders such as Cushing's disease hipothiroidism and although the mechanism of occurrence is unknown. If thyroid disease is the cause, need to look for other symptoms such as abnormal weight gain, hair loss and constipation.</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>DYSMENORRHOEA </b></div><div style="text-align: justify;">Dysmenorrhoea means painful menstruation. Is a complex phenomenon, accompanied by cramps in the lower abdomen. Pain radiating to the back and legs, and usually accompanied by gastrointestinal disorders, neurological and malaise. Pain can be felt before, during and after menstruation. Can be either colicky or constant. Based on the etiology, dysmenorrhoe can be divided into 2 primary dysmenorrhoea and secondary dysmenorrhoea.</div><div style="text-align: justify;">1. Dysmenorrhoea primary (idiopathic) There are various theories that explain why women may experience dysmenorrhoea, namely </div><div style="text-align: justify;">2. Hyperactivity of the uterus, was first presented in 1932. Since then, studies continue to be done to prove the truth of this theory. Patients often describe the pain like the pain during childbirth, and increased contractility of the uterus can be seen by measuring and comparing the intra-uterine pressure in women with dysmenorrhoea with women who did not experience it. </div><div style="text-align: justify;">3. Endothelins represents a potential in the uterus uterotonin women who are not pregnant. Allegedly involved in the contraction of smooth muscle myometrium. </div><div style="text-align: justify;">4. Prostaglandins, has been known that women who experienced dysmenorrhoea have increased synthesis of PGF 2 alpha on endometriumnya. No known reason why the level of prostaglandins in this setting increases. Primary Dysmenorrhoea occurred almost always in the cycle of ovulation and steroid hormones thought to affect the concentration of prostaglandins in the uterus and myometrial contractility. </div><div style="text-align: justify;">5. Vasopressin contained substances other stimulants in non-pregnant women, such as vasopressin which is a vasoconstrictor which stimulates uterine contractions. It was found that concentrations of vasopressin on the first day of menstruation of women with dysmenorrhoea higher when compared with women who did not. Therefore vasopressin analogue suspected to be an alternative in the management of dysmenorrhoea. </div><div style="text-align: justify;">6. Secondary Dysmenorrhoea, this condition can be associated with pelvic and uterine disorders such as fibroids, IUD, PID, adenomyosis, endometriosis or cervical stenosis. The cause of the pain itself is not so clear and the use of inhibitors of prostaglandin synthesis is not very effective to relieve pain. To find the etiology of menorrhagia and dysmenorhoea, required a complete diagnose. Characteristics to look for bleeding. Bleeding a lot, regular, cyclic without any spotting between cycles can lead to dysfunctional uterine bleeding. While the history of progressive pain during menstruation and is accompanied disparenia can lead to endometriosis. Also Asked postkoitus pelvic pain and bleeding. Endometrial cancer risk factors such as the use of tamoxifen, estrogen therapy, polycystic ovarian syndrome and obesity should always be sought in a diagnose. On physical examination may be obtained hipoparatiroid symptoms, anemia or blood clotting disorder. </div><div style="text-align: justify;">Abdominal and pelvic examination is mandatory in patients with symptoms of menorrhagia. In the laboratory examination of hemoglobin should not be overlooked when the patient's complaint is menorrhagia, and iron supplementation should be given when necessary. TSH and T4 is not absolutely necessary, unless there are other things that lead to a state of thyroid disorders. In addition, intra-uterine examination is also required to assess the direction of malignancy, which is usually found in women over age 45 years with irregular bleeding and acquired risk factors. The method can be performed to assess the endometrium are: </div><div style="text-align: justify;">7. Dilatation and curettage </div><div style="text-align: justify;">8. Hysteroscopy </div><div style="text-align: justify;">9. Endometrial sampling </div><div style="text-align: justify;">10. Ultrasound</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>MENORRHAGIA AND DYSMENORRHOEA </b><b>MANAGEMENT </b></div><div style="text-align: justify;">Currently divided into 3 parts:</div><div style="text-align: justify;">1. Non-hormonal (inhibitor of prostaglandin synthesis, antifibrinolitik and ethamsylate). Antifibrinolitik commonly used is an acid that can traneksamat reduce menstrual bleeding by 50%. These drugs are quite effective with minimal side effects that depend on the dose. NSAIDs is an inhibitor of prostaglandin synthesis which is the drug of choice for menorrhagia. The principle works is to decrease the concentration of endometrial prostaglandin. The drugs are usually used mefenamic acid, but keep in mind the side effects are gastrointestinal disorders such as syndrome of dyspepsia, nausea and diarrhea. Ethamsylate believed to decrease capillary fragility of endometrial, but not yet widely used because the results vary. </div><div style="text-align: justify;">2. Hormonal (progesterone, oral contraceptives and hormone replacement therapy). Synthetic progesterone is used widely for the treatment of menorrhagia. The effect is thus suppress endometrial glands are depleted and epithelium and decidual transformation formed thinner. There are several types of progesterone, cyclic progesterone, sustainable progesterone and intrauterine progesterone. In addition progesterone may also be given estrogen-progesterone combination, such as danazol or GnRH analogues. </div><div style="text-align: justify;">3. Surgical treatment. There are several things you can do with the way surgery is hysterectomy, endometrial ablation techniques and endometrial resection transervikal by way of thermal balloon and microwave endometrial ablation.</div>

By  Deden Sura Agung Abnormalities of menstruation is most reason for women to visit obstetricians and gynecologists, and menorrhagia are th...

Enteric fever (typhoid) is a systemic disease

<div style="text-align: justify;"><span style="font-family: georgia; text-align: left;">By </span><b style="font-family: georgia; text-align: left;">Deden Sura Agung</b></div><div style="text-align: justify;"><b style="font-family: georgia; text-align: left;"><br /></b></div><div style="text-align: justify;">Enteric fever (typhoid) is a systemic disease characterized by fever and abdominal pain caused by the spread of Salmonella typhi or Salmonella paratyphi. At the beginning of this disease called typhoid fever because it has clinical symptoms similar to typhoid.</div><div style="text-align: justify;">But in the early 1800s, typhoid fever is clearly defined as pathological abnormalities in the form of a disease that is different (unique) because the basic rule of diseases associated with enlarged lymph nodes Plaque Peyeri and mesenterik. In 1869, based on the site of infection, enteric fever term proposed as an alternative term to distinguish typhoid fever from typhus. However, at present the two terms are often swap places.</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>EPIDEMIOLOGY</b></div><div style="text-align: justify;">Some things that affect the spread of typhoid fever in developing countries is to population density, source of drinking water, food production, antibiotic-resistant strains, difficulty determining the identification and management of careers, delay making a definite diagnosis, pathogenesis and virulence are not yet fully known, and there is no vaccine, effective safe and cheap.</div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;">Bacteria S. typhi can survive in dried and frozen environments, sensitive to chlorination and pasteurization process at a temperature of 630 C. These organisms can survive several weeks in the ice, dust, dry waste, and clothes, able to survive on garbage for one week and can breed in milk, meat or its products without changing the color or shape.</div><div style="text-align: justify;">Humans are the only source of natural transmission via direct or indirect contact with a sufferer of chronic typhoid or career. Transmission of germs, especially with how to swallow food or water contaminated with human feces. Congenital transmission occurs from a mother who experienced bacteremia to the baby in the womb, or infected at birth by a mother is a career typhoid with faecal oral route.</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>ETIOLOGY </b></div><div style="text-align: justify;">Typhii Salmonella is a Gram negative, have flagella, no capsule, no spore-forming facultative anaerobes. Having a somatic antigen (O) consisting of oligosaccharides, flagelar antigen (H) consisting of protein and envelope antigen (K) consisting of polysaccharides. Having makromolekular lipopolysaccharide complexes that form the outer layer of the cell wall and called endotoxin. Typhi Salmonella can also obtain the R-factor plasmid associated with resistance to multiple antibiotics. </div><div style="text-align: justify;"><br /> </div><div style="text-align: justify;"><b><span style="color: #bf9000;">PATHOGENESIS</span></b> </div><div style="text-align: justify;">Path entry of bacteria into the body </div><div style="text-align: justify;">Infections acquired by swallowing contaminated food or drink and can also be by direct contact of contaminated fingers feces, urine, respiratory secretions, or with a pus-infected patients. To be able to cause clinical symptoms, is needed S. typhi in a dose of 106-109. In the early phase of typhoid fever are common symptoms of upper respiratory tract. It is possible that some of these germs into the bloodstream through the lymphoid tissue in the pharynx. At this early stage patients also often complain of pain swallow. The tongue was dirty white membrane closed to white to brown which is the result of epithelial cell death by the bacterium S. typhi. If there is an infection of the nasopharynx through the fallopian tubes into the ear of the middle eustachi and this can happen otitis media. </div><div style="text-align: justify;">In the stomach, organisms met with acidic pH and low in germs destroyed. Slow gastric emptying is a physiological protector. After going through the stomach acid barrier mikroorganiusme get to the small intestine and met two of the body's defense mechanisms, namely motility and normal intestinal flora. Decrease intestinal motility because of drugs or anatomical factors increase the degree of severity of disease and the incidence of complications, and to extend the state of konvalesens career.</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>CLINICAL MANIFESTATION</b></div><div style="text-align: justify;">In children, typhoid fever incubation period between 5-40 days with an average of 10-14 days. Clinical symptoms of typhoid fever varies from mild clinical symptoms and do not require special treatment to severe and should be treated. The variation of these symptoms are caused by strains of Salmonella factors, nutritional and immunological status of host and a long illness at his home. </div><div style="text-align: justify;">All patients with typhoid fever is always suffer in the early disease. In the era of antibiotic usage is not like today, the appearance of fever in typhoid fever cases have specific terms of the step ladder temperature chart that is marked by fever arising insidius, then rise gradually each day and reaches its highest point at the end of the first week, after that the fever will last high and at week-4 fever down slowly in lysis, except in the event the focus of infection such as cholecystitis, soft tissue abscess then the fever will settle. Many parents reported that patients with typhoid fever higher during the afternoon and evening than the morning premises. When fever is high, in the case of typhoid fever can be accompanied by symptoms of central nervous system, such as foggy consciousness or delirium or obtundasi, or decreased consciousness from apathy to coma.</div><div style="text-align: justify;">Other systemic symptoms that accompany the onset of fever are headache, malaise, anorexia, nausea, myalgia, abdominal pain, and sore throat. In cases of severe clinical-looking, high fever at the time would seem toxic / ill. Even can also ijumpai typhoid fever patients who come with hypovolemic shock due to lack of fluid intake and diet. Gastrointestinal symptoms in cases of typhoid fever vary widely. Patients may complain obstipasi, obstipasi then followed an episode of diarrhea, in some patients was dirty with a white tongue in the middle is reddish edges and ends. Many common symptoms meteorismus, in contrast to Western books on Indonesian children more prevalent than splenomegaly hepatomegaly. </div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>MEDICATION</b></div><div style="text-align: justify;">The majority of patients with typhoid fever can be treated at home with bed rest, adequate insulation, fluid needs, nutrition and provision of antibiotics. As for severe cases should be treated in hospital for the fulfillment of fluid, electrolytes and nutrition in addition to observation of the possible complications can be done carefully. </div><div style="text-align: justify;">Chloramphenicol is still the first choice in the treatment of patients with typhoid disease. The dose given was 100 mg / kg body weight / day divided into 4 times the provision for 10 to 14 days being the case with malnutrition or disease, treatment can be extended to 21 days. Chloramphenicol One disadvantage is the high relapse rate and a career. But the child that it is rarely reported. </div><div style="text-align: justify;">Ampisilin respond less clinical improvement when compared with chloramphenicol. The recommended dose is 100-200 mg / kg body weight / day divided 4 by oral administration or intravenous injection. Amoxicillin with a dose of 100 mg / kg body weight / day divided 4 times giving equivalent results with chloramphenicol, although a decrease fever longer. Trimetophin sulfamethoxazole combination gives results that are less good than chloramphenicol. In several countries have reported cases of typhoid fever resistant to chloramphenicol. Ceftriaxone and sefoperazon can provide cure rates of 90% and 0-4% relapse. Lately cefixime oral 15-20 mg / kg / day of the first 10 times can be given as an alternative, especially if the number of leukocytes <2000 or encountered resistance S.typhi. </div><div style="text-align: justify;">In severe cases, such as typhoid fever, delirium, coma or shock, high-dose dexamethasone 1-3 mg / kg body weight / day in addition to appropriate antibiotics can reduce mortality. Typhoid fever typhoid edngan premises npenyulit intestinal bleeding sometimes require blood transfusion. Whereas if perforation is suspected, the fluid in the peritoneum and free air on abdominal x-ray can help establish the diagnosis. Immediate laparotomy should be performed on intestinal perfusion didertai addition of antibiotic metronidazole may improve prognosis.</div><div style="text-align: justify;"><br /> </div><div style="color: #bf9000; text-align: justify;"><b>PREVENTION</b></div><div style="text-align: justify;">In general, to minimize the possibility of contaminated S.typhi, then each individual must consider the quality of food and drinks they consume. Salmonella typhi in the water will die if heated setting of 57 ° C for several minutes or by the process of iodination / chlorination. </div><div style="text-align: justify;">Food, heating to a temperature 57 ° C a few minutes and can also be equally deadly germs like salmonella typhi. Decrease endemicity of a country / region depends on the merits of water supply and waste disposal arrangements and the level of individual awareness of personal hygiene. Active immunization can help reduce the incidence of typhoid fever. </div><div style="text-align: justify;">Typhoid Fever Vaccine </div><div style="text-align: justify;">Three kinds of vaccine for typhoid fever, namely that contains the germ that is turned off, the bacteria live and components Vi of Salmonella typhi. Vaccines containing salmonella bacteria tyhi, S. paratyphi A, S. paratyphi B are turned off (TAB vaccine) has been used for decades by giving subcutaneous injections, but these vaccines provide only limited immunity, in addition to local side effects at the injection site quite often. Vaccines that contain germs live attenuated Salmonella typhi (Ty-21a) was given orally three times with interval of hose a day, giving the 6-year protection. Ty-21a vaccine given to children aged over 2 years. On the result of research in the field of protection efficacy is inversely proportional to the degree of disease transmission. The vaccine contains components of the Salmonella typhi Vi given intramuscular injection provides protection 60-70%.</div>

By  Deden Sura Agung Enteric fever (typhoid) is a systemic disease characterized by fever and abdominal pain caused by the spread of Salmone...