Case Report Neurology Division

CASE REPORT
NEUROLOGY DIVISION
CEREBRAL ABSCESS WITH OBSTRUCTIVE HYDROCEPHALUS IN A

15-YEAR OLD BOY WITH COVID 19 CONFIRMED,
LUNG TUBERCULOSIS AND NUTRITIONAL MARASMUS
Muhammad Alief Akbar Yusuf
Children’s Health Science Department, Faculty of Medicine
Hasanuddin University/ Dr. Wahidin Sudirohusodo Hosppital, Makassar
PRELIMINARY
Brain abscess is an uncommon condition, rare in children and
infants. A brain abscess is a focal intracerebral infection, which begins as
a localized area of cerebritis and develops into a collection of pus
surrounded by a well-vascularized capsule. It accounts for 2-5% of the
intracranial mass, mostly located in the cerebrum and rarely in the
cerebellum. In the United States, each year it is estimated that about
1,500-2,500 patients suffer from brain abscesses. Brain abscesses are
more common in men than women with a ratio of 3:1. 1,2
Brain abscess in children occurs after infection in adjacent or
adjacent structures such as otitis, sinusitis, mastoiditis or as a result of
hematogenous spread from a site, especially in children with congenital
heart disease or after meningitis. Staphylococcus aureus, Proteus
mirabilis, pseudomonas aeroginosa and Serratia marcescens are the most
common organisms that cause brain abscess. Brain abscess can be a
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complication of surgery, head trauma or because of inadequate treatment
of sepsis or meningitis. 1,2,3
The formation of a cerebral abscess is divided into 4 phases
based on CT-Scan and MRI images, the first is early cerebritis (1-4 days),
the second is advanced cerebritis (4-10 days), then the initial stage of
capsule formation (11-14 days) and finally, the stage of further capsule
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formation (more than 14 days).
Tuberculosis (TB) is an infectious disease caused by the
bacterium Mycobacterium tuberculosis. Tuberculosis (TB) is one of the
health problems in the world and it is estimated that one third of the
world's population has been infected with Mycobacterium tuberculosis.
Indonesia is the country with the most TB cases in the world after India
and China. In 2015 the proportion of TB cases in children in Indonesia
reached 9%. TB is systemic so that it can affect almost all organs of the
body with the most locations in the lungs which are usually the site of
primary infection.4
One of the problems of TB in children in Indonesia is diagnosis.
Since 2005 the pediatric TB scoring system has been socialized and
recommended as a diagnostic approach. The problem is, not all health
care facilities (fasyankes) in Indonesia have tuberculin test facilities and
chest x-ray examinations, which are 2 parameters in the scoring system.
As a result, in health facilities with limited access and facilities, there are
often underdiagnoses of TB in children. 5
2
During the COVID-19 pandemic, children who suffer from
malnutrition have a higher risk of death and affect the growth and
development of children. Malnutrition is still a major health problem in
developing countries, and is the underlying factor for more than 50% of
under-five deaths. Generally, people with malnutrition are children from
the age of infants, toddlers or school-age children. Nutritional problems
that often occur in children in Indonesia are Protein Energy Malnutrition
(kwashiorkor, marasmus, marasmik-kwashiorkor). 6
Marasmus is one of the three forms of malnutrition or Protein
Energy Malnutrition (PEM). Two other forms of PEM are kwashiorkor and
the mixed form of marasmus-kwashiorkor. Marasmus is a condition
caused by a deficiency of calories and energy which can be caused by
very less food intake and or increased calorie needs due to infection. 6
This paper reports a case of cerebral abscess with non-
communicating hydrocephalus with confirmed Covid 19, pulmonary
tuberculosis and nutritional marasmus. The purpose of this case report is
to monitor the course of the disease and the outcome of disease
interventions, as well as to observe the response to treatment.
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CASE REPORT
I. PATIENT IDENTITY
Name : RR
Sex : Boy
Age : 15 years 8 months
Date of birth : December 11th 2004
Medical record : 918729
Adress : Dusun Tanjung Manik
Date of Hospitalized : 2 Juli 2020
Date of examination : 2 Juli 2020
II. FAMILY DATA
Children (First of 2 sibling) No Miscarriage
NO. SEX DATE OF BIRTH HEALTHY.SICK BECAUSE

1. Boy 11-12-2004 Patient
2. Girl 10-12-2014 Healthy
FATHER MOTHER
Name : Mr A Mrs.B
Date o birth : 5/11/1966 27/6/1987
Age :54 years 33 years
Education : Senior high school Senior high school
Profession : Entrepreneur Household
III. Anamnesa (Autoanamnesis and Aloanamnesis Mother of patient)

Chief complaint : Shortness of breathe
3.1. History of current illness :
Patients admitted to the Children's IRD of Wahidin Sudirohusodo
Hospital were referred from the hospital. Lamadukelleng with a suspected
differential lung tumor with a diagnosis of lobar pneumonia. Patients with
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complaints of shortness of breath experienced since 2 weeks ago
worsened since 3 days before admission to the hospital. He had a cough
with phlegm since 1 month before he was admitted to the hospital. There
is a fever experienced since 1 month ago, not continuously. No seizures.
No vomiting. Children are lazy to eat and drink. Regular bowel
movements, yellow color. Urination of yellow color smoothly.
3.2. History of past illness

- A history of pulmonary tuberculosis and received OAT therapy for 6 months and
was declared cured by a pediatrician in 2013.
- History of fever fluctuating for more than 2 weeks.
- History of frequent night sweats since the last 1 week.
- History of cough more than 3 weeks
- History of weight loss of 5 kilograms in the last 2 months.
- History of contact with family who received OAT therapy, namely the patient's
father
- There is no history of contact with patients under Covid 19 surveillance
- History of frequent sneezing and itching of the nose when exposed to dust.
- A history of being treated at the Lamadukelleng Hospital for 1 day with a
suspected differential lung tumor diagnosed with lobar pneumonia, receiving
therapy with ampicillin, gentamicin, paracetamol.
3.3. History of family health
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The patient is the 1st child of 2 siblings. Another family member
who received OAT treatment for 6 months was the patient's father who
lived at home. No history of allergies in parents
3.4. History of patient social
The patient is a person who is easy to get along with and
socializes with those around him. The patient is currently sitting in high
school.
3.5. History of mother pregnancy
The patient is the eldest of two children. This pregnancy is a
desired pregnancy. At the time of pregnancy the mother was 18 years old.
During pregnancy, the mother routinely checks her pregnancy, she takes
vitamins and blood-boosting tablets. During pregnancy, the mother never
experienced excessive vomiting and never took drugs that were not
recommended by the doctor during pregnancy. There was no history of
diabetes, heart disease, and high blood pressure during pregnancy.
Mother had never had a miscarriage before.
3.6. History of labour
The patient was born by normal delivery at the hospital assisted
by a doctor. Term pregnancy, crying immediately with unknown APGAR
score. Birth weight 3,100 grams and birth length 50 cm. Immediately after
birth the patient received an injection of vitamin K and received
immunizations for hepatitis B0 and polio. The patient's condition after birth
according to the family was good, the patient was never yellow, never had
seizures or blue and there was never a history of bleeding.
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3.7. History of nutrition
The patient received breast milk from birth until the age of 1 year,
from the age of 6 months he was given additional food in the form of soft
porridge. And those over 1 year old are given family food. Currently the
patient consumes daily food, namely fish, rice and vegetables.
3.8. History of growth and development
Growth and development like any other normal child. If the child is
sick, the patient's family takes the child to the hospital. According to the
family, the patient's relationship with friends and other family members is
quite good.
3.9. History of immunization
The patient has received complete basic immunization
3.10. History of basic needs
Asuh (physics-biomedic)
The patient was breastfed from birth to 1 year of age.
Complementary feeding begins at 6 months of age. The patient received
complete basic immunization. When the child is sick, the patient
sometimes takes the child to the hospital or health center. Families are
able to meet their food and clothing needs.
Asih (pshycosocial)
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The patient is the first child of two siblings, getting enough love
from both his parents and siblings. The child is born from the first marriage
of both parents and is the expected child.
Asah (stimuli)
Parents give enough attention to the growth and development of
the patient.
3.11. History of family and economic-social
Both of the patient's parents are still alive. My father worked as a
self-employed employee. Father's income is uncertain. Sometimes 2 to 3
million per month. The last education of father and mother is high school.
The house he occupied was a stone house. The house consists of 3
bedrooms, 2 bathrooms, 1 kitchen, and a living room which is connected
to the dining room. Source of electricity from PLN. Source of water from
ground water (wells). As long as the patient is treated, the patient is
always looked after by the patient's mother. The patient lives with his
parents and siblings. The closest health facility is the Puskesmas. The
patient already has health insurance.
IV. PATIENT DATA WHEN BE CASE
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4.1. PHYSICAL EXAMINATION (OBJEKTIF)
a. Status present
- General condition : Severe ill/ poor nourish/ GCS 15
E4M6V5
- Blood pressure : 110/70 mmHg
- Pulse : 88 times/minutes
- Respiratory rate : 36 times/minutest
- Temperature : 38,6 °C
- Pain scale : 1 NRS
- Oksigen saturation : 95% (without oksigen) 99% (via nasal
kanul)
b. Status generalis
- Head : mesosefal, normosefal.
- Hair : black, straight, strenght
- Face : symmetric, no dismorphic face
- Eye : No conjungtivitis.
- Nose : No secret.
- Ear : No otorrhe.
- Mouth : No ulceration. Tonsil T1-T1, no hiperemis.
Faring no hiperemis.
- Neck : No lymphadenoapty, no neck stiffness.
- Thorax : Symmetric
Piano chest and subcostal retraction
Perkusi sonor, fremitus at left dan right
- Lung : Sound of breath vesikuler both of lung,
rhales at both of lung, no wheezing.
- Heart : Normal heart sound,regularly,no murmur
- Abdomen : No distended, normal peristaltic
Liver and spleen not palpable. No Ascites
- Ekstremity : Wasting,
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- Skin : BCG scar (+).
- Gland : No enlargement of gland / lymphadenopaty.
- Back : No gibbus and scoliosis
- Puberity : A3 M2 G3
c. Neurologic status
- Awareness : GCS 15 (E4 M6 V5)
- Nervus cranialis :
- Nervus I : Normal stifness
- Nervus II : pupil isocor diameter
2,5mm/2,5mm, positive light reflex
- Nervus III,IV,VI : Normal movement of eye
- Nervus V : Normal cornea refleks
- Nervus VII : No parese fasialis
- Nervus VIII : Normal hearing, balance
- Nervus IX,X, XI : Normal swallow
- Nervus XII : No deviation of tongue
- Meningeal sign : No neck stiffness
- Motoric : Normal strength, tonus
- Physiologic refleks : Knee Pees Refleks (KPR)
kesan normal, Achilles Pees Refleks (APR) within normal
limit
- Pathologic refleks : Babinsky, chaddock,
Gordon, Oppenheim negative
- Sensibility and otonom nerve : Normal sensibility
d. Antropometric status
- Beody weight (BW) : 32 kg
- Body height (BH) : 153 cm
- Head circumference : 54 cm (52-57 cm) 
Normosefal
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- Upper arm circumference : 16 cm
- Chest circumference : 68 cm
- Stomach circumference : 65 cm
- BW/BH : 74 % (Wasted)
- BW/A : 54,5% (severe under nourish)
- BH/A : 88,4% (Stunted)
Tuberkulosis score
- Contact with patient TB : 2 - Tuberkulin test :Not yet
- Nutritional status : 2 - Fever : 1
- Chronic cough : 1 - Lymphadenopaty n : 0
- Chest X-Ray : 1 - Swollen of bone : 0
TOTAL : 7
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Figurer 1. Curve CDC of BW to BH.
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4.2. SUPPORTING INVESTIGATION
Laboratorium (Wahidin Sudirohusodo Hospital, July 2nd -2020)
Date of examination Examination type Resultl Normal value
July 2nd2020 Hb 10,0 12-16 g/dl

Blood routine MCV 82 80-100 µm3
MCH 28 27-32 pg
Leukosit 9.100 4000-10.000 mm3
Eritrosit 4.150.000 3.800.000-

5.800.000/mm3
Trombosit 379.000 150.000-

400.000/mm3
Natrium 136 136-145 mmol/L
Kalium 3,5 3,5 - 5,1 mmol/L
Klorida 95 97 - 111 mmol/L
Bllod chemistry Ureum 14 10 - 50 mg/dl
Kreatinin 0,81 L(<1,3), P (<1,1)
SGOT 26 <38 U/L
SGPT 18 <41 U/L
Albumin 3,5 3,5-5,0 gr/dl
CRP 120 < 5 mg/l
Procalcitonin 0,5 < 0,05
IT ratio 13 < 15%
Blood smear Blood smear :

Erithrocyte : Anisositosis, normositik normokrom, ovalosit
(+), benda inklusi (-), normoblast (-)
Leucocyte : increase amount, PMN > Limfosit, Granulasi
toksik (+), vakuolisasi (+) sel muda (-).
Trombocyte :Normal amount, normal morfologic.
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Impression : Anemia normositik normokrom because
infection.
Blood culture No growth of aerob bacteria
Rapid test Anti-Sars-Cov-2 IgG non reaktif Anti-Sars-Cov-2 IgM non

reaktif
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Radiologic result
MSCT Thorax Wahidin Sudirohusodo Hospital ( Juli 2nd 2020)

- Homogeneous consolidation is seen with air bronchoram sign in it in the
anterior segment and superior lobe of the right lung
- Multiple calcifications of the left lung and inferior lobe of the right lung are
seen
- Trachea in midline
- Play bronchus within normal limits
- No visible enlargement of the paratracheal, subcarina, peribronchial
lymph nodes bilaterally
- Cor: size within normal limits, aorta and other large blood vessels within
normal limits
- No free fluid density is seen in the pleural cavity
- Liver, gastric and spleen were scabs within normal limits
- The scanned bones are intact
- Good surrounding soft tissue
Impression: Pneumonia dextra
Multiple calcifications in both lungs (post TB infection)
Figure 2. MSCT thoraks without contrast
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4.3. WORKING DIAGNOSE
- Patients under surveillance for covid 19 covid
- Sepsis
- Community Acquired Pneumonia
- Pulmonary tuberculosis
- Malnutrition marasmus type
- Short stature
- Anemia of chronic disease
- Lekocytosis
4.4. PLANNING OF THERAPY

a. Emergency therapy
Symptoms that require emergency action in this patient are
shortness of breath: nasal cannula oxygen is given 2 liters/minute.
b. Supporting investigation
Septic tracking: Septic Work Up (reticulocyte check, peripheral
blood smear, CRP, Procalcitonin, Blood culture)
Tracing the cause of anemia: check the peripheral blood smear,
reticulocytes and ferritin.
c. Therapy
Medicamentosa
- IVFD KAEN 3B 28 drips/minutes
- Ceftazidime 100 mg/kgbb/day = 1gr/12 hours/intravena
- Amikasin 20 mg/kgbb/day = 640 mg/24hours/intravena
- Administration of anti-tuberculosis drugs (WHO) intensive phase
- Isoniazid 10-15 mg/kg/day = 320-480 mg/day
- -Rifampicin 10-20 mg/kg/day = 320-640 mg/day
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- Pyrazinamide 30-40 mg/kg/day = 960-1,280 mg/day
- Ethambutol 15-25 mg/kg/day = 480-800 mg/day
- (Plan of 4FDC adult 4 regimens (rifampicin 150 mg/Isoniazid 75
mg/Pyrazinamide 400 mg/ethambutol 275 mg)
- 2 tablets/24 hours/oral for 2 months followed by 2FDC adult drugs
2 regimens (rifampicin 150 mg/Isoniazid 75 mg) 2 tablets/oral (3
times a week) for 4 months
- Paracetamol 10 mg/kg/dose = 320 mg/8 hours/intravenous (if
temperature > 38.5°C)
- Ambroxol 15mg/8hour/oral
- Cooperation of the Division of Nutrition and Metabolic disease
d. Nutritioanl Care
Nutritional assestment: Nutritional Marasmus
Nutritional requirement :
Calorei : 50%x RDA x BBI = 50% x 60 x 45 kg = 1.350 kkal
Liquid (holiday segar) 1.740 ml/day
Nutritional route : Enteral
Nutritional selection : F75 milk 12 x 150 ml
Nutritional monitoring : toleranse, side effect, increase of body
weight
e. Monitoring
- Monitoring the patient's general condition including subjective
complaints and vital signs.
- Monitoring by ensuring that the patient's family understands the
treatment plan at the infection center and the plan for a
nasopharyngeal swab examination (RT-PCR) to establish the
diagnosis of covid 19.
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- Monitoring by ensuring that only 1 patient and patient's family
accompany the patient, always wear a mask and maintain hygiene
and a swab examination will be carried out for the patient
companion after treatment at the infection center
- Monitoring disease progression, and complications as well as
treatment response, compliance, tolerance and possible side
effects of anti-tuberculosis drugs and other drugs.
- Monitoring nutritional status with anthropometry
f. Education and communication

- Open communication with family regarding covid 19 and
pulmonary tuberculosis tuberkulosis
- Provide an explanation to parents about the patient's condition
including the cause, course of the disease, complications,
prognosis and further action plans.
- Explaining to the patient's family about covid 19 and pulmonary
tuberculosis are diseases that require therapy for a long period of
time so that they need support from people around, especially
parents in monitoring the regularity of patients taking OAT and
explaining the problems that arise if they do not take OAT regularly.
- Explain the importance of nutritional intake according to the
patient's condition.
- Explain the importance of routine control for monitoring related to
patient's growth and development including anthropometric status,
developmental screening and evaluation of problems that are at risk
of disrupting the optimization of growth and development.
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V. FOLLOW UP THE TRAVEL OF DISEASE AFTER A CASE
Monitoring day 3 in Hospital (July 4th 2020)

Subjective The patient was admitted to the infection center on
day 3
The patient is placed on an oxygen nasal cannula
The tightness is reduced. There's a cough
No fever, no seizures.
No vomiting.
Children are lazy to eat and drink.
Yellow soft defecation.
Urination: smooth, reddish color
Objective General condition: Weak
Blood pressure: 110/70 mmHg
Pulse 80 beats/minute
Breath 32 times/minute
Temperature 37.0oC
pain scale 0 NRS
Oxygen saturation 99% via nasal cannula.
Minimal subcostal retraction.
Lungs: vesicular breath sounds, crackles in both
lung fields, no wheezing.
Heart: Pure regular I-II heart sounds, no noise
Abdomen: Normal peristalsis, liver and spleen not
palpable. No ascites.
Warm extremities, CRT < 2 sec
Nasopharyngeal Swab 2-7-2020 : negative
Assesment - Sepsis

- Pulmonary Tuberculosis
Planning - Oxygen nasal cannula 1 liter/minute
- Infusion of KAEN-3B 20 drops/minute
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- Ceftazidime 1gram /12 hours/ intravenously (day 3)
- Amikacin 480 mg/24 hours/intravenously (day 3)
- Paracetamol 320 mg / 8 hours / intravenously (if
the temperature is > 38.5°C)
- Ambroxol 15 mg/8 hours/oral
- OAT intensive phase of the first month Day 3:
(2 tablets 4 FDC/24hours/oral)
Isoniazid 320 mg/24hr/oral
Rifampicin 320 mg/24 hours/oral
Pyrazinamide 960 mg/24hr/oral
Ethambutol 480 mg/24 hours/oral
- Management of malnutrition (PNC) Transition
phase 3 hari
Calorie requirement
Energy = 75% x RDA x BBI = 75% x 60 x 45 = 2,000
kcal
Milk F100 = 10 x 200 kcal
- Vitamin B com 1 tab / 24 hours / oral
- Vitamin C 50 mg/12 hours/oral
- Folic acid 1mg/24hours/oral
- Moved lontara 4 isolation treatment

Subjective There is a cough, not shortness of breath.
No vomiting.
Children want to eat and drink.
Urination: smooth yellow color
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Temperature 36.7oC
pain scale 0 NRS
Oxygen saturation 98%
No subcostal retraction
Lungs: vesicular breath sounds, rhonchi and
wheezing are absent.
Abdomen: Increased peristalsis, liver and spleen are
not palpable. No ascites.
Tuberculin test 8-7-2020 : 0 mm (negative)
Gastric rinse 8-7-2020

BTA I staining: negative
BTA II staining: negative
BTA III staining: positive
Assesment - Sepsis

- - Anemia of chronic disease
Planning - Infusion of KAEN-3B 28 drops/minute
- Ceftazidime 1 gram / 12 hours / intravenously (7th
day)
- Amikacin 480 mg/24 hours/intravenous (day 7)
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- Ambroxol 15 mg/8 hours/oral
- OAT intensive phase 1st month Day 7 :
- Management of malnutrition (PNC) Transition
phase 5
Calorie requirement
kcal
Milk F100 = 10 x 200 kcal
- Folic acid 1mg/24hours/oral

Subjective There is a headache, feels like pressure, initially the
pain is in the right temporal area then it is all over the
head, the pain is intermittent.
There is a cough, not shortness of breath
There is fever, no convulsions. There is nausea. No
vomiting.
Urination: smooth reddish color
Breaths 28 times/minute
Temperature 38.8 oC
22
3 NRS pain scale
99% oxygen saturation
Neurological Status
Awareness : GCS 15 (E4 M6 V5)
Cranial nerves:
Nervus I: smell within normal limits
Nerve II: pupil isocor 2.5mm/2.5mm diameter, positive
light reflex
Nerves III,IV,VI: eye movement in all directions
Nerve V: corneal reflex is present
Nervus VII: facial paresis absent
Nervus VIII: normal sense of hearing and normal
balance
Nerves IX, X, XI: swallow reflex is present
Nervus XII: tongue deviation does not exist
Signs of meningeal stimulation: no neck stiffness
Motor: normal muscle tone, normal muscle strength
Physiological reflexes: Knee Pees reflex (KPR)
normal impression, Achilles Pees reflex (APR) normal
impression
Pathological reflexes: Babinsky, Chaddock, Gordon,
Oppenheim absent.
Sensibility and autonomic nervous system: normal
impression
No subcostal retraction
Lungs: vesicular breath sounds, crackles are present
in the right hemithorax and no wheezing.
Chest X-Ray Wahidin hospital July 17th 2020
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-Asymmetrical position, good photo condition, enough
inspiration
-Inhomogeneous consolidation appears with air
bronchogram sign in right lung center field
-Cor: CTI within normal limits, normal aorta
-Both sinus and diaphragm are good
-Intact bones
-Soft tissue around good
Impression: - Multiple pulmonary calcifications left
(post TB infection)
Laboratory Examination 07-13-2020 (Wahidin
Sudirohusodo Hospital)
Ferritin 314, Hb: 10.5 gr.dl, MCV 80 m3, MCH 28 pg,
MCHC 31 gr/dl, HCT 33%, Leukocytes 17,700 mm3,
Platelets 711,000/mm3, GDS 70 mg/dl, urea 20
mg/dl , creatinine 0.48 mg/dl, SGOT 26 U/L SGPT 57
U/L, albumin 3.5 gr/dl, Sodium 136 mmol/l, potassium
5 mmol/l, chloride 100 mmol/l
routine urine: yellow color, pH 7, negative glucose,
negative erythrocytes, negative leukocytes, negative
bilirubin, negative ketones, negative nitrite, leukocyte
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sediment 0, leukocyte sediment 1
Assesment - Sepsis
- Acute cephalgia
- Lekocytosis
- Reactive thrombocytosis
- Paracetamol 320mg/8hours/intravenously
- Vectrin syrup 5ml/8 hours/oral
- Management of malnutrition (PNC) Rehabilitation
Calorie requirement
Energy = 100% x RDA x BBI = 100% x 60 x 45 =
2,700 kcal
Regular food 3 x 500 kcal
Milk F100 4 x 250 kcal, Snack 2 x 100 kcal
Folic acid 1mg/24hours/oral
-Cooperation with the Neurology division
Subjective There is a severe headache, feels like pressure,
initially pain in the right temporal area then
generalized throughout the head, pain occurs for
about 20-30 minutes in one attack and causes the
patient to have difficulty sleeping.
25
No cough, no shortness of breath
There has been vomiting 5 times, filled with leftovers
and liquids, not spraying
Objective General condition: Weak, drowsiness
Temperature 36.8 oC
pain scale 5-6 NRS
Neurological Status
Nerve II: pupil isocor 2.5mm/2.5mm diameter,
positive light reflex
balance
Motor: normal of muscle tone, weakness of muscle
strength (4/4 superior, 4/4 inferior)
Physiological reflexes: Knee Pees reflex (KPR)
normal impression, Achilles Pees reflex (APR)
normal impression
26
Oppenheim absent.
impression
Lungs: vesicular breath sounds, rhonchi and
wheezing are absent.
MSCT Brain without contrast RSWS 7-25-2020
-Intraaxial multiple hypodense (20HU) lesions were

seen, well-defined, regular surface, non-calcified
with isodense margins, the largest size was 3.5 x
2.8 x 3.9 cm in the right frontotemporoparietal lobe
accompanied by perifocal edema which gave a
finger-like appearance, constricts the lateral
ventricles of the right anterior and posterior horns
and the third ventricle and causes a midline shift to
the left as far as 1.6 cm - Appears dilatation of the
left posterior horn of the lateral ventricles -
Physiological calcification of the pineal body - CPA,
pons and cerebellum are within normal limits -
Perselubungan lesions appear 11HU) in bilateral
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frontal sinuses, bilateral spheinodalis sinuses,
bilateral ethmoid sinuses ---Dome-shaped
hypodense lesion (6HU) in left maxillary sinus -Both
orbits and retroorbital space within normal limits
---Paranasal sinuses d an aircell mastoid scanned
within normal limits --bones intact
Impression:
-Multiple hypodense lesions of the right
frontotemporoparietal lobe suspect cerebral abscess
DD/tuberculoma that constricts the lateral ventricles
of the right anterior and posterior horns and the third
ventricle and causes subfalcine herniation to the left
as far as 1.6 cm
-Obstructive hydrocephalus
-Multisinusitis
- Retention cyst sinus maxillaris sinistra
Hb: 11.6 gr.dl, MCV 82 m3, MCH 29 pg, MCHC 33
gr/dl, HCT 33%, Leukocytes 13,900 mm3, Platelets
487,000/mm3, GDS 85 mg/dl, urea 22 mg/dl,
creatinine 0 ,5 mg/dl, SGOT 22 U/L SGPT 19 U/L,
albumin 3.5 gr/dl, Sodium 135 mmol/l, potassium 4.5
mmol/l, chloride 98 mmol/l
Assesment - Sepsis
- Acute cephalgia et causa cerebral abscess
differential diagnosis of tuberculoma
- Obstructive hydrocephalus
- Pulmonary Tuberculosis on treatment
- Multisinusitis
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- Paracetamol 450 mg/6 hours/intravenous
phase 9
Calorie requirement
Energy = 100% x RDA x BBI = 100% x 60 x 45 =
2,700 kcal
Milk F100 4 x 250 kcal
Snack 2 x 100 kcal
Neurosurgery collaboration:
MSCT Brain plan with contrast

Subjecti ve There is a severe headache, feels like pressure, initially
pain in the right temporal area then generalized
throughout the head, pain occurs for about 20-30
minutes in one attack and causes the patient to have
difficulty sleeping.
29
There was vomiting 2 times, filled with leftovers and
liquids, didn't spray
Yellow soft defecation. Urination: smooth reddish color
Pulse 84 times/minute
Temperature 36.6 oC
pain scale 6 NRS
Neurological Status
light reflex
balance
Motor: Motor: normal of muscle tone, weakness of
muscle strength (4/4 superior, 4/4 inferior)
Physiological reflexes: Knee Pees reflex (KPR) normal
impression, Achilles Pees reflex (APR) normal
impression
Oppenheim absent.
impression
30
No retraction
Lungs: vesicular breath sounds, rhonchi and wheezing
are absent.
Abdomen: Increased peristalsis, liver and spleen are not
MSCT Brain with contrast RSWS 27-7-2020
-Multiple intraaxial hypodense lesions (22HU) that

intensify at the edges (64HU) and ring enhancement
membranes, well demarcated, regular surface, non-
calcified with isodense margins, the largest size is 3.5 x
2.8 x 3.9 cm in the lobes. Right frontotemporoparietal
accompanied by perifocal edema that gives a finger-like
appearance, constricts the right anterior and posterior
horns of the lateral ventricles and the third ventricle and
causes a midline shift to the left as far as 1.6 cm. CPA,
pons and cerebellum were within normal limits -
Obscuring lesion (11HU) was seen in bilateral frontal
sinus, bilateral spheinodal sinus, bilateral ethmoid sinus -
-Dome-shaped hypodense lesion (6HU) was seen in the
left maxillary sinus -Both orbits and n Retroorbital space
within normal limits --Paranasal sinuses and mastoid
aircells scanned within normal limits --Intact bones
Impression:
-Multiple hypodense lesions of the right
31
frontotemporoparietal lobe suggest a cerebral abscess
that constricts the right anterior and posterior horn lateral
ventricles and the third ventricle and results in a 1.6 cm
left subfalcine herniation
-Obstructive hydrocephalus
-Multisinusitis and Retention cyst sinus maxillaris sinistra
Hb: 11.8 gr.dl, MCV 81 m3, MCH 30 pg, MCHC 32 gr/dl,
HCT 33%, Leukocytes 7,100 mm3, Platelets
341,000/mm3, GDS 87 mg/dl, urea 20 mg/dl, creatinine
0 ,4 mg/dl, SGOT 44 U/L SGPT 49 U/L, albumin 3.7
gr/dl, Sodium 135 mmol/l, potassium 4.1 mmol/l, chloride
99 mmol/l, PT 10 seconds, APTT 26 seconds, INR 0.95,
CRP 8.9, Procalcitonin 0.13
Blood culture: no aerobic bacteria growth
Peripheral Blood smear:
Erythrocytes: Anisocytosis, normochromic normocytic,
ovalocytes (+), inclusion bodies (-), normoblasts (-)
Leukocytes: Normal count, PMN > Lymphocytes, Toxic
granulation (+), vacuolization (+) young cells (-).
Platelets: Adequate number, normal morphology.
Impression: Leukocytes with signs of infection.
Assesment - Sepsis
- Obstructive hydrocephalus et causa cerebral abscess
- Pulmonary tuberculosis relapsed on treatment
- Multisinusitis
32
- Acetazolamide 125mg/12 hours/oral (first day)
- Furosemide 40mg/24hours/oral
Calorie requirement
kcal
Regular food 3 x 500 kcal,
Milk F100 4 x 250 kcal, Snack 2 x 100 kcal
- Metronidazole 500 mg /8 hours/intravenously (first day)
Abscess drainage craniectomy surgery plan
Covid team consul for nasopharyngeal swab
PICU Consul for postoperative care
Monitoring day 32 in Hospital (August 3th 2020)
Subjective There is a severe headache, feels like pressure, initially
No cough, no shortness of breath, no fever, no
convulsions.
There's been vomiting 3 times, filled with leftovers and
liquids, doesn't spray
33
Yellow soft defecation. Urination: smooth reddish color
Temperature 36.8 oC
5 NRS pain scale
Neurological Status
Cranial nerves:
light reflex
balance
Motor: Motor: normal of muscle tone, weakness of
muscle strength (4/4 superior, 4/4 inferior)
impression
Oppenheim absent.
impression
No retraction
Lungs: vesicular breath sounds, rhonchi, wheezing
34
absent.
459.000/mm3, GDS 99 mg/dl, urea 24 mg/dl, creatinine
95 mmol/l
Nasopharyngeal swab RT-PCR 3-8-2020: positive
Assesment - Covid 19 confirmed
- Sepsis
- Multisinusitis
- Meropenem 850mg/8hours/intravenously (first day)
- Oseltamivir 60 mg / 12 hours / orally (first day)
- OAT intensive phase second month Day 2:
35
- Acetazolamide 125mg/12 hours/oral (fifth day)
- Furosemide 40mg/24hours/oral
phase 17
Calorie requirement
kcal
Milk F100 4 x 250 kcal,
Snack 2 x 100 kcal
- Metronidazole 500 mg / 8 hours / intravenously (fifth
day)
(if the swab result is negative)

No fever, no seizures.No vomiting
36
Temperature 36.8 oC
pain scale 4 NRS
Neurological Status
Cranial nerves:
light reflex
balance
impression
Oppenheim absent.
impression
No retraction
are absent.
37
100 mmol/l
Nasopharyngeal swab I RT-PCR 3-8-2020: positive
Nasopharyngeal swab II RT-PCR 7-8-2020: positive
Nasopharyngeal swab III RT-PCR 10-8-2020: positive
Nasopharyngeal swab IV RT-PCR 8-13-2020: negative
Nasopharyngeal swab V RT-PCR 14-8-2020: negative
Assesment - Sepsis
- Multisinusitis

- OAT intensive phase second month Day 13 :
38
phase 28
Calorie requirement
kcal
Snack 2 x 100 kcal
Moving to the isolation treatment of the Lontara ward 4
(if condition is stable)
No fever, no seizures.No vomiting
22 breaths/minute
Temperature 36.9 oC
3 NRS pain scale
39
Neurological Status
Cranial nerves:
light reflex
balance
impression
Oppenheim absent.
impression
No retraction
are absent.
MSCT Brain with contrast RSWS 18-8-2020
40
-Multiple hypodense lesions (16HU) are spherical in
shape, intact walls, well-defined, various sizes that are
enhanced by post-contrast at the edges (89HU)
especially on the walls which give a ring enhancement
picture, well-defined, regular surface, non-calcified with
isodense edges on the corona. radiata dextra and in the
right temporal lobe accompanied by perifocal edema that
gives a finger-like appearance, constricts the lateral
ventricles of the right anterior and posterior horns and
the third ventricle and causes a midline shift to the
contralateral as far as 0.5 cm. Pons and cerebellum
within normal limits - Obscuring lesions (40HU) were
seen in the left frontal sinus, bilateral ethmoid sinuses
-Both orbits and retroorbital space within normal limits
--Si nus paranasalis and mastoid aircells were scanned
within normal limits - -bones intact
Impression:
-Multiple ring enhance lesion suggestive of cerebral
abscess
-Multisinusitis
41
100 mmol/l , PT 10.4 seconds , APTT 28 seconds, INR
1.0, Anti-Sars-Cov-2 IgG non reactive, Anti-Sars-Cov-2
IgM non reactive
Nasopharyngeal swab RT-PCR 8-14-2020: negative
Assesment - Sepsis
- Multisinusitis
phase 38
Calorie requirement
kcal
42
Snack 2 x 100 kcal
Today's abscess drainage craniotomy surgery plan and
PICU care after surgery

Subjective Postoperative pain
No fever, no seizures., No vomiting
43
22 breaths/minute
Temperature 36.9 oC
3 NRS pain scale
Neurological Status
Cranial nerves:
light reflex
balance
Motor: normal muscle tone, normal muscle strength
impression
Oppenheim absent.
impression
The postoperative wound is covered with a bandage in
44
the right temporal region
are absent.

HCT 33%, Leukocytes 17.700 mm3, Platelets
292.000/mm3, GDS 87 mg/dl, Sodium 138 mmol/l,
potassium 4 ,7 mmol/l, chloride 108 mmol/l
CRP 46.1, Procalcitonin 0.15, IT ratio 10
Blood culture: no aerobic bacteria growth
Peripheral Blood smear:
Erythrocytes: Anisocytosis, normochromic normocytic,
ovalocytes (+), inclusion bodies (-), normoblasts (-)
Leukocytes: Normal count, PMN > Lymphocytes, Toxic
granulation (+), vacuolization (+) young cells (-).
Platelets: Adequate number, normal morphology.
Impression: Leukocytes with signs of infection.
Cerebral abscess culture: Pseudomonas aeroginosa
45
Abscess tissue culture: no aerobic bacteria growth
Assesment - Post operative day 4 craniotomy cerebral abscess
drainage
- Sepsis
- Multisinusitis
- Meropenem 850mg/8hours/intravenously
- Metronidazole 500mg/8hr/intravenous
phase 42
Calorie requirement
kcal
Snack 2 x 100 kcal
Outpatient plan, polyclinic control 3 days later
46
VI. RESUME
A man aged 15 years 5 months was admitted to the Children's
IRD of Wahidin Sudirohusodo Hospital and was referred from the hospital.
Lamadukelleng with a suspected differential lung tumor with a diagnosis of
lobar pneumonia. Patients with complaints of shortness of breath
experienced since 2 weeks ago worsened since 3 days before admission
to the hospital. He had a cough with phlegm since 1 month before he was
admitted to the hospital. There is a fever experienced since 1 month ago,
not continuously. No seizures. No vomiting. Children are lazy to eat and
drink. Regular bowel movements, yellow color. Urination of yellow color
smoothly. A history of suffering from pulmonary tuberculosis and receiving
OAT therapy for 6 months and was declared cured by a pediatrician in
2013. A history of fluctuating fever for more than 2 weeks. History of
frequent night sweats since the last 1 week. History of cough for more
than 3 weeks History of weight loss of 5 kilograms in the last 2 months.
There is no history of contact with patients under Covid 19 surveillance.
There is no history of traveling out of town/country. A history of being
treated at the Lamadukelleng Hospital for 1 day with a suspected
differential lung tumor with a diagnosis of lobar pneumonia, receiving
therapy with ampicillin, gentamicin, paracetamol and ambroxol.
47
Based on the physical examination, it was known that the general
condition of the patient was seriously ill/malnourished/aware GCS 15
(E4M6V5). The child looks very thin, the ribs are visible, the extremities
are wasting. This patient was diagnosed with marasmus-type malnutrition
based on clinical and anthropometry, namely on physical examination, the
child looked very thin, ribs were visible, the extremities looked wasting,
and from anthropometry, the nutritional status based on weight/TB was
74% based on the CDC curve, based on BW/U is 54% based on the CDC
curve and short stature based on TB/U is 88%. From the examination of
vital signs, it was found that there was tachypnea of 40 times/minute
accompanied by 98% oxygen saturation (via nasal cannula) and a
temperature of 38.6 °C. Based on the generalist status examination,
minimal subcostal retraction was seen in the patient's chest. In the lungs,
vesicular breath sounds were found, additional sounds were crackles in
both lung fields, and there was no wheezing. In the extremities,
physiological reflexes were found to be normal, pathological reflexes were
not found. The skin showed BCG scars and no enlarged lymph nodes.
The generalist status in the other regions was within normal limits.
Examination of neurological status within normal limits. The patient's TB
score was 7 points. Based on the supporting examination, it is known that.
MSCT-Thorax showed the impression of Multiple calcifications after TB
infection.
VII. DEFINITIVE DIAGNOSE

- Post surgery craniotomy cerebral abscess drainage
- Obstructive hydrocephalus
48
- Sepsis
- Pulmonary Tuberculosis on treatment
- Covid 19 confirmed
- Short stature
- Multisinusitis
VIII. PROGNOSIS
- Quo ad vitam dubia
- Quo ad sanationam dubia
- Quo ad functionam dubia
IX.DISCUSSION
Brain abscess is a rare condition in children and neonates. In the
USA, each year there are 1500-2500 patients with brain abscess. The
most common causes of brain abscess are sinusitis, otitis media,
infections of the orbit, face, osteomyelitis, and pulmonary infections. In
some cases, brain abscess can be a complication of cyanotic congenital
heart disease, resulting from injuries that penetrate the skull and as a
result of insertion of a ventriculo-peritoneal shunt., 1,2 In this patient, there is
a history of frequent coughs, runny noses, and a history of dust allergy.
and headache, and a CT scan of the head revealed multisinusitis and can
cause a cerebral abscess.
Infection of the paranasal sinuses spreads through diploic venous
thrombophlebitis that does not have valves to the frontal or temporal lobes
in general will form a single abscess that is superficial and close to the
source of infection. Meanwhile, frontal sinus infection will cause abscesses
49
located in the anterior or inferior part of the frontal lobe, sinusitis
spheinodalis causes abscesses in the frontal or temporal lobes, sinusitis
maxillaris will cause abscesses in the temporal lobes and ethmoidal
sinusitis will cause abscesses in the frontal lobes.1
In this patient, a head CT scan revealed multisinusitis and caused
a cerebral abscess located in the right frontotemporal lobe.
In 75% of cases, the duration of the appearance of a brain
abscess is less than 2 weeks. In rare cases, the patient's condition may
suddenly worsen due to rupture of the subarachnoid or intraventricular
abscess. 7
Figurer 3. Pathogenesis sinusitis and complications
50
Clinical manifestations that appear as a result of abscess
expansion depend on the patient's age, location, size, stage, type of
bacteria, degree of brain edema. Common symptoms include signs of
infection in the form of high fever which is a symptom of cerebral abscess
in general, local signs of brain tissue infection such as seizures, which are
rare symptoms at the beginning of the disease, found in 25-40% of
patients, decreased consciousness, hemiparesis, motor disturbances. and
sensory, signs of increased intracranial pressure such as nausea/vomiting,
headache. In children, common symptoms are sepsis, meningitis and
seizures. In the early stages of the disease, a cerebral abscess appears
as a picture of encephalitis accompanied by signs of increased intracranial
pressure which is characterized by a protruding crown, on funduscopy
there is papilledema. This rapidly worsening condition is usually caused by
a cerebral abscess that has ruptured into the ventricular or subarachnoid
space. If the abscess has ruptured it can cause purulent meningitis. 1,8
In this case, the patient came with clinical manifestations of fever
since 1 month before admission to the hospital, not continuously, the
headache was felt while being treated at the hospital, felt like pressure,
initially pain in the right temporal area then all over the head, the pain was
intermittent. and causes the patient to have difficulty sleeping,
accompanied by nausea and vomiting, not spraying, the frequency is 5
times the contents of leftover food and fluids.
Investigations carried out, among others, on routine blood
examination revealed leukocytosis. About a quarter of patients have a
51
leukocyte count of less than 20,000/mm3. In blood electrolytes, serum
sodium can be low due to impaired production of the hormone ADH. Blood
cultures or abscesses may reveal the causative bacteria and elevated
CRP. Lumbar puncture is not performed if there are signs of increased
intracranial pressure. On a head CT scan for early detection of cerebral
abscess, precise localization of the abscess, assessing the characteristics
of the abscess determine the number, size and degree of abscess. On CT
scan examination can also see the presence of hydrocephalus, increased
intracranial pressure, cerebral edema and the presence of infectious

1,2,3
processes such as subdural empyema, ventriculitis.
In this case, the investigations carried out were routine blood
(leukocytosis), blood electrolytes within normal limits. On blood culture
examination, no aerobic bacterial growth was found, on cerebral abscess
culture, Pseudomonas aeroginosa, CRP 120 and Procalcitonin 0.5 were
found. In this case, a lumbar puncture was not performed because there
was an increase in intracranial pressure. CT scan showed multiple
abscesses in the left frontal region and right temporal region accompanied
by perifocal edema effusion, hydrocephalus obstruction and resulted in
midline shift.
Pseudomonas aeroginosa is a gram-negative bacterium that is
responsible for a wide range of diseases, from minor skin lesions to
severe invasive sepsis, pneumonia, and deep tissue abscesses.
Pseudomonas aeroginosa is the number one bacterium that causes
nosocomial pneumonia. Pseudomonas aeroginosa can cause cerebral
52
abscess by spreading continuously through parameningeal structures
such as the ear, mastoid and sinus. Pseudomonas aeroginosa can also
spread hematogenously from major sites of infection such as pneumonia,
urinary tract infections and endocarditis, penetrate the blood-brain barrier
and penetrate the cerebrospinal fluid. Research by Kevin Patel MD in
2014 in the USA on the types of bacteria in brain abscesses, showed that
Pseudomonas aeroginosa, Staphylococcus aureus, Streptococcus
pneumoniae were the most common causes found in cases of cerebral
abscess caused by infection in the sinus area, while in mastoid infections
Staphylococcus aureus, Streptococcus pneumoniae is the most common
cause.10 In this case, Pseudomonas aeroginosa was found.
Brain tissue is susceptible to infection and does not have a good
defense mechanism. Collagen capsule formation is the most important
response in limiting the spread of the abscess, which usually forms
completely within 14 days. There are 4 phases of capsule formation, the
first is early cerebritis (1-4 days), namely abscesses generally form in the
white matter or the meeting of white and gray matter. In this phase,
microorganisms are present in the center of necrotic tissue, collagen
tissue has not yet formed, there is only perivascular inflammation
(cerebritis), lesions are not well-defined and there is cerebral edema so
that symptoms of increased intracranial pressure will appear. The second
phase, advanced cerebritis (4-10 days) in which pus and debris has
formed, causes a large area of necrotic tissue surrounded by inflammatory
cells and macrophages. Reticin tissue has been formed by fibroblasts
53
which will become capsule precursors and the separation of abscess
tissue (there are microorganisms in it) and healthy tissue begins to occur
so that cerebral edema and abscess size reach the largest size and
cannot enlarge anymore, then the early stages of capsule formation (11-
14). days) where fibroblasts form a reticulin network surrounding the
necrotic tissue or capsule, where the more vascularization, the faster the
capsule formation, neovascularization and proliferation of astrocytes
appear, the size of the necrotic center and edema begins to shrink and
last, and the advanced stage of capsule formation (more than 14 days) ie
abscess has formed completely, there are 5 zones, necrotic area,
inflammatory cells, thick collagen capsule, neovascular layer, reactive
astrocytosis. The capsule becomes thinner in the direction of the ventricles
and becomes thicker in the direction of the cortex or the lining of the
brain.1 In this patient, the result of an MSCT scan of the head with
contrast was a cerebral abscess with a clearly visible capsule (advanced
stage of capsule formation).
Management includes conservative and surgical treatment (if the
abscess is more than 1.7 cm in diameter or the abscess is getting bigger).
Conservative treatment in the form of empirical antibiotic therapy because
it must be able to penetrate the blood brain barrier, able to penetrate the
capsule, broad spectrum due to the presence of various microorganisms
that cause cerebral abscess, including Metronidazole + 3rd generation
cephalosporin, Vancomycin + 3rd generation cephalosporin +
metronodazole, Penicillins + metronidazole, vancomycin + 3rd generation
54
cephalosporin, vancomycin + gentamicin or nafcillin + ampicillin +
gentamicin. Administration of corticosteroids to cerebral abscesses can
slow the encapsulation process, cause necrosis of the abscess, reduce
the penetration of antibiotics into the abscess and change the CT scan
image. If the use of corticosteroids is intended to reduce cerebral edema
then it should be used in the short term. Corticosteroids should be given to
patients with increased intracranial pressure or accompanied by
neurological disorders because it can increase life saving. Surgical action
in the form of excisional craniotomy is usually performed if the size of the
abscess remains enlarged after 2 weeks of antibiotics or if the size of the
abscess is more than 2 cm and there are signs of increased intracranial
pressure. Usually a cerebral abscess requires surgery in the form of
incision and drainage of the abscess.1,7
In this case, the patient received antibiotic therapy of 3rd
generation cephalosporin (ceftrazidime), amikacin and metronidazole for
14 days but did not respond well to treatment. In this case the patient was
not given corticosteroids. In this case, an excisional craniotomy was also
performed on the 53rd day of treatment, obtained 50 cc of pus.
The mortality rate of patients with brain abscess is 10-37%
especially in patients who show a rapid course of disease. Factors causing
poor outcome were patient age, level of consciousness, number of
abscesses formed, microorganisms obtained from pus culture. In patients
with neonatal abscess, the presence of signs of meningitis is critical to the
prognosis. Atiq et al reported that good prognostic factors in neonatal
55
brain abscess are clear cerebrospinal fluid, normal ventricular size on CT
scan, absence of seizures and early abscess aspiration. Factors that have
a better prognosis are good general condition, no loss of consciousness,
symptoms for more than 2 weeks and capsule abscess. In these patients,
poor prognostic factors are poor nutritional status, the presence of other
diseases such as pulmonary tuberculosis. Good prognostic factors are
age 15 years, no loss of consciousness, seizures, meningitis, abscess has
formed capsule on CT scan of the head, no history of long-term steroid
administration or decreased immunity due to HIV disease or malignancy. 8
Hydrocephalus is an active accumulation of cerebrospinal fluid
that causes dilatation of the ventricular system of the brain. This disorder
principally occurs as a result of an imbalance between the production,
obstruction and absorption of CSF. Thus, hydrocephalus is caused by
excess cerebrospinal fluid production or blockage of cerebrospinal fluid or
interference with cerebrospinal fluid absorption. 9
Figurer 4 Circulation of Liquor Serebrospinalis (CSS)
Non-communicating hydrocephalus/obstructive hydrocephalus is
a neurosurgical problem in pediatrics that is more common and usually
arises immediately after birth, obstructive hydrocephalus is usually caused
56
by a congenital abnormality, ie the abnormality is detected at birth or
prenatally, in addition to a brain abnormality that causes disturbances in
the brain. CSF drainage. Congenital hydrocephalus is often a part of a
series of malformations, such as in Sylvii aquaductal stenosis, Dandy-
Walker syndrome, Arnold-Chiari malformation types 1 and 2, Galeni
venous aneurysm. due to supratentorial tumors, intraventricular
hematomas, tumors of the ventricles, cerebral abscesses, granulomas and
arachnoid cysts. Communicating hydrocephalus in which the flow of fluid
from the ventricular system to the subarachnoid space is not blocked but
occurs because there is more CSF production than reabsorption.
Excessive production of CSF was found in choroid plexus papilloma. 11 In
this case, obstructive hydrocephalus was found due to a cerebral abscess.
57
Figure 5. Pathogenesis Hidrosefalus
High intracranial pressure can cause vomiting, irritability, lethargy,
sleep a lot and eat very little. There is often a "Setting Sun Appearance /
Sign", which is the retraction of the eyelids and the sclera protruding
because of the forward compression of the contents of the orbital space,
as well as disturbances in the movement of the eyeball upwards, so that
the eyeball looks like a sunset. The scalp appears thin and there is dilation
of the subcutaneous veins. On percussion of the child's head there will be
a "cracked pot" sound, which is like the sound of cracked glass. In
addition, other symptoms such as impaired level of consciousness,
vomiting, mental retardation, failure to grow optimally were also found. In
this type of patient there is usually no papilledema, but in the late stages
the optic disc appears pale and blurred vision. 11 In this case, the patient
58
complained of headache, vomiting, irritability, lethargy, slept a lot and ate
very little. This patient did not undergo a fundoscopic examination
because the patient refused a fundoscopic examination.
In obstructive hydrocephalus CT scan often shows widening of
the lateral and third ventricles. 11 In this case, CT scan of the head revealed
dilatation of the left posterior horn of the lateral ventricle and third
ventricle.
.Figure 6. Clinical Finding Hidrosefalus
The drugs that are often used for this therapy are acetazolamide
and furosemide. Acetazolamide is given orally 2-3 x 125 mg/day. This
dose can be increased to a maximum of 1,200 mg/day. Furosemide is
given orally 1-2 mg/kg BW 1x/day or IV injection 1mg/kg BW/day. If there
is no change after one week the patient is planned for VP-SHunt surgery.
The prognosis of hydrocephalus depends on the cause, magnitude of
59
symptoms, accuracy of diagnosis and treatment. The success of the
operation and the prognosis of hydrocephalus is determined by the
presence or absence of accompanying anomalies, which have a better
prognosis than hydrocephalus along with other malformations. 11
In this case, the patient was treated with Acetazolamide 125
mg/12 hours/oral for 7 days and Furosemide 40 mg/24 hours/oral for 7
days and there were no other accompanying malformations, where the
occurrence of obstructive hydrocephalus was caused by ventricular
compression due to a cerebral abscess so that after surgery Craniectomy
+ abscess drainage will remove the obstruction and no VP shunt is
required.
Tuberculosis (TB) is a disease that often causes morbidity and
mortality in children. In Indonesia, TB cases in children in 2015 amounted
to 7.51%. Based on the 2007 Basic Health Research (Riskesdas) report,
the prevalence of TB by age group was 0.47%, at the age of 1-4 years at
0.76% and between 5-15 years at 0.53%. . In this case, the patient is a 15
year old boy. It is estimated that the number of TB cases in children every
5 years is 5-6% of the total TB cases.12
TB disease is caused by Mycobacterium tuberculosis. A person
can become infected with TB from droplets containing the TB bacteria. 12
60
Figure 7 Pathogenesis TB
Post-primary pulmonary tuberculosis occurs after a specific
immune response that can occur in 2 ways, namely through inhalation of
new bacteria or primary pulmonary TB reinfection. This post-primary
pulmonary tuberculosis begins in the upper region of the lung (apical-
posterior lobe superior or inferior). The invasion is into the lung
parenchyma, not the hilar nodes of the lung. 4 In this case, the patient had
post-primary tuberculosis as a result of reinfection from previously
dormant bacteria or from infection with new bacteria.
61
Figure 8 Plot diagnose TB in children
Cough starts from a dry cough (non-productive) then after the
onset of inflammation becomes productive (producing sputum). The
advanced condition is in the form of coughing up blood because there are
broken blood vessels. Coughing up blood in TB mostly occurs in cavities,
but can also occur in bronchial wall ulcers. Shortness of breath will usually
be found in advanced disease, the infiltrates already cover half the lungs.
Chest pain is rather rare. Chest pain can occur when the inflammatory
infiltrate has reached the pleura, causing pleurisy. There is friction of the
two pleura when the patient inhales. Systemic symptoms arise due to the
62
reactivation of macrophages that release cytokines, causing fever,
anorexia and weight loss.4
The patient in this case report was admitted to the hospital with
complaints of shortness of breath since 2 weeks ago, worsening since 3
days before hospital admission. He had a cough with phlegm since 1
month before he was admitted to the hospital. There is a fever
experienced since 1 month ago, not continuously. No seizures. No
vomiting. Children are lazy to eat and drink. The patient has also lost 5
kilograms of weight in the last 2 months. This patient had a history of
frequent fever since the last 2 weeks and cough since the last 3 weeks.
There is a history of contact with patients with pulmonary tuberculosis. The
history of close contact referred to in this case is if the patient lives at
home with a TB patient, or if the patient has close contacts at school,
caregivers, playgrounds and so on. The existence of this close contact will
facilitate exposure to the patient. This exposure is also influenced by the
level of infectiousness, the intensity of coughing as the source of
transmission, and the length of time the exposure occurs. 5 In this case, the
patient had a history of contact with people suffering from TB disease.
The first examination of the patient's general condition revealed a
fever (subfebrile), very thin body and decreased weight. On physical
examination of the patient, nothing is often found, especially in early
cases. Likewise, if the primary focus is located in the interior of the lung, it
will be difficult to find abnormalities on physical examination, because the
conduction of vibration/sound more than 4 cm into the lung is difficult to
63
assess by palpation, percussion, and auscultation. In history and physical
examination, pulmonary TB is difficult to distinguish from ordinary
pneumonia. There will also be additional breath sounds in the form of wet,
rough and loud crackles.4
In this case, from the physical examination, the general condition
of the child appeared to be seriously ill, malnourished (mild-moderate
malnutrition, conscious GCS 15 (E4M6V5). From the examination of vital
signs, it was found that there was tachypnea, which was 36 times/minute
with 95% oxygen saturation without oxygen). and 99% (via nasal cannula)
and a temperature of 36.8 °C. On physical examination, there was a
subcostal retraction. In the lungs, vesicular breath sounds were found,
additional sounds were crackles in both lung fields, and there was no
wheezing. In the extremities, physiological reflexes were found to be
normal, pathological reflexes were not found. BCG scars appear on the
skin. The generalist status in other regions was within normal limits.
Examination of neurological status within normal limits.
The tuberculin test is done to determine whether a person is
infected with Mycobacterium tuberculosis. This test relies on the cellular
immune response to Mycobacterium tuberculosis antigens. This assay
uses a purified protein derivative fluid containing dozens of antigens, some
of which are also found in many species of non-tuberculosis mycobacteria
and the Bacillus Calmette-Guérin (BCG) vaccine, which has a fairly high
sensitivity and specificity.4
64
This assay has lower sensitivity in individuals with deficient
cellular immunity and also in malnourished children. A negative test result
cannot rule out TB in children. A negative tuberculin test can be found in
three conditions, namely no TB infection, in the incubation period of TB
infection, or anergy. Anergy is a condition in which the immune system is
suppressed by various conditions, such as poor nutrition, which causes no
reaction to tuberculin even though it is already infected with TB. In children
who have been infected with TB, the tuberculin skin test is negative in
50% of cases and a normal chest X-ray is found in 20-50% of cases. 4 In
this case report, the patient was anergic/poor nutrition so that the
tuberculin test result was negative (induration 0 mm).
Direct smear examination, TB PA picture and/or culture are the
gold standard examination. A definite diagnosis of tuberculosis in children
is established by finding M. tuberculosis as the causative bacteria. For
early diagnosis, sputum examination or gastric lavage is less sensitive
than the bacteriological and histological examination of liver or bone
marrow biopsy. In children, there are limitations in the examination of AFB
sputum because generally children have not been able to expectorate
sputum and have insufficient sputum production. In this case, it is
recommended that one day before the sputum examination, the patient is
advised to drink more than 2 liters of water and is taught to perform the
cough reflex. Can also give additional expectorant mucolytic drugs or by
inhalation of hypertonic saline solution for 10-20 minutes. Another attempt
to obtain sputum in children was carried out using the gastric rinse
65
method, however the results of AFB (+) remained low, ranging from 20-
40%.4 In this case report, the patient is 15 years old but has not been able
to spontaneously expel phlegm so a gastric lavage examination was
performed with the results of sputum smears 1 and 2 negative and sputum
smear 3 positive.
Cerebrospinal fluid examination and culture are very important for
the diagnosis of TB meningitis. Cerebrospinal fluid analysis showed a
leukocyte count of 10-500 cells/mm3 (at the beginning of the disease PMN
predominance, but generally dominated by lymphocytes, glucose levels
<40 mg/dl but rarely <20 mg/dl, cerebrospinal fluid protein levels increased
(400-5000 mg/dl) AFB smear from cerebrospinal fluid is positive in 30% of
cases and culture is positive in 50-70% of cases. 4 In this patient, no
lumbar puncture was performed because the patient was not suspected of
having TB meningitis.
Chest X-ray is one of the supporting diagnostics for tuberculosis
(TB). Lesions on chest X-ray such as infiltrates, fibrosis, calcifications,
cavities, pleural effusions or combinations of lesions are often found in TB
disease. The sensitivity and specificity of chest X-ray in diagnosing
Tuberculosis are 86% and 83% if the three patterns of abnormalities
above are found. The classic picture of post-primary pulmonary TB which
is located in the apex and upper lobe is due to the higher oxygen pressure
in the lung apex so that bacteria develop better. 13
66
Figure 9 Lung TB Paru in Chest X-RAy
In this case, the patient had a chest radiograph in the form of
multiple left pulmonary calcifications because an inhomogeneous
consolidation was found with an air bronchogram sign in the middle field of
the right lung. Thorax MSCT showed homogeneous consolidation with air
bronchoram sign in it in the anterior segment and superior lobe of the right
lung, and multiple calcifications of the left lung and inferior lobe of the right
lung.
In children with TB infection, the first 5 years after infection
(especially the first 1 year), complications are usually frequent. According
to Wallgren, there are 3 kinds of spread of pulmonary TB in children,
namely the spread of endobronchial TB, lymphohematogenous, and
chronic pulmonary TB. Endobronchial tuberculosis (segmental lesions
arising from enlargement of regional glands) may occur over a longer
period of time (3-9 months). As many as 0.5-3% of lymphohematogenous
spread will be miliary TB or tuberculous meningitis, this usually occurs 3-6
67
months after primary infection. The occurrence of chronic pulmonary TB
varies greatly, depending on the age of the primary infection. Chronic
pulmonary TB usually occurs due to reactivation of bacteria in lesions that
do not undergo complete resolution. This reactivation is rare in children,
but is common in adolescents and young adults. 4 In this patient, the
diagnosis of post-primary tuberculosis results from reinfection from a
previously dormant bacterium or from infection with a new bacterium in a
boy aged 15 years and 5 months.
Diagnosis of TB in children is quite difficult so that misdiagnosis
often occurs, both overdiagnosis and underdiagnosis. In general, to
diagnose TB can be based on the patient's clinical, typical radiological
picture, and a positive tuberculin test. IDAI has made the National
Guidelines for Childhood Tuberculosis using a scoring system, where the
doctor takes a history, physical examination and supporting examinations
and then is weighted using a scoring system. The diagnosis of TB in
children is generally obtained by a history of contact, especially with
active/new adult TB patients, typical clinical signs and symptoms of TB, a
positive tuberculin test, and a suggestive picture on a chest x-ray, such as
the classic picture of post-primary pulmonary TB which is located in the
apex and upper lobe caused by tuberculosis. because the oxygen
pressure in the lung apex is higher so bacteria thrive better. Children
generally have a lower number of germs (pausibacillary) so a definite
diagnosis is difficult to find. Therefore, the diagnosis of TB in children can
be based on clinical if the TB score is 6, and anti-tuberculosis drug therapy
68
(OAT) can be started. If the score is < 6 but clinically there is a strong
suspicion of TB, it is necessary to carry out other diagnostic tests as
indicated, such as gastric lavage, anatomic pathology, lumbar puncture,
pleural puncture, bone and joint photos, fundoscopy, CT scan, and
others.5
Based on the above case, the patient is known to have a TB
score of 7 points. This score was obtained from a history of contact with
TB patients with unknown results of AFB (2 points), poor nutritional status
(2 points), having a history of fever for 2 weeks (1 point), having a history
of coughing for 3 weeks (1 point), and have a chest x-ray examination with
a picture of TB (1 point).
Table 1 Scoring TB based on IDAI
Management of TB in children includes the provision of
medication, nutritional management and treatment of co-morbidities. It is
69
very important to trace the source of TB infection/transmission in children,
and if the source of TB infection is found, they must also get TB treatment.
The provision of medicine is inseparable from health education to the
community or to the patient's parents regarding the importance of taking
drugs regularly for a long period of time, monitoring the schedule for drug
administration, the belief that the drugs taken will improve the patient's
condition.4
In most cases of pediatric TB, 6 months of treatment is adequate.
After 6 months of drug administration, a clinical evaluation and supporting
examination will be carried out. Clinical evaluation of pediatric TB is the
best parameter to assess treatment success.4
This patient was diagnosed with pulmonary TB based on clinical
TB scoring with a score of 7. The medical management of bacteriologically
confirmed pulmonary TB was the administration of 4 types of OAT for the
first 2 months (56 days), followed by isoniazid and rifampin for 4 months
(16 weeks). The patient has received treatment for TB in the intensive
phase of the 1st month with 4 regimens of anti-tuberculosis drugs, namely
rifampin, isoniazid and pyrazinamide.
Table 2 Diagnostic categoric and Regiment of drugs
70
Table 3 Dose of drug TB in children
Table 4 Dose of drug TB in children depend on Body weight9
Table 5 Dose of adult drug TB in children depend on Body weight
In this case, the patient received FDC (fixed drugs combination)
adult OAT considering the child's weight was above 30 kilograms (patient
body weight = 32 kg). According to the guidelines in Indonesia, adult OAT
71
contains 4 different drug regimens, namely rifampicin, isoniazid,
pyrazinamide and ethambutol.14
Monitoring the results of TB treatment in children is the initial
stage of control child TB patients every week, to see compliance,
tolerance and the possibility of drug side effects and the follow-up stage of
control patients every month. After being given OAT for 2 months, the
patient's response to treatment should be evaluated. The response to
treatment is said to be good if the clinical symptoms present at the
beginning of the diagnosis are reduced, such as increased appetite,
weight gain, fever disappears, and reduced cough. If the response to
treatment is good, then OAT is continued for up to 6 months. Meanwhile, if
the response to treatment is poor or not good, TB treatment will continue
but the patient must be referred to a more complete facility. The
Tuberculin test is only used for diagnosis, not to assess treatment
outcomes. After administration of the drug for 6 months, OAT can be
discontinued by conducting a clinical evaluation and a chest X-ray
examination. In pediatric TB patients who at the beginning of treatment the
sputum smear test results were positive, treatment monitoring was carried
out by re-examining the sputum in accordance with the patient's treatment
monitoring.14
Management of TB Patients in Children with Irregular Medication
is Non-adherence to taking OAT in TB patients is the cause of treatment
failure. If the child does not take medication for >2 weeks in the intensive
stage or >2 months in the advanced stage and shows symptoms of TB,
72
give treatment again starting from the beginning. If the child does not take
medication for < 2 weeks in the intensive stage or < 2 months in the
advanced stage and shows symptoms of TB, continue the remainder of
the treatment until completion. Non-adherence to taking OAT in TB
patients will increase the risk of TB-drug ressistance. 4
The diagnosis of community-acquired pneumonia was based on
anamnesis and found shortness of breath since 2 weeks ago, worsening
since 3 days before admission to the hospital. He had a cough with
phlegm since 1 month before he was admitted to the hospital. There is a
fever experienced since 1 month ago, not continuously. No seizures. No
vomiting. Children are lazy to eat and drink. On physical examination,
there were subcostal retractions, vesicular breath sounds, additional
sounds of loud crackles in both lung fields. On investigation, a chest
radiograph of pneumonia dextra was found. The therapy that has been
given is Ceftazidime and Amikacin antibiotics for 14 days. 15
Malnutrition can be caused by a lack of food intake as well as
disturbances in absorption, digestion and the increased need for nutrients
in the body due to infection.16 In this patient, nutritional intake is very
lacking because the patient is lazy to eat and drink, exacerbated by the
infection process so that it can lead to severe malnutrition.
PEM is divided into several levels, namely mild, moderate,
severe, based on anthropometric results and clinical conditions. Severe
acute malnutrition is a condition where the child looks very thin, where the
BW/PB is below <3 SD (WHO) or BW/TB <70% (CDC), there is edema,
73
and in children 5-59 months the size of the upper arm circumference is
<11.5 mm. Severe PEM is divided into three types based on the clinical
picture that occurs, namely the Kwashiorkor type, Marasmus type and
Marasmic-Kwashiorkor type.17 In this case, the patient was diagnosed with
marasmus-type malnutrition based on anamnesis, physical examination
and anthropometrics. The patient is said to be malnourished with
marasmus type because the child's condition looks very thin, there are
ribs, there is wasting, on anthropometric examination using the CDC
curve, the weight/TB is 74%.
According to theory, malnutrition is one of the risk factors for TB
infection in children and there is an indirect relationship between
malnutrition and TB infection in children. If the child is in a state of
malnutrition, then this status will affect the child's immune system,
especially in the process of forming antibodies and lymphocytes. This
formation requires protein and carbohydrates as raw materials, so that in
children with poor nutrition, antibody and lymphocyte production is
inhibited which causes the immune system to become more susceptible to
infection, including TB infection. Malnutrition is known to exert a
deleterious effect on the host immune response to mycobacterial infection
by impairing various steps of cell-mediated immunity and affecting T
lymphocyte function and cytokine production. Like a two-way arrow,
malnutrition can increase the risk of developing tuberculosis and
malnourished tuberculosis patients have a slower recovery period and a
higher mortality rate than patients with normal nutritional status. 4
74
In general, there are 10 steps for managing malnutrition, namely
first, preventing and treating hypoglycemia and in this patient being given
formula milk to prevent hypoglycemia, second preventing and treating
hypothermia and in this patient using clothing and blankets to prevent
hypothermia, third preventing and overcoming dehydration. and this
patient was given formula milk and intravenous fluids to prevent
dehydration, the fourth was to treat electrolyte disturbances and in this
patient was given Kaen3B intravenous fluids to treat electrolyte
disturbances, the fifth was to treat infection and in this patient was given
antibiotics, the sixth corrected micronutrient deficiency and in this patient
this patient was given vitamin B complex, vitamin C and folic acid, the
seventh gave stabilization and transition food and this patient was only 3
months old so he had not received food only formula milk, the eighth
provided catch-up food, the ninth was sensory stimulation and emotional
support and Some of these patients have been given education to parents
to always provide stimulation and affection for patients, the tenth is
preparation for follow-up at home, namely routine education on
evaluation/monitoring every month to health facilities. 17
Dietary management in malnutrition is divided into 4 phases,
namely stabilization, transition, rehabilitation and follow-up phases. In the
stabilization phase, an increase in the amount of formula is given gradually
with the aim of providing initial food (F75 milk) so that the child is in a
stable condition. In the transition phase, when the child begins to stabilize,
75
F100 is given. In the rehabilitation phase, aiming to catch up the child's
growth is given Formula 100 or Formula 135. 17
In this case, a patient with a diagnosis of Nutritional Marasmus,
in the stabilization phase, a 15 year old patient was given F75 milk 12 x
150 ml. Patients are also given parenteral nutrition (NP) when the patient
experiences shortness of breath while being treated at the infection center
and when the patient is vomiting or intake is not guaranteed. NP is the
provision of nutrition containing carbohydrates, proteins, fats, vitamins and
minerals through an intact vein. The goal is to provide the nutrients
needed for children to grow and develop like other children who receive
enteral nutrition support.18
Parenteral nutrition (NP) is an alternative nutritional support
that has been proven to support child growth and development during
illness. NP is indicated for sick children who cannot or cannot consume
food orally/enterally. The steps in the management of NP include
determining nutritional status (clinical, anthropometric), calculating
nutritional needs (energy, fluids and nutrients), selecting and calculating
fluids to be used and how to administer them, determining access to NP
(central or peripheral), implementing administration and monitoring of
complications. NP contains carbohydrates, fats, proteins, minerals and
electrolytes, such as calcium (Ca), phosphorus (P), sodium (Na),
potassium (K), chloride (Cl), acetate and magnesium (Mg). 18
In this case, the patient has been declared to be improving
because there has been clinical improvement, no fever, no vomiting, no
76
diarrhea, no edema, and a good appetite, the food/milk given can be
spent, there is a weight gain of more than 50 grams/kgBW /week for 2
consecutive weeks.17
Coronavirus disease 2019 (COVID-19) is a respiratory tract
infection caused by severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) which is a virus containing a single-stranded RNA genome.
This virus has a high mutation rate, the disease is reported to have a
mortality rate of 2-3%. COVID-19 can be suspected if you have respiratory
symptoms, such as fever >38⁰C, cough, runny nose, sore throat
accompanied by a history of traveling to areas with local transmission or a
history of contact with suspected cases or confirmed cases of COVID-19.
The pathophysiology of COVID-19 begins with the interaction of viral spike
proteins with human cells. After entering the cell, genome encoding occurs
and facilitates the expression of genes that aid in the adaptation of severe
acute respiratory syndrome coronavirus 2 in the host. Recombination,
gene exchange, gene insertion, or deletion, will cause changes in the
genome that lead to later outbreaks. Confirmation of the diagnosis of
COVID-19 is by history taking and assessing the patient's contact history.
Reverse-transcriptase polymerase chain reaction (RT-PCR) examination
of nasopharyngeal swab specimens is the gold standard for COVID-19
diagnosis.19
Symptoms of COVID-19 generally appear after an incubation
period of 2–14 days. Fever, weakness, and dry cough are the most
common symptoms of COVID-19. In addition, also experienced sore
77
throat, myalgia, dyspnea, and coughing up phlegm. Gastrointestinal
symptoms such as nausea, vomiting and diarrhea may also occur in
COVID-19 patients. However, it may be asymptomatic or asymptomatic.
Some cases show severe symptoms such as pneumonia and acute
respiratory distress syndrome. The management of COVID-19 is given
anti-viral therapy such as Oseltamivir, vitamins such as vitamin B, vitamin
C, zinc and antibiotics such as azithromycin and supportive therapy, such
as antipyretics, antitussives, and expectorants can be used to relieve the
patient's symptoms.19
In this case, the diagnosis of Covid 19 was confirmed based on the
history, it was found that there was shortness of attention since 2 weeks
before entering the hospital with cough and fever. On physical
examination, there were subcostal retractions, vesicular breath sounds,
additional sounds of loud crackles in both lung fields. On investigation, a
chest radiograph of pneumonia dextra was found. Positive RT-PCR
oropharyngeal swab results. Indicates that the patient has been infected
with the Covid 19 virus. The patient is receiving Oseltamivir therapy
60mg/12hours/oral. The patient was declared cured after being clinical,
the patient had no complaints of shortness of breath, no cough, no fever.
From the physical examination, there were no retractions, no vesicular
breath sounds, additional rhonchi and wheezing. On investigation, the
oropharyngeal RT-PCR swab results were negative on 2 examinations at
the infection center and the patient was transferred to the ward care in the
isolation room.
78
In this case, the patient was diagnosed with anemia of chronic disease
based on the anamnesis, no paleness, no jaundice and lymphadenopathy
on physical examination, no hepatosplenomegaly, no spontaneous
bleeding manifestations, on laboratory examination, normochromic
normocytic anemia with ferritin 314. Peripheral blood analysis Normocytic
anemia normochromic with leukocytosis suspected infectious cause. 20
The patient underwent a craniotomy to drain a cerebral abscess
during the 53rd day of treatment at Wahidin Sudirohusodo Hospital with an
indication of a cerebral abscess on August 24, 2020. On the 54th day of
treatment, the patient was admitted to the PICU. The patient transferred
treatment from the PICU to neurosurgical treatment on the 55th day of
treatment. The patient was allowed to be outpatient on the 57th day of
treatment, after clinical, the patient had no complaints, vital signs were
within normal limits.
SUMMARY
A case of cerebral abscess with non-communicating
hydrocephalus has been reported in a 15-year-old boy with confirmed
COVID-19, pulmonary tuberculosis and marasmus-type malnutrition. The
diagnosis is made based on history, physical examination, tuberculin test,
and chest x-ray examination. The management of this patient was with
antibiotics, cranicetomy surgery for abscess drainage, combined OAT with
4 drug regimens, oseltamivir and management of malnutrition. Prognosis
quo ad vitam dubia and quo ad sanationam dubia.
79
BIBLIOGRAPHY
1. Saharso D. Brain Abscess. Textbook of Children's Neurology, second
edition. Indonesian Pediatrician Association, Jakarta.2000.
2. Murtaza M. Iftikhar M, Latif MI, Munaidy RK. Brain Abscess:
pathogenesis, diagnosis and management. International Journal of
Research in Applied. 2014;2(5);299-308
3. Brook I. Microbiology and management of brain abscess in children. J
Pediatric Neurology. 2004:2(3);125-130
4. Rahajoe NN, Setyanto DB. Tuberculosis in children. Textbook of
Children's Respirology, first edition. Indonesian Pediatrician Association,
Jakarta. 2018.
5. National Guidelines for Childhood Tuberculosis, second edition, UKK
Respirology. Indonesian Pediatrician Association. Jakarta. 2008
6. J. Susanto et al, Textbook of Child Nutrition and Metabolic Disease.
Severe acute malnutrition and community-based nutritional therapy. IDAI
publishing body. Jakarta: 2011. Pages 128-64
7. Dattatraya M, Sukhdeep J, Goel A. Brain abscess: An overview.
International Journal of Surgery. 2011;9:36–144
8. Atiq M, Ahmed US, Allana SS etc. Brain Abscess in Children. Indian
Journal of Pediatrics, June 2006 : Vol 73; 401-403
10. Kelvin Patel MD, David B Clifford, Bacterial brain abscess. Department
of Neurology, Washington University, USA, 2014.
11. Satyanegara. Hydrocephalus. Neurosurgery, fifth edition. Gramedia
Pustaka Utama. Jakarta. 2014
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12. Ministry of Health of the Republic of Indonesia. Technical guidelines
for the management and management of pediatric TB. Asik, Hastuti EB,
Evarini Y, editors. Jakarta: Bakti Husada; 2016.
13. Icksan. Aiza G, Luhur and Reny. Radiology Thorax Pulmonary
Tuberculosis. Jakarta. 2008
14. Amin Z, Bahar A, Pulmonary Tuberculosis. Internal medicine textbook.
Faculty of Medicine, University of Indonesia. 2007
15. Said M. Community Acquired Pneumonia in children. Textbook of
Children's Respirology, first edition. Indonesian Pediatrician Association,
Jakarta. 2018.
16. Ministry of Health of the Republic of Indonesia. Guidelines for Child
Malnutrition Services. Jakarta: Ministry of Health of the Republic of
Indonesia; 2011.
17. Ministry of Health of the Republic of Indonesia. Technical Guidelines
for the Management of Children with Malnutrition: Book I. Jakarta: Ministry
of Health of the Republic of Indonesia; 2011.
18. Prawirahartono, EP. Parenteral Nutrition. Textbook of Pediatric
Nutrition and Metabolic Disease. Volume I, 2011
19. Ministry of Health of the Republic of Indonesia. Guidelines for the
Prevention and Control of Coronavirus Disease (Covid-19). Jakarta:
Ministry of Health of the Republic of Indonesia; July 2020.
20. Endang W, Yetti MN, Bambang S, Textbook of Pediatric Oncology
Hematology. Anemia of Chronic Disease. Jakarta: IDAI publishing agency.
2018.
81
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CASE REPORT

CEREBRAL ABSCESS WITH OBSTRUCTIVE HYDROCEPHALUS IN A

infants. A brain abscess is a focal intracerebral infection, which begins as

a localized area of cerebritis and develops into a collection of pus

surrounded by a well-vascularized capsule. It accounts for 2-5% of the

intracranial mass, mostly located in the cerebrum and rarely in the

cerebellum. In the United States, each year it is estimated that about

1,500-2,500 patients suffer from brain abscesses. Brain abscesses are

more common in men than women with a ratio of 3:1. 1,2

Brain abscess in children occurs after infection in adjacent or

adjacent structures such as otitis, sinusitis, mastoiditis or as a result of

hematogenous spread from a site, especially in children with congenital

heart disease or after meningitis. Staphylococcus aureus, Proteus

mirabilis, pseudomonas aeroginosa and Serratia marcescens are the most

common organisms that cause brain abscess. Brain abscess can be a

of sepsis or meningitis. 1,2,3

The formation of a cerebral abscess is divided into 4 phases

Tuberculosis (TB) is an infectious disease caused by the

bacterium Mycobacterium tuberculosis. Tuberculosis (TB) is one of the

world's population has been infected with Mycobacterium tuberculosis.

and China. In 2015 the proportion of TB cases in children in Indonesia

One of the problems of TB in children in Indonesia is diagnosis.

recommended as a diagnostic approach. The problem is, not all health

care facilities (fasyankes) in Indonesia have tuberculin test facilities and

chest x-ray examinations, which are 2 parameters in the scoring system.

often underdiagnoses of TB in children. 5

development of children. Malnutrition is still a major health problem in

under-five deaths. Generally, people with malnutrition are children from

the age of infants, toddlers or school-age children. Nutritional problems

that often occur in children in Indonesia are Protein Energy Malnutrition

(kwashiorkor, marasmus, marasmik-kwashiorkor). 6

Marasmus is one of the three forms of malnutrition or Protein

the mixed form of marasmus-kwashiorkor. Marasmus is a condition

caused by a deficiency of calories and energy which can be caused by

This paper reports a case of cerebral abscess with non-

communicating hydrocephalus with confirmed Covid 19, pulmonary

tuberculosis and nutritional marasmus. The purpose of this case report is

to monitor the course of the disease and the outcome of disease

interventions, as well as to observe the response to treatment.

II. FAMILY DATA

Children (First of 2 sibling) No Miscarriage

NO. SEX DATE OF BIRTH HEALTHY.SICK BECAUSE

III. Anamnesa (Autoanamnesis and Aloanamnesis Mother of patient)

Hospital were referred from the hospital. Lamadukelleng with a suspected

differential lung tumor with a diagnosis of lobar pneumonia. Patients with

worsened since 3 days before admission to the hospital. He had a cough

is a fever experienced since 1 month ago, not continuously. No seizures.

No vomiting. Children are lazy to eat and drink. Regular bowel

movements, yellow color. Urination of yellow color smoothly.

3.2. History of past illness

was declared cured by a pediatrician in 2013.

- History of fever fluctuating for more than 2 weeks.

- History of frequent night sweats since the last 1 week.

- History of cough more than 3 weeks

- History of weight loss of 5 kilograms in the last 2 months.

- There is no history of contact with patients under Covid 19 surveillance

- A history of being treated at the Lamadukelleng Hospital for 1 day with a

suspected differential lung tumor diagnosed with lobar pneumonia, receiving

therapy with ampicillin, gentamicin, paracetamol.

3.3. History of family health

lived at home. No history of allergies in parents

3.4. History of patient social