case6nbss

Px. fisikPx. fisik

• UnconsciousUnconscious• Dilatated pupil reaction : lambatDilatated pupil reaction : lambat• BPBP ;; 170/100 mmhg 170/100 mmhg hipertensi hipertensi

Stage 2Stage 2• Pulse ;Pulse ; 60 beat/min, regular 60 beat/min, regular N N• Respiration ;Respiration ; 30 beat/min, irregular 30 beat/min, irregular • Body Temperature ;Body Temperature ; 42 ⁰C 42 ⁰C • Funduscopy ;Funduscopy ; papiledema (+)papiledema (+)

Gang. ksdrnGang. ksdrn

Kuman – kuman yang meningkatKuman – kuman yang meningkat

Mengganggu kerja vili araknoid Mengganggu kerja vili araknoid

Reabsorbsi CSS tergangguReabsorbsi CSS terganggu

HidrosefalusHidrosefalus

Peningkatan TIKPeningkatan TIK

Perfusi darah menurunPerfusi darah menurun

Gangguan metabolik sel – sel saraf (terutama Gangguan metabolik sel – sel saraf (terutama bagian basal)bagian basal)

Penurunan kesadaranPenurunan kesadaran

HeadacheHeadache

VomitVomit

papiledemapapiledema

Tingkat KesadaranTingkat Kesadaran

1.1. KomposmentisKomposmentis :: Sadar penuhSadar penuh2.2. ApatisApatis : Acuh tak acuh, segan.: Acuh tak acuh, segan.3.3. SomnolenSomnolen :: Dpt dibangunkan dg rangsang ringan, tetapi tidur Dpt dibangunkan dg rangsang ringan, tetapi tidur

lagi (letargi)lagi (letargi)4.4. SoporSopor :: Tak dpt dibangunkan, tetapi masih bereaksi thd Tak dpt dibangunkan, tetapi masih bereaksi thd

rangsang yang kuat rangsang yang kuat 5.5. KomaKoma :: Tak ada respon thd rangsang apapunTak ada respon thd rangsang apapun6.6. KonfuKonfu :: Bingung, dg respon psikologis yg lambat Bingung, dg respon psikologis yg lambat

(perhatiannya berkurang)(perhatiannya berkurang)7.7. DeliriumDelirium :: Kesadaran menurun dengan kacau motorik (ada Kesadaran menurun dengan kacau motorik (ada

periode tidur bangun, agitasi,irritable, periode tidur bangun, agitasi,irritable, halusinasi )halusinasi )

Refleks pupil• Pupillary light reflex in general:Light enters the eye the pupil constrictsDirect pupillary reflex:Light goes in one eye the ipsilateral pupil constrictsConsensual pupillary reflex:Light goes in one eye the contralateral pupil constricts

• Dinyatakan ; = tidak ada reaksi± = reaksi lambat+ = reaksi normal (ada)

Neural pathways for direct reflex

lght goes in one eye

then to ipsilateral Edinger-Westphal nucleus and

to ipsilateral pretectal nucleus

to optic tract ipsilaterally

then through optic nerve

through ipsilateral oculomotor nerve (CN3)

to ciliary ganglion, then

short post-ganglionic ciliary nerves activate the constrictor

ciliary ganglion

RETINA

ciliary ganglion

CHIASM

PRETECTALNUCLEUS

PRETECTALNUCLEUS

EDINGERWESTPHALNUCLEUS

CN 3 CN 2

EDINGERWESTP HALNUCLEUS

Neural pathways for consensual reflex

Note: there are 2 places Note: there are 2 places where information can where information can crosscross

• From the pretectal From the pretectal nucleus to the Edinger-nucleus to the Edinger-Westphal nucleusWestphal nucleus

• At the optic chiasmAt the optic chiasm

ciliary ganglion

RETINA

ciliary ganglion

CHIASM

PRETECTALNUCLEUS

PRETECTALNUCLEUS

EDINGERWESTPHALNUCLEUS

CN 3 CN 2

EDINGERWESTP HALNUCLEUS

The following slides show the 2 The following slides show the 2 routes separately, but light travels routes separately, but light travels both routes simultaneously.both routes simultaneously.

11. Neural pathway for . Neural pathway for consensualconsensual reflex, reflex, crossing at chiasmcrossing at chiasmlight goes through optic light goes through optic nerve nerve

crosses at crosses at chiasmchiasm to to contralateralcontralateral optic tract optic tract

continues to pretectal nucleus and continues to pretectal nucleus and Edinger-Westphal nucleus Edinger-Westphal nucleus contralateral to light stimuluscontralateral to light stimulus

then out through the then out through the oculomotor nerve contralateral oculomotor nerve contralateral to light stimulusto light stimulus

to ciliary ganglion, from which to ciliary ganglion, from which ciliary nerves activate the ciliary nerves activate the constrictorconstrictor

ciliary ganglion

RETINA

ciliary ganglion

CHIASM

PRETE CTALNUCL EUS

PRETECTALNUCLE US

EDINGERWESTPHALNUCLEUS

CN 3 CN 2

EDINGERWESTP HALNUCL EUS

2.2. Neural pathway for Neural pathway for consensualconsensual reflex, reflex, crossing from pretectal nucleuscrossing from pretectal nucleuslight goes through one light goes through one optic nerve optic nerve to optic tract to optic tract ipsilaterallyipsilaterallyto ipsilateral pretectal to ipsilateral pretectal nucleusnucleuspretectal cells send axons across pretectal cells send axons across midline in posterior commissuremidline in posterior commissure

to Edinger-Westphal nucleus then out to Edinger-Westphal nucleus then out through the oculomotor nerve, both through the oculomotor nerve, both contralateral to light stimuluscontralateral to light stimulus

to ciliary ganglion, and to ciliary ganglion, and pupillary constrictorpupillary constrictor

ciliary ganglion

RETINA

ciliary ganglion

CHIASM

PRETECTALNUCLEUS

PRETECTALNUCLEUS

EDINGERWESTPHALNUCLEUS

CN 3 CN 2

EDINGERWESTP HALNUCLEUS

Nilai Normal Tekanan DarahNilai Normal Tekanan Darah

KATEGORIKATEGORI SISTOLIK SISTOLIK (mmHg)(mmHg)

DIASTOLIK DIASTOLIK (mmHg)(mmHg)

HipertensiHipertensi

Stage 3Stage 3 ≥ ≥ 180 180 ≥ ≥ 110110

Stage 2Stage 2 160-179160-179 100-109100-109

Stage 1Stage 1 140-159140-159 90-9990-99

Normal TinggiNormal Tinggi 130-139130-139 85-8985-89

NormalNormal <130<130 <85<85

OptimalOptimal <120<120 <80<80

Merupakan hipertensi neurogenik• Akibat lesi saraf1. Masalahnya mungkin adalah kesalahan kontrol

tekanan darah akibat defek di pusat kontrol kardiovaskuler atau baroreseptor

2. Hipertensi neurogenik juga dapat terjadi sebagai respons kompensasi terhadap penurunan aliran darah otak- cth: krn sebuah pembuluh besar otak tertekan oleh tumor. Sebagai respons thdp penurunan aliran darah otak, dimulai suatu refleks yg meningkatkan tekanan darah sebagai usaha untuk mengalirkan darah kaya O2 ke jaringan otak secara adekuat

Normalnya

• Pulse Rate = 80-100x/menitPulse Rate = 80-100x/menit• RR = 16-24x/menit, regulerRR = 16-24x/menit, reguler• TemperatureTemperature = 36-37= 36-37°C°C

Pulse

• Nodus sinoatrium a/ pemacu jtg normal• Potensial aksi kontraksi sel2 otot jtg u/

mendorong drh• Jtg berkontraksi atau berdenyut sec berirama

akbt pot. Aksi yg dtmblknny sndr otoritmisitas

2 jns o/ jtg (sel kontraktil & otoritmik)

• Sel2 otoritmik jtg tdk memiliki pot. Istirahat. Sel2 tsbt mmprlhtkn aktivitas pemacu (pacemaker activity) membran mrk sec perlahan mengalami depolarisasi, atau bergeser, antara potensial2 aksi sampai ambang tercapai, pd saat membran mnglami pot. Aksi

• Mell siklus pergeseran dan pembentukkan pot. Aksi yg b’ulang2 tsbt, sel2 otoritmis ini sec siklis mencetuskan pot. Aksi menyebar ke slrh jtg u/ mencetuskan denyut sec berirama tanpa perangsangan saraf apapun

Respirasi

• Basil tuberkel mencapai permukaan alveolus basil tuberkel membangkitkan reaksi peradangan leukosit polimorfonuklear memfagosit bakteri tp, tdk membunuh organisme tsb leukosit diganti oleh makrofagalveoli yg terserang akn mengalami konsolidasipeneumonia akut

• Infeksi pada parenkim paru peneumonia

Respirasi tinggi

• Akibat adanya gangguan parenkim paru• Mekanisme Jar. Paru yg masih sehat rusak (mis; ser

bakteri,virus,fungus,protozoa,atau sel2 ganas serta inhalasi debu dan asap yg merangsang) edema pada interstisial, dinding alveolus dan intra alveolar jar fibrosis yg b’lbhn tbtk sbg gej sisa bbgai pnykt, biasanya b’asal dr peradangan or alergi keregangan paru berkurang & t’hmbt jalur difusi gas

Pengaturan suhu

• Dari sudut pandang termoregulatorik, tubuh inti ditengah (central core) dengan lapisan pembungkus di sebelah luar (outer shell)

• Suhu inti bag dlm : org2 abdomen& thoraks,SSP,serta otot rangka

• Suhu internal inilah yg dianggap sbg suhu tubuh dan menjadi seujek pengaturan ketat u/mempertahankan kestabilannya

Produksi panas Produksi panas internalinternal

Produksi panas Produksi panas internalinternal

Pemasukan Pemasukan panaspanas

Pemasukan Pemasukan panaspanas

Lingkungan Lingkungan eksternaleksternal

Lingkungan Lingkungan eksternaleksternal

Pengeluaran Pengeluaran panaspanas

Pengeluaran Pengeluaran panaspanas

Kandungan Kandungan panas totalpanas totalKandungan Kandungan panas totalpanas total

Suhu intiSuhu intiSuhu intiSuhu inti

Demam

Infeksi atau peradanganNeutrofil

Pirogen endogenProstaglandin

Titik patokan hipotalamusMengawali “respons dingin”

Produksi panas; pengurangan panasSuhu tubuh ke titik patokan yg baru = demam

+

Mengeluarkan

+

Funduskopi

• Perhatikan keadaan papil, apakah ada edema, perdarahan, dan eksudasi, serta bagaimana keadaan pembuluh darah.

• Tekanan intrakranial yg meninggi dpt mnybb terjadinya edema papil. Pada perdarahan subarakhnoid dapat dijumpai perdarahan subhialoid. Pada retinopati diabetik dapat dijumpai mikroanerisma di pembuluh darah retina

Normal Fundus

Px. neurologi• Tes kernig : (+)• Tes Brudzinski : (+)• Saraf kranial : kelumpuhan saraf VI• Fungsi refleks :• Refleks fisiologis:

bisep/trisep/refleks radial:refleks mata kaki/achilles:

• Refleks patologis: refleks babinski (+)• Refleks primitif: negatif

Tes kernig

• Pasien yg sedang berbaring fleksikan pahanya pada persendian panggul sampai membuat sudut 90 drajat

Biasanya kita dapat melakukan ekstensi ini s/d sudut 135, antara tungai bawah dan atas.

Bila ada tahanan dan rasa nyeri sebelum tercapai sudut ini, maka dikatakan bahwa tanda kernig +Terjadi krn rangsangan selaput otak, dan iritasi akar lumbosakral atau pleksusnya (mis pada HNP-lumbal)

Pada meningitis biasanya positif bilateral, sedang HNP-lumbal dapat unilateral

Tes brudzinskiPatient placed in supine position Patient placed in supine position and neck is passively flexed and neck is passively flexed towards the chesttowards the chestPositive test is elicited when Positive test is elicited when flexion of neck causes flexion at flexion of neck causes flexion at knees and/or hips of the patientknees and/or hips of the patient

Saraf VI nervus abdusen

• Kelumpuhan lesi N.VI melumpuhkan otot rektus lateralis, jadi melirik ke arah luar (lateral, temporal) terganggu pd mata yg terlibat, yg mengakibatkan diplopia horisontal. Bila pasien melihat lurus ke depan, posisi mata yang terlibat sedikit mengalami aduksi, dsbb o/ aksi yg berlebihan dari otot rektus medialis yg tdk terganggu

Penyebab gangguan n.VI• Vaskuler, misalnya pada:• Infark• Arteritis• Anerisma (a.basilaris)• Trauma, misalnya pada:• Fraktur os petrosum• Tekanan intrakranial tinggi• Mastoiditis• Meningitis• Sarkoidosis• Glioma di pons

Refleks fisiologis

Refleks tendon achilles

• Bhs blnd achillespeesreflex (APR)• Tungkai bwh difleksikan sedkt, pegang kaki pd

ujungnya u/ mmbrkn sikap dorsofleksi ringan pd kaki, diketok kontraksi m.triseps sure & mmbrikan gerak plantar fleksi pd kaki

• Lengkung refleks mll s1,s2

Px Refleks BabinskiPx Refleks Babinski

• Reflex babinski adalah reflex abnormal yaitu Reflex babinski adalah reflex abnormal yaitu bila dorsoflexi ibu jari kaki disertai jari-jari kaki bila dorsoflexi ibu jari kaki disertai jari-jari kaki lain terbuka seperti kipaslain terbuka seperti kipas

• Untuk menunjukkan gangguan pada UMNUntuk menunjukkan gangguan pada UMN• refleks Babinski (refleks Babinski (++))

Refleks babinskiRefleks babinski

Refleks primitif

Refleks Refleks MoroMoro

Refleks Refleks MencariMencari

Refleks Refleks Menggenggam Menggenggam

(Grasping)(Grasping)

Refleks Refleks ParasutParasut

Refleks Tonus Refleks Tonus Leher Leher

(Rooting)(Rooting)

Refleks primitif pada bayi

Lab

• Hb : 12.4 gr/dL N(p:12-16 g/dL l:13,5-18g/dL)

• PCV: 60% (p: 38-47% l:40-54%)

• Leukocytes : 38.000 /mm³ (4000-11.000/mm³)

• Thrombocyte : 240.000 /mm³ N(150.000-400.000/uL)

Hb• a/ pigmen pengangkut oksigen utama &

terdapat di eritrosil• u/membentuk eritrosit matang yg fungsional,

yg beredar dlm darah perifer & menyalurkan oksigen ke jaringan, harus tercapai keseimbangan yg rumit antara sintesis porfirin, pasokan besi, dan sintesis globin yg terkemas rapih dalam membran SDM yg lemtur shgg eritrosit dpt melewati kapiler halus dlm jaringan

• Defek pd tiap tahap ini dpt mnybb gang penyaluran O2 ke jaringan

PCV packed cell volume/hematokrit

• Dpt diukur pd darah vena or kapiler dg teknik makro or mikrokapiler.

• Metode mikrohematokrit memungkinkan u/ mmprkrkan sec visual vol sel drh pth n trombosit yg mmbtk buffy coat antara sdm dan plasma.

• Plasma supernatan jg dpx u/ mlht ada tdknya ikterus or hemolisis

Leukosit

• Tdr dr: granulosit, limfosit, dan monosit mmbntk populasi leukosit normal, ttp jg tdpt sjmlh kcl sel drh pth ygmungkin b’ada dlm stadium k2 dr teakhr pmtngan

• Memberikan informasi mengenai bbgai keadaan pnykt

• Jmlh absolut bbgai jns sel ini jg dpt mmbr ptunjuk apkh tdpt pnykt sumsum tulang primer, or apakah kelainan merupakan suatu reaksi thdp proses pykt sekunder

Trombosit

• Merupakan fragmen sel, tdk memiliki nukleus. Dilengkapi organel n sistem enzim sitosol u/ mnghslkn energi n mensintesis produk sekretorik yg disimpan dgranula2 yg tsbr di sel. Sitosolnya.

• Trombosit mngandung aktin n miasin dlm konsentrasi yg tgg trombosit dpt berkontraksi

• Kemampuan sekretorik n kontraksi pptg dlm hemostasis (mis. Mencegah hilangnya darah dari pembuluh drh yg rusak)

LP

• WBC : 5000 /µL (< 5 cells/mm3)with a preabdominance of neutrophils• RBC : - (< 10/mm10/mm33..)• Glucose : 20 mg/dL (50 and 80 mg/dl50 and 80 mg/dl )• Protein : 200 mg/dL (0.2-0.4g/l 0.2-0.4g/l )/20-

40mg/dL• Gram’s stain : +• Culture : +• BTA ziehlneelson : +

LPPungsi lumbal dapat dilakukan Pungsi lumbal dapat dilakukan untuk : untuk :

• mengambil sampel LCS mengambil sampel LCS demi Px mikroskopik dan demi Px mikroskopik dan bakteriologis bakteriologis

• Untuk menyuntikan obat Untuk menyuntikan obat demi mengatasi infeksidemi mengatasi infeksi

• Induksi anestesi Induksi anestesi

Contraindications for LPContraindications for LP::

• Absolutely contraindicated Absolutely contraindicated in the presence of infection in the presence of infection in the tissues near the in the tissues near the puncture site.puncture site.

• Relatively contraindicated Relatively contraindicated in presence of SOL or in presence of SOL or increased ICPincreased ICP

• Caution advised when Caution advised when lateralizing signs or signs of lateralizing signs or signs of uncal herniation.uncal herniation.

CSF FormationCSF Formation

• 140 ml spinal and cranial 140 ml spinal and cranial CSFCSF

• 30 ml in the spinal cord30 ml in the spinal cord• Production is approx. 0.35 Production is approx. 0.35

ml/minml/min• Net flow out of ventricles Net flow out of ventricles

50 – 100 ml/day50 – 100 ml/day• Reduces brain weight Reduces brain weight

from 1400 to 50g.from 1400 to 50g.

LPLP

• Protein• Glucose• Cell count with

differential• Gram stain and culture• PCR• Myelin basic protein• Smear• Lactate• Pyruvate

• Herniation• Cardiorespiratory

compromise• Pain• Headache (36.5%)• Bleeding• Infection• Subarachnoid

epidermal cyst• CSF leakage

InterpretationsInterpretations• PressurePressure

– Opening pressure is taken promptly, avoiding Opening pressure is taken promptly, avoiding falsely low values due to leakage through and falsely low values due to leakage through and around the needlearound the needle

– Normal pressure is between 70 and 180 mm HNormal pressure is between 70 and 180 mm H2200

InterpretationInterpretation• AppearanceAppearance

– If CSF is not crystal clear, a pathologic condition of If CSF is not crystal clear, a pathologic condition of the CNS should be suspectedthe CNS should be suspected

– Compare fluid to waterCompare fluid to water– Fluid may be clear with as many as 400 RBCs/mmFluid may be clear with as many as 400 RBCs/mm33

and 200 WBCs/mmand 200 WBCs/mm33

InterpretationInterpretation• CellsCells

– WBC counts over 5 cells/mmWBC counts over 5 cells/mm33 should be taken to indicate should be taken to indicate the presence of pathologic conditionthe presence of pathologic condition

– Polymorphonuclear leukocytes are never seen in normal Polymorphonuclear leukocytes are never seen in normal adultsadults

– Neutrophilic pleocytosis is commonly associated with Neutrophilic pleocytosis is commonly associated with bacterial infections or early stages of viral infections, bacterial infections or early stages of viral infections, tuberculosis, meningitis, hematogenous meningitis, and tuberculosis, meningitis, hematogenous meningitis, and chemical meningitis due to foreign bodies.chemical meningitis due to foreign bodies.

Pungsi lumbalPungsi lumbal

• Leukosit : predominan neutrofilLeukosit : predominan neutrofil normalnya leukosit tdk adanormalnya leukosit tdk ada neutrofil menandakan infeksi bakteri akutneutrofil menandakan infeksi bakteri akut

• Red blood cells : negatifRed blood cells : negatif tdk ada perdarahantdk ada perdarahan

InterpretationInterpretation• CellsCells

– Eosinophils are always abnormal and most commonly Eosinophils are always abnormal and most commonly represent a parasite infestation.represent a parasite infestation.

– Eosinophils have also been reported in cases of Eosinophils have also been reported in cases of subarachnoid hemorrhage, lymphoma, Hodgkin’s disease, subarachnoid hemorrhage, lymphoma, Hodgkin’s disease, brucellosis, fungal meningitis, mycoplasma pneumonia brucellosis, fungal meningitis, mycoplasma pneumonia infection, measles, lymphocytic choriomeningitis, infection, measles, lymphocytic choriomeningitis, rickettsial infections, leukemia, demyelinating disease, rickettsial infections, leukemia, demyelinating disease, sarcoiodosis, acute inflammatory demyelinating sarcoiodosis, acute inflammatory demyelinating polyneuropathy, allergic reactions, and idiopathic polyneuropathy, allergic reactions, and idiopathic eosinophilic meningitis.eosinophilic meningitis.

InterpretationInterpretation• CellsCells

– Normal CSF RBCs are less than 10/mmNormal CSF RBCs are less than 10/mm33..– Counts that are otherwise unexplained may be Counts that are otherwise unexplained may be

due to a traumatic tap.due to a traumatic tap.– Herpes simplex virus encephalitis may elevate the Herpes simplex virus encephalitis may elevate the

CSF RBC count in many patients.CSF RBC count in many patients.

InterpretationInterpretation• GlucoseGlucose

– Low CSF glucose concentration indicates increased Low CSF glucose concentration indicates increased glucose use in the brain and the spinal cord. glucose use in the brain and the spinal cord.

– The normal range of CSF glucose is between 50 The normal range of CSF glucose is between 50 and 80 mg/dland 80 mg/dl

– 60-70% of serum glucose concentration60-70% of serum glucose concentration– Only low concentrations of glucose are Only low concentrations of glucose are

significancesignificance

Interpretation

• Low CSF Glucose SyndromesBacterial meningitisBacterial meningitis SyphilisSyphilis

Tuberculous meningitisTuberculous meningitis Chemical meningitisChemical meningitis

Fungal meningitisFungal meningitis Subarachnoid meningitisSubarachnoid meningitis

SarcoidosisSarcoidosis Mumps meningitisMumps meningitis

Meningeal Meningeal carcinomatosiscarcinomatosis

Herpes simplex Herpes simplex encephalitisencephalitis

Amebic meningitisAmebic meningitis HypoglycemiaHypoglycemia

CysticercosisCysticercosis TrichinosisTrichinosis

InterpretationInterpretation• ProteinProtein

– Increase in CSF total protein levels are a Increase in CSF total protein levels are a nonspecific abnormality associated with many nonspecific abnormality associated with many disease states.disease states.

– Levels > 500mg/dl are uncommon and are seen Levels > 500mg/dl are uncommon and are seen mainly in meningitis, in subarachnoid bleeding, mainly in meningitis, in subarachnoid bleeding, and with spinal tumors.and with spinal tumors.

CSF Analysis with InfectionsCSF Analysis with Infections

• Bacterial InfectionsBacterial Infections– The Gram stain is of great importance, because this often The Gram stain is of great importance, because this often

dictates the initial choice of antibiotic.dictates the initial choice of antibiotic.– Gram-negative intracellular or extracellular diplococci are Gram-negative intracellular or extracellular diplococci are

indicative of indicative of Neisseria meningitidisNeisseria meningitidis– Small Gram-negative bacilli may include Small Gram-negative bacilli may include Haemophilus Haemophilus

influenza,influenza, especially in children. especially in children.– Gram-positive cocci indicates Gram-positive cocci indicates Streptococcus pneumoniae, Streptococcus pneumoniae,

otherother Streptococcus Streptococcus species, or species, or StaphylococcusStaphylococcus..– 20% of Gram stains may be falsely negative.20% of Gram stains may be falsely negative.

CSF Analysis with InfectionsCSF Analysis with Infections

• Bacterial InfectionsBacterial Infections– While the culture is pending, one may suspect a bacterial While the culture is pending, one may suspect a bacterial

infection in the presence of an elevated opening pressure infection in the presence of an elevated opening pressure and a marked pleocytosis ranging between 500 and 20,000 and a marked pleocytosis ranging between 500 and 20,000 WBCs/mmWBCs/mm33..

– The differential count is usually chiefly neutrophils.The differential count is usually chiefly neutrophils.– A count above 1000 cells/mmA count above 1000 cells/mm33 seldom occurs in viral seldom occurs in viral

infections. infections.

CSF Analysis with InfectionsCSF Analysis with Infections

• Bacterial InfectionsBacterial Infections– CSF glucose levels less than 40 mg/dl or less than CSF glucose levels less than 40 mg/dl or less than

50% of a simultaneous blood glucose level should 50% of a simultaneous blood glucose level should raise the question of bacterial meningitis.raise the question of bacterial meningitis.

– The CSF protein content in bacterial meningitis The CSF protein content in bacterial meningitis ranges from 500 to 1500 mg/dl.ranges from 500 to 1500 mg/dl.

CSF Analysis with InfectionsCSF Analysis with Infections

• Viral StudiesViral Studies– The organisms most commonly isolated in viral The organisms most commonly isolated in viral

meningitis are enteroviruses and mumps.meningitis are enteroviruses and mumps.• Enteroviruses: summer and fallEnteroviruses: summer and fall• Mumps: winter and springMumps: winter and spring

Lumbar Puncture-CSF StudiesLumbar Puncture-CSF Studies

• Tube 1: gram stain and culture, cell countTube 1: gram stain and culture, cell count• Tube 2: glucose, proteinTube 2: glucose, protein• Tube 3: cell countTube 3: cell count• Tube 4: hold Tube 4: hold

– Bacterial antigen studiesBacterial antigen studies– Viral PCRViral PCR– Fungal or mycobacterium culturesFungal or mycobacterium cultures

NEUROPATHOLOGY IIINEUROPATHOLOGY III• CSF . CSF .

-Normal. Meningitis -Normal. Meningitis pressurepressure pyogenicpyogenic TBTB 60-120mm >200 mm 60-120mm >200 mm >200mmH2O >200mmH2O appearance appearance

• crystal clear turbid opalescent crystal clear turbid opalescent • cell contentcell content

0-4mononucl. >1000PMN´s lymphos. 0-4mononucl. >1000PMN´s lymphos. • proteins proteins

0.2-0.4g/l 1-10 g/l 1-3g/l 0.2-0.4g/l 1-10 g/l 1-3g/l glucose glucose 50-80 mg/100ml 50-80 mg/100ml decreaseddecreased low low

CSF DiagnosisWBCWBC GlucoseGlucose ProteinProtein

NormalNormal <5 (lymphs <5 (lymphs 70%, PMN’s 70%, PMN’s 3%)3%)

2/3 serum 2/3 serum glucoseglucose

20-50 (½ 20-50 (½ serum serum level)level)

BacteriBacterial al

MeningMeningitisitis

>100, PMN’s >100, PMN’s predominatepredominate

Low Low compared compared to serum to serum (<20)(<20)

Elevated Elevated (>100)(>100)

Aseptic Aseptic MeningMening

itisitis

Elevated Elevated (PMN’s (PMN’s early, early, lymphs late)lymphs late)

Normal to Normal to lowlow

Normal or Normal or slightly slightly elevatedelevated

TB TB MeningMening

itisitis

Elevated Elevated (PMN’s (PMN’s early, early, lymphs latelymphs late

Low (<50)Low (<50) Elevated Elevated (>100)(>100)

Parameter (normal)

Bacterial

Viral Neoplastic

Fungal

OP (<170 mm CSF)

>300m>300mmm

200m200mmm

200200 300m300mmm

WBC (<5mononuclear)

>1000>1000 <1000<1000 <500<500 <500<500

%PMN’s (0)

>80%>80% 1-50%1-50% 1-50%1-50% 1-50%1-50%

Glucose (>40mg/dL)

<40<40 >40>40 <40<40 <40<40

Protein (<50mg/dL)

>200>200 <200<200 >200>200 >200>200

Gram stain (-)

++ __ -- __

Cytology (-)

__ __ ++ ++

Results

• Typical Cerebrospinal Fluid Findings in Various Types of Meningitis

• Test Bacterial Viral Fungal Tubercular

• Opening pressure Elevated Usually normal Variable Variable

• White blood cell count ≥1,000 per mm3 <100 per mm3 Variable Variable

• Cell differential Predominance of Predominance of Predominance Predominance • PMNs* lymphocytes† of lymphocytes of lymphocytes

• Protein Mild to marked Normal to elevated Elevated Elevated • elevation

• CSF-to-serum glucose Normal to marked Usually normal Low Low • ratio decrease

• CSF = cerebrospinal fluid; PMNs = polymorphonucleocytes. • *—Lymphocytosis present 10 percent of the time. • †—PMNs may predominate early in the course.

Ziehl-neelsenZiehl-neelsen• Cara pewarnaan:Cara pewarnaan:1.1. Sediaan kuman diwarnai dgn lar. Fukhsin karbol n Sediaan kuman diwarnai dgn lar. Fukhsin karbol n

dipanaskan dgn api kcl shg keluaar asap,biarkan 5 dipanaskan dgn api kcl shg keluaar asap,biarkan 5 menitmenit

2.2. Sediaan dicuci dgn air dimasukan dlm lar h2so4 Sediaan dicuci dgn air dimasukan dlm lar h2so4 5% slm 2 dtk5% slm 2 dtk

3.3. Cuci dgn alkohol 60% shg tdk ada wrna mrh Cuci dgn alkohol 60% shg tdk ada wrna mrh mengalirmengalir

4.4. Sediaan dicuci dgn air n diwarnai dgn lar biru Sediaan dicuci dgn air n diwarnai dgn lar biru metilen 1-2 mnt,cuci dgn air keringkanmetilen 1-2 mnt,cuci dgn air keringkan

Hasil:Hasil:Kuman tahan asam = merahKuman tahan asam = merahKuman tdk thn asam= biruKuman tdk thn asam= biruPada m.tuberculosis:Pada m.tuberculosis:Pd pewrnaan thn asam akn tlht kuman bwrna Pd pewrnaan thn asam akn tlht kuman bwrna

mrh n latar blkg wrn birumrh n latar blkg wrn biruHasil + ditentukan o/ jmlh kuman Hasil + ditentukan o/ jmlh kuman

5000-10000/ml bahan5000-10000/ml bahan

• Hasil + dilaporkan sec kuantitatif, biasanya Hasil + dilaporkan sec kuantitatif, biasanya digunakan skala Bronkhorst,yi:digunakan skala Bronkhorst,yi:

++ apabila tdpt 10 kuman stlh prksa 15 meitapabila tdpt 10 kuman stlh prksa 15 meit++ 20 kuman dlm 10 lapang penglihtn++ 20 kuman dlm 10 lapang penglihtn+++ 60 kuman dlm 10 lapang pnglhtn+++ 60 kuman dlm 10 lapang pnglhtn++++ 120 kuman dlm 10 lapang penglihtn++++ 120 kuman dlm 10 lapang penglihtn+++++ >120 kuman dlm 10 lapang penglhtn+++++ >120 kuman dlm 10 lapang penglhtn

• EEG EEG u/ mlht aktiifitas otak/gelombang otak u/ mlht aktiifitas otak/gelombang otak shg dpt mnyngkrkn D/D spt epilepsi atau shg dpt mnyngkrkn D/D spt epilepsi atau echephalitis viralechephalitis viral

• MRI MRI u/mlht apa ada masa dlm tengkorak n u/mlht apa ada masa dlm tengkorak n otak. Untuk menyingkirkan dugaan abses otak. Untuk menyingkirkan dugaan abses otak.otak.

Referensi Referensi

• Neurologi klinik; pemeriksaan fisik dan mental UINeurologi klinik; pemeriksaan fisik dan mental UI• Fisiologi manusia; dari sel ke sistem sherwoodFisiologi manusia; dari sel ke sistem sherwood• Buku ajar mikrobiologi kedokteran UIBuku ajar mikrobiologi kedokteran UI• Buku ajar neurologi klinis harsonoBuku ajar neurologi klinis harsono• Neurologi klinis dasar dian rakyatNeurologi klinis dasar dian rakyat• Tinjauan klinis hasil pemeriksaan laboratprium Tinjauan klinis hasil pemeriksaan laboratprium

sachr&mcphersonsachr&mcpherson• Patofisiologi konsep kliis proses2 penyakit Patofisiologi konsep kliis proses2 penyakit

price&wilsonprice&wilson