Molluscum contagiosum could become an early sign of HIV infection

HIV is a type of virus that attack the immune system, causing it unable to function normally and putting the person in a condition called immunocompromised and is vulnerable to lots of infection. People living with HIV are prone to complications if there is persisting infection and inflammation. One of the inflammation markers is theneutrophil-lymphocyte ratio(NLR). Complication on the skin is one of the frequently happened. One of it is Molluscum contagiosum. Molluscum contagiosum caused by virus infection which target the epidermal layer of the skin that result in formation of round, umbilicated, painless papule or nodule. In this case report, we present a male, 49 years old which has complained of persistent fatigue and diarrhea. There is multiple rounds, skin-colored, painless papules on his face and neck since 6 month ago which keep increasing. Laboratory result show decrease in hemoglobin and high neutrophil lymphocyte ratio. In HIV, the NLR value has a significant negative correlation with the CD4 amount. The existence of molluscum contagiosum in an adult with unknown HIV status need to be considered as a possibility of an immunocompromised especially if accompanied with other conditions. In the patient with HIV, with the existence of Molluscum contagiosum, the possibility of decreasing CD4 and increasing viral load need to be suspected. The patient抯 obedience in consuming ARV also needs a careful attention.

Safety of oral graded challenges as a diagnostic approach hypersensitivity reaction to anti-tuberculosis drugs: a case report

Tuberculosis (TB) still becomes a significant health problem in developing countries, especially in Indonesia. Allergy to antitubercular drugs is a real hindrance to the management of TB. The first-line anti-TB drug (ATD) is still the most effective TB drug, but it can have some side effects. One of these side effects is drug hypersensitivity reactions (DHR) which can affect a patient's compliance. The recommended diagnostic approach to DHR is a graded challenge by introducing drugs safely and optimally under a threshold dose until the usual daily dose is reached. We present a case of DHR to ATB drug and oral graded challenge as the diagnosis approach.

Drug-induced liver injury after anti tuberculosis drugs administration, how to diagnose? a case report

Drug-induced liver injury (DILI) is a liver injury caused by various drugs, herbs, or other xenobiotics, which causes abnormalities in liver tests or liver dysfunction in the absence of other causes of liver damage. The most common causative drugs are antituberculosis drugs (ATDs), anti-infective drugs, and natural herbal medicines. The diagnosis of DILI can be difficult due to the lack of specific signs, symptoms and tests and is partly a diagnosis based on exclusion. In this case report, we will discuss how to diagnosis DILI TB and causative assessment using RUCAM score. A male, 64 years old, has complained of weakness since 1 week ago and worsened since 1 day ago. The patient also felt persistent nausea for 1 week, so his eating and drinking decreased. Besides, he complained getting abdominal pain, especially in the upper right region and heartburn. The patient has been on first category of TB treatment since 20 days ago. Chest X-ray showed Lung TB with infiltrate inmultiple cavities. Abdominal ultrasound showed no abnormality. The patient was discharged from our hospital after 6 days of hospitalization. DILI remains a diagnosis of exclusion based primarily on a detailed history and judicious use of blood tests, hepatobiliary imaging, and liver biopsy. TheRoussel Uclaf causality assessment method (RUCAM)system is an assigning point for clinical, biochemical, serologic and radiologic features of liver injury. We use RUCAM score to make an assessment that show the likelihood of the hepatic injury due to a specific medication.

Cholestatic drug induced liver injury in active pulmonary tuberculosis patient: a case report

Drug induced liver injury (DILI) has been a long-standing concern in the treatment of tuberculosis. Anti-tuberculosis therapy (ATT) is known to have hepatotoxicity effect. DILI is diagnosed clinically using liver biochemical test, such as alanine transaminase (ALT), alkaline phosphatase (ALP), and total bilirubin. Calculating ratio (R) of ALT over ALP, is useful to classify types of injury pattern in DILI. Roussel Uclaf causality assessment method (RUCAM)scaleserves as a method to assess the causality agents for DILI. Here we report a case of 59 years old male who developed cholestatic DILI on fourth weeks of ATT. Patient came in with loss of consciousness, jaundice, nausea, pruritus, and abdominal tenderness. Patient抯 ALT level was normal, but ALP and total bilirubin was significantly elevated, with R values less than 2, indicating a cholestatic type of injury. Patient sputum was positive for tuberculosis bacteria, showing an active infection. Patient was admitted and ATT was discontinued. Patient showed improvement, but eventually fall into sepsis and developed respiratory distress on sixth day of admission despite adequate treatment and close monitoring. Despite most of the cases resolves spontaneously upon cessation of the toxic agents, in the severe form, it may fall into chronic liver injury, acute liver failure, and eventually death. Preventing DILI is readily important by educating, screening for risk factors, and routine evaluation of liver enzymes in patient under ATT. Early diagnosis and prompt treatment are needed to avoid poor prognosis in the course of the disease.

Neutrophil to lymphocyte ratio, platelet to lymphocyte ratioand one year survival of lung cancer in Sanglahhospital

Background:Lung cancer is ranked third as the most common cancer in Indonesia. The one-year survival rate of advanced-stage non-smallcell lung carcinoma (NSCLC) patient is quite low, that is 24.6%. Effective and inexpensive prognostic markers need to be further studied due to an increasing incidence of cancer. Inflammation plays an important role in tumorigenesis and research showed an association of NLR and PLR values with poor prognosis in patients with various solid tumors, but current cutoff values still vary. This study wanted to determine the value of NLR, PLR and their relationship with the survival rate of advancedstage NSCLC patients at Sanglah hospital.Methods:A retrospective cohort study using the medical record of 96 advanced-stage NSCLC patients who underwent treatment since January 2018 in Sanglah hospital, was closely monitored for a year since diagnosed. Analysis was performed with ROC, Kaplan Meier analysis, log rank test, and time independent cox regression model.Results:The one-yearsurvival rate of advancedstage NSCLC patient is 14.6%, with median survival 3.26 months. Cut off NLR> 3.37, median survival 2.66,p=0.00. Cut off PLR>178.55, median survival 3.26, p=0.35. Multivariate analysis showed that NLR, HR=2.75 and performance status, HR=1.78 were associated with survival.Conclusions:NLR with cut off>3.37 is associated with one-year survival rate of advanced-stage NSCLC patient. PLR did not have any significant association with one-year survival rate of advanced-stage NSCLC patient.

Managing severe thrombocytopenia in co-infection of COVID-19 and dengue hemorrhagic fever: a case report

COVID-19 pandemic in dengue endemic countries has becoming a concern due to its similarities in early clinical symptoms and laboratory features. The cases of co-infection between the two diseases are inevitable and associated with higher morbidity and mortality. Here we presented a case of a 28 years old female diagnosed with co-infection of COVID-19 and dengue hemorrhagic fever that complicated with severe thrombocytopenia and spontaneous bleeding.She came with fever that started 3 days prior to admission. Laboratory examination showed leucopenia, thrombocytopenia, elevated liver enzymes, and D-dimer. Patient tested positive for non-structural protein 1 (NS-1)dengue antigen. She had a pre-screening rapid test for COVID-19 as part of hospital protocol, and she tested positive. Followed by positive COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR)test confirmingthe diagnosis. During admission, patient started menstruating, resulting in active spontaneous bleeding while platelet counts dropped to below 10×109/l. Patient was given platelet transfusion, supportive therapy and put under close monitoring. The case ofco-infection between COVID-19 and dengue is inevitable in tropical and sub-tropical countries. Both infections shared similar pathophysiology through different mechanism, such as plasma leakage, thrombocytopenia, and coagulopathy.Complications may arise and physician must aware of the therapeutical approach. Diagnostic testing must not be withheld when there was suspicion towards the infection. Prompt treatment and close monitoring can result in good prognosis.

Stevens-Johnson syndrome induced by carbamazepine andamitriptyline in diabetic patient: a case report

Stevens-Johnson syndrome (SJS) is systemic immune reactions (type IV hypersensitivity) that are usually present by blistering and erosions of skin and mucous membranes with involvement of multiple organ systems. The incidence of SJS is rare, with the common comorbidities are diabetes mellitus, epilepsy, hypertension, and stroke. This condition is associated with systemic proinflammatory state. Diabetes mellitus is a metabolic disorder that is characterized by abnormally elevated levels of blood glucose due to glucose intolerance, hyperglycemia, and impaired insulin secretion. Nowadays, pathogenesis of diabetes is considered to be dysregulation of immune factors that are recognized as important etiological components in the development of insulin resistance. We report a case of a 30-years-old man with fever and sore throat, who had type 2 diabetes mellitus (T2DM) and used carbamazepine and amitriptyline for diabetic neuropathy, then followed by redness and blistering on his lips, palates, face, and trunk which subsequently diagnosed with SJS.

A reminder of life-threatening reaction of hymenoptera sting cause anaphylaxis shock

The prevalence of hymenoptera sting in general population still high. Large local reaction (LLR) is more common manifestation but can also causeanaphylactic shock and loss of consciousness, or even cardiac or respiratory arrest that all is defined as severe systemic sting reaction (SSR). The risk is generally considered low for future SSR in subjects with LLR but need to be considered and recognized immediately. We reporteda case of 39-year-old women was stung by a wasp when driving motorcycle and presented to emergency room with anaphylactic shock (fulfill the amended NIAID/FAAN criteria). She also stung by wasp 2 years ago and cause her left upper and lower arms became swollen slowly and improved 3 days later after treatment with allergy drugs. Electrocardiography result refer to sinus bradycardia. Significant laboratory result showed hypokalemia (2.9 mmol/l). Patient treated by injecting epinephrine intramuscularly and glucocorticoids to preventing protracted symptoms and biphasic reactions.

A rare case of thrombocytosis presentation in patient alcoholic liver disease with portal hypertension gastropathy: a stepwise evaluation

Thrombocytosis is rarely found in patient with chronic liver disease (CLD). The possibility of reactive thrombocytosis could be due to sustained process such as iron deficiency anemia (IDA) because of occult bleeding. Occult bleeding can happen in CLD patient because of portal hypertension gastropathy (PHG) as complication of portal hypertension. A carefully evaluation of anemia can lead to underlying cause of disease, even in limited of supportive evaluationand some other confounding presentation that is thrombocytosis.We report a case of 54 years-old male patient with severe anemia. He had same symptom previously and got transfusion. Peripheral blood smear showed microcytic hypochromic anemia, anisocytosis, and poikilocytosis even pencil cells (pencil cells or cigar cells) with thrombocytosis. No symptom of acute inflammation setting and no clear blood loss was founded. As patient admitted to smoking and heavy alcohol consumption in the past, Ultrasound was performed for screening of underlying disease that cause occult bleeding. Ultrasound of the liver showed generally increased echogenicity suggestive of liver cirrhosis, splenomegaly and minimal ascites. Thus, our patient clinically be suggestive of CLD with portal hypertension that cause PHG.

Cardiac asthma or bronchial asthma: a case report

Wheezing is often found in patients with asthma bronchialebut wheezing may also be found in paroxysmal nocturnal dyspnea and pulmonary edema (cardiac asthma). Cardiac asthma has been used to explain wheezing and airflow obstruction due to heart failure (HF). The respiratory symptoms such as wheezing, shortness of breath and cough. These symptoms normally occur at night and are common in elderly.Both asthma bronchiale and cardiac asthma are important to diagnose because treatments for asthma bronchiale and HF are different. Here we presented a case report of a 59-years old female diagnosed with cardiac asthma due to heart failure.Cardiac asthma defined as congestive heart failure (CHF) associated with wheezing represents one third of CHF in elderly patients. It is often confused with asthma and exercise-induced bronchospasm. These diseases have different therapies. Cardiac asthma using diuretics and asthma using bronchodilator therapy. CHF can lead to pulmonary congestion and pulmonary edema (PE), and this is classically thought to be the primary cause of cardiac asthma. Current management of cardiac asthma focuses on controlling the underlying HF and PE.

Coincidence of drug induced liver injury and cholecystitis on human immunodeficiency viruspatient with anti-tuberculosis treatment

Tuberculosis (TB) is a serious health problem. Anti-TBtreatment has good efficacy, but in some cases side effects can occur that can affect medication adherence and development of drug resistance. One of the serious side effects of anti-TB treatment is drug induced liver injury. We reported the case of a 56yearold male patient with TB-HIV confection who developed symptoms of hepatotoxicity after 3 weeks of intensive phase of anti-TB treatment.

Bowel angina: Henoch-Schonleinpurpura in adult patient based on clinical approach: a case report

The GI involvement of Henoch-Schonlein purpura (HSP) has often been described as self-limiting, with no long term morbidity.GI manifestation is higher in adult patient. HSP is an autoimmune disorder characterized by the deposition of IgA immune complexes in the wall of small to medium size arteries. We present a 41-year-old patient with GI involvement (Bowel angina) in HSP case admitted at Wangaya Regional Hospital Denpasar. The case are treated by steroid and symptomatictreatment. Diagnosis is established through a clinical approach with EULAR criteria. The patient recovered with supportive treatment and had a favourableclinical outcome.

Fatal systemic reactions, concurrent of anaphylaxis and systemic toxic reactions to hymenoptera-sting

Hymenoptera-stingcan cause localized and systemic reactions (SR). SRs such asanaphylaxis and systemictoxic reactions (STR). Itis estimated to occur in 3% of adultsand can be life-threatening. Diagnosis is based on clinical manifestations,previous of allergic history, IgE-mediated confirmation and the offending insect identification. Anaphylaxis patients should immediately receive adrenaline intramuscularly, emergency medical attention and other supporting treatment. We report a36-year-old man with fatal SRs, concurrent of anaphylaxis and systemic toxic reaction due to multiple hymenoptera-stings.

COVID-19 pneumonitis and lupus pneumonitis: a challenge in diagnosis and early therapeutic consideration

Coronavirus disease 2019 (COVID-19) is an acute respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It has various clinical manifestations, from asymptomatic to severe disease with possible multi-organ involvement, with respiratory and vascular systems being the frequent affected. COVID-19 can affect patients with autoimmune diseases including systemic lupus erythematosus (SLE). The concurrent of both diseases may show the similar characteristic which can asa challenge in diagnosis and early therapeutic consideration. We report a case of 53 year-old Balinese woman patient who previously diagnosed with acute respiratory iIlness (Pneumonitis),The patient with past history of SLE since 2005, takes 200 mg hydroxychloroquine (HCQ) and 4 mg methylprednisolone once a day orally without adverse effect. Then she was confirmed with SARS-CoV-2 infection (COVID-19 pneumonitis) concurrent with SLE flare (Lupus pneumonitis). The clinical similarities were fever, dry coughand shortness of breath with the chest X-ray(CXR) was bilateral interstitiil infiltrate. Laboratory results; a positive SARS-CoV-2 polymerase chain reaction test, leucophenia, increased ESR, slightly increased CRP, decreased CD4 and CD8 cell count. Decreasedoxygen saturation, requiring 4 L of oxygen via nasal cannula on admission.She was given therapyofantibiotics, antivirus and other symptomatic. The prior SLE maintenance therapywas continued with increasingmethylprednisolone dose. The patient抯condition was improved and weaned off her oxygen requirements. Shewas dischargedandfollowed by home isolation for 14 days.

Anaphylaxis: lesson learned from five cases.

Anaphylaxis is a severe hypersensitivity reaction. Its clinical manifestations vary, affecting several organs at once. Skin symptom is the most frequent manifestation; however, diagnosis of anaphylaxis will only be established when involving one or both vital organs, which are cardiovascular and respiratory system. Other symptom, such as that involving central nervous system or gastrointestinal tract, may accompany. We present five cases of anaphylaxis which vary in onset of symptoms, allergen, degree of severity, therapeutic response and clinical manifestation. Anaphylactic reaction to drugs in these cases is mainly manifested as anaphylactic shock and reaction to food allergen causing obstruction of respiratory tract. Four anaphylactic events occurred at home and only one occurred in a hospital, thus education on anaphylaxis to general community is very important, especially for the patients and their families. Prompt medical assistance in patients with anaphylactic symptoms determines their therapeutic response. Skin test prior to administration of cephalosporin does not give negative predictive value toward anaphylactic event.