Nata Pratama Hardjo Lugito

A Lethal Case of Sphingomonas paucimobilis Bacteremia in an Immunocompromised Patient

Sphingomonas paucimobilis is a yellow-pigmented, glucose nonfermenting, aerobic, Gram negative bacillus of low pathogenicity. This organism was found in the implantation of indwelling catheters, sterile intravenous fluid, or contaminated hospital environment such as tap and distilled water, nebulizer, ventilator, and hemodialysis device. A 55-year-old female was hospitalized for diabetic foot ulcer in the presence of multiple comorbidities: diabetes mellitus, colonic tuberculosis, end-stage renal disease, and indwelling catheters for central venous catheter and hemodialysis. The patient passed away on the 44th day of admission due to septic shock. The organism found on blood culture on the 29th day of admission was multidrug resistant S. paucimobilis. Severe infection and septic shock due to S. paucimobilis have been reported particularly in immunocompromised patients, but there has been only one reported case of death in a premature neonate with septic shock. This is the first reported lethal case of S. paucimobilis bacteremia in an adult patient.

Mycobacterium tuberculosis resistance pattern against first-line drugs in patients from urban area

OBJECTIVE/BACKGROUND Tuberculosis (TB) infection is still a major public health burden in Indonesia. TB cases in Indonesia constitute 35% of all the TB cases detected worldwide and the prevalence of TB drug resistance in this country is approximately 3%. The aim of this study was to evaluate the resistance of Mycobacterium tuberculosis to first-line TB drugs among isolates from clinical specimens from a hospital in an urban area. METHODS This laboratory-based study was conducted in Tangerang District, Indonesia, from January 2011 to December 2014. Sputum and other clinical specimens were obtained from patients with pulmonary and extrapulmonary TB. The specimens were stained with Ziehl-Neelsen, inoculated on Löwenstein-Jensen media for 6-8 weeks, and tested for sensitivity against first-line TB drugs [isoniazid (INH), rifampicin (RIF), ethambutol (EMB), and streptomycin (SM)]. RESULTS All TB patients in this study lived in urban areas with male preponderance. Of the 127 M. tuberculosis isolates collected, 22% showed resistance to first-line TB drugs. Among these resistant isolates, 20.5% showed resistance to at least one of the first-line TB drugs and 0.8% showed multidrug resistance (MDR). Resistance to EMB, INH, RIF, and SM was seen in 6.3% 6.3%, 4.7%, and 1.6% of isolates, respectively. Polyresistance to EMB and INH, EMB and RIF, and EMB, INH, and RIF was seen in 0.8% of the isolates, respectively. CONCLUSION Our study confirms that drug resistance, including MDR, observed against all first-line TB drugs was a real threat in the management of TB infection in Indonesia. The resistance pattern identified in this study could assist clinicians in providing appropriate treatment regimen to TB patients and improve their clinical outcome.

Pulmonary Arterial Hypertension in Graves’ Disease

Background: Cardiovascular manifestations in Graves’ disease (GD) occur frequently with various phenotypes. A link between GD and pulmonary hypertension has been reported. There is limited data about prevalence PAH and related factors in GD in Indonesia. Objective: To identify the prevalence and related factors of PAH in GD. Method: This retrospective study is using secondary data from transthoracic echocardiographic database of General Hospital since last year. PAH was measured by continuous-wave Doppler echocardiography (pulmonary artery systolic pressure >35 mmHg). Sixty five patients who were diagnosed as GD were enrolled to study participant. Results: Of 65 eligible participants consist of 52 female and 13 male and median ages 42 year old (18–66 year old). Cardiac abnormalities were encountered in 79% participant of which consist of PAH in 15.4%. The patients with pulmonary hypertension had significantly higher pulmonary vascular resistance (PVR), cardiac output compared to those without (p < 0.001 and p < 0.021 respectively). The possible explanations in addition to the effect of thyroid hormone on the cardiovascular system, autoimmune-mediated pulmonary vascular remodeling may play a role in Graves’ disease-linked elevated pulmonary artery systolic pressure. Conclusion: The prevalence of PAH in GD was 15.4%. There is still needed future research to know the factors related to PAH especially related to clinical and laboratory abnormalities in GD.

Diabetic foot gangrene patient with multi-drug resistant Pseudomonas putida infection in Karawaci District, Indonesia

Pseudomonas putida is a rod-shaped, non fermenting Gram-negative organism frequently found in the environment that utilizes aerobic metabolism, previously thought to be of low pathogenicity. It had been reported as cause of skin and soft tissue infection, especially in immunocompromised patients. A female green grocer, 51 year-old came to internal medicine out-patient clinic with gangrene and osteomyelitis on her 1st, 2nd and 3rd digit and wound on the sole of the right foot since 1 month prior. The patient had history of uncontrolled diabetes since a year ago. She was given ceftriaxone 2 grams b.i.d, metronidazole 500 mg t.i.d empirically and then amikacin 250 mg b.i.d, followed by amputation of the digits and wound debridement. The microorganisms culture from pus revealed multi drug resistant Pseudomonas putida. She recovered well after antibiotics and surgery.

Poor Sleep Quality of Hospitalized Geriatric Patients in General Hospital in Karawaci, Tangerang, Banten Province, Indonesia

Background: In Indonesia, geriatric population in the year 2005 was 15.8 million (7.2 % population), and expected to reach 11.34% in the year 2020. There was growing evidence for poor sleep as an independent risk factor for poor physical and mental health. Geriatric population may be particularly vulnerable to effects of sleep disturbance due to significant age-related changes in both sleep and inflammatory regulation Objective: To study the epidemiological (gender, age group) and health status (co-morbidities), sleep quality according to Pittsburgh Sleep Quality Index (PSQI) and its associations in geriatric population hospitalized in General Hospital in Karawaci, Tangerang, Banten Province, Indonesia. Materials and Methods: A hospital based cross sectional study was conducted from January to June 2014. A total of 92 subjects aged 60 years and above were selected consecutively from hospitalized geriatric patients for this study. The data was analyzed by means and proportions. Results: The male and female subjects were 51.1% and 48.9%. Mean age was 66.79 + 5.448 years. The age group of 60 – 75 years and above 75 years was 92.4% and 7.6% consecutively. Subjects with diabetes, hypertension, allergy, asthma, cardiac failure and chronic kidney disease were 30.4%, 62.0%, 18.5%, 21.7%, 21.7%, 20.7% consecutively and 63.0% with more than 2 co-morbidities. According to PSQI 72.8% subjects have poor sleep quality. Associations between poor sleep quality to epidemiological and health status were not significant except for diabetes (RR= 3.208 [95% CI: 1.045 – 9.848], p = 0.022) and chronic kidney disease (RR= 6.247 [95% CI: 0.902 – 43.279], p = 0.017) Conclusions: Seventy two percents of subjects have poor sleep quality, and associations between poor sleep quality to epidemiological and health status were not significant except for diabetes.

Essential thrombocythemia, hemolytic anemia and hepatic cirrhosis: Could there be an association?

Vascular events are the most common clinical complication of essential thrombocythemia, leading to sign and symptoms of this disease. There are various sign and symptoms of essential thrombocythemia, such as thrombosis in artery or vein, and enlarged spleen. Portal hypertension and hepatic cirrhosis could be caused by essential thrombocythemia via intrahepatic thrombus. Anemia in essential thrombocythemia patient treated with hydroxyurea could be the side effect of bone marrow supression and also hydroxyurea induced hemolytic anemia. Association betweeen autoimmune hemolytic anemia and primary biliary cirrhosis or hepatic cirrhosis has been discussed. This case report presented an patient diagnosed with essential thrombocythemia. He later developed hepatic cirrhosis possibly caused by intra hepatic thrombus in the setting of hypercoagulabuility in myeloproliverative disorders. He also sufferred from anemia due to hydroxyurea induced hemolytic anemia. Association between autoimmune hepatic cirrhosis and autoimmune hemolytic anemia should also be considered in this patient.

Nightmare and Abnormal Dreams: Rare Side Effects of Metformin?

Background Metformin is widely known as an antidiabetic agent which has significant gastrointestinal side effects, but nightmares and abnormal dreams as its adverse reactions are not well reported. Case Presentation Herein we present a case of 56-year-old male patient with no known history of recurrent nightmares and sleep disorder, experiencing nightmare and abnormal dreams directly after consumption of 750 mg extended release metformin. He reported his dream as an unpleasant experience which awakened him at night with negative feelings. The nightmare only lasted for a night, but his dreams every night thereafter seemed abnormal. The dreams were vivid and indescribable. The disappearance and occurrence of abnormal dreams ensued soon after the drug was discontinued and rechallenged. The case was assessed using Naranjo Adverse Drug Reaction (ADR) probability scale and resulted as probable causality. Conclusion Metformin might be the underlying cause of nightmare and abnormal dreams in this patient. More studies are needed to confirm the association and causality of this findings.

Antimicrobial Resistance of Salmonella enterica Serovars Typhi and Paratyphi Isolates from a General Hospital in Karawaci, Tangerang, Indonesia: A Five-Year Review

Typhoid and paratyphoid fever known as enteric fever pose important global public health problem, with 21.6 million cases and approximately 250,000 deaths annually. It is a prevalent disease in Indonesia, but data on the antimicrobial resistance pattern is limited. This study aim was to provide data on the antimicrobial resistance pattern of S. Typhi and S. Paratyphi bloodstream isolates in a general hospital in Karawaci, Tangerang, Banten, Indonesia, during the period of January 2011 to December 2015. Susceptibility against antimicrobials was detected according to the guidelines of the Clinical and Laboratory Standards Institute (CLSI). Out of a total of 168 isolates 55.4% were S. Typhi and 44.6% S. Paratyphi A. Most of the isolates, 92.9%, were from children aged 6–18 years and adult population. There was low resistance of S. Typhi against ampicillin, trimethoprim-sulfamethoxazole, ceftriaxone, ciprofloxacin, and levofloxacin, similar to previous studies in Indonesia. In the 2011–2015 period, resistance rates against most antimicrobials and MDR rate of S. Typhi and S. Paratyphi were low, emphasizing that there is a distinct epidemiological dynamic of the enteric fever in Indonesia.

Hydronephrosis as an unusual cause of acute pancreatitis.

Acute pancreatitis is an inflammatory disease of the pancreas. The most common cause of acute pancreatitis is gallstone impacting the distal common bile-pancreatic duct (38%) and alcoholism (36%). There have been a few reports in the literature of acute pancreatitis associated with an obstructed urinary system. This case describes a 38-year-old male with acute pancreatitis occurring in the setting of hydronephrosis. A magnetic resonance cholangiopancreaticography (MRCP) showed right-sided severe hydronephrosis pushing the duodenum and head of pancreas anteriorly, thus obliterating distal segment of the common bile duct. There were also multiple right renal stones causing ureteral obstruction and hydronephrosis. Right nephrostomy was performed to release bile duct obstruction. However, sepsis and disseminated intravascular coagulation developed as a complication of acute pancreatitis, and the patient passed away. Although gallstone and alcoholism are the most common causes of acute pancreatitis, other causes should always be considered. Physicians should be aware of right hydronephrosis as one of the possible causes of acute pancreatitis in their workup of patients.

Defining Cut-off of Intradialytic Hypertension in Indonesian Population

Background: Increasing BP during maintenance hemodialysis or intradialytic hypertension (IDH) is associated with increased morbidity and mortality. Some studies have tried to define IDH, but there is limited study published reporting the definition of IDH in Indonesian population. Objective: To define the criteria of IDH in Indonesian population. Method: We performed a cross-sectional study in adult hemodialysis (HD) patients in our hospital. We recorded those variables for 2 consecutive weeks (6 HD sessions): pre-, intra-, and post-HD systolic blood pressure (SBP). Average SBP of pre-HD (method 1), ID (method 2), post-HD (method 3), pre-post-HD (method 4), and pre-intra-post-HD (method 5) were tested using ROC curved to gain the best sensitivity and specificity. Result: Among the 46 participants, mean age was 52 ± 11.7 years, 58.7% were men, average length of HD was 2.3 ± 1.6 year, body mass index was 21.5 ± 3 kg/m2, with body weight pre-HD 56.9 ± 9.3 kg, and post-HD 54.5 ± 9.1 kg, serum albumin 3.3 ± 0.4 g/dL and serum hemoglobin 10.6 ± 1.2 g/dL. The most common etiology of chronic kidney disease was hypertension in 50% subject. Eighty nine percent of which were on antihypertensive drugs, average number of antihypertensive used was 1.4 ± 1.1. From ROC curve of at least 4 of 6 HD sessions, the highest sensitivity and specificity gained by post-HD SBP (method 3) with 94% sensitivity and 82% specificity, with cut-off points SBP of 148 mmHg. Conclusion: Consideration using post-HD SBP as preferable method in diagnosing IDH in Indonesian population should be done with cut-off point SBP of 148 mmHg.