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INDONESIA
Indonesian Journal of Case Reports
Published by PT. Heca Sentra Analitika
ISSN : -     EISSN : 30253578     DOI : https://doi.org/10.60084/ijcr
Core Subject : Health, Science,
Health Professions Medicine & Pharmacology Neuroscience Public Health
The journal aims to present challenging and stimulating cases in an educational format, enabling readers to engage as if they are actively collaborating with caring clinician scientists in patient management. Topics of this journal includes, but not limited to Exploration of new diseases and their manifestations, Investigation of new presentations or variations of known diseases, Identification of new associations between diseases or symptoms, Examination of new diagnostic techniques for skin, hair, and nail conditions, Evaluation of new treatment methods, including adverse events and procedural techniques, Reporting of unreported or unusual side effects or adverse interactions involving medications, Analysis of unexpected or unusual disease presentations, Discussion of new associations or variations in disease processes, Presentation, diagnosis, and management of new and emerging diseases, Reporting of unexpected events in patient observation or treatment, Discovery of findings that contribute to the understanding of disease pathogenesis or adverse effects
Arjuna Subject : Kedokteran - Kedokteran (Lain-Lain)
Articles 26 Documents
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Liver Involvement During Flare-ups in Pediatric SLE: Lupus Hepatitis vs. Other Causes Utama, Adelia Anggraini; Kisworini, Priyanti; Raihan, Raihan
Indonesian Journal of Case Reports Vol. 1 No. 1 (2023): August 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i1.48

Abstract

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by production of autoantibodies that can affect multiorgan of the body, including the liver. Liver dysfunction is not part of the SLE classification criteria and rarely found compared to other organs. In patient with SLE with liver involvement signed by abnormal liver enzyme should consider whether it is SLE-associated hepatitis, known as lupus hepatitis, or cause by other entities such as drug-induced hepatitis, or a primary liver disease such as viral hepatitis and autoimmune hepatitis condition that coexisting with SLE. We are reporting a 13-year-old boy that has been diagnosed with SLE who had flare since he discontinued his medication by himself. He presented with jaundice, alopecia, oral ulcers, pale and malaise. Laboratory examination showed anemia, thrombocytopenia, elevated transaminases and bilirubin level. It is important to differentiate the cause of deranged liver function test in patient with SLE, because other entities may present similar to lupus hepatitis, but they have a different management and prognosis.
An Intriguing Case of Erythroderma Possibly Related to Psoriasis Vulgaris Earlia, Nanda; Umborowati, Menul Ayu; Tasrif, Aqil Yuniawan; Pradistha, Aldilla; Liana, Mahda Rizki; Bulqiah, Mikyal
Indonesian Journal of Case Reports Vol. 1 No. 1 (2023): August 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i1.56

Abstract

Erythroderma or generalized exfoliating dermatitis is an inflammatory disease characterized by erythema and thickened scales. A woman, 34 years old, was consulted with complaints of red spots accompanied by blisters and peeling skin almost all over her body for 4 days. Complaints are accompanied by itching and burning sensations. The patient had experienced complaints like this 5 months ago and had been treated at three different hospitals. Physical examination found in the facial region, thorax, superior and inferior right and left extremities, erythematous patches with diffuse borders, thick scales, erosions, and a generalized distribution. The patient's fingernails were found to have a change in shape (pitting nails). Examination of the ANA profile was negative, IgE atopy did not show an allergic reaction to a specific allergen, and histopathological examination was within normal limits. The patient was diagnosed with erythroderma based on psoriasis vulgaris. Treatment includes injection of methylprednisolone, cetirizine 10 mg tablets, and wound care with wet gauze and topical cream. After giving therapy, the patient's clinical improvement. Erythroderma occurs because of an underlying condition and cannot be prevented by itself. Erythroderma because of an underlying inflammatory skin condition usually resolves with treatment but can recur at any time. Overall, the prognosis for erythroderma depends on the underlying cause and is generally good if the underlying disease can be treated effectively.
Optimal intervention: Flexible Fiberoptic Bronchoscopy’s Role in Chronic Aspiration Foreign Body Removal Zulfikar, Teuku; Akbar, Syarial; Arnanda, Rifian
Indonesian Journal of Case Reports Vol. 1 No. 1 (2023): August 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i1.64

Abstract

Foreign body aspiration in the lower airway is prevalent among children under 5 years old and rare among adults, except in cases of neurodegenerative or neuromuscular conditions. This condition is linked to substantial morbidity, necessitating awareness of potential complications. Flexible bronchoscopy stands as a primary method for foreign body removal. We present a case of a 56-year-old male who aspirated a denture 15 years ago. Recent symptoms encompassed persistent hemoptysis, worsening over two weeks, accompanied by mucopurulent sputum, fever, chest pain, and dyspnea. Physical examination indicated shortness of breath with positive rhonchi. X-ray revealed tubular opacities and atelectasis. Two days post-admission, flexible bronchoscopy exposed moderate mucopurulent secretion in both bronchial trees, with multifocal hyperemic edematous mucosal changes in the right bronchial tree. A denture was successfully extracted from the lower left lobe during the procedure. Treatment included antibiotics, bronchodilators, and mucolytics. Flexible fiberoptic bronchoscopy's adaptability allows local anesthesia usage, reducing costs and risks. The integration of high-definition imaging in flexible bronchoscopes enhances airway visualization and foreign body localization, ensuring precise and safe removal.
Neurological Uniqueness: A Case Study of Hepatitis A-Induced Acute Inflammatory Demyelinating Polyneuropathy Abubakar, Azzaki; Murdia, Murdia; Diana, Diana
Indonesian Journal of Case Reports Vol. 1 No. 1 (2023): August 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i1.68

Abstract

Acute inflammatory Demyelinating Polyneuropathy (AIDP) with hepatitis A (HA) is more likely to affect men, develop at a younger age, and have a better prognosis overall. The progression of the Hepatitis A Virus (HAV)-caused liver inflammation and the neurological difficulties could lead to AIDP in the early stages of the hepatitis signs and symptoms. The World Health Organization (WHO) estimates 1.5 million clinical HAV cases annually. Extrahepatic complications of this disease are rare. The etiology of HA associated AIDP remains unclear, with cross-reactive HA epitopes between the peripheral nervous system and other authors have hypothesized that the presence of CSF antibodies reflects direct entry into the central nervous system. Our patient presentations favored AIDP most commonly in HA. A 22-year-old man, with no prior significant medical history, presented to neurology emergency with a 3-day history of acute onset, had been complaining of nausea, general weakness, yellowing of the sclera and history of fever for 5 days. Further investigation revealed marked elevation of liver enzymes in a pattern suggestive of hepatocellular processes. Serum titres of hepatitis B, C, and E were negative, but IgM anti-HAV was positive (enzyme immunoassay). Elevation of Cerebrospinal fluid (CSF) protein and myelitis transversa shown by magnetic resonance imaging were established. The diagnosis as AIDP was taken and treated by symptomatic and neurology treatment. However, the patient regained strength and underwent physiotherapy during two weeks. Approximately 3 months after discharged, the patient's gait had nearly returned to baseline at follow-up and the symptoms slowly improved.
Challenges in Hypermature Senile Cataract with Intracapsular Cataract Extraction for Wide Zonular Dehiscence: A Case Study Imelda, Eva; Jannah, Raudhatul; Jannah, Siti Rain; Adev, Sarra Mutiara; Toshniwal, Navneet Shamsundar
Indonesian Journal of Case Reports Vol. 1 No. 1 (2023): August 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i1.70

Abstract

A cataract is a condition characterized by clouding of the eye's lens. Senile cataracts progress through four stages: incipient, immature, mature, and hypermature. These stages are determined by the degree of lens cloudiness and the extent of lens mass involvement. In the hypermature stage, the entire lens capsule becomes wrinkled, and its contents become either solid and wrinkled or soft and liquid. An 83-year-old female patient presented to the Department of Ophthalmology at RSUD dr. Zainoel Abidin Banda Aceh with a gradual decrease in vision over the past four years. Ophthalmological examination using a slit lamp revealed cloudiness throughout the lens mass, a brownish-white lens color, wrinkling of the anterior capsule, and visible zonular dehiscence at approximately 90 degrees. The patient's left eye pressure measured 23 mmHg. A surgical plan for Intracapsular Cataract Extraction (ICCE) was made. Despite the surgery, the patient's visual function remained poor. Consequently, a second surgery for IOL insertion was scheduled six weeks after the initial procedure. The patient's visual function is anticipated to improve following the second IOL insertion surgery.
From Bright to Brightness: Mastering the Management of Bilateral Congenital Cataracts Imelda, Eva; Nuzhatuddin, Fatimah; Jannah, Siti Rain; Adev, Sarra Mutiara; Adev, Alya Mutiara; Toshniwal, Navneet Shamsundar
Indonesian Journal of Case Reports Vol. 1 No. 2 (2023): December 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i2.97

Abstract

Congenital cataract is the leading cause of vision loss in newborns and children, and it is caused by an opacity of the eye's lens that occurs at birth or within the first few months of life. Congenital cataracts may develop as unilateral or bilateral. Around 50% of cases of it are considered as idiopathic. A 4-month-old boy was brought by his parents to the Department of Pediatric Ophthalmology and Strabismus in RSUD dr. Zainoel Abidin Banda Aceh with a chief complaint of a white spot on the patient’s right eye. The spot had appeared since birth and became more visible when he was 2 months old. The patient's overall condition was good. Both eyes' visual acuity was blink reflex. The ocular pressure in both eyes was normal. An ophthalmologic examination revealed a fully clouded right eye lens and aphakia in the left eye. The patient had undergone cataract surgery on his left eye on September 6th, 2023. He was diagnosed with Congenital Cataract Oculus Dexter (OD) and Aphakia Oculus Sinister (OS) before surgery. The patient underwent right eye cataract surgery with aspiration irrigation (AI), Primary Posterior Capsulotomy (PPC), and Anterior Vitrectomy (AV) without Intraocular Lens (IOL) implantation within the next two weeks.  Following the surgery, the patient's visual function improved to fix and follow the object, the pupils looked round in both eyes, aphakia, and no membrane development. The patient was prescribed glasses for optical rehabilitation.
A Clinical Chronicle: The Use of Ventriculo-Atrial Shunt in Tuberculous Hydrocephalus Treatment Abidin, Zainal; Lahdimawan, Ardik; Hosea, Nathania
Indonesian Journal of Case Reports Vol. 1 No. 2 (2023): December 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i2.104

Abstract

Tuberculous meningitis (TBM) is the predominant bacterial meningitis form in children under 13, with an incidence of 8.6 per 100,000 before age 15. Tuberculous Hydrocephalus (TH), often presenting with hydrocephalus, poses a significant challenge in Indonesia for both children and adults. The commonly used Ventriculo-peritoneal (VP)-shunt procedure for TH, though prevalent, is associated with multiple complications. As an alternative, the Ventriculo-atrial (VA)-shunt procedure has been explored, but reports on its use in TH in Indonesia are lacking. This case report details a 1-year-old girl with TH who initially underwent a VP-shunt procedure, which proved unsuccessful. Subsequently, the VA-shunt procedure was employed, leading to a complete recovery. Our findings contribute valuable insights into the potential effectiveness of the VA-shunt as an alternative intervention for TH, especially in the Indonesian medical landscape.
Comprehensive Treatment Approaches in a Unique Case of Generalized Pustular Psoriasis Earlia, Nanda; Maulida, Mimi; Badiri, Istanul; Pradistha, Aldilla; Bulqiah, Mikyal; Fajrina, Nur
Indonesian Journal of Case Reports Vol. 1 No. 2 (2023): December 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i2.113

Abstract

Psoriasis is an immunological inflammatory disease characterized by skin inflammation and epidermal hyperplasia. One type of psoriasis is Generalized Pustular Psoriasis (GPP), which is usually preceded by other diseases. A 56-year-old woman presented to the Department of Dermatology and Venereology with a recent onset of red spots accompanied by pustules distributed across her body. The initial manifestation of these symptoms occurred approximately one month prior, and the condition has progressively worsened over the past three days. Physical examination of dermatological status showed erythematous plaques with smooth, well-defined scales with irregular, round edges, lenticular size, multiple, discrete, and confluent distribution, generalized distribution in the pedis dextra et sinistra, manus dextra et sinistra, and femoral regions. Skin biopsy examination results showed skin tissue with hyperkeratosis, acanthosis, and parakeratosis, with PMN inflammatory cells (Munro's micro abscess). The conclusion of the skin biopsy is pustular psoriasis. The patient was diagnosed with GPP. Patients were given Methotrexate, calcitriol tablets 0.25 mcg twice a day, cetirizine tablets 10 mg twice a day, and topical cream. After one week of treatment, the patient's lesions improved. Treatment continues, and patients are given education to avoid trigger factors such as stress, excessive activity, extreme temperature changes, and focal infections. The management must consider various influencing factors, including genetic factors, skin barriers, predisposing factors, and trigger factors. Prevention is also important. The patient needs to be educated about the details of the disease, how to prevent a recurrence, and treatment when the disease recurs.
Secondary Syphilis Reinfection with Suspected Asymptomatic Neurosyphilis Mahono, Charles Kurnia; Niode, Nurdjannah Jane
Indonesian Journal of Case Reports Vol. 1 No. 2 (2023): December 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i2.119

Abstract

Syphilis, a sexually transmitted disease caused by Treponema pallidum, poses a significant global health threat, with an annual incidence of around 12 million cases, predominantly affecting individuals aged 15-49. Reinfection occurs in 11 out of 120 patients, underscoring the importance of effective management. If untreated, 4-9% of cases may progress to early neurosyphilis, often presenting asymptomatically. We present the case of a 22-year-old male with reddish-brown patches on the face, palms, and soles, along with erythematous papules on the genital region, following a history of recent promiscuity. Physical examination revealed distinctive manifestations, including nickels and dimes on the face, syphilitic roseola, Biett's collarette on the palmoplantar region, and erythematous papules-plaques on the scrotal and penile areas. The VDRL test indicated a titer of 1:32, TPHA test >1:5120, and a non-reactive HIV rapid test. Initiating treatment with a single intramuscular injection of benzyl benzathine penicillin G (2.4 million IU) resulted in successful symptom resolution, accompanied by a four-fold decrease in VDRL titer to 1:8 by the third month. However, a subsequent increase to 1:32, following sexual intercourse in the sixth month, indicated reinfection and raised suspicions of asymptomatic neurosyphilis. The patient received oral doxycycline (100 mg twice daily) for 30 days. Unfortunately, treatment success could not be determined as the patient was lost to follow-up. This case report highlights that elevated VDRL titers signify reinfection, treatment failure, or neurosyphilis. Asymptomatic reinfection is common due to lead-time bias and partial immunity, especially with multiple episodes of syphilis. Early neurosyphilis may coexist with primary or secondary syphilis and is frequently asymptomatic. Continued efforts in monitoring and treatment adherence are crucial for effective syphilis management on a global scale.
Strategies for Preserving Vision in Secondary Glaucoma Post Congenital Cataract Surgery Imelda, Eva; Gianty, Jauza Aqilla; Adev, Alya Mutiara; Toshniwal, Navneet Shamsundar
Indonesian Journal of Case Reports Vol. 1 No. 2 (2023): December 2023
Publisher : Heca Sentra Analitika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60084/ijcr.v1i2.127

Abstract

Congenital cataract is an eye disorder in the form of impaired lens transparency due to cloudiness that appears at birth or immediately after birth. Post-congenital cataract surgery requires regular monitoring to prevent complications that can reduce visual function. Therefore, this case report aims to describe the incidence of secondary glaucoma in patients with aphakia after congenital cataract surgery with uncontrolled post-operative monitoring regularly. A 4-year-old boy patient was brought by his parents with complaints of reappearance of white spots in the left eye which had become increasingly widespread in the last 2-3 months. Complaints accompanied by a feeling of glare in bright places. The patient's parents said the patient could not focus on seeing objects around him. The patient had a history of congenital cataract surgery in both eyes 2 years ago and did not have routine follow-up after cataract surgery. Congenital cataract is a lens clouding that can occur unilaterally or bilaterally when the child is born or immediately after birth. If monitoring is not carried out routinely, the most common condition that occurs in aphakic after congenital cataract surgery is secondary glaucoma. Regular monitoring after congenital cataract surgery is necessary to achieve successful management and prevent complications.

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