Hepatic Hydrothorax in a Patient with Liver Cirrhosis: a Case Report

Hepatic hydrothorax is a transudative pleural effusion which presents in 5-10% patients with liver cirrhosis. Although fairly uncommon, it is associated with higher morbidity and lower survival rate. The mechanism is yet to be understood fully, but the most widely accepted pathogenesis involves the presence of portal hypertension, diaphragmatic defects, and negative intrathoracal pressure, all of which lead to the formation of unidirectional passage of ascitic fluid from peritoneal cavity into pleural space. Due to its origin, the pleural effusion has similar characteristics to ascitic fluid. We herein report the case of a 60-year-old woman with advanced liver cirrhosis and right-sided moderate hepatic hydrothorax. Treatment given to the patient includes diuretics, sodium restriction, and repeated thoracentesis. Subsequent evaluation of the patient revealed improvement both clinically and radiologically.

Diagnostic Patterns of Suspected Covid-19 Patients Using Scor Covid-19, PCR Test and Serological Test in Dr. Soetomo Hospital Surabaya, Indonesia

Objective: To find out the diagnostic pattern of COVID-19 using RT-PCR or a rapid antibody test in the suspected group patients.Method: The study was conducted in Dr. Soetomo General Hospital (referal hospital for covid-19, 1500 beds). The study used data on patients with suspected covid-19 who were hospitalized at the Dr. Soetomo General Hospital in Surabaya.Result: There were 200 suspected COVID-19 patients enrolled in this study, the main complaints of cough, fever, dyspnoea, around 69.5%, 75%, and 76.5%, respectively. Although not a common symptom, it seems that anosmia (14%) is typical for COVID-19. Based on this scoring system, a total of 196 patients had a high risk of being infected with COVID-19, and 125 (64%) of them finally showed a positive PCR test. PCR test mostly positive (62.5%), while serological test (rapid imunoglobulin test) mostly non reactive, but there were nonsignificant different between PCR and Serological test (p=0.16 OR: 1.5(0.84-71). Furthermore, if we compare the various existing variables, namely the covid-19 score, immunoglobulin rapid test, and radiological examination, only the radiological examination results can be used as a strong predictor of positive PCR results (p=0.005, OR: 1.68 (0.17-16.43).In this study, we found that abnormal chest radiographs are a good parameter for diagnosing COVID-19, (OR: 2.92; 95% CI, 1.34 -6.34).Conclussion: The initial radiological examination combined with the clinical symptoms of Covid-19 is the most important thing to predict the presence of this disease.

MANAGEMENT OF GESTASIONAL DIABETES MELLITUS IN A BETA MAJOR THALASSEMIA PATIENT

Gestational diabetes mellitus (GDM) is a hyperglycemic condition that is first discovered during pregnancy. GDM is a high-risk condition during pregnancy, for both mother and fetus. GDM affects about 1–14% of pregnancies. In the last 20 years, the incidence of gestational diabetes has been increasing. High iron load and disorders of iron metabolism have been associated with glucose metabolism. The beta thalassemias are a group of hereditary hemoglobinopathies. Treatment for beta thalassemias patients is transfusion, but intensive transfusion can aggravate iron overload in patients. In this study, a case of GDM in a pregnant woman with beta-thalassemia was reported.

A CASE REPORT: CHALLENGES IN THE MANAGEMENT OF TOXIC MULTI NODULAR THYROID IN PREGNANCY WHO HAD CRISIS THYROID

Managing crisis thyroid in toxic multi nodular thyroid in pregnancy is challenging. This case objective is to highlight comprehensive treatment going to safe mother & baby’s life. A woman, 43 years old in 13th week of her third pregnancy, admitted in emergency room with palpitating and vomiting as her chief complaints. Her complaints had started since she stopped taking propylthiouracyl. She used to take it since diagnosed hyperthyroid. She was diagnosed crisis hyperthyroid in pregnancy. The first main goal was to stabilize the patient, curing the precipitate factors, and assist her to have a healthy baby. She was discharged from hospital day 7th. She was routinely checked FT4 for evaluation and switch on Thyrozol during 25-26th weeks and continued it until postpartum. Her baby was delivered vaginally with normal APGAR score and growing well. Based on her experience, she agreed to have IUD to prevent unplanned pregnancy.

CORRELATION BETWEEN HCV RNA VIRAL LOAD AND HOMA-IR IN CHRONIC HEPATITIS C PATIENTS

Background: Insulin resistance (IR) is one of the extrahepatic complications of hepatitis C virus (HCV) infection that needs to be recognized early. HOMA-IR is an effective way to measure insulin resistancy. Core proteins, NS-3, and NS-5 are the main components of HCV RNA proteins which are involved in the incidence of IR. Seeing this, a hypothesis was developed that the level of HCV RNA viral load was related to the HOMA-IR. This study was designed to identify the correlation between HCV RNA viral load with HOMA-IR in chronic hepatitis C patients.Method: We conducted a cross-sectional approach from the medical record of chronic hepatitis C patients at the outpatient clinic dr. Soetomo Hospital, Surabaya. A total of 30 patients aged >19 years old with complete medical records were included. Clinical and laboratory (including HCV RNA viral load level and HOMA-IR) data were obtained from the availability of medical records.Result: A total of 30 chronic hepatitis C patients, 17 (56.7%) were women and 13 (43.3%) were men, with mean age was 50.90 ± 7.17 years. The median of HCV RNA viral load level was 3,14 x106 IU/ml and the median of HOMA-IR was 4.50. The result of the Spearman correlation test showed a moderate positive association between HCV RNA viral load and HOMA-IR (r=0.537 ; p=0.002).Conclusion: A positive moderate correlation was obtained between HCV RNA viral load with HOMA-IR in chronic hepatitis C patients.

Diagnostic and management problems of chylous effusion in a patient with newly-diagnosed tuberculosis

Tuberculosis (TB) remains a major cause of morbidity and mortality globally. Although TB most commonly affects the lungs, any organ or tissue can be involved. Extra-pulmonary forms of TB are commonly unrecognized or late diagnosed. Chylous effusion, i.e. chylothorax and chylous ascites, which is characterized by the presence of chyle in the pleural and peritoneal cavities, is an uncommon manifestation of extra-pulmonary TB. A 22-year-old male, referred to Dr. Soetomo Hospital with complaints of dyspnea, fever, and abdominal distension. Chest X-ray showed pleural effusion. Analysis of fluid obtained from thoracentesis and paracentesis showed chylothorax and chylous ascites. M. tuberculosis had been found in sputum smear examination. ADA (adenosine deaminase) test was performed on ascites fluid and a positive result was obtained. Chylous effusion in this patient were concluded to be related to TB. Patient was then treated with anti-TB drugs and somatostatin. Chylothorax and chylous ascites improved after treatment with somatostatin for 1 week. Administration of anti-TB drugs was planned to be continued for 9 months. The most common causes of non-traumatic chylous effusion in developing countries are infection of TB and filariasis. Chylous effusion is caused by obstruction or disruption of the lymphatic system. ADA test is a new biomedical method that begins to expand its use in body fluids to diagnose extra-pulmonary TB. Fasting, together with total parenteral nutrition, can decrease the lymph flow and balance metabolic impairment. Somatostatin has been used in the treatment of chylous effusion as it diminishes peristalsis and intestinal absorption of fats as well as decreases portal pressure.

Management Of Residual Pituitary Adenoma Patient With Manifestation of Acromegaly and Hyperprolactinemia

Pituitary adenoma is one of intracranial tumors that grows and develops in the pituitary gland which plays a role in regulating the hormonal balance in the body. Most pituitary adenomas are benign and do not spread to other organs. Pituitary adenoma can be classified based on radiological features, tumor size and the type of hormone produced. There are several ways to establish of diagnosis of pituitary adenoma, in addition to recognizing the symptoms and clinical signs are hormonal function tests and imaging. The surgery is the first medical actions. The postoperative recovery rate reached 90% in relatively benign cases and tumor recurrence rate is 5-10% depending on the size of the tumor, the stage of the tumor during surgery, experience of neurosurgical. A woman, 46 years old referred to Soetomo Hospital from Soebandi Jember Hospital for treatment the recurrent adenoma pituitary with complains of headache, double-vision and changing shape of his face, his enlarged lips and nose. Patient was diagnosed based on head CT scan and already had surgery on January, 2015. The head MRI evaluated post surgery was still a residual mass from the previous tumor. 3 monts after surgery no complains any more. The complains reappear at the end of 2017. The head CT scan on January, 8, 2017, size tumor: 1.2 cm x 1.8 cm. The head MRI results on December, 20, 2017 size tumor : size 1.6cm x 2.1cm and abnormal hormonal result, high prolactine, low cortisol and high IGF1. In Soetomo Hospital was diagnosed as pituitary macroadenoma with acromegaly and hyperprolactinemia and received bromocriptine 3x5 mg evaluated for 2 weeks then lowered to 3x 2.5 mg after obtaining a decrease in prolactin levels and methyl prednisolone 3x1 / day until cortisol level was normal. Patients will also plan for surgery of EETH (Endoscopic Endonasal Transphenoidal).

MANAGEMENT OF A PATIENT WITH ANKYLOSING SPONDYLITIS TYPE SPONDYLOARTHRITIS AND LATENT TUBERCULOSIS INFECTION

Ankylosing spondylitis (AS) is one of the most common types of spondylarthritis (SpA) and Disease-Modifying Antirheumatic Drug (DMARD) is one of the modalities for treating the disease. An increased risk of latent tuberculosis infection (LTBI) reactivation in rheumatic patients receiving DMARD has been reported. Management of patients with rheumatic diseases who are also infected with LTBI needs to be understood in order not tobecome active TB. We reported a case of a 57-year-old man with AS. Patient was planned to be treated with DMARD so that hepatitis and TB screening performed. It was discovered that this patient had LTBI. The prophylactic therapy for TB was given. DMARD therapy started 1 month after TB prophylactic therapy was given. For monitoring the disease progression,anamnesis, physical, laboratory, and radiology examination performed regularly.

DIAGNOSTIC PROBLEMS OF A MALE PATIENT WITH MIXED CONNECTIVE TISSUE DISEASE

Mixed connective tissue disease (MCTD) is an overlap disease, has been recognized as an entity disease with a mixture of clinical manifestations from systemic lupus erythematosus (SLE), systemic sclerosis (SSc), polymyositis/dermatomyositis, and rheumatoid arthritis, accompanied by the presence of high titers antibodies to U1 ribonucleoprotein (anti-U1RNP). We had reported case of a male patient who has chronic dysphagia, progressive dyspnea, and the presence of skin lesions. Based on the examination, it was found chronic dysphagia, progressive dyspnea caused by pneumonia and suspected interstitial lung disease, autoimmune hemolytic anemia, discoid lesions, and skin biopsy revealed scleroderma. This patient did not meet the diagnostic criteria of MCTD because anti-U1RNP examination had not been performed as one of the requirements in the diagnostic criteria. However, because he has strong signs and symptoms toward MCTD where there were overlapping symptoms of SLE as well as symptoms of SSc, so we diagnosed him as MCTD.

The Correlation between Serum C3 and C4 Complement Levels with Disease Activity Systemic Lupus Eritematosus Patients In Dr. Soetomo Hospital, Surabaya

Introduction: The Systemic lupus erythematosus (SLE) is autoimmune disease that results in inflammation, and tissue damage. SLE often creates difficulties in the diagnosis and assessment of disease activity. Disease activity is important as basis for selecting the appropriate therapy. In addition to clinical SLE, supporting investigations are needed to determine disease activity, one of which is complement examination. Complement plays an important role in autoimmune disease and thought to mediate tissue damage. This study aimed to analyze correlation between serum complement C3 and C4 levels with disease activity of SLE patients in Dr. Soetomo Hospital Surabaya.Methods: This study used an observational analytic method with a cross-sectional design. The sampling technique was consecutive sampling. The samples of this study were SLE patients who were treated in the inpatient room and poly rheumatology in January-December 2018 periods. The data were analyzed statistically using the Pearson test.Results: There were 150 SLE patients, most of whom were women (90.0%) with mean age of 29.01±9.8 years. Most levels of complement were low levels (C3 = 48.0% and C4 = 50.7%). Most disease activities were severe flares (44.7%). Results of the Pearson test complement C3 with disease activity were p =0.001, and level of correlation was r =-0.287. However, results of the Pearson test complement C4 with disease activity were p =0.026, and level of correlation was r =-0.182.Conclusion: There is negative correlation between C3 and C4 complement levels with disease activity of SLE patients in Dr. Soetomo Hospital, Surabaya which is significant, weak and opposite.