Download - Kusta-dr. Renate
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KustaKusta
dr. Renate T. dr. Renate T. Kandou,SpKK Kandou,SpKK
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PendahuluanPendahuluan
gejala dini tidak khasgejala dini tidak khas ““the great imitator”the great imitator” pengobatan benar, lebih dini pengobatan benar, lebih dini
dapat disembuhkandapat disembuhkan
kecacatan kecacatan psikososial psikososial
angka kesakitan:2,6/10.000 angka kesakitan:2,6/10.000 pddk(Sulut) 2005pddk(Sulut) 2005
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DefinisiDefinisi
Kusta :Kusta : Peny. infeksi kronikPeny. infeksi kronik Penyebabnya Penyebabnya Mycobacterium lepraeMycobacterium leprae Saraf tepi: afinitas pertamaSaraf tepi: afinitas pertamakulit, kulit,
mukosa tr.resp.bgn atasmukosa tr.resp.bgn atasorgan organ lain(kecuali ssp)lain(kecuali ssp)
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SinonimSinonimLepra, Morbus HansenLepra, Morbus Hansen
EpidemiologiEpidemiologiIndonesia urutan ke-3(India,Brasil)Indonesia urutan ke-3(India,Brasil)Cara penularan,ada 2 anggapan:Cara penularan,ada 2 anggapan:1. kontak lgsg antar kulit lama&erat1. kontak lgsg antar kulit lama&erat2. inhalasi2. inhalasiMasa tunas:Masa tunas:sgt bervariasi, 40 hr – 40 thn,ratasgt bervariasi, 40 hr – 40 thn,rata22 3 – 5 thn 3 – 5 thnSumber infeksi: manusia, lain ?Sumber infeksi: manusia, lain ?
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EtiologiEtiologi
Mycobacterium lepraeMycobacterium leprae• bersifat tahan asambersifat tahan asam• berbentuk batangberbentuk batang P:1-8µ,L 0,2-0,5P:1-8µ,L 0,2-0,5• berkelompok, satuberkelompok, satu22
• hidup dlm sel(jaringanhidup dlm sel(jaringanbersuhu dingin)bersuhu dingin)
• tidak dapat dikulturtidak dapat dikulturdlm media buatandlm media buatan
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PatogenesisPatogenesis Cara masuk:Cara masuk:
kulit lecet, mukosa nasalkulit lecet, mukosa nasal Sel target u/pertumbuhan M.lepraeSel target u/pertumbuhan M.leprae
sel Schwann (saraf)sel Schwann (saraf) Kusta tipe LL:Kusta tipe LL:
sist.imun.selulersist.imun.seluler makrofag tdk mampu makrofag tdk mampuhancurkan kuman hancurkan kuman multiplikasi multiplikasi jar.rusak jar.rusak
Kusta tipe TT:Kusta tipe TT:sist.imun.selulersist.imun.seluler makrofag hancurkan kuman makrofag hancurkan kuman makrofag jd sel epiteloid makrofag jd sel epiteloid rx rx jar. rusak jar. rusak
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PatogenesisPatogenesis
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KlasifikasiKlasifikasi
Tujuan:Tujuan:
1.1. Menentukan rejimen tx,prognosis &Menentukan rejimen tx,prognosis &
komplikasi.komplikasi.
2.2. Menemukan pasienMenemukan pasien22 menular menular (target utama pengobatan)(target utama pengobatan)
3.3. Identifikasi pasien yg akan Identifikasi pasien yg akan menderita cacatmenderita cacat
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KlasifikasiKlasifikasi
Modifikasi WHO (1988):Modifikasi WHO (1988):
Kusta PB Kusta PB I, TT, BT (BTA -) I, TT, BT (BTA -)
(Ridley & Jopling)(Ridley & Jopling)
I & T (Madrid)I & T (Madrid)
Kusta MB Kusta MB LL, BL, BB, BT (BTA +) LL, BL, BB, BT (BTA +)
(Ridley & Jopling)(Ridley & Jopling)
B & L (Madrid)B & L (Madrid)
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KlasifikasiKlasifikasi
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Gambaran klinikGambaran klinik
Kusta Kusta IndeterminateIndeterminate• makula/infiltratmakula/infiltrat• hipopigmentasi sisik hipopigmentasi sisik , ,
kulit sktr normalkulit sktr normal• jumlah sedikit jumlah sedikit
(satu/beberapa)(satu/beberapa)• asimetrikasimetrik• hipestesihipestesi• sdkt penebalan sarafsdkt penebalan saraf• ekst ekstremitas, ekst ekstremitas,
bokong, mukabokong, muka
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Gambaran klinikGambaran klinik
Kusta PBKusta PBLesi:Lesi:* Tipe: makula, infiltrat, makula dibatasi * Tipe: makula, infiltrat, makula dibatasi
infiltratinfiltrat• Warna: hipopigmentasi/eritemWarna: hipopigmentasi/eritem• Permukaan kering,skuama+,halus agak Permukaan kering,skuama+,halus agak
berkilatberkilat• Distribusi asimetrisDistribusi asimetris• Jumlah 1 – 5Jumlah 1 – 5Saraf:Saraf:• Hilangnya sensasi jelasHilangnya sensasi jelas• Hanya 1 cabang sarafHanya 1 cabang sarafBTA: negatifBTA: negatifTes Lepromin: positifTes Lepromin: positif
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Kusta PBKusta PB
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Kusta MBKusta MB
LesiLesi* Tipe:makula,plak,papul,* Tipe:makula,plak,papul,
infiltrat, nodusinfiltrat, nodus• Permukaan:halus berkilatPermukaan:halus berkilat• Distribusi lebih simetrisDistribusi lebih simetris• Jumlah Jumlah 5 lesi 5 lesi• Hilangnya sensasi Hilangnya sensasi jelas jelas• Kerusakan saraf banyak Kerusakan saraf banyak
cabangcabang• BTA:positifBTA:positif• Tes Lepromin: negatifTes Lepromin: negatif
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Kusta MBKusta MB
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Pure neurotic leprosyPure neurotic leprosy
- Penebalan saraf, Penebalan saraf, tidak ditemukan pdtidak ditemukan pd
penyakit lainpenyakit lain- India (+)India (+)- Tanpa lesi kulitTanpa lesi kulit
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DiagnosisDiagnosis
Tanda kardinal (utama):Tanda kardinal (utama):
1. Bercak kulit yg mati rasa1. Bercak kulit yg mati rasa
2. Penebalan saraf tepi2. Penebalan saraf tepi
3. Ditemukan kuman tahan asam3. Ditemukan kuman tahan asam
Dx Dx : minimal 1 dari 3 tanda,: minimal 1 dari 3 tanda,
bila (-)bila (-)tersangka kusta, observasitersangka kusta, observasi
3 – 6 bulan 3 – 6 bulan periksa kembali periksa kembali
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Bercak kulit mati rasaBercak kulit mati rasa• Gangguan fungsi sensorisGangguan fungsi sensoris
- rasa nyeri- rasa nyeri
- rasa raba- rasa raba Anestesi Anestesi
- rasa suhu- rasa suhu• Gangguan fungsi motorisGangguan fungsi motoris
paresis/paralisisparesis/paralisis• Gangguan fungsi otonomGangguan fungsi otonom
kulit kering,retak,edema,pertumbuhankulit kering,retak,edema,pertumbuhan
rambut terganggurambut terganggu
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Penebalan saraf tepiPenebalan saraf tepi
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Basil Tahan Asam positifBasil Tahan Asam positif
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Pemeriksaan pasienPemeriksaan pasien
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TES FUNGSI SARAFTES FUNGSI SARAF
A. Tes sensoris A. Tes sensoris * Rasa raba* Rasa raba
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* Rasa nyeri* Rasa nyeri
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B. Tes otonomB. Tes otonom
Dasar: gangguan berkeringat di Dasar: gangguan berkeringat di makula anestesi makula anestesi
Tes anhidrosis:Tes anhidrosis:
* Tes dgn pinsil tinta* Tes dgn pinsil tinta
(tes Gunawan)(tes Gunawan)
* Tes pilokarpin* Tes pilokarpin
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C. Tes motorisC. Tes motoris
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PEMERIKSAAN SARAF TEPIPEMERIKSAAN SARAF TEPI N. Aurikularis magnus N. Aurikularis magnus
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N.UlnarisN.Ulnaris
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N.Peroneus lateralisN.Peroneus lateralis
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PEMERIKSAAN PEMERIKSAAN BAKTERIOSKOPISBAKTERIOSKOPIS
a. Indeks Bakteri (IB)a. Indeks Bakteri (IB)
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b. Indeks Morfologi (IM)b. Indeks Morfologi (IM)
Jlh seluruh kuman utuhJlh seluruh kuman utuh
IM =---------------------------- x 100%IM =---------------------------- x 100%
Jlh seluruh kuman diperiksaJlh seluruh kuman diperiksa
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PEMERIKSAAN PENUNJANGPEMERIKSAAN PENUNJANG
Pemeriksaan histopatologisPemeriksaan histopatologis
(biopsi kulit dan biopsi saraf)(biopsi kulit dan biopsi saraf) Pemeriksaan serologisPemeriksaan serologis
- MLPA- MLPA
- PCR- PCR
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TATALAKSANA UNTUK TATALAKSANA UNTUK PENANGANAN PENYAKIT PENANGANAN PENYAKIT
KUSTAKUSTA 1.1. PENGOBATAN KAUSAL : MDT- WHOPENGOBATAN KAUSAL : MDT- WHO
ObatObat PB PB (6 bulan)(6 bulan) MB MB (12 bulan)(12 bulan)
RifampicinRifampicin 600mg /bln,600mg /bln, **supervisedsupervised
600mg /bln600mg /bln **supervisedsupervised
DDSDDS 100mg /hari100mg /hari 100mg/hari100mg/hari
LampreneLamprene -- 300mg/ bln* 300mg/ bln* + 50mg/hari+ 50mg/hari
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DOSIS ANAKDOSIS ANAK MDT MB usia 10 – 14 tahunMDT MB usia 10 – 14 tahun
Klofazimin 150 mg/bulan diawasiKlofazimin 150 mg/bulan diawasi 50 mg/selang sehari50 mg/selang sehari
RifampisinRifampisin 450 mg/bulan diawasi450 mg/bulan diawasiDapson Dapson 50 mg/hari 50 mg/hari(Lama pengobatan: 12 – 18 bulan)(Lama pengobatan: 12 – 18 bulan)
MDT PB usia 10 – 14 tahunMDT PB usia 10 – 14 tahunRifampisin 450 mg/bulan diawasiRifampisin 450 mg/bulan diawasiDapson Dapson 50 mg/hari 50 mg/hari(Lama pengobatan 6 – 9 bulan)(Lama pengobatan 6 – 9 bulan)
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TATA-LAKSANA TATA-LAKSANA : :
ALTERNATIF : ALTERNATIF : Bila salah satu obat MDT tidak bisa Bila salah satu obat MDT tidak bisa diberikan diberikan – Ofloxacine Ofloxacine 400mg/hari 400mg/hari – Minocycline Minocycline 100mg/hari 100mg/hari
– ClarithromycineClarithromycine 250mg/hari 250mg/hari
CATATAN :CATATAN : Lama pemberian obat bervariasi, Lama pemberian obat bervariasi, semakin lama semakin baik semakin lama semakin baik
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TATA-LAKSANA :TATA-LAKSANA :
2.2. PENGOBATAN SIMTOMATIS :PENGOBATAN SIMTOMATIS : pengobatan ulkus pengobatan ulkus pengobatan reaksi pengobatan reaksi
3.3. PERBAIKAN GIZI/K.U.PERBAIKAN GIZI/K.U.
4.4. REHABILITASI MEDIKREHABILITASI MEDIK
5.5. EDUKASI :EDUKASI : keteraturan berobat keteraturan berobat pencegahan kecacatanpencegahan kecacatan
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Diagnosis BandingDiagnosis Banding(vitiligo)(vitiligo)
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Birth mark (tanda lahir)Birth mark (tanda lahir)
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Pitiriasis versikolorPitiriasis versikolor
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Pitiriasis roseaPitiriasis rosea
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Psoriasis vulgarisPsoriasis vulgaris
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Liken simpleks kronikusLiken simpleks kronikus
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NeurofibromatosisNeurofibromatosis
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Tinea korporisTinea korporis
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KOMPLIKASIKOMPLIKASI
Reaksi kusta:Reaksi kusta:• Pelbagai gejala & tanda radang akut Pelbagai gejala & tanda radang akut
lesi pasien kusta,sbg kelaziman pd lesi pasien kusta,sbg kelaziman pd perjalanan peny./bgn komplikasi perjalanan peny./bgn komplikasi peny. Kustapeny. Kusta
• Penyebab pasti ?Penyebab pasti ?• Reaksi sistem kekebalan tubuhReaksi sistem kekebalan tubuh
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Faktor pencetusFaktor pencetus
Setelah tx antikusta yg intensifSetelah tx antikusta yg intensif Infeksi rekurenInfeksi rekuren PembedahanPembedahan Stres fisikStres fisik ImunisasiImunisasi KehamilanKehamilan Saat-saat setelah melahirkanSaat-saat setelah melahirkan
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Pembagian ReaksiPembagian Reaksi
Ada dua tipeAda dua tipe
1. Reaksi kusta tipe 1(r.reversal)1. Reaksi kusta tipe 1(r.reversal)
2. Reaksi kusta tipe 22. Reaksi kusta tipe 2
(eritema nodosum leprosum = ENL)(eritema nodosum leprosum = ENL)
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Reaksi Reversal & ENLReaksi Reversal & ENLTandaTanda Reaksi tipe 1Reaksi tipe 1 Reaksi tipe 2Reaksi tipe 2
KUlitKUlit Lesi eritem Lesi eritem Nodus,baru,Nodus,baru,
banyak,nyeri,banyak,nyeri,
eritem eritem SarafSaraf Membesar,Membesar,
nyerinyeriMembesar, Membesar,
nyerinyeri
Keadaan Keadaan umumumum
Baik,demam Baik,demam /-/-
Jelek,demamJelek,demam+, malaise+, malaise
Waktu timbul Waktu timbul & tipe pasien& tipe pasien
Awal MDT, Awal MDT, PB&MBPB&MB
Akhir MDT,MBAkhir MDT,MB
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Organ lain yang diserang:Organ lain yang diserang:
MataMata : nyeri, penurunan visus, : nyeri, penurunan visus, limbus merah, iritis limbus merah, iritis
Rx tipe 1 & 2Rx tipe 1 & 2
TestisTestis : lunak, nyeri & membesar: lunak, nyeri & membesar
Rx tipe 2Rx tipe 2
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a. Reaksi Reversala. Reaksi Reversal
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b. Reaksi ENLb. Reaksi ENL
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Penanganan Reaksi KustaPenanganan Reaksi Kusta
• Reaksi ringanReaksi ringan1.Non medikamentosa:1.Non medikamentosa: Istirahat, imobilisasi berobat jalanIstirahat, imobilisasi berobat jalan2.Medikamentosa:2.Medikamentosa: Aspirin,Klorokuin,Antimon,TalidomidAspirin,Klorokuin,Antimon,Talidomid
• Reaksi beratReaksi beratMRS MRS Tipe 1: kortikosteroid, Tipe 2: klofazimin, Tipe 1: kortikosteroid, Tipe 2: klofazimin, talidomid, kortikosteroid talidomid, kortikosteroid
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Prednison:Prednison:Dimulai 30 – 80 mg prednison/hari, Dimulai 30 – 80 mg prednison/hari, diturunkan 5-10 mg/2 minggu:diturunkan 5-10 mg/2 minggu:2 minggu I2 minggu I :30 mg/hari:30 mg/hari2 minggu II2 minggu II :20 mg/hari:20 mg/hari2 minggu III2 minggu III :15 mg/hari:15 mg/hari2 minggu IV2 minggu IV :10 mg/hari:10 mg/hari2 minggu V2 minggu V : 5 mg/hari: 5 mg/hari
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LagoftalmusLagoftalmus
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Facies leoninaFacies leonina
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Saddle noseSaddle nose
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Ulkus plantar pedisUlkus plantar pedis
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