Acta medica Indonesiana最新文献

Pemphigus vulgaris (PV) is a group of autoimmune diseases that cause abnormalities in the form of lesions or blisters on the skin and mucous membranes. It often presents diagnostic challenges due to its varied clinical manifestations. Accurate diagnosis and treatment are essential to reduce mortality in patients with PV. Traditional diagnostic methods, such as histopathology and direct immunofluorescence, may not always provide conclusive results, especially if the patient does not have an intact bulla. Our report emphasizes the role of desmoglein autoantibody testing using enzyme-linked immunosorbent assay to confirm the diagnosis, allowing for prompt and targeted therapeutic interventions.

Piriformis syndrome is an often overlooked cause of chronic buttock or low back pain, sometimes radiating to the posterior thigh. Despite various treatment options, a definitive standard therapy has not been established. Dry needling has recently gained attention as a non-pharmacological intervention, especially when guided by ultrasound to enhance accuracy and safety. A 69-year-old woman presented with a 9-month history of fluctuating right gluteal pain, aggravated by prolonged sitting and movements. Physical examination revealed tenderness in the piriformis area and positive provocative tests, with no neurological deficits. After failure of previous pharmacological and physiotherapeutic interventions, the patient underwent ultrasound-guided dry needling of the piriformis muscle. The procedure was performed using an in-plane technique with a 0.3 x 75 mm needle and elicited a twitch response. After two sessions, the patient reported a significant reduction in pain intensity from 7/10 to 2/10. Ultrasound-guided dry needling offers several benefits, including precise targeting of the piriformis muscle, avoidance of chemical agents, and reduced risk of adverse effects. The analgesic effect is attributed to inactivation of myofascial trigger points and neuromodulation involving reduced levels of substance P and calcitonin gene-related peptide. We conclude that ultrasound-guided dry needling appears to be a safe, effective, and minimally invasive option in the management of piriformis syndrome, particularly when conventional therapies fail.

Erosive esophagitis (EE) is an inflammation of the esophageal mucosa resulting from gastric and duodenal acid reflux, affecting approximately 55% of gastroesophageal reflux disease (GERD) patients in Indonesia. Effective acid suppression is essential for mucosal healing and symptomatic relief. Histamine-2 receptor antagonist (H2RA) was initially used for standard treatment for GERD, including EE, reducing gastric acid secretion by blocking H2 receptors. However, their efficacy is limited by inadequate acid suppression. Proton pump inhibitors (PPIs) became the mainstay therapy due to their stronger and longer-lasting acid suppression. Although PPIs have been proven to be quite effective, they have several limitations, including slow onset and inability to provide sustained acid suppression over a full 24-hour period. In recent years, Potassium-competitive acid blockers (PCAB) have become known as a category of drugs that effectively suppress gastric acid production, through a slightly different mechanism, and have advantages over PPIs, including faster onset and longer time of action. Both PPIs and PCABs can be used as therapy for patients with EE. PCABs are more recommended, especially in patients with severe grades of EE. H2RAs may still be considered in patients who have already received PPI therapy but continue to experience unresolved nocturnal acid symptoms.

The most recent definition of sepsis highlights the dysregulation of the host's immune response to infection, which varies between individual hosts, with patients predominantly presenting with either hyperinflammation, immunoparalysis, or a combination of both states. Therefore, management strategies must be tailored to accommodate the heterogeneity of patients with sepsis, as these conditions are associated with distinct prognoses and therapeutic approaches. Identification of the immune response in patients with sepsis can be achieved through advanced techniques, such as gene expression profiling or, more simply, through a subphenotypic approach. This article introduces a subphenotypic classification of the sepsis immune response into macrophage activation-like syndrome (MALS), where pathological macrophage activation leads to excessive hyperinflammation, immunoparalysis, or neither. Patients are classified using serum ferritin levels and monocyte HLA-DR expression, which is assessed using peripheral blood. This classification demonstrates significant differences in survival across groups, which is attributed to their distinct underlying biological processes. Immunotherapeutic options also differ for these three groups. In the future, such immune response classifications will be valuable in sepsis management algorithms for personalized prognostication and therapy.

Poorly controlled Crohn's disease is associated with several complications, including malabsorption of vitamins and minerals such as vitamin D, vitamin B12, and vitamin B1 (thiamine). Thiamine, among other vitamins, plays a crucial role in Adenosine Triphosphate formation as well as nerve propagation. Thiamine deficiency initially manifests as wet or dry beriberi but may lead to the devastating Wernicke-Korsakoff syndrome. In this report, we present a case of full-blown Wernicke encephalopathy associated with uncontrolled Crohn's disease. An 18-year-old young man was admitted with a chief complaint of hematemesis for 2 weeks before admission. He was previously diagnosed with Crohn's disease in the past year, with constipation as the predominant symptom, and has been taking mesalazine 500 mg twice daily. Esophagogastroduodenoscopy and colonoscopy re-evaluation showed a worsening picture of Crohn's disease pangastritis. The patient experienced swelling in both legs, the scrotum, and the upper extremities during hospital admission. On day 14 of hospitalization, the patient fell into a state of confusion with visual and auditory hallucinations, ophthalmoplegia, and ataxia. A Brain MRI showed a typical picture of Wernicke encephalopathy. Intravenous thiamine was administered, and the patient regained consciousness. His clinical symptoms improved every day until he was discharged. Uncontrolled Crohn's disease may have several complications that clinicians need to be aware of, including thiamine deficiency. Wernicke encephalopathy shows a devastating clinical picture, but with thiamine therapy, it may resolve before further deterioration leads to irreversible Korsakoff syndrome.

Background: The current hypothesis regarding the mechanism of Non-Alcoholic Fatty Liver Disease (NAFLD) is the multiple hit theory, where one of the factors involved is gut microbiota. Short-chain fatty acid (SCFA) is the main metabolite of gut microbiota and is suspected to play a role in the development of NAFLD. This study aims to determine the correlation between SCFA levels (acetate, propionate, butyrate) and the degree of fibrosis and steatosis in patients with NAFLD assessed by controlled attenuation parameter (CAP) and transient elastography (TE).

Methods: A cross-sectional study that included 33 consecutively selected patients at Cipto Mangunkusumo Hospital was conducted from January to August 2023. Fecal sample collection was performed for SCFA examination using GC-MS (Gas Chromatography-Mass Spectrometry). Absolute fecal SCFAs were analyzed for correlation with steatosis and fibrosis based on controlled attenuation parameter (CAP) and transient elastography (TE) values.

Results: Subjects were predominantly female (51.5%), with an average age of 49 years, an average CAP value of 296 dB/m, and a median transient elastography value of 6.1 kPa. The ratio of acetate, propionate, and butyrate values in the subjects was 59:24:17. A moderate negative correlation was observed between the absolute butyrate and CAP values (r=-0.522; p=0.002).

Conclusion: There is no correlation was identified between short-chain fatty acid levels and transient elastography values.

Thyrotoxicosis, a state of excess thyroid hormone, often presents with diverse clinical manifestations, including thyroid storm, a rare but critical condition. Here, we present a case of a 28-year-old woman with thyrotoxicosis, hyperbilirubinemia, and total atrioventricular (AV) block. The patient exhibited jaundice, chest discomfort, and a history of chronic diarrhea, weight loss, tremors, and exertional dyspnea. She was on propylthiouracil and propranolol for two weeks. Physical examination revealed jaundice, proptosis, a large goiter, and tremors. Laboratory tests on admission indicated elevated liver enzymes, hypokalemia, and markedly elevated thyroid hormones. ECG revealed total AV block. Treatment involved hydrocortisone, thiamazole, discontinuation of propranolol, and gradual correction of electrolyte imbalances. The patient improved clinically, and propranolol's discontinuation improved the rhythm disturbance. The Patient was discharged for outpatient Graves' disease management. Future assessments may include an electrophysiology study if needed. Total AV block in thyrotoxicosis is rare. This case highlights the complexity of managing thyrotoxicosis with concurrent hepatic and cardiac complications, emphasizing the importance of tailored treatment strategies and close monitoring.

Background: There is currently no gold standard for assessing frailty syndrome in older adults with heart failure. The Cardiovascular Health Study (CHS) is a reference standard for evaluating frailty in older adults with heart failure. Still, it requires a dynamometer and a spacious space, rendering it impractical in daily practice. The INA-FRAIL and Study of Osteoporotic Fractures (SOF) Index can often be easy to use; however, it has not been evaluated for diagnostic performance on older adults with heart failure in Indonesia. This study aimed to assess the diagnostic performance of INA-FRAIL and SOF-Index in diagnosing frailty in older adults with heart failure.

Methods: This cross-sectional study evaluated the diagnostic performances of INA-FRAIL and SOF-Index compared to CHS as the gold standard in this study. The population was heart failure patients aged > 60 at Cipto Mangunkusumo Hospital.

Results: Analysis from 81 samples shows the prevalence of frailty based on CHS (35.5%), INA-FRAIL (23.5%), and SOF-Index (8,6%). Diagnostic performance analysis of INA-FRAIL showed a sensitivity of 55,17% (95% CI 35.69-73.55), specificity 94.23% (95% CI 84.05- 98.79), and AUC 0.805 (95% CI 0.698-0.912). Diagnostic performance analysis of SOF showed 20,69% sensitivity (95% CI 7.99 - 39.72), 98.08% specificity (95% CI 89.74 - 99.95), and AUC 0.719 (95% CI 0.595 - 0.843).

Conclusion: INA-FRAIL and SOF-Index had a significant association with CHS. The cut-off point of INA-FRAIL ≥1 showed the highest sensitivity, while INA-FRAIL ≥2 showed the highest Youden index. The cut-off point of SOF ≥1 showed the highest sensitivity and the highest Youden index.

Background: In-stent restenosis (ISR) is an event of coronary atherosclerosis re-budling following the stent implantation in percutaneous coronary intervention. The events of ISR have been significantly reduced since the introduction of drug-eluting stents. However, ISR could still occur, and factors affecting the incident have not yet been discovered. This study aims to evaluate the risk factors of coronary in-stent restenosis in drug-eluting stents.

Methods: Studies on the factors and risks of ISR in patients with drug-eluting stents were systematically searched in databases (PubMed, ScienceDirect, Springer, Google Scholar, and ProQuest) on September 20th, 2023. The odds ratio (OR) and mean difference (MD) were analyzed using Review Manager 5.4.

Results: Diabetes mellitus (OR 1.73 [95%CI 1.56, 1.91] p < 0.00001) and smoking (OR 1.24 [95%CI 1.13, 1.36] p<0.0001) are the patients' clinical characteristics that are associated with ISR in DES. It is closely related to the contribution of diabetes mellitus in promoting platelet adhesion and smoking in enhancing intimal hyperplasia. As in the angiography characteristics, stent lesion at LAD (OR 1.20 [95%CI 1.07, 1.35] p = 0.002) and stent length (MD 3.61 [95%CI 1.81, 5.42] p < 0.0001) are correlated with the events of ISR. Every millimeter excess of stent length significantly increases the risk of ISR. Therefore, reducing the excess stent length may contribute to the reduced risk of ISR in DES.

Conclusion: The identification of risk factors contributing to ISR in DES may help cardiologists modify the attributable factors and prevent the occurrence of ISR.

Tuberculosis (TB) has become one of the global burdens of disease, with increasing morbidity and mortality every year. Tuberculosis can affect not only the lungs but also the extrapulmonary organs. The prevalence of drug-resistant tuberculosis (DR-TB) is rising and has caused a higher mortality rate than drug-susceptible tuberculosis (DS-TB). This article presents a patient with a rare co-infection of pulmonary DS-TB and pleural DR-TB. Pulmonary and pleural TB (pTB) was diagnosed using the Xpert MTB/RIF assay. The patient was treated with an individualized DR-TB regimen and recovered.