Unspecific congenital toxoplasmosis in a two-month-old baby

A two-month-old baby boy diagnosed with unspecific congenital toxoplasmosis was referred by a pediatrician to the Clinical Parasitology referral center at the Faculty of Medicine, Universitas Indonesia. Baby was post-hospitalized in the NICU and required ventilation support for one month. Furthermore, there was history of from various medical conditions, such as intracranial bleeding, convulsion, hypertrophic cardiomyopathy, retinopathy, and renal failure. After two month, there was no significant weight gain, anti-Toxoplasma IgM showed positive results, and anti-Toxoplasma IgM and IgG of the mother were also positive. Baby and mother were successfully treated with pyrimethamine, cotrimoxazole, and folinic acid for one month. At 2 years, there signs of normal motoric, eye, and hearing development with underdeveloped kidneys. Therefore, pre-pregnancy counseling and education aimed at preventing toxoplasmosis during pregnancy should be increased and conducted routinely by health workers or trained cadres to reduce the risk of fetal defects.

Determinant of parasite clearance and density on uncomplicated falciparum malaria infections in malaria-endemic area of Lampung Province, Indonesia

Lampung is a malaria-endemic region in Indonesia with an annual parasite incidence of 0.06 per 1,000 population. The socio-demographic factors, clinical conditions, and artemisinin combination therapy (ACT) types might affect parasite clearance and parasite density. This study aims to investigate factors that influence parasite clearance and parasite density in malaria patients. A retrospective analytic observational and a cross-sectional approach was used to conduct this study. A total of 66 malaria patients were examined to investigate parasite density and clearance, socio-demographic profiles, clinical conditions, and ACT types. To analyze data, univariate, bivariate, and multivariate tests were used. Age (P=0.045; r=0.238) and ACT type (P=0.021; r=0.273) were the only variables that had a significant correlation with parasite clearance. Age (P=0.003; r=0.345) had a significant correlation with parasite density. The most influential factors related to parasite clearance were the ACT type (dihydroartemisinin piperaquine) (P=0.017; odds ratio (OR) 0.109; 95.0% confidence interval (CI), 0.018-0.675) and age (P=0.030; OR 0.132; 95.0% CI, 0.021-0.823). Age (P=0.046; OR 0.320; 0.105-0.978, 95.0% CI) was the most significant variable associated with parasite density.

Emerging Multiple Parasite Reinfection as Neglected Tropical Disease: A Case Series

Soil-transmitted helminth infection is endemic in Indonesia, with cases of reinfection despite individualized therapy and a mass treatment program. Three cases of multiple helminth infections were described that might be associated with chronic bloody diarrhea and stunted growth. These case series alert pediatricians that untreated helminthic infections are part of the differential diagnosis in children with gastrointestinal bleeding. Environmental surveillance should be performed in high-risk areas to prevent reinfection and growth alteration. In endemic areas, bloody diarrhea warns for an early routine fecal analysis. Correct diagnosis, prompt treatment, and source control are crucial to prevent long-term complications.

C75. Premature Coronary Artery Disease in Young Male Patient with Strong Family History

Background

Coronary artery disease (CAD) occurring in less than 45 years of age is termed as premature CAD (PCAD). Recent studies showed a prevalence of 4-10 % of PCAD. PCAD is associated with unfavorable outcomes for the patients and had a greater impact on the quality of life. Family History is the best method to explained complex interaction between shared risk factor.

Case Summary

A 37-years old male admitted to Saiful Anwar Hospital for further evaluation of anginal pain. The patient complains of recurrent chest pain since 5 months ago but still relieved by rest. The electrocardiogram showed Wellens Type B which is specific for critical stenosis of the left anterior descending artery (LAD). Then the patient undergoing DCA Ad Hoc. The implantation of a 46 mm DES at proximal until distal LAD was performed. The patient discharged after a day observation.

Discussion

The challenging point, in this case, was it happen at a young age with strong family history. There was positive family history of PCAD in 1st degree relative on her brother and mother, despite several risk factors were identified in this case consist of smoking, and dyslipidemia, which make CAD risk higher. Despite adequate control of risk factors, family screening is important to reveal subclinical atherosclerosis.

C101. Toxoplasmic Myocarditis in Immunocompetent Patient: A Rare Case Report

Background

Toxoplasmosis is the most frequent protozoan infection among human. Primary acquired infections in immuno-competent hosts are usually asymptomatic or may cause only slight, self-resolving and not pathognomonic symptoms. Although often considered as benign, acute infections in young healthy adults can lead to heart inflammation, including acute myocarditis.

Case Illustration

A 28-year-old man was admitted to the hospital with a chief complaint of flu-like illness with intermittent fever and sharp chest pain. His physical examination was unremarkable. The electrocardiography showed no significant ST-T changes. His laboratory investigations gave the following results: elevated level of HsTrop T (571 ng/L; reference: <4 ng/dL), SGOT (112 U/L; reference: <41 U/L), SGOT (114 U/L; reference: <41 U/L). The echocardiography showed lateral pericardial thickening with preserved left ventricular function. He underwent cardiac MRI (cMRI). The cMRI showed myocardial edema without ischemic scar. The serological test is positive for recent Toxoplasma infection. Therefore, the patient was diagnosed with acute toxoplasmic myocarditis and subsequently treated with corticosteroid, ACE-I, beta blocker, and a combination of pyrimethamine and clindamycin. His symptoms was improved.

Discussion

We reported a case of an acute toxoplasmic myocarditis in an immunocompetent young man. This case demonstrates the importance of determining the etiology of myocarditis in order to start an appropriate therapy and prevent possible sequeale.

C75. Premature Coronary Artery Disease in Young Male Patient with Strong Family History

Background

Coronary artery disease (CAD) occurring in less than 45 years of age is termed as premature CAD (PCAD). Recent studies showed a prevalence of 4-10 % of PCAD. PCAD is associated with unfavorable outcomes for the patients and had a greater impact on the quality of life. Family History is the best method to explained complex interaction between shared risk factor.

Case Summary

A 37-years old male admitted to Saiful Anwar Hospital for further evaluation of anginal pain. The patient complains of recurrent chest pain since 5 months ago but still relieved by rest. The electrocardiogram showed Wellens Type B which is specific for critical stenosis of the left anterior descending artery (LAD). Then the patient undergoing DCA Ad Hoc. The implantation of a 46 mm DES at proximal until distal LAD was performed. The patient discharged after a day observation.

Discussion

The challenging point, in this case, was it happen at a young age with strong family history. There was positive family history of PCAD in 1st degree relative on her brother and mother, despite several risk factors were identified in this case consist of smoking, and dyslipidemia, which make CAD risk higher. Despite adequate control of risk factors, family screening is important to reveal subclinical atherosclerosis.

C101. Toxoplasmic Myocarditis in Immunocompetent Patient: A Rare Case Report

Background

Toxoplasmosis is the most frequent protozoan infection among human. Primary acquired infections in immuno-competent hosts are usually asymptomatic or may cause only slight, self-resolving and not pathognomonic symptoms. Although often considered as benign, acute infections in young healthy adults can lead to heart inflammation, including acute myocarditis.

Case Illustration

A 28-year-old man was admitted to the hospital with a chief complaint of flu-like illness with intermittent fever and sharp chest pain. His physical examination was unremarkable. The electrocardiography showed no significant ST-T changes. His laboratory investigations gave the following results: elevated level of HsTrop T (571 ng/L; reference: <4 ng/dL), SGOT (112 U/L; reference: <41 U/L), SGOT (114 U/L; reference: <41 U/L). The echocardiography showed lateral pericardial thickening with preserved left ventricular function. He underwent cardiac MRI (cMRI). The cMRI showed myocardial edema without ischemic scar. The serological test is positive for recent Toxoplasma infection. Therefore, the patient was diagnosed with acute toxoplasmic myocarditis and subsequently treated with corticosteroid, ACE-I, beta blocker, and a combination of pyrimethamine and clindamycin. His symptoms was improved.

Discussion

We reported a case of an acute toxoplasmic myocarditis in an immunocompetent young man. This case demonstrates the importance of determining the etiology of myocarditis in order to start an appropriate therapy and prevent possible sequeale.

Prognostic value of myocardial injury biomarker in COVID-19: a systematic review and meta-analysis

Background

An accurate prognostic tool that can help with risk stratification at first admission is crucial in COVID-19 patients, as severe complications and mortality rate can be reduced with prompt treatment and close follow up. The myocardial injury biomarker, Troponin, is reported to be a potential predictor of mortality in COVID-19 cases.

Purpose

This study aims to investigate the utility of cardiac troponin level as a prognosis tool in COVID-19 patients.

Methods

On March 12th, 2021, data was collected from PMC, PubMed, Google Scholar, Science Direct, and Scopus, using combination of keywords associated with myocardial injury biomarker, Troponin, and its prognostic value for mortality in COVID-19 patients. Included publications are original clinical trials, limited to those with English manuscripts, and all were reviewed and evaluated by 5 authors to minimise bias. Inclusion criteria for studies are original clinical trials with a study population of adults (≥18 years old) patients with confirmed SARS-CoV-2 infection through PCR. The quality of each studies included was assessed using the Newcastle-Ottawa Scale (NOS) and data synthesis and statistical analysis were carried out using Review Manager software.

Results

A total of 19 studies consisting of 13,789 COVID-19 patients were included. All 19 studies were good quality according to the NOS. Studies found that myocardial injury, indicated by the elevation of its biomarker, Troponin, is a strong predictor of in-hospital mortality. Furthermore, elevated troponin level itself is an independent marker of mortality, regardless of its concomitant cardiac disease. Meta-analysis of 9 included studies revealed a significant association between elevated cardiac troponin levels and mortality (HR 4.13; 95% CI 3.42 - 5.00; P<0.001). Based on GRADE, the result of this systematic review and meta-analysis proved to be moderate in quality as there are no inconsistency and variability in results and there are no publication biases.

Conclusion

Cardiac troponin level is found to be a strong predictor of mortality in COVID-19 patients and therefore should be treated both as an evaluation for cardiac involvement and as an important prognostic marker. Patients with elevated troponin levels within admission should be closely monitored and given prompt treatment to decrease mortality.

Funding Acknowledgement

Type of funding sources: None. Forest plot figure

Does elective orthopaedic surgery in pandemic era increase risk of developing COVID-19? A combined analysis of retrospective and prospective study at Cipto Mangunkusumo Hospital, Jakarta, Indonesia

BACKGROUND

To date, no recommendations have been published on when and how to start again carrying out elective, non-urgent surgery on COVID-19-negative patients after the epidemic peak has been reached in a given country or region and the pressure on healthcare facilities, healthcare workers and resources has been released by so far that elective surgery procedures can be safely and ethically programmed again. This study aims to investigate whether elective orthopaedic surgery will increase the risk of developing COVID-19.

MATERIALS AND METHODS

This was a combined retrospective and prospective studies performed at a national tertiary hospital in Jakarta, Indonesia. Subjects were patients who underwent elective orthopaedic surgeries at our institution from April to May 2020. Those who were previously infected with COVID-19 from polymerase chain reaction (PCR) reverse transcriptase (RT) examination obtained via nasopharynx and oropharynx swab, as well as those who were reluctant to participate were excluded from the study.

RESULTS

A total of 35 subjects (mean age 32.89 ± 17.42) were recruited. Fifteen (42.9%) subjects were male, and 20 subjects (57.1%) were female. Mean duration of surgery was 240 min with the longest and shortest duration of 690 and 40 min, respectively. General anaesthesia was performed in the majority of cases in 18 surgeries (51.4%) with local anaesthesia as the least in 2 surgeries (5.7%). Length of stay of our study was 6 days of average. None of the patients developed symptoms suggestive of COVID-19 infection.

CONCLUSION

We found that elective orthopaedic surgery may not be associated with increased cases of COVID-19 cases. However, our study was limited by short duration of follow-up. Further studies are required in order to investigate the affect of undergoing elective surgery and the number of COVID-19 cases.

Toxoplasma gondii SAG2 type III in an atypical presentation of ocular toxoplasmosis in Indonesia

OBJECTIVE

This study aimed to perform genotyping of Toxoplasma gondii strain or variant causing atypical toxoplasmic uveitis in Indonesian patients.

METHODS

Ocular fluid samples originating from 46 uveitis patients with non-specific ocular manifestations were analysed for Toxoplasma infection by PCR of the B1 locus. The clonal type was determined by amplification, sequencing and phylogenetic analysis of SAG2 and GRA6 loci in B1-positive samples. Clinical data were obtained from the medical records.

RESULTS

Pan uveitis was the most frequent manifestation (65.2%) and mostly unilateral (76.1%). PCR of the B1 locus identified eight positive subjects (12.5%); six had panuveitis and two of these had diabetes mellitus. Phylogenetic analysis with maximum likelihood of the SAG2 locus in the B1-positive samples resulted in Toxoplasma gondii SAG2 type III allele. No positive result was obtained from the PCR of GRA6 locus.

CONCLUSION

Toxoplasma gondii SAG2-type III allele was identified in an atypical presentation of toxoplasmic uveitis in Indonesia.

Blastocystis ST-1 is associated with Irritable Bowel Syndrome-diarrhoea (IBS-D) in Indonesian adolescences

Objective

IBS is a functional gastrointestinal disorder and commonly presents in children and adolescences, presented as diarrhoea, constipation or mixed type. Blastocystis is a common intestinal protozoa found worldwide, which pathogenicity is still controversial. This study aimed to identify the risk factors of IBS, the association between IBS types with Blastocystis subtypes and analyse Blastocystis pathogenicity.

Design

A comparative cross-sectional study was conducted among senior high school students. Rome III Criteria for IBS diagnosis, questionnaires on the risk factors of IBS and types of IBS were recorded. Students were further selected and classified into IBS and non-IBS groups to analyse the association between IBS, IBS types with Blastocystis infection and its subtypes. Direct microscopic stool examination to identify single Blastocystis infection was performed, followed by culture in Jones' medium, PCR, sequencing of 18S rRNA and phylogenetic analysis to determine Blastocystis subtype. Data was analysed using SPSS v22.0 and P value <0.05 was considered statistically significant (95% confidence intervals).

Results

IBS was found in 30.2% of 454 students, consisted of 33.3% IBS Diarrhoea, 27.7% IBS Mixed, 27.7% IBS Unclassified and 11.1% IBS Constipation. Major risk factors to IBS consisted of family history of recurrent abdominal pain, abuse, bullying and female gender in respective order (OR 3.6–2.1). Blastocystis ST-1 was significantly associated to IBS-D with 2.9 times risk factor.

Conclusions

Blastocystis infection is a risk factor to develop IBS-D type in adolescence; Blastocystis ST-1 can be regarded as a pathogenic subtype.

Breast Cancer Education and Screening in Indonesian Rural Community: A Programme Trial

Background and context: Breast cancer has the highest incidence and prevalence among cancers in Indonesia. Indonesian rural society has low level of breast cancer knowledge and self examination practice. Difficulty for accessing breast cancer primary health care screening also caused negligence. Furthermore, ignorance and economy situation made patients chose alternative treatments. Hence, most cases are detected at late stages, in which late diagnosis and treatment resulted in high mortality. Aim: Decrease breast cancer mortality by increasing breast cancer knowledge level, monthly self-examination practice awareness, and mass screening for early detection of breast cancer. Strategy/Tactics: In conjunction with National Cancer Control Committee event at 2017, we did a one day social occasion of education and early detection screening for breast cancer in Indonesia rural communities. Participants were gathered with mass announcement from primary health care workers. An expert brought an education class, then parallel screening rooms were provided for all participants. Program/Policy process: Phase one (2017) consists of establishing a good basic education and screening system. We gave free invitation to district health office to be distributed to a local primary health care and participate in a small education class brought by breast cancer specialist. Materials consist of basic knowledge and risk factors, self-examination awareness, diagnostic and treatment procedure, and referral process. Afterward, participants got breast physical exam screening by general clinicians. In phase two (2018), we added questionnaires to assess the effectiveness of education class in increasing knowledge level and self-practice awareness. An ultrasonography examination was added to narrow the diagnosis. Participants with higher risk factor or positive findings were given extra consultation. All participants were referred to our secondary referral General Hospital at Karawaci district, Tangerang, Banten, Indonesia. Outcomes: In 2017, 10% of participants had positive results and referred for further tests. In 2018, education class significantly increase knowledge and breast self-exam practice awareness. Moreover, ultrasonography examination narrowed positive diagnosis from 13% to 7%. What was learned: Education and early detection screening to primary health cares across Indonesia are needed to gather breast cancer cases at earliest stadium, hopefully could decrease breast cancer mortality. Feedbacks from participants showed that feeling of importance played important role and can only be developed internally after the disease became personal. Mobile mammography examination will help establishing breast cancer diagnosis. Budget is an issue, participants must be filtered beforehand based on risk factors for positive diagnostic results. A follow up and reminder system is needed to ensure participants follows proper management steps.

Presentation, etiology, and outcome of brain infections in an Indonesian hospital: A cohort study

Background

Little detailed knowledge is available regarding the etiology and outcome of CNS infection, particularly in HIV-infected individuals, in low-resource settings.

Methods

From January 2015 to April 2016, we prospectively included all adults with suspected CNS infection in a referral hospital in Jakarta, Indonesia. Systematic screening included HIV testing, CSF examination, and neuroimaging.

Results

A total of 274 patients with suspected CNS infection (median age 26 years) presented after a median of 14 days with headache (77%), fever (78%), seizures (27%), or loss of consciousness (71%). HIV coinfection was common (54%), mostly newly diagnosed (30%) and advanced (median CD4 cell count 30/µL). Diagnosis was established in 167 participants (65%), including definite tuberculous meningitis (TBM) (n = 44), probable TBM (n = 48), cerebral toxoplasmosis (n = 48), cryptococcal meningitis (n = 14), herpes simplex virus/varicella-zoster virus/cytomegalovirus encephalitis (n = 10), cerebral lymphoma (n = 1), neurosyphilis (n = 1), and mucormycosis (n = 1). In-hospital mortality was 32%; 6-month mortality was 57%. The remaining survivors had either moderate or severe disability (36%) according to Glasgow Outcome Scale.

Conclusion

In this setting, patients with CNS infections present late with severe disease and often associated with advanced HIV infection. Tuberculosis, toxoplasmosis, and cryptococcosis are common. High mortality and long-term morbidity underline the need for service improvements and further study.

Diagnosis and Identification of Blastocystis Subtypes in Primary School Children in Jakarta

Blastocystis hominis is an enteric protozoan with many subtypes. It is frequently found in children and may cause chronic diarrhea. This study revealed Blastocystis subtypes among primary school children and comparison of molecular technique and culture method in Blastocystis diagnosis. A total of 141 stools were collected, examined microscopically, selected into the Blastocystis and negative parasite groups, for diagnostic comparison between culture and 18S rRNA polymerase chain reaction (PCR) methods. Positive PCR amplicons were subsequently sequenced for subtyping. The PCR results revealed 89%, 78%, 80% and 88% sensitivity, specificity and positive and negative predictive values, respectively, in comparison with the culture method (McNemar, p > 0.05). Sixteen PCR samples were successfully sequenced and resulted in three Blastocystis subtypes 1, 3 and 4. In conclusion, PCR was sensitive enough and can be used to exclude Blastocystis infection up to 88% of the cases. Subtypes 3 and 1 were the main subtypes found in apparently healthy school children in Jakarta.