Update Info : H1N1 Flu Vaccine Fast-Tracked to September?

Sunday, July 19, 2009

from WebMD — a health information Web site for patients
Daniel J. DeNoon

swine-flu

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July 17, 2009 — Pandemic swine flu vaccine should be fast-tracked, with vaccinations starting in mid-September — soon after schools open.

That recommendation came today in a unanimous vote by the National Biodefense Safety Board (NBSB), an influential board of outside advisors to Health and Human Services Secretary Kathleen Sebelius.

Getting swine flu vaccine by September means skipping all but the most preliminary clinical tests of vaccine safety and effectiveness. But it means getting some 60 million to 80 million doses nearly at the same time the CDC expects the next wave of the pandemic to hit the U.S.

"We cannot wait beyond mid-August [to make a decision] if vaccine is to be in supply by mid-September," the panel's pandemic influenza working group states in its recommendations. "A critical goal is to have some [standalone] novel H1N1 vaccine available by mid-September 2009, should it be needed."

Why rush through a swine flu vaccine? The first wave of the swine flu pandemic is only just starting to ebb in the U.S. But the virus spreads quickly among children — and the nation's schools begin opening in late August.

"A second wave is likely to occur, as soon as fall 2009," the recommendations state. "Best estimates suggest that infection rates will be two to three times higher than expected with seasonal influenza. The second wave could peak in October, but we must anticipate onset as early as September."

Initial doses likely will go to those most severely hit by the pandemic so far: infants, toddlers, school-age children, pregnant women, and adults with risk factors for severe flu disease. Next week, the CDC's vaccine advisory board will recommend a priority list for exactly who will first get the vaccine.

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The NBSB recommendation puts into words a fear that government officials have so far expressed only privately.

"Having vaccine only after the peak [of the pandemic] may be worse than having no vaccine at all: It incurs all of the risk and cost with no potential benefit," the recommendation reads.

The National Biodefense Science Board advises Sebelius on emergency preparedness for biological threats. Whether to act on the NBSB's decision is up to her — and, ultimately, to President Barack Obama.

Why deploy a vaccine that hasn't completed safety and efficacy testing? Because we already have a lot of experience with similar vaccines, concluded the NBSB flu vaccine working group, led by University of Utah flu expert Andrew Pavia, MD.

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Pandemic swine flu is a type A, H1N1 flu virus. For decades, a type A H1N1 vaccine has been part of the regular seasonal flu vaccine, and the new vaccine is made exactly the same way.

Fast-tracking the vaccine will mean guessing at the best dose, but that's an educated guess based on the well-established dosage for the seasonal H1N1 vaccine.

A more critical guess is whether people will be protected against the new flu bug with only one shot of vaccine. The NBSB working group suggests that previous exposure to H1N1 virus and H1N1 vaccine will prime virtually the entire population so that only one dose is needed — even though the seasonal vaccine does not protect against pandemic swine flu.

Fast-tracking the vaccine would also mean deciding who's first in line. Robin Robinson, PhD, director of BARDA, the Health and Human Services agency responsible for the logistics of emergency medical supplies, says 60-80 million doses could be available in mid-September — if vaccine makers start packaging their products in mid-August. Similar quantities would follow in each subsequent month until demand was met.

Voting members of the NBSB include experts from universities, the pharmaceutical industry, and medical groups. NBSB chairwoman Patricia Quinlisk, MD, MPH — who was absent from today's telephone-based meeting — is director of the Iowa health department. Nonvoting members of the NBSB include representatives of the White House, the Health and Human Services Department, national security agencies, the FDA, and NASA.

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SOURCES:

National Biodefense Science Board: "H1N1 Countermeasures Strategy and Decision-Making: Detailed Report," and executive summary, July 17, 2009.

National Biodefense Science Board meeting (by telephone), July 17, 2009.

Authors and Disclosures

Journalist
Daniel J. DeNoon

Daniel J. DeNoon is senior medical writer at WebMD.

WebMD Health News © 2009 WebMD Inc.
This news article was written and produced by staff at
WebMD Health and is intended for a consumer audience. Questions or comments? Email newstip@webmd.net.

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AVIAN INFLUENZA A (H5N1) - OVERVIEW

Saturday, July 18, 2009

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INTRODUCTION

The first outbreak of avian influenza A (H5N1) occurred among humans in Hong Kong in 1997. To estimate the risk of person-to-person transmission, a retrospective cohort study was conducted to compare the prevalence of H5N1 antibody among health care workers (HCWs) exposed to H5N1 case-patients with the prevalence among nonexposed HCWs. Information on H5N1 case-patient and poultry exposures and blood samples for H5N1-specific antibody testing were collected. Eight (3.7%) of 217 exposed and 2 (0.7%) of 309 nonexposed HCWs were H5N1 seropositive (P=.01). The difference remained significant after controlling for poultry exposure (P=.01). This study presents the first epidemiologic evidence that H5N1 viruses were transmitted from patients to HCWs. Human-to-human transmission of avian influenza may increase the chances for the emergence of a novel influenza virus with pandemic potential.

Influenza A virus subtype H5N1, also known as "bird flu," A(H5N1) or simply H5N1, is a subtype of the Influenza A virus which can cause illness in humans and many other animal species. A bird-adapted strain of H5N1, called HPAI A(H5N1) for "highly pathogenic avian influenza virus of type A of subtype H5N1", is the causative agent of H5N1 flu, commonly known as "avian influenza" or "bird flu". It is enzootic in many bird populations, especially in Southeast Asia. One strain of HPAI A(H5N1) is spreading globally after first appearing in Asia. It is epizootic (an epidemic in nonhumans) and panzootic (affecting animals of many species, especially over a wide area), killing tens of millions of birds and spurring the culling of hundreds of millions of others to stem its spread. Most references to "bird flu" and H5N1 in the popular media refer to this strain.

The H5N1 flu virus has affected hundreds of thousands of birds, and more than 200 humans worldwide. Health officials are concerned that it will become the next pandemic influenza strain in humans. However, it’s very hard for people to get H5N1 bird flu from each other. Most people get it from direct contact with birds or their droppings. That’s why there have been so few human cases.

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Control of avian influenza A(H5N1): public health concerns

The current outbreaks of highly pathogenic H5N1 avian influenza in poultry in parts of Asia have had immediate and severe consequences for the agricultural sector.1 Human cases, with a high fatality, have been reported in two countries, Viet Nam and Thailand, with very widespread outbreaks in poultry.

It can be anticipated that human cases will also be detected in other countries where outbreaks in poultry are rapidly spreading.

The number of human cases presently detected is very small compared with the large number of infected birds distributed over a wide geographical area. This suggests that the H5N1 virus strain may not easily infect humans.

To date, no human-to-human transmission is known to have occurred. However, the continuing presence of infection in poultry may also create opportunities for the emergence of a new influenza virus subtype with a capacity to spread easily among humans, thus marking the start of an influenza pandemic. Should this rare event occur (three pandemics occurred during the previous century), it would immediately have serious consequences for human health throughout the world.

For this reason, public health concerns about the present H5N1 situation must be given the highest priority when weighing the immediate and measurable economic losses in animals against possible yet unpredictable consequences for humans.

Several other diseases in animals can be transmitted to humans. Experience with such diseases, known as “zoonoses”, has shown that strict measures on animal health, imposed by the need to protect human health, helped rebuild consumer confidence.2

Recent experience has also shown that measures for the control of zoonotic diseases, aimed at halting further spread in animals and minimizing economic losses, need to be closely coordinated with measures that minimize the longer-term risks to human health. In the present situation, measures aimed at eliminating the disease in poultry will also reduce the presence of the virus in the environment and thus reduce opportunities for human exposures and infections. These measures must be carried out urgently, giving highest priority to the protection of human health. Previous outbreaks of highly pathogenic avian influenza associated with human infections occurred in areas, such as Hong Kong and the Netherlands, with industrial poultry production and well developed health and agricultural infrastructures. Even so, elimination of infection in poultry was a complex, difficult, and costly undertaking. Both outbreaks were eventually controlled through immediate culling of infected flocks, quarantine and disinfection of farms, strict biosecurity, restrictions on the movement of animals, and compensation for farmers.

The present situation is different. Control of outbreaks of highly pathogenic avian influenza is known to be especially difficult in areas where poultry range freely. In several affected countries, up to 80% of the total poultry population is raised in small backyard farms. Most rural families keep a small free-range flock.

Given these features of the present situation there is potential that the H5N1 virus could become established in bird populations in this geographical region and possibly spread to other parts of the world. This was one of several conclusions reached during a joint FAO/OIE/WHO technical consultation on the control of avian influenza, held in Rome from 3–4 February.

No single blueprint for control in animals, and thus reduction of risks for humans, is available. Over the past four decades, only 18 outbreaks of highly pathogenic avian influenza, most caused by strains other than H5N1, have occurred throughout the world. Existing evidence will not suffice to provide universally applicable recommendations for a rapid and effective response in affected countries.

Control measures must be tailored to each country’s unique epidemiological situation and unique capacity, with health and agricultural sectors working hand-in-hand. Agricultural authorities face the immediate challenge of rapidly eliminating the H5N1 reservoir in poultry. Authorities in all affected countries need to work together in a coordinated way

Transparency in reporting of human and animal disease is absolutely essential.

Despite the uncertainties, experts fully agree that immediate culling of infected and exposed birds is the first line of defence for both the protection of human health and the reduction of further losses in the agricultural sector. Other measures, such as the vaccination of healthy flocks, may play a supportive role in some cases when undertaken in conjunction with measures for preventing further spread of infection. WHO has repeatedly stressed the need to ensure that culling is carried out in a way that does not fuel more human cases. and that vaccination of poultry should not lead to the dropping of vigilance or compromise other necessary control measures.

In responding to the situation, WHO emphasises three strategic goals: to avert an influenza pandemic, to control the present human outbreaks and prevent further spread, and to conduct the research needed for better preparedness and response, including the immediate development of a new vaccine for humans against H5N1. WHO has issued a series of technical guidelines aimed at minimizing the risk of further human cases and facilitating a coordinated international response.

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Inexpensive Test Detects H5N1 Infections Quickly and Accurately

Scientists from the University of Colorado at Boulder and the Centers for Disease Control and Prevention (CDC) have developed an inexpensive “gene chip” test based on a single influenza virus gene that could allow scientists to quickly identify flu viruses, including avian influenza H5N1. The researchers used the MChip to detect H5N1 in samples collected over a three-year period from people and animals in geographically diverse locales. In tests on 24 H5N1 viral isolates, the chip provided complete information about virus type and subtype in 21 cases and gave no false positive results, report the scientists. They say the MChip could provide a significant advantage over available tests because it is based on a single gene segment that mutates less often than the flu genes typically used in diagnostic tests. As a result, the MChip may not need to be updated as frequently to keep up with the changing virus.

The research was led by University of Colorado scientist Kathy L. Rowlen, Ph.D., and funded by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. A paper describing the work, now available online, is scheduled to appear in the December 15 issue of the American Chemical Society’s journal Analytical Chemistry.

“Concerns about a possible influenza pandemic make it imperative that we continue to devise reliable and easy-to-use diagnostic tests for H5N1 that can be employed on-site where outbreaks are suspected,” says NIAID Director Anthony S. Fauci, M.D. “The MChip developed by Dr. Rowlen and her colleagues performed extremely well in initial tests and has the potential to be a valuable tool in global influenza surveillance efforts.”

The MChip has several advantages over the FluChip, a flu diagnostic previously developed by the same research team, says Dr. Rowlen. While the FluChip is based on three influenza genes — hemagglutinin (HA), neuraminidase (NA) and matrix (M) — the MChip is based on one gene segment. Unlike HA and NA, which mutate constantly and thus are technically difficult to use to develop gene chip diagnostic tests, the M gene segment mutates much less rapidly, Dr. Rowlen explains. “The M gene segment is much less of a moving target than the HA or NA gene. We believe that a test based on this relatively unchanging gene segment will be more robust because it will continue to provide accurate results even as the HA and NA genes mutate over time. The work summarized in our paper strongly supports that idea,” she says.

Another potential advantage is that the MChip would, for the first time, create a way to simultaneously screen large numbers of flu samples to learn both the type and subtype of virus present. Current real-time tests provide information about the type of virus (type A or B) in a sample, but additional tests must be run to determine the virus subtype (for example, H5N1 subtype.)

Working in biosafety-level-3-enhanced labs in Atlanta, CDC scientists, including Catherine B. Smith, M.S., extracted H5N1 genetic material from virus samples derived from human, feline and multiple avian hosts, including geese, chickens and ducks. The samples represented infections that had occurred between 2003 and 2006 over a vast geographic area, including Vietnam, Nigeria, Indonesia and Kazakhstan. Six of the human viral isolates were taken from an Indonesian family in which human-to-human H5N1 virus transmission was suspected. The virus diversity in the samples is important, explains Dr. Rowlen, because any diagnostic tool designed for eventual use on a rapidly changing virus, such as H5N1, must be able to detect as many variants as possible.

Dr. Rowlen and her colleagues tested the ability of the MChip to correctly identify 24 different H5N1 viral isolates, and distinguish those from seven non-H5N1 isolates. The MChip accurately identified and gave complete subtype information (identifying the samples as H5N1) for the 21 out of 24 strains of H5N1. Importantly, notes Dr. Rowlen, the test gave no false positives, meaning that the chip never indicated the presence of H5N1 when none was present. Following exposure to a viral isolate, the MChip displays results as a pattern of fluorescent spots. To automate the process of interpreting this pattern — thus eliminating the possibility of human error — the researchers developed an artificial neural network trained to recognize the distinctive pattern indicative of H5N1. Automating the interpretation of MChip results could allow it to be used more readily by health workers at the site of possible flu outbreaks, notes Dr. Rowlen.

“This new technology, once manufactured and distributed, could have the potential to revolutionize the way laboratories test for influenza,” says Nancy J. Cox, Ph.D., director of the CDC’s influenza division. “The MChip could enable more scientists and physicians, possibly even those working in remote places, to more quickly test for H5N1 and to accurately identify the specific strain and its features. This would greatly increase our ability to learn more about the viruses causing illness and take the best steps to respond.”

The raw materials for the MChip cost less than 10 dollars, Dr. Rowlen says, and discussions are under way to commercialize its manufacture.

For more information on influenza see http://www3.niaid.nih.gov/news/focuson/flu. Also visit http://www.PandemicFlu.gov for one-stop access to U.S. Government information on avian and pandemic flu.

NIAID is a component of the National Institutes of Health. NIAID supports basic and applied research to prevent, diagnose and treat infectious diseases such as HIV/AIDS and other sexually transmitted infections, influenza, tuberculosis, malaria and illness from potential agents of bioterrorism. NIAID also supports research on basic immunology, transplantation and immune-related disorders, including autoimmune diseases, asthma and allergies. News releases, fact sheets and other NIAID materials are available on the NIAID Web site at http://www.niaid.nih.gov.

Since it was founded in 1946 to help control malaria, CDC has remained at the forefront of public health efforts to prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats. Today, CDC is globally recognized for conducting research and investigations and for its action oriented approach. For more information on CDC and its programs, visit www.cdc.gov.

The National Institutes of Health (NIH) — The Nation's Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

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Avian Influenza Health Advice

Winter to spring is the seasonal high risk period for avian influenza. The detection of H5N1 among wild birds and carcasses of poultry recently is a cause of concern. In this regard, members of the public are advised to pay extra attention to stay away from the disease by refraining from contacting live poultry, especially dead or sick poultry.
Though our genetic analysis shows that the virus has no mutation for the time being and there is no sign of human-to-human transmission, we should not be off guard against the disease.
While the Government is highly vigilant and will continue to strictly enforce preventive measures against avian influenza, members of the public also have a role to play.
Members of the public should remain vigilant against avian influenza infection and observe the following measures:
* Avoid direct contact with poultry and birds or their droppings; if contacts have been made, they should wash hands thoroughly with soap and water;
* Poultry and eggs should be thoroughly cooked before eating;
* Wash hands frequently;
* Cover nose and mouth while sneezing or coughing, hold the spit with tissue and put it into covered dustbins;
* Avoid crowded places and contact with sick people with fever;
* Wear a mask when you have respiratory symptoms or need to take care of patients with fever;
* When you have fever and influenza-like illnesses during a trip or when coming back to Hong Kong, you should consult doctors promptly and reveal your travel history.
People working in poultry farms, wholesale and retail markets should strictly adhere to the following biosecurity measures:
* Take precautions to prevent any contact between poultry and other birds.
* Use enclosed caging to prevent poultry from leaving/entering livestock premises.
* Feeders and drinking water containers should be properly placed to avoid contact with wild birds and contaminants.
* Newly acquired birds must be isolated for observation. Immediately report any abnormal health condition of the flock.
* Wear suitable protective clothing when touching birds.
* Clean and disinfect thoroughly after touching birds or handling their droppings.
* Seek medical treatment immediately when feeling unwell.

READ MORE - AVIAN INFLUENZA A (H5N1) - OVERVIEW

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MALARIA DENGAN IKTERIK ( Malaria with Jaundice )

Friday, July 17, 2009

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PENDAHULUAN

Malaria adalah penyakit infeksi parasit yang disebabkan oleh Plasmodium yang menyerang eritrosit dan ditandai dengan ditemukannya bentuk aseksual didalam darah.1

Malaria masih menjadi masalah kesehatan global di 40 % populasi dunia,  lebih dari 2400 juta orang berisiko terpapar malaria. Infeksi malaria tersebar pada lebih dari 100 negara di benua Afrika, Asia, Amerika dan Oceania serta kepulauan Caribia. Ditambah lagi dengan meningkatnya orang bepergian dari tempat yang non malaria terinfeksi dan biasanya menjadi parah setelah kembali ke daerah asalnya.1,2

Dalam siklus hidupnya plasmodium falciparum mempunyai dua hospes yaitu vertebra dan nyamuk. Siklus aseksual didalam hospes disebut skizogoni dan siklus seksual yang membentuk sporozoit di dalam nyamuk disebut sporogoni. 3

Diagnosa malaria falciparum berdasarkan gejala klinis, pemeriksaan fisik dan pemeriksaan mirkroskopis.2

Komplikasi malaria umumnya disebabkan karena Plasmodium falciparum dan sering di sebut pernicious manifestations. Sering terjadi mendadak tanpa gejala – gejala sebelumnya, dan sering terjadi pada penderita yang tidak imun. Komplikasi terjadi 5 – 10% pada seluruh penderita malaria yang dirawat di RS dan 20% merupakan kasus yang fatal.2

Malaria yang disertai dengan ikterus atau jaundice disebut sebagai Malaria Biliosa merupakan komplikasi yang sering dijumpai pada infeksi malaria falciparum. Pada penelitian di Minahasa dari 836 penderita malaria, hepatomegali 15,9%, hiperbilirubinemi 14,9% dan peningkatan serum transaminase 5,7%. Pada malaria biliosa ( malaria dengan ikterus ) dijumpai ikterus hemolitik 17,2%; ikterus obstruktif intra-hepatal 11,4% dan tipe campuran parenkimatosa, hemolitik dan obstruktif 78,6%.1

Penanganan malaria tergantung kecepatan dan ketepatan diagnosis seawal mungkin. Prinsip penanganan malaria ialah :

a. Tindakan umum/ tindakan perawatan

b. Terhadap parasitemianya; yaitu dengan:

I. Pemberian obat anti malaria

II. Exchange transfusion (transfusi ganti)

c. Pemberian cairan / nutrisi

d. Penanganan terhadap gangguan fungsi organ yang mengalami komplikasi.2

Pada Malaria Biliosa biasa ditambahkan terapi Vitamin K 10 mg/ hari i.v dapat diberikan selama 3 hari untuk memperbaiki faktor koagulasi yang tergantung vit. K. Gangguan faktor koagulasi lebih sering dijumpai pada penderita dengan ikterik berat. Hati-hati dengan obat-obatan yang mengganggu fungsi hati seperti parasetamol, tetrasiklin.2

LAPORAN KASUS

Seorang penderita perempuan, umur 49 tahun, sudah menikah, pendidikan tamat SLTA, pekerjaan ibu rumah tangga, agama Kristen protestan, alamat Kombos timur Manado, suku Minahasa, masuk rumah sakit tanggal 9 Juni 2009 dengan keluhan utama panas. Panas dialami penderita sejak 7 hari sebelum masuk rumah sakit. Panas naik secara perlahan – lahan. Panas biasanya diawali dengan menggigil, jika panas turun penderita berkeringat banyak dan dapat melakukan aktivitas seperti biasa sama ketika penderita tidak panas. Panas disertai dengan kuning serta mual dan muntah, frekuensi ± 10 kali, isi cairan dan sisa makanan, volume ± 150 cc. Nyeri ulu hati dirasakan pasien ± 4 hari sebelum masuk rumah sakit, pusing dan sakit kepala ada, nyeri otot dan sendi-sendi ada. Penderita tidak pernah berpergian keluar kota juga tidak berasal dari daerah banjir. Nyeri menelan tidak ada, batuk disertai sesak tidak ada, nyeri perut disertai berak cair tidak ada. Buang air besar : tinja seperti dempul tidak ada, tinja berwarna hitam tidak ada, tinja disertai darah tidak ada. Penderita buang air besar 1 kali tiap 3 hari sama seperti penderita sebelum sakit. Buang air kecil : sakit waktu kencing tidak ada, kencing berpasir tidak ada, kencing warna merah tidak ada, warna seperti teh. Riwayat penyakit dahulu : malaria 2001, asam urat 2005. Darah tinggi, gula, jantung dan ginjal tidak ada. Riwayat pengobatan dirumah sakit akibat infeksi tidak ada.

Dari pemeriksaan fisik didapatkan keadaan umum sakit sedang, kesadaran kompos mentis, tekanan darah 100/70 mmHg, nadi 70 kali/menit, regular, isi cukup, respirasi 20 kali/menit, suhu 37,4 oC, bentuk badan mesomorf, dan mobilitas aktif. Berat badan 50 kg, tinggi badan 162 cm.

Pada pemeriksaan kepala, ekspresi wajah wajar, simetris, rambut hitam tak mudah dicabut. Pada pemeriksaan mata, tekanan bola mata normal pada perabaan, konjungtiva tidak anemis, sklera tampak ikterus, pupil bulat isokor, refleks cahaya ada. Pada pemeriksaan telinga didapatkan liang telinga ada, sekret tidak ada, nyeri tekan di procesus mastoideus tidak ada, membran timpani utuh. Pada pemeriksaan hidung, tampak luar simetris, deformitas bagian luar tidak ada, deviasi septum tidak ada, sekret tidak ada, penyumbatan tidak ada, epistaksis tidak ada. Pada pemeriksaan mulut, bibir tidak sianosis, selaput lendir basah, gigi karies tidak ada, lidah beslag tidak ada, perdarahan gusi tidak ada, faring tidak hiperemis, tonsil T1 – T1 normal, foeter tidak ada. Pada pemeriksaan leher tidak terdapat pembesaran kelenjar getah bening, pembesaran kelenjar gondok tidak ada, trakea letak tengah, JVP 5+0 cm, pulsasi pembuluh darah normal, kaku kuduk tidak ada, tumor tidak ada.

Pada pemeriksaan dada, bentuk simetris normal, sela antar iga tidak melebar, retraksi tidak ada. Palpasi stem fremitus kiri sama dengan kanan. Pada perkusi sonor kiri sama dengan kanan, batas paru hati pada linea midklavikularis dekstra ICS VI dengan peranjakan 2 cm. Pada auskultasi suara pernapasan vesikuler, ronki tidak ada, wheezing tidak ada. Pada pemeriksaan paru-paru belakang, dari inspeksi gerakan dinding dada simetris, retraksi tidak ada. Pada palpasi stem fremitus kiri sama dengan kanan. Pada perkusi sonor kiri sama dengan kanan. Batas paru belakang kiri bawah pada linea skapularis vertebra torakal X dan pada batas paru belakang kanan bawah pada linea skapularis vertebra torakal IX. Pada auskultasi suara pernapasan vesikuler, ronki tidak ada, wheezing tidak ada.

Pada pemeriksaan jantung, didapatkan iktus kordis tidak tampak dan tidak kuat angkat, batas kanan jantung pada ICS IV linea sternalis dekstra dan batas kiri jantung pada ICS V linea midklavikularis sinistra, denyut jantung 70 kali/menit, regular, M1>M2, T1>T2, A2>A1, P2>P1, A2>A1, bising tidak ada.

Pada pemeriksaan abdomen, didapatkan perut cembung, lemas ada nyeri tekan epigastrium, asites tidak ada. Hepar teraba 2-3 cm bawah arcus costae, tepi tumpul, konsistensi lunak, permukaan datar, nyeri tekan tidak ada. Lien teraba S-1 , bunyi ketok timpani, dan bising usus ada normal, ada nyeri tekan suprapubik, nyeri ketok CVA tidak ada, Murphy sign tidak ada. Pada pemeriksaan genitalia didapatkan alat kelamin perempuan normal. Pemeriksaan anus dan rectum tidak dievaluasi, anggota gerak otot eutrofi, tophi sendi tidak ada dan gerakan aktif.

Pada pemeriksaan tangan, tremor tidak ada, kekuatan otot 5/5, tidak terdapat edema pada kedua lengan. Pada tungkai/kaki otot eutrofi, jaringan parut tidak ada, tophi tidak ada, gerakan normal, kekuatan otot 5/5, suhu raba hangat, tidak terdapat edema pada kedua tungkai. Refleks fisiologis normal, reflex patologis tidak ada.

Dari pemeriksaan laboratorium didapatkan Hb 13,9 g/dl, leukosit 5900/mm3, eritrosit 4,99.106/ul, trombosit 28.000/mm3, GDS 142 mg/dl, DDR falciparum (++). Bilirubin total, direct, indirect belum ada.

Pasien ini di diagnosis kerja dengan Malaria dengan ikterik. Penatalaksanaan pasien ini dengan bed rest, IVFD NACL 0,9% 20 tetes/menit, Artesunat 2,4 mg/kgbb. pada jam 0, jam 12, jam 24 dan seterusnya tiap 24 jam, sistenol tab 500 mg 3 x 1, domperidon tab 10 mg 3 x 1, observasi vital sign tiap 4 jam, balance cairan. Rencana pemeriksaan pada pasien ini adalah darah lengkap, GDS, DDR, Urinalisa, Ureum, kreatinin, asam urat, bilirubin total, direct, indirect, SGOT, SGPT.

Pada perawatan hari kedua (10/06/2009), keluhan dari pasien pusing serta rasa mual dan muntah. Keadaan umum sakit sedang. Kesadaran kompos mentis. Tekanan darah 100/80 mmhg, nadi 80 kali/menit, respirasi 22 kali/menit, suhu 36,8oC. Konjungtiva tidak anemis, sklera ikterik. Pada pemeriksaan toraks didapati jantung dan paru dalam batas normal. Abdomen didapatkan perut cembung, tegang ada nyeri tekan epigastrium, hepar teraba 2-3 cm bawah arcus costae, lien teraba S-1 , bunyi ketok timpani, dan bising usus ada normal. Ekstremitas hangat, edema tidak ada. Hasil pemeriksaan darah lengkap Hb 13,1 g/dl, leukosit 6600/mm3, Hematokrit 41,2 %, trombosit 69.000/mm3. GDS 112 mg/dl. Urinalisa epitel 10-15/lpk, leukosit 8-10/lpk, eritrosit 20-25/lpk. Diagnosis pasien ini Malaria Biliosa. Penatalaksanaan pasien ini dengan IVFD Nacl 0,9% 20 tetes/menit, sistenol tab 500 mg 3 x 1, domperidon tab 10 mg 3 dd 1, artesunat 2,4 mg/kgbb. Rencana pemeriksaan darah lengkap, DDR, ureum, kreatinin, asam urat, bilirubin total, direck, SGOT, SGPT.

Pada perawatan hari ketiga (11/06/2009), keluhan dari pasien pusing dan rasa mual, muntah mulai berkurang. Keadaan umum sakit sedang. Kesadaran kompos mentis. Tekanan darah 100/70 mmhg, nadi 84 kali/menit, respirasi 22 kali/menit, suhu 36,6oC. Konjungtiva tidak anemis, sklera ikterik. Pada pemeriksaan toraks didapati jantung dan paru dalam batas normal. Abdomen didapatkan perut cembung, lemas, nyeri tekan epigastrium berkurang, hepar teraba 2-3 cm bac, lien teraba S-1 , bunyi ketok timpani, dan bising usus ada normal. Ekstremitas hangat, edema tidak ada. Hasil pemeriksaan darah lengkap Hb 12,3 g/dl, leukosit 4900/mm3, Hematokrit 37,3 %, trombosit 112.000/mm3. DDR (-), Bilirubin total 2,46 mg/dl, bilirubin direck 1,22 mg/dl, kreatinin 1,0 mg/dl, ureum 44 mg/dl, asam urat 3,0 mg/dl, SGOT 26 u/l, SGPT 62 u/l. Diagnosis pasien Malaria Biliosa. Penatalaksanaan pasien ini dengan IVFD Nacl 0,9% 20 tetes/menit, domperidon tab 10 mg 3 x 1, artesunat 2,4 mg/kgbb. Rencana pada pasien ini adalah darah lengkap, DDR, GDS.

Pada pemeriksaan hari keempat (12/06/2009), keluhan dari pasien pusing mulai membaik, mual dan muntah makin berkurang Keadaan umum sakit sedang. Kesadaran kompos mentis. Tekanan darah 100/80 mmhg, nadi 88 kali/menit, respirasi 22 kali/menit, suhu 36,4oC. Konjungtiva tidak anemis, sklera ikterik. Pada pemeriksaan toraks didapati jantung dan paru dalam batas normal. Abdomen didapatkan perut cembung berkurang, lemas, nyeri tekan epigastrium berkurang, hepar teraba 1-2 cm bac, lien teraba S-1 , bunyi ketok timpani, dan bising usus normal. Ekstremitas hangat, edema tidak ada. Diagnosis pasien Malaria Biliosa. Penatalaksanaan pasien ini dengan . IVFD Nacl 0,9% 20 tetes/menit, domperidon tab 10 mg 3 x 1, artesunat 2,4 mg/kgbb. Pasien pulang paksa.

Malaria-cycle

DISKUSI

Pada kasus ini di diagnosa dengan Malaria dengan Ikterik. Diagnosa ditegakkan berdasarkan anamnesis, pemeriksaan fisik dan laboratorium. Pada anamnesis didapatkan gejala dari trias malaria yaitu menggigil, demam dan berkeringat disertai dengan gejala-gejala pusing, mual, muntah, nyeri otot dan sendi. Pada pemeriksaan fisik didapatkan adanya sklera ikterik, nyeri epegastrium, hepar membesar 2-3 cm bac, tepi tumpul, konsistensi lunak, permukaan datar, nyeri tekan tidak ada. Lien juga membesar S-1. Pada pemeriksaan laboratorium pada hapusan darah tepi terdapat plasmodium Falciparum (++), bilirubin total 2,46 mg/dl, bilirubin direck 1,22 mg/dl. Hal ini sesuai dengan kepustakaan diagnosa malaria falciparum berdasarkan gejala klinis, pemeriksaan fisik dan pemeriksaan mirkroskopis.4

1. Gejala klinis

Sebelum gejala klinis timbul biasanya terdapat gejala prodromal seperti lesu, sakit kepala, nyeri otot/ tulang, mual, anoreksia, diare ringan, perut tak enak, dan kadang- kadang rasa dingin dipunggung, sedangkan gejala klasik yaitu terjadinya trias malaria (malaria proxysm) secara berurutan yaitu :

a. Periode dingin

Mulai menggigil, kulit dingin dan kering , penderita sering membungkus diri dengan selimut atau sarung dan pada saat menggigil sering seluruh tubuh bergetar dan gigi gemertak, pucat sampai sianosis seperti orang kedinginan. Periode ini berlangsung 15 menit sampai 1 jam diikuti dengan meningkatnya temperatur.

b. Periode panas

Muka penderita merah, kulit panas dan kering, nadi cepat dan panas badan tetap tinggi dapat sampai 400C atau lebih. Periode ini lebih lama dapat sampai 2 jam atau lebih diikuti keadaan berkeringat.

c. Periode berkeringat

Penderita berkeringat mulai dari temporal, diikuti seluruh tubuh, sampai basah, temperatur turun, penderita merasa capek dan sering tertidur.

2. Pemeriksaan miroskopis

Pemeriksaan mikroskopis dengan sediaan darah tebal dan tipis merupakan pemeriksaan yang terpenting. Interpretasi pemeriksaan mikroskopis yang terbaik adalah berdasarkan hitung kepadatan parasit dan indentifikasi parasit yang tepat. Pemeriksaan mikroskopis satu kali yang memberi hasil negatif tidak menyingkirkan diagnosa demam malaria dan untuk itu diperlukan pemeriksaan serial dengan interval pemeriksaan diantara satu hari. Dalam hal ini waktu pengambilan sampel darah sebaiknya pada akhir perode demam memasuki periode berkeringat . Periode ini tropozoit dalam sirkulasi mencapai jumlah maksimal dan cukup matur sehingga memudahkan indentifikasi spesies parasit . Pemeriksaan miroskopis dapat dilakukan dengan menggunakan sediaan darah tebal dan tipis. Pemeriksaan miroskopis adalah merupakan standard baku dan apabila dilakukan dengan cara yang benar mempunyai nilai sensitivitas dan spesifitas hampir 100 %

Sedangkan ikterik yang dialami penderita ini merupakan salah satu dari komplikasi yang dapat dialami oleh penderita malaria falciparum. Hal ini sesuai dengan kepustakaan bahwa komplikasi malaria umumnya disebabkan karena Plasmodium falciparum dan sering di sebut pernicious manifestations. Sering terjadi mendadak tanpa gejala – gejala sebelumnya, dan sering terjadi pada penderita yang tidak imun. Komplikasi terjadi 5 – 10% pada seluruh penderita malaria yang dirawat di RS dan 20% merupakan kasus yang fatal.2

Ikterus yang dialami pada pasien ini tidak mengindikasikan bahwa pasien menderita Malaria berat, sebab pada pemeriksaan laboratorium yaitu Bilirubin total hanya 2,46 mg/dl sedang untuk Malaria berat dengan ikterik haruslah > 3,0 mg/dl. Ikterik sering dijumpai pada infeksi malaria falciparum. Pada penelitian di Minahasa dari 836 penderita malaria, hepatomegali 15,9%, hiperbilirubinemi 14,9% dan peningkatan serum transaminase 5,7%. Pada malaria biliosa ( malaria dengan ikterus ) dijumpai ikterus hemolitik 17,2%; ikterus obstruktif intra-hepatal 11,4% dan tipe campuran parenkimatosa, hemolitik dan obstruktif 78,6%, peningkatan SGOT rata – rata 121 mU/ml dan SGPT 80,8 mU/ml dengan ratio de Ritis 1,5. Peningkatan transaminase biasanya ringan sampai sedang dan jarang melebihi 200 iu, ikterus yang berat sering dijumpai walaupun tanpa diikuti kegagalan hati. Penelitian di Minahasa pada 109 penderita malaria berat, kadar bilirubin tertinggi ialah 36,4 mg/dl, dijumpai 28 penderita (25%) mortalitasnya 11%, bilirubin 1,2 mg% - 2 mg/dl dijumpai pada 17 penderita (16%) mortalitasnya 17%, bilirubin >2 mg/dl – 3 mg/dl dijumpai pada 51 penderita (46%) dan mortalitasnya 33%. Serum SGOT bervariasi dari 6-243 u/l sedangkan SGPT bervariasi dari 4 – 603 u/l.1

Pengobatan pada pasien ini selain menggunakan pengobatan simptomatis juga menggunakan pengobatan utama yaitu Artesunate, dimana sesuai dengan kepustakaan yaitu Penanganan malaria adalah tergantung kecepatan dan ketepatan diagnosis seawal mungkin. Sebaiknya penderita yang diduga menderita malaria, apalagi terdapat komplikasi dirawat intensif untuk pengawasan serta tindakan yang tepat. Prinsip penanganan malaria ialah :

1. Tindakan umum/ tindakan perawatan

2. Terhadap parasitemianya; yaitu dengan:

I. Pemberian obat anti malaria

II. Exchange transfusion (transfusi ganti)

3. Pemberian cairan / nutrisi

4. Penanganan terhadap gangguan fungsi organ yang mengalami komplikasi.2

Tindakan umum

Pertahankan fungsi vital : sirkulasi, respirasi, kebutuhan cairan dan nutrisi.2

1. Hindari trauma : dekubitus, jatuh dari tempat tidur

2. Hati-hati komplikasi: kateterisasi, dekubitus, edema paru karena overhidrasi

3. Monitoring : suhu, nadi, tensi, dan respirasi tiap 1/2 jam. Perhatikan timbulnya ikterus dan perdarahan.

4. Monitoring : ukuran dan reaksi pupil, kejang, tonus otot.

5. Baringkan/ posisi tidur sesuai dengan kebutuhan

6. Sirkulasi: posisi Trendelenburg pada hipotensi. Perhatikan warna dan temperatur kulit

7. Cegah hiperpireksi:

- jangan memakai botol panas/ selimut listrik

- kompres air/ air es/ alcohol

- kipas dengan kipas angin/ kertas

- baju yang tipis/ terbuka

- cairan cukup

8. Pemberian cairan : oral, sonde, infus, maksimal 1500 ml.

- cairan masuk dan keluar diukur per 24 jam

- kurang cairan akan memperberat fungsi  ginjal

- kelebihan cairan menyebabkan edema paru

9. Diet : porsi kecil dan sering, cukup kalori, karbohidrat dan garam.

10. Perhatikan kebersihan mulut

11. Perhatikan diuresis dan defekasi, aseptik kateterisasi.

12. Kebersihan kulit : mandikan tiap hari dan keringkan.

13. Perawatan mata : hindari trauma, tutup dengan kain/kasa lembab.

Pemberian obat anti malaria

Derivat Artemisinin

Obat baru berasal dari China (Qinghaosu) dengan efektivitas tinggi terhadap strain multiresisten. Salah satunya :

· Artesunate dalam bentuk puder, dikemas dengan pelarutnya dapat diberikan i.v/i.m. Baik iv maupun im pada studi di Afrika atas anak-anak memberikan klirens parasit yang sama adekuat. Pada studi SEAQUAMAT, di 4 negara meliputi 1461 kasus malaria berat, artesunate menurunkan mortalitas 34.7% secara absolut dibandingkan kina ( CI 95%; p= 0.0002) (mortalitas quinine 22% vs. mortalitas artesunate 15%). Keuntungan lain ialah efek hipoglikemi yang kurang dan efek kardiotoksik yang juga minimal. Dosis artesunate ialah : 2,4 mg/kgbb. pada jam 0, jam 12, jam 24 dan seterusnya tiap 24 jam sampai penderita sadar/membaik. Bila penderita sadar pemberian parenteral diganti oral dengan dosis 2 mg artesunate/kgbb./hari sampai hari ke-7. Untuk mencegah rekrudensi ditambahkan doksisiklin 2 x 100 mg/hari selama 7 hari atau tetrasiklin 3 x 500 mg/hari selama 7 hari. Untuk penderita ibu hamil dan anak-anak digunakan klindamisin 2 x 150 mg/hari selama 7 hari.2

Prognosis pada pasien ini adalah dubia, dimana dengan pengobatan yang tepat dan cepat akan meningkatkan angka keberhasilan terapi.

DAFTAR PUSTAKA

1. P.N. Harijanto. 2006. Malaria. Buku Ajar ilmu Penyakit Dalam. Edisi IV. Hal 1754-66. Jakarta. FKUI.

2. P.N. Harijanto. 2006. Perubahan Radikal dalam Pengobatan Malaria di Indonesia. www.cerminduniakedokteran.com. Diakses 20 juni 2009.

3. Miguel C Fernández, MD. 2009. Malaria. www.emedicine.com. Diakses 20 Juni 2009.

4. Jerahim Tarigan. 2003. Kombinasi Kina Tetrasiklin pada pengobatan Malaria Falciparum tanpa komplikasi di daerah resisten. www.yahoohealth.com. Diakses 20 Juni 2009.

READ MORE - MALARIA DENGAN IKTERIK ( Malaria with Jaundice )

Pediatrics, Child Sexual Abuse ( Kekerasan Seksual Pada Anak )

Tuesday, July 14, 2009

An excerpt from "The Prophet" by Kahlil Gibran


And a woman who held a babe against her bosom said,
"Speak to us of Children".
And he said:

Your children are not your children,
They are the sons and daughters of Life's longing for itself.
They come through you but are not from you,
And though they are with you yet they belong not to you.

You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them, but seek not to make them like you.
For life goes not backward nor tarries with yesterday.

You are the bows from which your chilren
as living arrows are sent forth.
The archer sees the mark upon the path of the infinite, and
He bends you with His might that His arrows may go swift and far
Let your bending in th earcher's hand be for gladness;
For even as He loves the arrow that flies,
So he loves also the bow that is stable.

Kahlil Gibran's book, published in 1923 is especially relevent and helpful
for these times and is a wonderful gift for yourself or a loved one.
"The Prophet"



T_1220443992child-abuse Ann S Botash, MD, Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University

Updated: Jul 2, 2008





Introduction

Background

Child sexual abuse affects more than 100,000 children a year. Many of these children present to the emergency department (ED). The following article outlines triage determinants for examinations, examination techniques, and interpretations of genital findings of sexual abuse.

Pathophysiology

Child sexual abuse has been defined by the American Academy of Pediatrics as the engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and violate the social taboos of society.1 In general, children cannot consent to any sexual activity, but the legal age of consent may vary by state.

Sexual activities involving a child may include activities intended for sexual stimulation, such as those involved in contact sexual abuse (eg, touching the child's genitalia or the child touching an adult's genitalia), penetrating injury (eg, penile, digital, and object insertion into the vagina, mouth, or anus), and nonpenetrating injury (eg, fondling, sexual kissing).

Noncontact sexual abuse, which may include exhibitionism, voyeurism, and the involvement of a child in verbal sexual propositions or the making of pornography, often occurs.

Physical findings of sexual abuse are often not present. The most important determinant for abuse is the child's (or a witness's) account of the incident. Physical indicators may be present, such as bruises to the skin (eg, on the arms and legs from pinch marks or force), abrasions to wrists and ankles (eg, from tethering), bruises to the genital area and mucosa, oral palatal bruises and/or petechiae, and rectal abnormalities. Hymenal abnormalities may be present from chronic abuse or acute injury. Sexually transmitted diseases (STDs) may be present in sexually abused children and teenagers.


Frequency
United States

In 2005, 83,850 children in the United States reported to Child Protective Services, were determined to be suspected victims of child sexual abuse. The actual number is likely to be higher because these numbers reflect only children whose cases are investigated by Child Protective Services.2

Mortality/Morbidity

Although perforation of the vagina or viscera could result in injury and death, death resulting from sexual abuse is unusual.

  • Most of the morbidity associated with sexual abuse is a result of emotional and psychological trauma.
  • Reactions to sexual abuse can include posttraumatic stress disorder, depression, anxiety, anger, impaired sense of self, dissociative phenomena, suicidal behavior, sexually reactive behaviors that are beyond the scope of normative child sexual development, and indiscriminate sexual behavior.
  • STDs may result in further morbidity. However, the prevalence of STDs in sexually abused children varies with geographic location and with the child's age. Most STD prevalence rates in prepubertal children tend to be below 4%; in adolescents, the prevalence rate is approximately 14%.
Sex

It is estimated that 1 in 4 girls and 1 in 6 boys will have experienced an episode of sexual abuse while younger than 18 years. The numbers of boys affected may be falsely low because of reporting techniques.

Clinical

History

abusepic1 Children suspected of being sexually abused require a behavioral, social, gynecologic, and general medical history. Sufficient information about the current incident of sexual abuse is needed to ensure that all needed evidence is properly collected.

  • In addition to information obtained from the child, details about the abuse should be obtained from other reliable sources, if possible.
  • Obtain a history from the parent or caregiver alone. Social workers and physicians should build rapport with the child in order to establish trust.
  • Possible warning signs regarding the social environment include the following:
    • Parents who share intimate feelings and emotions in front of their children
    • Parents who know little about the child's health or have vague recollections of past medical history
    • Parents who are overly concerned with custody issues
    • Social isolation
    • Alcohol and/or drug abuse
    • Intimate partner violence or other violence in the home environment of the child
  • The history should also include questions regarding possible behavioral indicators of abuse.
    • Abrupt behavioral changes - Aggression, depression, suicidal behaviors, withdrawal, low self esteem, nightmares, phobias, regression, school problems
    • Self-destructive behaviors - Substance abuse, sleep disorders, prostitution, cutting or other self-mutilation
    • Sexualized behavior inappropriate for developmental level (eg, excessive masturbation, forcing sexual acts on other children)
    • Runaway behavior in teens, loss of memory for events following a social gathering, intimate partner violence
  • Physical complaints
    • Foreign bodies in the vagina or rectum, genitourinary complaints, painful defection or urination, vaginal discharge, bleeding or itching, grasp or rope marks, oral complaints, STDs, or possible pregnancy
    • General somatic complaints including headaches, abdominal pain, constipation, diarrhea, encopresis, and general fatigue
  • In adolescents, the gynecologic history should always include the following:
    • Date of last menstrual period, number of pregnancies, possible gynecologic surgery or traumatic injury to the genital area
    • Date of the last consensual intercourse and use of contraceptives
    • Prior STDs
  • Depending on local protocols, the forensic (investigative) interview may best be performed with the assistance of trained law enforcement officials or social workers from Child Protective Services. The forensic interview differs from a good medical history.
    • This interview is essential to prosecution of a case and is often a critical aspect of the evaluation.
    • The forensic interview is mostly concerned with detailed answers to who, what, where, and when the abuse occurred.
    • The forensic interview should not replace the medical history obtained by the health care provider from the child.
    • If possible, professionals in the field of child sexual abuse should interview children alone.
    • Children may spontaneously disclose abuse to the physicians during the physical examination.
    • The medical record should clearly document who was present when the child disclosed the information, what question or activity prompted the disclosure, and, if possible, the exact words spoken recorded in quotation marks.
    • Questions regarding the incident should be focused but not leading. For example: "What were you touched with?" is an appropriately focused question. "Did he touch you with his fingers?" is a leading question.
    • Children with special communication needs, such as children with developmental disabilities, may require sign language, use of assistive devices, or illustrations.
  • Family and social histories are vital to understanding the environment in which the abuse occurred.
  • A brief developmental history may be critical in legal aspects of a child's case and should be documented.
  • Screening tools for the behavioral and medical history for sexual abuse have been developed and may be utilized.3
Physical

Child Abuse_0002.wmv1 Complete physical examinations in prepubertal children should include an examination of the external genitalia. Children who are suspected of being sexually abused may need an examination emergently, urgently, or electively scheduled for a later time with their own physician. If the child and family are adequately prepared for this examination, it will improve the diagnostic capability of the examiner.

  • Following an initial phone call from a parent or from a person from Child Protective Services, pediatric patients may be triaged for a medical examination to find evidence of sexual abuse.
    • Emergent examinations: Any child with acute bleeding or injury should be examined immediately. Children with a history of sexual contact within 96 hours of presentation should be examined for evidence of sexual abuse. Children in severe emotional or psychological crisis also deserve an emergent examination. Children exposed to HIV-positive alleged perpetrators need to begin HIV postexposure prophylaxis within 36 hours of exposure. Adolescents who wish to obtain pregnancy prevention need to be evaluated within 120 hours.
    • Urgent examinations may take place within 2-3 days of an incident of sexual abuse. Indications for an urgent examination include vaginal discharge, the possibility of STDs, and pregnancy in the pubertal child.
    • Delayed presentations are most common because children generally do not disclose abuse until they feel safe. This may occur months or years after the incident of abuse.
    • Other children may not disclose the abuse at all, and only behavioral indicators will be present.
    • If persons from Child Protective Services or law enforcement agencies request examinations of children with nonemergent cases, the examination can be deferred to a scheduled office visit or be referred to a child sexual abuse team.
    • The examination of a child who is involved in a custody situation is challenging. Whether the allegations of abuse are true or not, children involved in sexual abuse allegations must be considered to be victimized. An examination is almost always indicated.
  • Preparation of the child and family should be a part of every examination for sexual abuse.4
    • The discussion should include the following:
      • Information regarding the need for an external examination of the genitalia
      • The fact that almost all prepubertal children do not need a speculum or internal examination
      • Information on the use of cotton-tipped swabs to check for infections (if determined that these will be needed)
    • If a colposcope will be used for the examination, children should be allowed to look at the equipment and look through the eyepieces or at the video screen.5 Parents and older children should be informed of the use of the equipment and given opportunities to consent to the use of photographs for legal documentation. Note: Consent for photographs may not be necessary if the case is under investigation by Child Protective Services, but it is recommended.
  • The examination of the external genitalia should occur as part of the natural progression of the complete head-to-toe pediatric examination.
    • Proper positioning of the child for the genitalia examination enables better visualization. Common positions for female prepubertal children include the supine-frog-leg position, the knee chest position, and use of the labial traction technique.
    • Some physicians utilize a technique with a Foley catheter to get a better view of the hymen or utilize water to "float" the hymen for better visualization.6
    • The male genitalia can be examined with the child supine or standing.
  • Abnormal findings that are suspicious for sexual abuse are rare.
    • Findings of sexual abuse in boys may include injuries to the glans, shaft of the penis, or scrotum. Anal findings are unusual but may include scars (most apparent if located off the midline), distorted or irregular folds, flattening of the anal folds, and poor anal tone.
    • Most cases of suspected or substantiated sexual abuse of prepubertal girls have normal examination findings. This may be due to elasticity of the hymenal tissue and genital mucosa and rapid healing of any injuries.7,8
      • In most cases, children who are sexually abused are not physically injured (as in fondling), and the abuse does not leave physical evidence.
      • The normal crescent-shaped hymen is most common in prepubertal girls.
      • Other normal findings may include midline avascular areas, periurethral bands, longitudinal intravaginal ridges, superior and lateral notches, and some bumps and hymenal tags.
      • Other anatomical configurations of the hymen, which may normally be observed in prepubertal girls, include an annular hymen, fimbriated hymen, septate hymen, and microperforate hymen.
  • Physical findings in sexually abused prepubertal girls may include lacerations and bleeding of the genital area or more subtle chronic findings. Findings on the hymen should be documented by noting the location with the analogy of the hands of a clock. Findings may be significant for abuse.9
    • A hymenal tear may result in a healed transection of the hymen. However, over time, a hymenal tear may heal completely, leaving no signs of trauma or scarring.
    • Absence of all or part of the hymen, particularly in the posterior portion of the hymenal ring should be confirmed using different examination positions or techniques. For example, hymenal tissue may be adherent to part of the vaginal wall. Using a moist swab or drops of water to loosen the edge should clarify the finding.
    • Measuring the vaginal introital diameter is not necessary. When the examiner notices a subjectively large diameter, the hymenal rim should be observed for signs of narrowing and attenuation or absence of tissue. However, superficial notches in the hymen may be a normal finding.
    • Fresh lacerations or tears located in the genital area without a history of accidental trauma should be noted.
  • Other areas of the body should be inspected for signs of injury, including the oral pharynx for bruises to the hard or soft palate and grasp, rope, or tie marks on the extremities.
Causes
  • Risk factors
    • Parent abused as a child: Most perpetrators are not strangers but are known to the child (eg, stepfathers, uncles, mother's paramour). Female perpetrators are reported less often. Parents who have been abused do not always abuse their own children, but the risk for continued familial abuse is present.
    • Multiple caretakers for the child
    • Caretaker or parent who has multiple sexual partners
    • Drug and/or alcohol abuse
    • Stress associated with poverty
    • Social isolation and family secrecy
    • Child with poor self-esteem or other vulnerable state
    • Other family members (eg, siblings, cousins) abused
    • Gang member associations

More on Pediatrics, Child Sexual Abuse

READ MORE - Pediatrics, Child Sexual Abuse ( Kekerasan Seksual Pada Anak )

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