Khazanah Riset

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CHAPTER III INFECTIOUS DISEASE 73

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The Worsening Factors of Dengue Hemorrhagic Fever (DHF) Based on Cohort Study with Nested Case-Control in A Tertiary Hospital Soroy Lardo, M H N E Soesatyo, Juffrie and S R Umniyati Abstract The clinical pathway of DHF has a broad pathophysiological and pathogenesis spectrum. Clinical and laboratory characteristics are some of the parameters to determine the factors that contribute to the worsening of the disease. The objective of this study is to determine the clinical and laboratory characteristics which contribute to the worsening of DHF. The study had been conducted from January 2012-December 2014 at the general ward of the Internal Medicine Department, Indonesia Army Central Hospital Gatot Soebroto. There were 101 male patients (64.7%) and 55 female patients (35.3 %) ages ranging from 14 - 62 years old. The diagnosis was divided into: 124 patients DHF grade I, 6 DHF grade II, 20 DHF grade III and 6 with dengue shock syndrome (DSS) patients. Clinically and statistically, there were 4 variables apparently found with the severity of DHF, as follows: decreased appetite with p = 0.007 (OR 4.87), hepatomegaly with p = 0.009 (OR 27.00), systolic blood pressure with p = 0.037 (OR 0.95), and initial thrombocyte with p = 0.000 (OR 0.97). This cohort and nested case-control study found that worsening of DHF is related with decreased appetite, hepatomegaly, systolic blood pressure and initial thrombocyte count. 75

The Effect of A Unique Propolis Compound (Propoelixtm) on Clinical Outcomes in Patients with Dengue Hemorrhagic Fever Lardo Soroy, Sulistyo Bagus, Iswandi Purnama Yongkie, Wibisono Djoko Abstract Background: Dengue fever is a mosquito-borne virus belonging to the family Flaviviridae. It is an old virus that has re-emerged globally over the past 20 years and now causes a global burden of 50 million infections per year across approximately 100 countries. Despite this, there is no safe vaccine available, and therapy is largely supportive. Its pathogenesis is multifaceted and currently still poorly understood, leading to a lack of disease-specific therapy. Propolis is a natural antiviral and anti- inflammatory product derived from the saps of plants and mixed with the saliva of honeybees. Propoelix™ is a uniquely potent and water-soluble extract of propolis containing high concentrations of anti-inflammatory compounds like caffeic acid phenethyl ester. Objective: The primary objective is to determine the effectiveness of a unique propolis extract (Propoelix™) on the clinical course of patients with dengue hemorrhagic fever (DHF). The secondary objective is to examine the effect of Propoelix™ on tumor necrosis factor-α (TNF-α) levels in patients with DHF. Methods: A double-blind, randomized, placebo- controlled trial was conducted at the Department of Internal Medicine, Gatot Soebroto Central Army Hospital in Jakarta, Indonesia, from May 2012 to July 2013. Sixty-three patients who met the inclusion criteria were enrolled in the trial. Patients were randomized to receive either two capsules of Propoelix™ 200 mg three times a day or placebo daily for 7 days. Clinical and laboratory variables of both groups, including the anti- inflammatory marker TNF-α, were investigated. Patients were deemed technically fit for discharge if their platelet counts had recovered and exceeded 100,000/µL but were all observed as inpatients for 7 days. Results: There were 31 patients in the Propoelix™ treatment group and 32 patients in the placebo group. Platelet counts in the Propoelix™-treated group showed a trend toward a faster recovery by day 3 of admission and became statistically significant by day 6 (101.42±48.79 vs 80.78±43.35 [103 /mL], P=0.042) and day 7 (146.67±64.68 vs 107.84±57.22 [103 /mL], P=0.006). Patients treated with Propoelix™ had a significantly greater decline in TNF-α levels on day 7 of therapy compared with patients in the 76

placebo group (P=0.018). They also had a significantly shorter length of hospitalization compared with those in the placebo group (4.69±0.78 days vs 5.46±1.16 days, P=0.012). Conclusion: Propoelix™ appears to hasten the improvement in platelet counts and TNF-α levels and shortens the duration of hospitalization in patients with DHF. Keywords: effectiveness, Propoelix™, DHF 77

Association of Initial Intracellular Signalling Pathway and Cytokine Level with Early Mortality in Severe Sepsis Patients KC Lie, D Widodo, S Lardo, Eppy & R Sinto Abstract Introduction: During the course of systemic inflammation, most of the immune cell types get activated to a certain degree as part of, or contributing to, the cascade of physiopathological events. Whether for some cells, classically phagocytes of the innate immune system, it is clear that direct sensing of pathogen-associated molecular patterns leads to activation initiating systemic inflammation, the picture is not so clear for natural killer (NK) cells. While NK cells have been shown to express toll-like receptors (TLR), the role of these receptors on NKs during systemic inflammation has not been directly addressed. Methods: To directly assess the role of TLR expression on NK cells we used an adoptive transfer model in which NKs purified from the spleens of WT, TLR4KO and TLR2/4DKO mice were transferred intravenously to RAG2-/-gc-/- (devoid of T, B and NK cells). Five days after reconstitution the mice were challenged intraperitoneally with conventional or TLR-grade lipopolysaccharide (LPS). Immune cell activation and production of IFNƔ by NK cells was determined after 6 hours by FACS analysis. Results: We observed no differences in reconstitution of the recipient mice with NK cells from different backgrounds suggesting no difference in trafficking and survival of the transferred cells. At 6 hours after LPS challenge, WT, TLR4KO or TLR2/4DKO NK cells recovered from the spleen and lungs of RAG2-/-gc-/- mice showed comparable levels of CD69 activation marker expression. Intracellular labeling for IFNƔ in NK cells also revealed no significant differences. Conclusion: Whether there is a role for direct TLR signaling on NK cells remains the objective of further investigations; however, our data show that in the course of a systemic inflammatory process, like endotoxinemia, the expression of TLR2 and TLR4 by NK cells makes no difference in terms of their activation and secretion of IFNƔ. 78

Sepsis Pulmonary Embolism Following Appendectomy Surgery Soroy Lardo, Anna Ariane, Khie Chen Abstract Septic Pulmonary embolism is a rare condition where there were numerous pulmonary infarcts resulting from blood clot emboli that also contains microorganism. This disorder is insidious onset, It is clinical features usually unspecific and the diagnosis usually difficult to establish. A 43 old woman who underwent an appendicitis surgery, reentered the hospital at the sixth day after surgery presented with fever, pain at the surgical site, progressive severe dyspnea and chest tightness. From the physical examination finding there were tachycardia, tachypneu, wet rough basal rhonki on the right rear and tenderness at right lower region of the abdomen. The thorax-abdomen CT scan result was pleuropneumonial with minimal effusion in the right side. A CT angiography scan of the chest and abdomen showed intralumen emboli in medial lobe segmen of right pulmonary artery, right pleuropneumonia with segmental lession in segmen 10 right lobe and inflammation process along right lateral wall of the abdomen. Laboratory results that also supported diagnosis were D dimer 3442 ng/mL and culture result from surgical site pus showed E. Coli ESBL (+). Base on these findings, this case was established as a septic pulmonary embolism. Keywords: septic pulmonary embolism, appendicitis surgery, E. coli ESBL (+) 79

Concurrent Infections of Dengue Viruses Serotype 2 and 3 in Patient with Severe Dengue from Jakarta, Indonesia Soroy Lardo, Yaldiera Utami, Benediktus Yohan, Seri MMU, Tarigan, Widayat Djoko Santoso, Leonardo Nainggolan, R. TedjoSasmono Abstract Objective: to describe the clinical manifestation of patient with severe dengue, to identify the serotypes and genotypes of dengue viruses (DENV) which concurrently infecting the patient, and to explore the possible relationship of severe dengue with the concurrent infection of DENV. Methods: Dengue diagnosis was performed using NS1 antigen detection and IgG/IgM ELISA. Standard clinical and laboratory examinations were performed to obtain the clinical and hematological data. DENV concurrent infections were detected and confirmed using RT-PCR and DENV Envelope gene sequencing. Phylogenetic analyses were performed to determine the genotypes of the viruses. Results: The patient was classified as having severe dengue characterized by severe plasma leakage, hemorrhage, and organ damage involving lung, liver, and kidney. Concurrent infection of DENV serotype 2 and 3 was observed. The infecting DENV-2 virus was grouped into Cosmopolitan genotype while DENV-3 virus was classified into Genotype I. Both viruses were closely related to isolates that were endemic in Jakarta. Viremia measurement was conducted and revealed a significantly higher virus titer of DENV-3 compared to DENV-2. Conclusions The occurrence of multi-serotype DENV infections was presented in a patient with severe clinical manifestation in Indonesia. The hyperendemicity of dengue in Indonesia may contribute to the DENV concurrent infections cases and may underlie the severity of the disease. Keywords: Severe dengue, Concurrent infections, DENV-2, DENV-3 80

Preliminary Study of Safety and Toxicity of Cempedak Capsules as an Alternative Complementary Drug for Malaria Prophylaxis at Nanga Badau, Kalimantan Soroy Lardo, A. Widyawaruyanti, I. Tantular, W. Budiman, B. Sulistyo, A. Fakhrizal, A. F. Hafid, D. Rusdianto, B. Y. Rimba and Nasronudin Abstract Background: The increasing rate of travelling especially to endemic areas and the emergence of malaria parasites resistant to current antimalarial drugs become major problems in malaria control. These conditions raise the need of research in developing new drugs to fight malaria, particularly chemoprophylactic drugs. Plants are the most potential sources of antimalarial drugs, especially cempedak (Artocarpus champeden). In Indonesia, cempedak had been used empirically in malaria treatment. The extract of cempedak stem bark was known in exhibiting antimalarial activities in vitro against Plasmodium falciparum as well as in vivo on Plasmodium berghei infected mice. As an attempt to develop cempedak plant as an herbal medicine to overcome malaria, the extract of cempedak stem bark was formulated and produced in capsules form (cempedak stem bark ethanol extracts, EEC). These capsules were intended to be used as a complementary therapy in increasing the efficacy of antimalarial drugs as well as in reducing the rise of drugs resistance of malaria parasites. Our previous study of complementary therapy of EEC and artesunate proved that EEC was effective as complementary drugs in malaria treatment. Preclinical and clinical studies have shown that EEC had potential as complementary drugs in malaria treatment and are safe without any toxic effects to the liver and kidney functions. Methods: This study was an experimental research with a randomized controlled trial design. EEC capsule used in this study was produced by Institute of Tropical Disease Universitas Airlangga in collaboration with pharmaceutical company, PT Kimia Farma Tbk. Each EEC capsule contained 120 mg of cempedak stem bark ethanol extract. This study took place in the operational task area of Indonesia - Malaysia border at Nanga Badau Kalimantan as a malaria-endemic area. The subjects treated in this study included 100 soldiers of Infantry Battalion 315 assigned in that area. These soldiers were divided into three groups. Group I was given one EEC capsule twice a day. Group II was given one capsule of 100 mg doxycycline twice a day. Group III was given one placebo capsule twice a day. The drugs 81

were given to the soldiers three days before departure and 27 days after arrival in the endemic area, starting from 26th June to 25th July, 2014. The drugs safety was evaluated by microscopic studies of venous blood sampling completed every three days whereas the drugs toxicity was determined by kidney and liver functions examined every ten days. Results: The results showed that 100 soldiers were not infected of malaria based on the microscopic results. Liver and kidney functions were found to be normal in all groups. In group I, the AST mean was 29.06 ± 9.71 U/L; ALT mean was 31.23 ± 12.21 U/L; BUN (Blood urea nitrogen) mean was 23.78 ± 4.12 mg/dL; creatinine mean was 0.43+0.13 mg/dL. In group II, the AST mean was 29.72 ± 10.01 U/L; ALT mean was 25.87 ± 12.98 U/L; BUN mean was 20.90 ± 5.26 mg/dL; creatinine mean was 0.37 ± 0.13 mg/dL. In group III, the AST mean was 30.08 ± 9.71 U/L; ALT mean was 26.68 ± 7.46 U/L; BUN mean was 22.93 ± 5.51 mg/dL; and creatinine mean was 0.40 ± 0.12 mg/dL. The statistical analysis found that there was no significant difference among the three groups, including the early and mid comparisons of the research with p value of > 0.05. Conclusion: EEC capsule as complementary drugs for malaria prophylaxis was safe without any toxic effects to the liver and kidney functions when given for onemonth at a dose of 120 mg twice a day Keywords: Artocarpus, Stem bark, Prophylaxis, Malaria, Indonesia 82

A Clinical Profile of Hepatitis A Patients in Jakarta, Indonesia Randy Adiwinata, Andi Kristanto, Timoteus Richard, Daniel Edbert, Frida Angelina, Soroy Lardo, Erni J Nelwan Abstract Background: To determine the incidence of hepatitis A infections and the clinical profiles of adult patients admitted to public hospitals in Jakarta, Indonesia. Methods: This was a cross-sectional study that utilised consecutive secondary data from internal medicine wards of seven public hospitals in Jakarta between 2011 and 2013. Eligibility criteria included patients over the age of 18 years and an ICD-10 diagnosis code of B15, acute hepatitis A. Case proportion was reported per 1000 people by dividing incidence per year to total in-ward patients. Clinical profiles were reported descriptively. Laboratory results were compared and categorised into groups of patients aged below and above 25 years old. Results: Data revealed that hospitalisations of patients with hepatitis A had decreased from 2011 to 2013. 289 patients were studied, the majority were young adults (18-25 years old) and their common chief complaints were nausea (36%), fever (24%), and jaundice (21%). Higher bilirubin levels were seen in older patients. There were 13 patients coinfected with hepatitis B, one patient coinfected with hepatitis C, and one patient coinfected with HIV. Conclusions: The proportion of hepatitis A infection amongst adults admitted to public hospitals in Jakarta was low and had decreased during the study period. Most of the patients reported classical clinical manifestations. This study found that the targeted age group may benefit from receiving routine hepatitis A vaccinations. Keywords: epidemiology, Hepatitis A, Indonesia, vaccination 83

The Autoimmune Mechanism in Degue Hemorrhagic Fever Soroy Lardo, Marsetyawan HNE Soesatyo, Juffrie, Sitti R. Umniyati Abstract The immune response of dengue fever/dengue hemorrhagic fever is a series of immunopathogenesis processes starting from viral infection to the target on monocytes and macrophages. It may consequently cause a cascade of viremia in the circulation that stimulates the afferent, efferent, and effector mechanism by the interaction of the humoral and complement system. The cascade results in inflammatory substance that will affect capillary permeability and activate coagulation factors leading to further effects on endothelial level. The mechanism involving pathogenesis of DHF/DSS is still vague. So far, a theory of heterologous infection has been developed, which explains that on second infection, there is subneutralization that induce viral replication. The autoimmune mechanism development leads to the better understanding of DHF. It also explains the autoimmune response of the viral infection, which consists of molecular mimicry, bystander activation and viral persistence. The development of the autoimmune pathomechanism is related to the role of autoantibody and endothelial dysfunction that may have role in worsening DHF. Keywords: autoimmune, dengue, hemorrhagic fever 84

Adult-Onset Still’s Disease as A Differential Diagnosis in Prolonged Fever: Diagnosis and Treatment Experience Felix F. Widjaja, Diah Martina, Soroy Lardo, Suryo A. K. Wibowo Abstract Adult onset Still‟s disease is a rare systemic disease that may involve many organs and may mimick many disease such as infection, autoimmune disease, and also malignancy. The diagnostic approach and treatment strategies have not been well established due to its rarity; however, there are some diagnostic criteria that may help. We present a case of 36-year old man who experienced high prolonged fever which firstly thought as infection. He also had unilateral wrist and knee joint pain and maculopapular rash. Laboratory examination showed high leukocytes count with elevated polymorphonuclear neutrophil count, high platelet count, high ferritin levels, and negative results of many infection markers (typhoid antibody, procalcitonin, malaria test, blood culture, urine culture, IgM pneumonia, ASTO, syphilis test, antiHIV, HBsAg, antiHCV, etc). Chest X- ray, joint X-ray, ultrasonography, and echocardiography showed normal result. The patient was then diagnosed with Adult-onset Still‟s disease and received intravenous methylprednisolone and the fever was disappeared in 3 days. Six months later the arthralgia appeared again, methotrexate was administered and the pain was then relieved. Keywords: adult onset Still’s disease, prolonged fever, diagnosis, treatment. 85

Plasmodium Ovale Infection After One Year Mefloquine Prophylaxis in A Young Indonesian Soldier Frans Liwang, Dewi M. Ratih, Soroy Lardo Abstract Malaria chemoprevention using mefloquine has become the WHO standard regimen for military personnel who stay in the endemic area for an extended period of time. We reported a case of Plasmodium ovale infection in a young Indonesian Soldier following one year mefloquine prophylaxis 250 mg weekly. Typical fever and chills were experienced two weeks after returning from one year duty in Congo, West-Central Africa. The diagnosis of ovale malaria was made by peripheral blood smear, and 35/250 parasites in small microscopic view was found. Then, he recovered after dihydroartemisin and primaquine combination therapy. This was an unusual case of long-term prophylaxis failure since mefloquine has been recognized as the agent for malaria prevention, even multi-drug-resistance Plasmodium. Dormant stage of Plasmodium ovale, quinoline-resistance potential, and the efficacy of mefloquine itself are discussed as the cause of that phenomenon. Keywords: plasmodium ovale, mefloquine, malaria prophylaxis, tertiana malaria 86

Diagnostic Validity of Blue Plasma Lymphocyte for Dengue Infection Diagnosis Yongkie Iswandi Purnama Abstract The gold standard modality for confirmation of dengue infection is not feasible at all primary health care facilities and remote areas in Indonesia. The amount of blue plasma lymphocyte will increase in dengue cases and it can be counted using simple equipment. This study was conducted to measure the diagnostic validity of blue plasma lymphocyte for confirmation of dengue infection diagnosis This study was an observation cross-sectional study as diagnostic test. Subjects were patients admitted in Sanglah hospital with diagnosis suspect dengue infection and aged 12 years old or more. Subjects were recruited by consecutive sampling. The gold standards for confirming dengue infection were NS1 antigen or anti dengue IgM antibody. Blue plasma lymphocyte was counted by 2 clinical pathologists using Giemsa staining peripheral blood smear on the 6th day since the onset of fever. The counting result was reported in percentage of 100 leucocytes. Data was analyzed by statistic computer software include Bland-Altman limit of agreement, receiver operating characteristic curve, and 2x2 table. Total subjects were 70 patients, consist of 44 (62.9%) males and 26 (37.1%) females. There were 24 (34.3%) dengue confirmed subjects. Mean percentage of blue plasma lymphocyte counting result was 8.75 ± 6.64 in dengue confirmed subjects and 2.30 ± 2.43 in subjects who were not dengue confirmed. Sensitivity more than 80% could be achieved by blue plasma lymphocyte cutoff value 2.5 or less. Specificity more than 80% could be achieved by blue plasma lymphocyte cutoff value 5.5 or more. The conclusions of this study were: blue plasma lymphocyte cutoff value 2.5 or less could be used as screening tool and cutoff value 5.5 or more could be used as dengue infection diagnostic tolls. Keywords: blue plasma lymphocyte, dengue, diagnostic validity. 87

Factors Related to ODHA in Carrying Out ARV Therapy in RSPAD Gatot Soebroto Central Jakarta Antonius Ivan Priyono Saputro Abstract Antiretroviral (ARV) is a drug that until now is the only major benefiter for people with HIV (ODHA). ARV aims to increase the CD4 lymphocytes and improve the quality of life of the sufferer by suppressing the maximum HIV replication. Compliance is crucial in carrying out ARV therapy if it is expected to work effectively and not cause further long-term health problems. The purpose of this challenger is to analyse the relationship between knowledge, conception and support of the family with ODHA compliance in conducting ARV therapy. This type of research is analytic with cross sectional study design conducted in May-August 2016 in RSPAD Gatot Soebroto. The number of samples in this study was 130 respondents. The research instruments used are questionnaire that contains the characteristics of respondents, ARV treatment compliance, knowledge, conception and support of the family. Analysis of the data on this research is the analysis of Univariate and bivariate which uses Chi square test with a confidence level of 95% and α = 0.05. The results of the study gained as much as 23.8% of respondents did not observe antiretroviral treatment, while 76.2% obeyed treatment. The results of the statistical test conducted acquired the relationship between knowledge (P = 0,032) and conception (P = 0,000), on the contrary there is no relationship between family support with ODHA compliance in undergoing ARV therapy (p = 0,217). The conclusion of the study is that there is a relationship between knowledge and conception, but there is no relationship between family support and the compliance of the ARV therapy. 88

Factors That Influence Survival of Antiretroviral (ARV) Theraphy Patients in One Hospital in Jakarta 2007-2017 Fauziah Hasani Abstract Antiretroviral therapy (ARV) is a revolution in the treatment of HIV/AIDS patients. Some prognosis factor that are known to affect the survival of ARV patients are age, gender, education level, marital status, clinical stage, functional status, initial CD4 level transmission of HIV, opportunistic infections, type of ARV used, and adherence. This study aims to determine prognosis factors that influence the survival of ARV therapy patients at the Central Army Hospital (RSPAD) Gatot Soebroto Jakarta in 2007-2017 the design of this study was retrospective cohort using medical record data on ARV therapy patients at Gatot Soebroto Hospital in Jakarta. The study sampel was a native ARV patients.This study found the probability of survival of antiretroviral therapy patients is opportunistic infections, where patients who have opportunistics infections have a risk of death 9.5 times compared to those who do not have opportunistic infections. Keywords: survival, antiretroviral therapy, prognosis factors 89

Analysis of Biological Factors Affecting The Quality of Life of ODHA Patients in HIV Polyclinics RSPAD Gatot Soebroto Ditkesad 2014 Jaemi Abstract The quality of life of HIV/AIDS is very important to note because the infection is chronic and progressive, wide impact on all aspects of life both physical/biological, psychological, social, and spiritual. Physical/biological problems especially opportunistic infections, stadium clinics, immune system (CD4) and drug side effects to be analyzed in this research identification and explaining the analysis. The study used the study plan of cutting latitude and recruiting samples by 64 respondents as many as 64 respondents with purposive sampling techniques. The results showed that most respondents had poor quality of life (56.3%) With infusion caching (70.3%) With Symptomatic Clinic Stadium (68.8%), with the immune system (CD4) < 350 (75%) and drug side effects (39.1%). In correlation analysis there is a meaningful relationship between biological factors (opportunistic infection, clinical station, immune system (CD4) and drug side effect with quality of life with value of OR = 4.012. The recommendation of this research is that it is necessary to monitor and evaluate the intervention to improve the immune system with a healthy lifestyle, taking regular and regular antiretroviral drugs and prevention and treatment of biological problems. Keywords: opportunistic infections, stadium clinics, immune system. Drug side effects, quality of life of ODHA . 90

Relationship Prediction of Mortality and Vulnerability in HIV-Infected Indonesian Army Period in 2018 Deka Larasati Abstract The use of antiretroviral therapy provides the impact of lowering mortality and the condition of the vulnerability (frailty) in HIV-infected individuals. Therefore individuals with HIV infection can perform activities in accordance with the functional capacity like normal individuals. One assessment of the current vulnerability level is based on fried phenotype criteria involving physical activity as a component of the Stabiler. VACS Index is a tool to determine the prediction of mortality has a component age, CD4 counts, the number of HIV-1-RNA viruses, hemoglobin, Fib-4 eGFR and infectious Hepatitis C. The purpose of this research seeks the link between mortality's prediction with the degree of vulnerability in HIV- infected TNI AD soldiers. The research design is Cross Sectional. A total of 100 ARMY soldiers who have used antiretroviral therapy at least 1 month in medicine at the HIV Service clinic in 4 rumkits TNI AD Following the research of sample recovery methods using consecutive sampling method. A total of 98% of male genders with ages from 23 to 56 years. 88% educated high school, 57% in the rank of Tamtama, 7% officers and the rest of Bintara. A total of 48% served in Kodam Jaya, 49% of Javanese ethnicity, 21% Batak, 68% using Antiretrovirus Fixed Dose Combination Therapy (TDF-3TC-EFY) with duration of treatment from 1 to 11 years. There is a significant association (SIG-2 tailed 0.009) between Vacs Index which is a predictor of mortality with a degree of vulnerability according to the Fried phenotype criteria with Coefesien correlation 0.261. Keywords: frullty, VACS index, army soldier, HIV 91

Integrated System of Monitoring and Evaluation of TB HIV Collaboration in The Gatot Soebroto Central Army Hospital Elisabeth Sri Lestari Handayani Abstract This thesis discusses about integrated system of monitoring and evaluation of TB HIV collaboration in The Gatot Soebroto Central Army Hospital from The research found that the running system still has a problem that is not able to product completely. Quickly and accurately information Incomplete of recording and reporting led to difficulties in producing indicators of TB HIV collaborative activities and other problem such as raise proportion of patients who ever missed/passed follow-up-every year in this system of monitoring and evaluation adds inputs and process to complement the output so that monitoring and evaluation can be integrated and expected to assist management of organization in activities program. Help produce quickly and completely information that will be useful for providing information in decision making, program planning anf may increase adherence (compliance of patients taking medication) and the draft SOP for supporting the system integrated monitoring and evaluation can be developed because of the data of routine. TB and HIV patient care which is the basic information for surveillance, Where one of the best systems to obtain this information through a computerized TB recording system alse records information of HIV status and from this information can be used for monitoring and indentifying at an early stage areas where HIV testing and TB screening programs should be developed. Keywords:System monitoring and evaluation, TB HIV collaboration, which is integrated 92

Increases Quality of Life HIV AIDS Patient with Pressure Ulcers Siti Anisah Abstract Background. Elderly people frequently have wounds such as pressure ulcers. These occur especially in frail elderly. Patients have pressure ulcers at home needs special education and support of nurses or the order caregiver professional health. These patient also taken of effectiveness modern dressing so easier to use and less frequently follow up. The dressing has to be changed less frequently; this means longer periods of rest for the wound, promotes healing, and reduces the risk of potential maceration. Finally, the patient‟s quality of life is this improved. Methods. Share an experience reported 3 cases study of elderly patient with extremely pressure ulcers on her body. Results. Modern dressing and appropriate nursing wound care had a quality of life for elderly patients and successful healing. Conclusion. The foam dressing for 3 weeks on a 4rd degree pressure ulcers with necrotic and high level of exudate showed the following: foam dressing managed in an optimal way the high level of exudate in the first phases of treatment. These was no leakage from dressing and no maceration of the peri_ulcers skin was observed. The autolytic and osmotic debridement were promoted, and necrotic tissue was cleaned from ulcers. During the next phase of healing, where the amount of exudate decreased, the wound bed didn‟t dry out and granular tissue was given sufficient protection. Healing was promoted and the patient feel comfortable throughout. Family support, enough resources material modern dressing, control good level glucose with self monitoring blood glucose (SMBG) caring all. Family, caregivers and nutritional supported the whole healing processed. 93

Difference of Procalcitonin Levels in Gram-Positive and Gram- Negative Bacterial Sepsis Patients of Indonesia Army Central Hospital Gatot Soebroto In 2016 Nindy Handayani, Soroy Lardo, Nunuk Nugrohowati Abstract Objective: To determine the difference of procalcitonin levels between Gram-positive and Gram-negative bacterial sepsis patients. Methods: This study used quantitative method with cross sectional approach. The population of this study were bacterial sepsis patients of Gatot Soebroto Army Hospital in 2016. The samples were divided into two groups, they were Gram-positive and Gram-negative bacterial sepsis patients with the number of each group were 30 samples. The technique of data collection was using consecutive sampling. The data from medical record were analyzed by using independent t test. Results: This study showed that mean levels of procalcitonin in Gram- positive bacterial sepsis patients was 6.47 ng/ml and Gram-negative was 66.04 ng/ml. There was a significant difference between mean levels of procalcitonin in Gram-positive and Gram-negative bacterial sepsis patients of Indonesia Army Central Hospital Gatot Soebroto in 2016 with p value = 0.000 (p < 0.05). The most causative bacterial species of Gram-positive bacterial sepsis patients was Staphylococcus epidermidis and Gram- negative bacterial sepsis patients was Klebsiella pneumoniae ssp pneumonia. Conclusions: The mean difference of procalcitonin levels in Gram- negative bacterial sepsis patients were higher than Gram-positive bacterial sepsis patients, because Gram-negative bacteria have lipopolysaccharide which is a strong immunostimulator and increase TNF-α production higher than Gram-positive bacteria. Keywords: Procalcitonin Levels, Gram-positive Bacteria, Gram-negative Bacteria, Bacterial Sepsis 94

The Relationship Between APACHE II SCORE and The Mortality of Sepsis Patients in The Intensive Care Unit (ICU) of Indonesia Army Central Hospital Gatot Soebroto January - December 2013 Hendra Leofirsta , Soroy Lardo, Sri Wahyuningsih, Hartono, Dis Bima Purwaamidjaja Abstract Sepsis is a systemic inflammatory response that occurs as a result of the presence of pathogenic microorganisms that enter the blood circulation. The death rate from sepsis is still very high in the intensive care (ICU) in hospitals of developing countries and developed countries. The mortality rate for septic patients in the ICU around 20% for sepsis, 40% for severe sepsis, and> 60% for septic shock. Based on that, we need a scoring system that can predict the risk of death of patients. APACHE II SCORE is one of the grading system of the human body physiological variables that have good accuracy for predicting the risk of death in patients affected by certain diseases that are often used in the ICU at the hospital. The purpose of this study was to determine the relationship between APACHE II SCORE with the mortality in sepsis patients at ICU Gatot Subroto Army Hospital during the period January to December 2013. This research is analytic- Observational cross-sectional design. The number of sample were 129 patients, and the sampling technique using a consecutive sampling. Data were analyzed by chi square test. Chi-square statistical test using software obtained probability (p) on the independent variables tested were APACHE II score (p: 0.000) with a value of α = 0.05. Thus it can be concluded that there is a relationship between APACHE II score at ICU mortality in sepsis patients Gatot Subroto Army Hospital. Keywords : ICU, Mortality of sepsis patients, APACHE II SCORE 95

The Diagnostic Test of Nelwan Score Towards Tubex Tf Titer (Anti- Salmonella IgM) to Diagnose Typhoid Fever at RSPAD Gatot Soebroto In 2014-2015 Mochammad Hargo, Soroy Lardo, Sri Wahyuningsih Abstract Typhoid fever remains to be public health problem in tropical countries including Indonesia with the incidence of 760-810 cases for 100.000 population a year. This disease placing the third rank in the list of Top Ten Inpatient Disease in hospital. Typhoid fever is a systemic infection disease caused by Salmonella typhi. The diagnosis of typhoid fever can be made by history taking (anamnesis), physical examination, and laboratory examination. Currently, the most preferred examination which is used as main reference is Tubex TF test,because the test provide a rapid result and good sensitivity and specificity value. However, history taking and physical examination can also be used to diagnose typhoid fever by using Nelwan Score method. This diagnosis method is easier, simpler, and more economical. The aim of this study was to see the diagnostic value of Nelwan Score method towards Tubex TF test. This study was an analytic observational study using cross sectional design which type of diagnostic test. The number of samples was 66 which obtained from typhoid fever inpatient medical record at RSPAD Gatot Soebroto in 2013-2015 and the data was analyzed using diagnostic 2x2 table test. The result was Nelwan Score established sensitivity of 94%, specificity of 87% and accuracy of 90%. This result showed that Nelwan Score has a good and proper diagnostic value so that can be used as a method to diagnose typhoid fever easier, simpler and more economical. Keywords : Typhoid fever, Tubex TF, Nelwan Score, sensitivity, and specificity 96

Anti – NS1 Antibody in Dengue Hemorrhagic Fever: Role as Predictor for Severity and Protective Function Lardo S, Marsetyawan, Juffrie, Umniyati SR Abstract Background: Dengue Hemorrhagic Fever is a disease found in the tropics. It is caused by four serotypes of dengue viruses and transmitted by the Aedes aegypti mosquito. Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) are the true spectrum of the disease. When a patient with either DHF or DSS is not handled well, death may result. The mechanism of the DHF/DSS pathogenesis is still unclear. Currently, there are several mechanisms that explain the auto-immune response of the viral infection, such as: molecular mimicry, bystander activation and viral persistence. According to WHO, the decrease of thrombocyte and the increase of hematocrit may the sign DHF. Several new researches prove that DHF is caused by an auto-immunephenomena sparked off by dengue viral infection. Based on the above finding, it is important to know wether NS1 auto-immune antibody plays significant roles in the severity of DHF. Method: The nested case control study on DHF grade I and II based on the WHO 1997 crieteria, was conducted at Indonesia Army Central Hospital Gatot Soebroto from January 2012 - December 2014. The method of sampling was based on consecutive sample. For DHF Grade III/DSS group, total sampling was conducted whereas for DHF Grade I/II group, random sampling was conducted using Epicalc 2000 Software. Measurement of Anti NS1- antibody of IgM and IgG anti- NS-1 between severe and non-severe DHF patients was made, unpaired with alternative Mann-Whitney. The correlation between NS1 and thrombocyte again using Pearson, followed by a probability test via a multivariate test of DHF severity. Results: Our investigation shows that there is a severe DHF with an average thrombocyte of 59.500 /µL at the early of treatment and an average of 28.500 /µL for day 4-5 of treatment.A proportional analysis was made of the NS1 antibody and thrombocytopenia and the TNFα content on severe DHF. Obtained proportion of Ig M Anti NS1 (+) to platelets > 50,000 33.3% compared to platelets <50,000 27.3%. Proportion of TNFα (+) to platelets > 50,000 33.3% compared to platelets < 50,000 for 20.0%. Proportion Ig M Anti NS1 (+) more in the control group (DHF Grade I) amounted to 78.7% compared to the case group (GradeIII DHF/DSS) of 97

30.4 % (p < 0.001, OR 0, 12) . After multivariate analysis and probability test, it was found that a significant proportion among DHF parameters namely platelet count < 50,000/ µL, ALT > 40 U/L , Leucocyte < 4,500/ µL with positive results of Ig M Anti NS1 and Ig G Anti- NS1. Conclusion: IgM antibody positive Anti NS1 proportionally found to be greater in the control group (DHF Grade I/II ) with (p < 0.001 , OR 0.12). Based on multivariate analysis it also related to the parameters that indicate worsened DHF like decreased platelets value, ALT and decreased leucocyte. Ig M Anti NS-1 could not be a positive predictor of severe DHF, but it can be a protective factor against clinical worsening of DHF. Keywords: NS I Antibody – DHF – Thrombocytopenia 98

Therapeutic Response of Grazoprevir Plus Elbasvir in Chronic Hepatitis C Infection Patients on Maintenance Hemodialysis and Associated Factors Dwi Edi Wahono, Aida Lydia, Irsan Hasan, Ikhwan Rinaldi Abstract Background : Patient on hemodialysis are at risk of Hepatitis C Virus infection. HCV infection increase mortality related chronic liver and cardiovascular disease. DAA cure rate for HCV infection above 90%. Most DAA metabolite eliminated by kidney. Grazoprevir-Elbasvir is the drug of choice for chronic HCV infection in hemodialysis patients, and have higher cure rates and less adverse events. Until now the factor that influence therapeutic response is still unknown. Objective : Assessing therapeutic response and side effect of Grazoprevir- Elbasvir for Hepatitis C Virus in routine hemodialysis patient. Method : Cohort prospective observational study on all patients with Chronic HCV infection with routine HD. Clinical and Laboratory Data was collected and analysed for therapeutic response and determined the factors that related with therapeutic response. Viral load, degree of fibrosis, and duration of HD treatment and relation with respons SVR12 as analysed using bivariate method of statistical analysis Inclusion criteria for respondent in this study is routine HD patient age ≥ 18 years with a positive HCV RNA, willing to participate in the study and sign the inform consent. Exclusion criteria in this study is patient with uncomplete medical record or with hepatocellular carcinoma or decompensated cirrhosis. Result : 75 subjects that met inclusion criteria. The average age in this study is 50,2 ± 13,2 years with age range from 19-80 years old, In this study, chronic hepatitis C patients who underwent HD with female sex were more than men, 56% and 44% respectively. In this study the median duration of HD was 6.2 years, with a range of 8 months to 21 years. The highest prevalence of HCV RNA was obtained in the first 3 years of undergoing HD (38.9%). The duration of HD is 6.9±4.7 years, with the duration of infection with VHC was 4.01 ± 2.86. There is a correlation between the duration of HD and the duration of HCV infection (p<0.05) In this study before starting therapy and EBV GZR, found subjects with HCV RNA viral load<800.000 IU/mL more than ≥800.000 IU/ml. respectively 57.3% and 42.7%. Subjects who received GZR and EBV 99

combination therapy were patients with Metavir F0-F3 (non cirrhosis) and F4 (cirrhosis) with compensated liver fibrosis. In this study the number of non-cirrhotic subjects (Metavir score F0-F3) was 80.6% more patients than hepatic cirrhosis (Metavir score F4) was 19.4% with median transient elastography result 7.5 kPa (2.8–70 , 6 kPa). The most common underlying disease for ESRD is glomerulonephritis 20 subject (27%), followed by hypertension 19 subject (26%). SVR12 achievement is 97,2%. 2 subjects experienced treatment failure where 1 patient relapsed and 1 patient did not respond to therapy. Relapsed patients had mild liver fibrosis (F1) and 7.04 x 105 IU / mL VHC RNA. From SVR12 subgroup analysis there was no significant association between sex, age, HCV RNA baseline, degree of fibrosis, or duration of undergoing HD and SVR12 achievement in chronic hepatitis C patients undergoing routine HD. (Figure 4) The relative risk of SVR12 based on viral load. Conclusion : Grazoprevir-Elbasvir therapy in HD patient with chronic HCV is effective, and minimal side effects. SVR12 is not influenced by viral load, degree of fibrosis or duration of HD. Keywords: Hemodialysis; Hepatitis C Virus infection; SVR12; GrazoprevirElbasvir; DAA 100

Therapeutic Response of Grazoprevir Plus Elbasvir in Routine Hemodialysis Patients with Chronic Hepatitis C Virus Infection and Factors Associated with Sustained Virological Response Dwi Edi Wahono, Aida Lydia, Irsan Hasan, and Ikhwan Rinaldi Abstract Background: Patients on hemodialysis are at risk of hepatitis C virus (HCV) infection. Chronic HCV infection increases mortality related to chronic liver and cardiovascular disease. Direct Acting Anti-viral (DAA) is a therapeutic choice for HCV infection in patients with Chronic Kidney Disease (CKD) including patients who are hemodialysis-dependent. But until now the treatment of HCV infections in hemodialysis patients are suboptimum because most of the DAA metabolite eliminated by the kidney. Grazoprevir plus elbasvir is the drug of choice for chronic HCV infection in hemodialysis patients which has strong anti-viral effects and minimal adverse events. However, the therapeutic response of grazoprevir plus elbasvir in routine hemodialysis patients in Indonesia and the factors associated still unknown. Objective: Assessing therapeutic response of grazoprevir plus elbasvir for chronic HCV infection in a routine hemodialysis patients and factors associated with sustained virological response at 12 weeks after the end of treatment (SVR12). Methods: Observational prospective cohort study on all routine hemodialysis patients with chronic HCV infection that received grazoprevir plus elbasvir for 12 weeks. Clinical and laboratory data, including age, gender, baseline HCV RNA, degree of liver fibrosis, duration of hemodialysis treatment and achievement of rapid virological response (RVR) were analyzed using bivariate method of statistical analysis for determining factors related to SVR12. Results: Seventy-five subjects met inclusion criteria. The average age is 50.2±13.2 years, subjects with female were more than male. The average duration of hemodialysis is 6.9±4.7 years. SVR12 achievement is 97,2%. Relative risk of SVR12 based on viral load. Conclusions: Grazoprevir plus elbasvir therapy in hemodialysis patients with chronic HCV is an effective, and minimal adverse event. SVR12 is not influenced by either viral load, degree of fibrosis or duration of hemodialysis. Is 6.9 ±4.7 versus ≥800.000 were 1.01 (95%Cl 0.93-1.10, 101

p=1.00), score Metavir F4 versus to F0-F3 were 0.95 (95%Cl 0.81-1.10 p=0.35), achieved RVR duration of hemodialysis <3 years versus ≥3 years were 1,04 (95%Cl 0.99-1.09 p=1.00). the adverse effect of this drug is minimal. Keywords: grazoprevir plus elbasvir; hemodialysis; hepatitis C infection 102

The Correlation of Inappropriate Antibiotic Prophylaxis with Post Laparatomy Surgical Site Infection at Gatot Soebroto Army Central Hospital Year 2014 to 2017 Yuliarna Sari dewi, Asri Adisasmita, Syahrizal Syarif, Soroy Lardo Abstact Surgical Site Infection (SSI) is one of the most commonly infection found Healthcare Associated Infection's (HAI's) type as surgery procedure increases. Laparotomy is the type of surgery that is the most at risk for infection. One of the prevention efforts of surgical site infection is antibiotic prophylaxis administration before, during and up to 24 hours after surgery in cases of clinically missing signs of infection. This study aims to determine the correlation of inappropriate antibiotics prophylaxis with the post laparatomy surgical site infection in Army Central Hospital (RSPAD) Gatot Soebroto from 2014 to 2017. The research design was case control study with retrospective data retrieval, using 268 samples from medical record data of post laparotomy patient at Army Central Hospital (RSPAD) Gatot Soebroto from 2014 to 2017, (cases of 67 patients with SSI and control of 201 patients without SSI). Data was analyzed using regression logistic conditional matching test. The result of the study showed that the inappropriate timing of antibiotic administration in preoperative treatment made a risk of 5.17 times higher on the incidence of surgical site infection (OR = 5.17; 95% CI = 1.85-14.40) after control of other variables. Covariate variables, related to the incidence of surgical site infection, was digestive operation diagnose (OR = 3.51; 95% CI = 1.04-11.83), albumin level (OR = 3.83; 95% CI = 1.30-11.25) and comorbid disease (OR = 4.05; 95% CI = 1.40-11.66). The results of this study hopefully can be an input data for Army Central Hospital (RSPAD) Gatot Soebroto, to improve adherence of correct timing, type, dose and duration of antibiotics prophylaxis according to guidelines of surgical site infection prevention. Keywords: Antibiotic Prophylaxis, Surgical Site Infection, Laparato 103

Association Between Opportunistic Infection and CD4+ T Lymphocyte Counts among HIV-Infected Patients Taking Antiretroviral Therapy in Gatot Soebroto Central Army Hospital Fatia A Ramadhana, Elisabeth Handayani, Soroy Lardo, Yongki Iswandi Purnama, Sri Wahyuningsih, Alexander K Ginting Abstract Background: HIV infection has become a significant health challenges in the world, include in Indonesia. The high HIV infection mortality rates were associated with opportunistic infection manifestations. It has been known that declining CD4+ T lymphocyte counts as an indicator of immunological status of HIV-infected patients is increasing the risk of that manifestation among patients not taking antiretroviral therapy. The aim of this study was to determine the association between opportunistic infection and CD4+ T lymphocyte counts among HIV-infected patients taking antiretroviral therapy in Gatot Soebroto Central Army Hospital in 2011 – 2012. Methods: An observational analytical – retrospective study was conducted with cross-sectional study design. Secondary data were collected from medical record and analyzed using the Mann-Whitney test. Results: 87 samples were enrolled in this study. Most samples were male and in reproductive age. The main sources of transmission were heterosexual (69.0%) and intravenous drug user (13.8%). Most samples were in the clinical stage III (63.2%). About 83.9% using combination of the first line antiretroviral drugs consisted of Zidovudine, Lamivudine, and Nevirapine. The most common opportunistic infections present were pulmonary TB (87.3%), candidiasis (69.0%), and pneumonia (22.5%). Median CD4+ T lymphocyte counts before taking antiretroviral therapy was 75.00 cell/mm3 and mean CD4+ T lymphocyte counts after 6 months taking antiretroviral therapy was 234.85 cell/mm3. The statistic analysis results of association between opportunistic infection and CD4+ T lymphocyte counts before taking antiretroviral therapy showed p = 0.003 (p < 0.05) and association between opportunistic infection and CD4+ T lymphocyte counts after 6 months taking antiretroviral therapy showed p = 0.040 (p < 0.05). Conclusion: Opportunistic infection was associated with CD4+ T lymphocyte counts before and after 6 months taking antiretroviral therapy. Keywords : HIV infection, opportunistic infection, CD4+ T lymphocyte counts, antiretroviral therapy 104

Patterns of Sepsis Based on Representation of Multiple Organ Dysfunction Syndrome (MODS), Kind of Microorganism, Antibiotic Combination and Mortality Rate in ICU of Paviliun Kartika Indonesia Army Central Hospital Gatot Soebroto Dessy Krissyena, Yongki Iswandi Purnama Soroy Lardo, Cut Fauziah, Dis Bima Purwaamidjaja Abstract Introduction : Sepsis is a disease commonly found in intensive care unit that caused by SIRS (Systemic Inflammatory Response Syndrome) and infection. Sepsis is diagnosed based on clinical manifestation that presents multiple organ failure (MODS) with the suspicion or confirmation of microorganism finding in blood. This research aimed to know characteristics and patterns of sepsis. Method : The design of study was cross-sectional. Samples from patients aged more than 20 years old who hospitalized in ICU of Paviliun Kartika Indonesia Army Central Hospital Army Hospital, Jakarta from September 2012 until Desember 2013. Results : There were 40 subjects fulfilled inclusion criteria. The most primary disease is lung disease (45%). Classification of sepsis based on medic problem (75%), whereas post-operative (25%). Patients who suffered MODS (40%), that coagulation system failure is the most organ failure. The most detected microorganism from bacteria is Klebsiella sp (40%), followed by Enterobacter aerogenes (17.5%), while from fungi is Candida sp. (10%). Patients who suffered MDR (85%). Patients who received 2 combination antibiotic therapy (65%) with consuming antibiotic time during 1-6 days (60%). Anti fungal therapy was given to 32.5% patients. Patients who died because of sepsis (57.5%). Conclusion: The most primary disease is lung disease. Only few patients that suffered MODS, with coagulation system failure is the most. The most microorganism is Klebsiella sp.Majority patients encounter MDR. Patients more get two combination antibiotic with consuming antibiotic time during 1-6 days. Mainly, patients have died. Keywords: sepsis, MODS, MDR, microorganism, antibiotic combination, mortality rate 105

Sofa Score Value and Infection Source Description in Sepsis Patients Who Run in Hospital in General Care Indonesia Army Central Hospital Gatot Soebroto Kemal Fariz Kalista, Yongki Iswandi Purnama, Soroy Lardo, Khie Chen Abstract Background: Sepsis is a systemic manifestation response that is destructive to an infection. Sepsis can cause a more severe gradation, namely severe sepsis and sepsis shock. One of the scoring systems used to assess the severity of organ dysfunction and to predict output in sepsis, severe sepsis and sepsis shock is the SOFA (Sequential Organ Failure Assessment) score. This study aims to look at the description of SOFA scores and sources of infection in sepsis patients treated in the Indonesia Army Central Hospital Gatot Soebroto Method: The study used a cross-sectional study conducted at the Gatot Soebroto Army Central Hospital. Sampling was carried out in the general care ward (PU) floor 1 to 6th floor of all sepsis patients treated. from November 4 to December 18, 2013. Result: In this study 21 patients with sepsis were collected. The average SOFA score in this study was 4.7 and the majority of patients had a SOFA score <11 (95.2%). And obtained if the SOFA score ≥ 11 then the mortality rate is 100% while if <11 the mortality rate is 20%. The majority of patients had type 2 diabetes mellitus (DM) comorbid (42.9%), comorbid malignancy (19%) and hypertension (19%). Pneumonia was the main cause of sepsis in this study with 52%, followed by skin and soft tissue infection (SSTI) with 24%, then urinary tract infection (UTI) by 10%. In patients who died it was found that the most sources of infection were pneumonia (60%) and SSTI (40%). Whereas the main comorbid factor in patients who died was DM type 2 (60%), followed by malignancy (20%) and systemic lupus erythematosus (20%). Conclusion :SOFA score at the time of diagnosis of sepsis can describe the condition of organ dysfunction that occurs in sepsis patients and can be used as one of the scores to estimate the patient's prognosis. Pneumonia is the most common source of infection in sepsis patients and in sepsis patients who die. Type 2 DM is the most common comorbid factor in sepsis patients and in sepsis patients who die. Keywords: SOFA Score - Sepsis 106

Drug Eruption Pattern in HIV / AIDS patients at The Voluntary Counseling and Testing (VCT) Clinic Indonesia Army Central Hospital Gatot Soebroto Iin Rahmania Inayatillah, Dyani Taher, Elizabeth Handa, Yongki Iswandi Purnama, Soroy Lardo, Alexander Ginting Abstract Patients infected with HIV have a high risk for eruption medicine compared to the general population, so it has an effect significant effect on the patient's condition and subsequent treatment options. This matter probably due to immune system dysregulation, metabolic disorders of drugs or due to polypharmacy. The most common forms of drug eruption in HIV-infected patients include exanthematous morbilliform eruption, hyperpigmentation, urticaria, Stevens-Johnson syndrome, epidermal toxic necrolysis and drug hypersensitivity syndrome. The research conducted aims to determine the characteristics and patterns of drug eruption in HIV patients visiting the Gatot Hospital VCT clinic Soebroto There were found 24 patients infected with HIV who experienced an eruption medicine, most are aged between 30-35 years of age the majority of men. The pattern of drug eruption that occurs is partly mild ie urticaria and the eruption of maculopapular drugs and nevirapine are drugs most cause drug eruption in HIV patients. Keywords: HIV, drug eruption, antiretroviral 107

Odontogenic Acute Rhinosinusitis Mulyaningrum Moerseto Abstract Background: Odontogenic acute rhinosinusitis is inflammation of the nasal cavity mucosa and paranasal sinuses that lasts for less than 12 weeks and has an etiology of odontogenic infection. Purpose: To explain diagnosis and management in case of odontogenic acute rhinosinusitis. Case: 43-year-old male patient with complaints of unilateral purulent rhinorrhea and left-sided facial pain for 4 weeks. Management: Management of odontogenic acute rhinosinusitis includes conservative therapy and surgery. Surgical therapy is mainly performed to restore the function of paranasal sinus drainage ventilation and eradication of infection to prevent orbital complications. In this case functional endoscopic sinus surgery (FESS) was performed. Conclusion: Management of odontogenic acute rhinosinuitis is selected based on clinical manifestations. Surgery with an endoscopic exploration approach has advantages such as high success rates and low complications. Keywords: odontogenic acute rhinosinusitis, orbital complication, functional endoscopic sinus surgery 108

The Frequency of TB in Patients with DM Treated in General Care RSPAD Gatot Soebroto Sutami Abdullah, Susi Setiowaty, Syafruddin ARL Abstract Introduction: World Burden on Diabetes mellitus (DM) and tuberculosis is very large. Nearly a third of the world's population is infected with Mycobacterium tuberculosis and about 10% of it is at risk of developing into an active form of illness depending on its interactions. Increased cases of TB in DM patients also occur in Indonesia. Quite a lot of patients who experience TB and it increases the morbidity and mortality of TB with DM. Method: Design research is a descriptive research cut latitude by using data collection based record hospital medical patient in the general treatment room RSPAD Gatot Soebroto Jakarta from January S. D December 2012. Results : There are a total of 602 patients who enter on the six floors of the public treatment room RSPAD with the diagnosis of diabetes mellitus and there are 8 of 602 who suffer from DM with pulmonary tuberculosis. Of the eight patients, the men were larger than women. The diagnosis is largely enforced with a photo check without a BTA sputum examination. Conclusion: In this research is obtained DM patients who suffer from TB from 602 DM patients only found 8 patients with DM with TB. Of the eight patients, men were more than women. Keywords: DM, TB 109

Comparison Study on : The Effectivity of Oral Hygiene Using Piper betle Boiled Water and Povidine Iodine 1% on The Number of Candidiasis and Level of Comfort in Patients with HIV/AIDS Elly Nurachmah, Dewi Gayatri, Siti Anisah, Soroy Lardo Abstract HIV (Human Immunodeficiency Virus) has infected and spread out around the world. The disease can cause human sef defense and immunity system decreased drastically. The disease also produces many complication effects that can worsening the physical condition of the patient. Oropharyngeal Candidiasis (OC) is the most opportunistic infection often experienced by the patients with HIV/AIDS (ODHA). This opportunistic infection has sign and symptom of dysphagia, esophagitis, and oral lesion with mucosytis (oral sore). The impact of this condition can lead to the comfort disturbances especially due to oral sore, decrease motivation to eat and sometime depression among severe cases. Many efforts include conventional medical intervention have been implemented in RSPAD Gatot Subroto involves using mouth rinse Povidone Iodine 1%. Many nursing literatures have concluded that one of the complementary therapies such as herbal therapy has been assumed can reduce suffering of OC in patients with HIV/AIDS. The most often method used is piper betle boiled water to rinse the patients‟ mouth with OC. A preliminary study to six ODHA who experienced OC has demonstrated a good result, but it has to be further approved empirically in order for others to use the same method effectively. The purpose of this research was to identify differences of the effectivity of mouth rinse use piper betle boiled water and povidone iodine 1 % to the number of candidiasis and level of comfort of patients with HIV/AIDS who experiencing OC. Design of the research. A Randomized Clinical Trial there were two intervention groups; piper betle boiled water and Povidone Iodine 1% groups. The number of respondents was 40 ODHA who experienced OC and intervention allocation is determined by blocked random. The setting was at RSPAD Gatot Subroto, Jakarta. The results showed that more than half of respondents is male and Intravenous Drug User (IDU) as the only cause of transmition. The 110

minimum education background of the respondents is senior high school. There is a significant different between mouth rinsing using piper betle boiled water and povidone iodine 1% in the level of comfort. There is no significnat different in the number of candidiasis between mouth rinsing using piper betle boiled water and povidone iodine 1%. The study recommends that replicated studies in other setting with a better design of research and the number of respondents, and also comparing with other mouth rinsing fluid are still required. 111

Esophageal Stricture Caused by Fungal Infection in HIV Patient Iin Indra Pertiwi, Nia Noviyanti Siregar, Deka Larasati, Diany Taher, Soroy Lardo Abstract Background: Incidence of esophageal candidosis has increased since many of HIV patient detected. Esophageal stricture is one of the complication esophageal candidosis infection and need comprehensive treatment. Case Presentation: A 36-year-old woman, suffering HIV and consuming antiretroviral (ARV) for three years, admitted to the hospital with chief complain unable swallowing since a year ago. This complain worsened progressively. The patient can swallow fluid and liquid food only. There is no history of swallowing corrosive products, recurrent vomiting, burned sensation in neck or chest. Patient has loss 10 kilograms of weight within a year. Epigastric pain and melena also happened within a year. Subfebrile condition has happened for 2 weeks later without any typical pattern. Patient has been diagnosed tuberculosis. She has been consuming anti tuberculosis drugs for 4 months. In physical examination, the patient has oral candidosis, epigastric pain, febrile temperature, and melena in rectal examination. Laboratory findings were normocytic normochrom anemia, leukocytosis, positif finding of the fecal blood smear, low number of CD4 (110 sel/uL). By esophagogastroduodenoscopy we found esophageal stricture 20 centimetres from oral cavity. Patient was treated by once daily of 150 mg oral fluconazole in 10 days, once daily of 960 mg cotrimoxazole, and non-spesific antibiotic for the pneumonia and urinary tract infection. Patient consumes liquid food. The parameters of infection were better. Procedure of esophageal dilatation will be held if patient unable swallowing anything and no clinical improvement with the therapy. Discussion: The etiologies of esophageal stricture were chronic esophagitis, swallowed of corrosive product, or recurrent infection. Esophageal infection caused by fungal mostly happened in HIV patient or steroid consumer. The treatment of esophageal stricture caused by infection is not only esophageal dilatation but also prevention of recurrent infection. Opportunistic infection caused by fungal are treated by antifungal and improvement of immune system. Adequate nutrition and antiretroviral drugs will repair the immune system and prevent infection. 112

Conclusion: Esophageal candidosis in HIV patient increases the incidence of esophageal stricture. The comprehensive treatments for this problem are adequate nutrition,antifungal drug, antiretroviral drug, and procedure of esophageal dilatation if needed. Keywords: Esophageal candidosis, esophageal stricture, HIV 113

Encephalopathy Dengue with Obesity and Melena Nur Chandra Bunawan, Andreas Pekey,Deka Larasati, Soroy Lardo Abstract Dengue, a flavivirus-arthroprode borne infection, is still contributing significant number of mortality and morbidity in tropical area. Clinical manifestation ranging from asymptomatic viral infection unto dengue shock syndrome. Since 1999 there is a significant increase in dengue incidence in Indonesia causing an increase number of atypical case or special population. Dengue infection in obesity is unique given the role of increasing White Adipose Tissue (WAT) in producing excess cytokine. As a consequences, patient with obesity is more prone to have severe dengue. We presented a case of 32 years old obese man presenting with decrease level of consciousness after having 3 days of fever. Patient also reported melena, nausea, diarrhea, and myalgia. Physical examination revealed BMI 32. Laboratory finding was positive for hemoconcentration, leucopenia, thrombocytopenia, increased liver transaminase, hyponatremia, and coagulopathy. Blood sugar was normal. Ig M and Ig G dengue were both positive. Procalcitonin level was 1.16. ECG and Chest x-ray was normal. Ultrasound revealed hepatosplenomegaly, bilateral pleural effusion, and minimal ascites. Patient was hospitalized and transferred to intermediate care unit. CVC was inserted, IV fluid resuscitation was given as severe dengue protocol from WHO 2011. Other treatment included PPI, vitamine C, paracetamol, hepatoprotector, and ceftriaxone. His hospitalization was complicated by pulmonary oedema on day 3 of admission which was responded with Furosemide. He was sent home on day 8th of admission with full recovery and mild increase of liver transaminase. Recognizing obesity as one of risk factor of severe plasma leakage could lead to prompt treatment and improve outcome in dengue patient. Keywords: Encephalopthy, Melena, Obesity 114

Eradication of Thypoid Carrier Pradipto Utomo, Andreas Pekey, Deka Larasati, Soroy Lardo Abstract Thyphoid carrier is a person whom his/her stool or urine contains S.typhi after a year have thyphoid fever without clinical manifestation. Thyphoid carrier is asymptomatic and 25% of the case deny of having a thyphoid infection. Thyphoid carrier often accompany by chronic infection of urinary tract and elevated risk of gall bladder carcinoma, colorectal carcinoma, pancreatic carcinoma, lungs carcinoma and other organs malignancy. Pathophysiology and pathogenesis process of thyphoid carrier was not well known. Body defense mechanism to Salmonella typhi was not well known. Cellular immunity suspected to have an important role. In Indonesia, thyphoid fever spread in all province with incidence in rural area 358/100.000 people/year and in urban area 760/100.000 people/year or aproximately 600.000 and 1,5 million cases per year. Moreover, fo the thyphoid carrier prevalence is aproximately 4% of all thyphoid fever. We presented a 48 years old male with chief complain of fever since 4 months before admission. In 2014 patient had history of thyphoid fever and had levofloxacin 1x500 mg for 7 days. Result of recent Tubex test was +6. Feses culture showed existence of Salmonella spp with resistant to Ciprofloxacin and Levofloxacin. Result of abdominal USG described fatty liver and right nephrolithiasis and showed no cholelithiasis. Then, patient was given antibiotic based on culture, in this case we choosed cefepim 2x1 grams for 7 days. Other therapy were miodex 3x1 and cernevit 1x1. After the administration of antibiotic, the result of gall culture and feses culture showed the absence of Salmonella spp. Keywords : Eradication, Thypoid Carrier 115

A Case of Deep Vein Thrombosis in Patient with Human Immunodeficiency Virus Infection: Diagnostic and Treatment Approach Jeremia Immanuel Siregar, Ariska Sinaga, Soroy Lardo, Deddy Zaelani Abstract Introduction: Human immunodeficiency virus (HIV) infection has been known as a prothrombotic condition in which the risk of serious complications such as deep vein thrombosis (DVT), pulmonary embolism, and thromboembolism could increased up to ten-fold compared with the general population.1 Proper diagnosis and management of DVT in patients with HIV is essential in order to reduce morbidity and mortality from this disease. Case Presentation: A 33-year old man was admitted to Indonesia Army Central Hospital Gatot Soebroto ward with chief complaint of swelling mainly on left leg since 2 weeks before hospital admission. The patient had history of HIV disease since 1 year ago with a risk factor of intravenous drug use. The results of a thorough history, physical examination and laboratory tests showed the patient had a deep vein thrombosis, in addition to the wells predictive value scores, which indicate a high probability for DVT. Patients were then treated with anticoagulant, analgesic, antiretroviral drugs, physiotherapy and the use of stockings. Significant improvement in clinical and laboratory values were obtained from the results of this treatment. Doppler ultrasound examination of the current outpatient evaluation in these patients showed no further thrombosis in these patients as well as other possibilities that can cause unilateral swelling in the limbs of these patients, concluding a resolved DVT in this patient. Discussion: Diagnosis of DVT in this patient was established based on clinical symptoms, wells score as well as significant increased in d-dimer values. Several studies have reported that HIV was associated with hypercoagulable state and endothelial dysfunctions, which could increase the possibility of thrombosis. Moreover, previous history of intravenous drug usage of this patient could increase the thrombosis risk up to fifteen-fold. Signficant reduction in the swelling of the leg after intensive anticoagulant therapy, as well as absence of vein thrombosis afterwards, showed by Doppler ultrasound, indicated that this patient suffered from thrombotic conditions. 116

Conclusion: This case report is one of many cases that indicate a prothrombotic state in patients with symptomatic HIV. Through this case, every physicians needs to include thromboembolism as a differential diagnosis in patients with non-infectious HIV, given the complications of the disease which can be fatal. With the approach of the diagnosis and prompt and proper treatment, morbidity and mortality of this disease can be lowered significantly. Keywords : DVT, Diagnostic and Treatment, HIV 117

Correlation of CD4 Counts, Adherence and Opportunistic Infection Toward Mortality Status of People With HIV/AIDS Treated with Antiretroviral Therapy in Gatot Soebroto Central Army Hospital Sariputri Deviana, Soroy Lardo, Suciati Yuli Abstract Background: Antiretroviral therapy clinically decreased number of mortality, also increased the quality of people with HIV/AIDS‟s life. Objectives: The study is proposed to discover the relation between CD4 counts, adherence and opportunistic infection toward the death of people with HIV/AIDS who treated with antiretroviral therapy for a year. Methods: The study applies cross sectional design,sample was taken consecutively started from March 2014 to May 2015 from RSPAD Gatot Soebroto internal medicine polyclinic using 73 respondents with HIV/AIDS. Results: Based on 73 respondents of people with HIV/AIDS which the percentage of male respondents 68,5% with range of age between 30-39 years old reaching 3rd-4th stadium with most frequent infection transmitted through heterosexual sex with adherence of antiretroviral therapy >95% (83,6%), the most frequent opportunistic infection are Tuberculosis and Oral Candidiasis with 13 respondents died. CD4 counts (p=0,00) and adherence (p=0,00) have correlation with the mortality status of people with HIV/AIDS treated with antiretroviral therapy. Although, opportunistic infection does not have correlation toward mortality status of people with HIV/AIDS (p=0,347). The adherence have bigger correlation (PR=62,5) toward the mortality status of people with HIV/AIDS compared with CD4 counts (PR=12,65). Conclusion: The adherence is the most influential factor toward the mortality status of people with HIV/AIDS treated with antiretroviral therapy. Keywords: CD4 counts, adherence, opportunistic infection, mortality, antiretroviral. 118

The Outcomes of Infants with HIV Infected Mother in A Tertiary Hospital in Indonesia Hapsari Widya Ningtiar, Leny Kartina, Dwiyanti Puspitasari, Dominicus Husada, Parwati Setiono Basuki, Ismoedijanto Abstract Background: Infant from HIV mother face the risk of HIV infection. Effective prevention on mother-to-child transmission (PMTCT) program increasing the number of uninfected infants in East Java Indonesia. This study describes the outcomes of infants with HIV mother in Dr. Soetomo Hospital, a tertiary referral hospital in East Java, related to outcome (infectious morbidity, nutritional status, immunodeficiency status, growth / development, and incidence of anemia). Methods: This cross-sectional study analyzed 0-18 months infant and HIV mother pairs at HIV outpatient clinic Dr. Soetomo General Hospital from January to April 2017. The data were collected and analyzed using Fisher‟s exact test and chi-square test with P<0.05. Results: Fourty HIV-infected mothers and infants pairs were analyzed, separated into two groups positive (3 infants) and negative (37 infants) Anti HIV PCR. There were 19 male. Age distribution (6 weeks-5 months 40%; 6- 11 months 47.5%; 12-18 months 12.5%). Five percent were born prematurely, 77.5% infant has normal birth-weight. Only 2.5% were fed breast milk, AZT-cotrimoxazole were given to 87.5% infant while the rest received AZT/3TC/NVP. Immunizations of the infants were mostly (60%) up to date. Infectious morbidity (P=0.433), WAZ-score (P=0.666), LAZ-score (P=0,973), WLZ-score (P=0.219) and incidence of anemia (P=0.548) were not significant differences between groups. The development test using DDST II (P=0,001), as well as immunodeficiency status [presence of immunodeficiency (P<0.001)] was significantly different between groups. Conclusion: There were significant effects of HIV exposed on the development and immunodeficiency status in 0-18 months infant. Keywords: HIV-exposed infants, outcomes, Prevention on mother-to-child transmission/PMTCT. 119

Infective Endocarditis Due to Burkholderia Cepacia in A Neonate E. Yonas, R. Pranata, and N. Nusarintowati Abstract Background: Burkholderia is a pathogen that is rarely seen on clinical cases, this or- ganism is being found in increasing number in hospitals. Case Report: A newborn was referred to our neonatal intensive care unit due to re- spiratory distress. Delivered the previous night via cesarean section. On physical ex- amination: intercostal retractions (þ) and weak cry(þ). Gestational history: pre- term, Small for gestational age, preterm premature rupture of membrane for 14 h. The newborn was initially diagnosed with respiratory distress syndrome upon arrival to our facility. CPAP was administered to the patient. Multiple antibiotics regiment consisting of ampicillin sulbactam, gentamycin, meropenem, and ceftriaxone were also administered to the patient. Insertion of PICC was performed. Lab: low blood al- bumin and globulin, anaemia, leukopenia. Blood culture: Bulkholderia cepacia (þ), resistant to ampicillin, piperacillin, amikacin, gentamicin, ciprofloxacin and cefazo- lin. CXR: suprahilar infiltrates on both lungfields, and right paracardial region. Echocardiography: two vegetations on tricuspid valve with dimension of 3.5 - 2 mm and 2.3 - 3.4 mm respectively. Discussion: Burkholderia can survive inside microbicides. This may originate from the improper use of these products. There have been reports of outbreaks associated with chlorhexidine gluconate and benzalkonium diluted using water containing bur- kholderia. It has been reported to cause sepsis and arthritis in pediatric patients. And as in another report of NICU outbreak of burkholderia, as in this case, all pa- tients have been exposed to intravascular procedures such as central IV line insertion or as in this case, PICC, also, all of the patients has been treated at an intensive care unit for some time. This signifies in the transmission of burkholderia itself, liq- uid, as like water, may mediate the transmission by spreading bulkholderia to equipments connected to intravascular devices. Conclusion: Burkholderia cepacia is a rare pathogen to be involved in infective endo- carditis. With the capabilities of this organism to colonize 120

water and grow on micro- bicides, presence of such organism in a patient‟s blood warrants a further investiga- tion in institutions providing care. Keywords: bulkhorderia, endocarditis, neonate, resistance 121