Acta Medica Indonesiana

Unusual Co-existence of Drug-Susceptible Lung Tuberculosis and Drug-Resistant Pleural Tuberculosis: A Rare Case Presentation of Dual Infection

Herikurniawan Herikurniawan — 2025-07-08

Tuberculosis (TB) has become one of the global burdens of disease, with increasing morbidity and mortality every year. Tuberculosis can affect not only the lungs but also the extrapulmonary organs. The prevalence of drug-resistant tuberculosis (DR-TB) is rising and has caused a higher mortality rate than drug-susceptible tuberculosis (DS-TB). This article presents a patient with a rare co-infection of pulmonary DS-TB and pleural DR-TB. Pulmonary and pleural TB (pTB) was diagnosed using the Xpert MTB/RIF assay. The patient was treated with an individualized DR-TB regimen and recovered.

A 28-Year-Old Woman with Impending Thyroid Storm, Hyperbilirubinemia, and Total Atrioventricular Block

K. Heri Nugroho Hario Seno — 2025-07-08

Thyrotoxicosis, a state of excess thyroid hormone, often presents with diverse clinical manifestations, including thyroid storm, a rare but critical condition. Here, we present a case of a 28-year-old woman with thyrotoxicosis, hyperbilirubinemia, and total atrioventricular (AV) block. The patient exhibited jaundice, chest discomfort, and a history of chronic diarrhea, weight loss, tremors, and exertional dyspnea. She was on propylthiouracil and propranolol for two weeks.
Physical examination revealed jaundice, proptosis, a large goiter, and tremors. Laboratory tests on admission indicated elevated liver enzymes, hypokalemia, and markedly elevated thyroid hormones. ECG revealed total AV block. Treatment involved hydrocortisone, thiamazole, discontinuation of propranolol, and gradual correction of electrolyte imbalances.
The patient improved clinically, and propranolol’s discontinuation improved the rhythm disturbance. The Patient was discharged for outpatient Graves’ disease management.
Future assessments may include an electrophysiology study if needed. Total AV block in thyrotoxicosis is rare. This case highlights the complexity of managing thyrotoxicosis with concurrent hepatic and cardiac complications, emphasizing the importance of tailored treatment strategies and close monitoring.

Role of Desmoglein Autoantibody in the Diagnosis of Pemphigus Vulgaris: A Case Report

Diane Lukito Setiawan — 2025-07-08

Pemphigus vulgaris (PV) is a group of autoimmune diseases that cause abnormalities in the form of lesions or blisters on the skin and mucous membranes. It often presents diagnostic challenges due to its varied clinical manifestations. Accurate diagnosis and treatment are essential to reduce mortality in patients with PV. Traditional diagnostic methods, such as histopathology and direct immunofluorescence, may not always provide conclusive results, especially if the patient does not have an intact bulla. Our report emphasizes the role of desmoglein autoantibody testing using enzyme-linked immunosorbent assay to confirm the diagnosis, allowing for prompt and targeted therapeutic interventions.

Wernicke Encephalopathy Associated with Crohn’s Disease

Marco Vidor — 2025-07-08

Poorly controlled Crohn’s disease is associated with several complications, including malabsorption of vitamins and minerals such as vitamin D, vitamin B12, and vitamin B1 (thiamine). Thiamine, among other vitamins, plays a crucial role in Adenosine Triphosphate formation as well as nerve propagation. Thiamine deficiency initially manifests as wet or dry beriberi but may lead to the devastating Wernicke–Korsakoff syndrome. In this report, we present a case of full-blown Wernicke encephalopathy associated with uncontrolled Crohn’s disease.
An 18-year-old young man was admitted with a chief complaint of hematemesis for 2 weeks before admission. He was previously diagnosed with Crohn’s disease in the past year, with constipation as the predominant symptom, and has been taking mesalazine 500 mg twice daily. Esophagogastroduodenoscopy and colonoscopy re-evaluation showed a worsening picture of Crohn’s disease pangastritis. The patient experienced swelling in both legs, the scrotum, and the upper extremities during hospital admission. On day 14 of hospitalization, the patient fell into a state of confusion with visual and auditory hallucinations, ophthalmoplegia, and ataxia. A Brain MRI showed a typical picture of Wernicke encephalopathy. Intravenous thiamine was administered, and the patient regained consciousness. His clinical symptoms improved every day until he was discharged.
Uncontrolled Crohn’s disease may have several complications that clinicians need to be aware of, including thiamine deficiency. Wernicke encephalopathy shows a devastating clinical picture, but with thiamine therapy, it may resolve before further deterioration leads to irreversible Korsakoff syndrome.

Acute Shock Liver in Inferior ST-Segment Elevation Myocardial infarct with Total Atrioventricular block: A Case Report

Mochamad Rizky Hendiperdana — 2025-07-08

Liver dysfunction frequently accompanies heart diseases, especially in hemodynamically unstable acute heart failure or cardiogenic shock. This condition is marked by significant elevation of liver transaminases and brings high morbidity and mortality for > 50 % of cases. Despite the high mortality rate, early recognition with prompt management results in the recovery of liver function. A 53-year-old man presented with late-onset non-reperfused inferior STEMI. The patient presented with persistent chest pain and shortness of breath. The electrocardiogram showed atrioventricular (AV) block grade III and ST-segment elevation evolution in the inferior lead. The patient was diagnosed with a late-onset inferior STEMI with cardiogenic shock and total AV block complication, acute shock liver, lactic acidosis, and acute renal failure. We administered inotropic and chronotropic support drugs as well as post-MI anti-remodelling therapy to treat heart failure (HF) and left ventricular (LV) systolic dysfunction, such as angiotensin-converting enzyme inhibitor and aldosterone antagonist, after systemic perfusion improved. Anti-ischemic therapy, such as antithrombotics, was also administered. Renal and liver function test evaluation after a week of patient discharge showed normalization of these parameters. There is no definite treatment strategy for shock liver. The management strategy is directed at the treatment of underlying causes. Hemodynamic insult is the mainstay therapeutic target. Recovery of liver transaminases was demonstrated after the underlying insult had been eliminated.

Role of Gastric Acid Suppression Therapy in Erosive Esophagitis: From H2 Receptor Antagonists, Proton Pump Inhibitors, to Potassium-Competitive Acid Blockers

Ryan Herardi — 2025-07-08

Erosive esophagitis (EE) is an inflammation of the esophageal mucosa resulting from gastric and duodenal acid reflux, affecting approximately 55% of gastroesophageal reflux disease (GERD) patients in Indonesia. Effective acid suppression is essential for mucosal healing and symptomatic relief. Histamine-2 receptor antagonist (H2RA) was initially used for standard treatment for GERD, including EE, reducing gastric acid secretion by blocking H2 receptors. However, their efficacy is limited by inadequate acid suppression. Proton pump inhibitors (PPIs) became the mainstay therapy due to their stronger and longer-lasting acid suppression. Although PPIs have been proven to be quite effective, they have several limitations, including slow onset and inability to provide sustained acid suppression over a full 24-hour period. In recent years, Potassium-competitive acid blockers (PCAB) have become known as a category of drugs that effectively suppress gastric acid production, through a slightly different mechanism, and have advantages over PPIs, including faster onset and longer time of action. Both PPIs and PCABs can be used as therapy for patients with EE. PCABs are more recommended, especially in patients with severe grades of EE. H2RAs may still be considered in patients who have already received PPI therapy but continue to experience unresolved nocturnal acid symptoms.

Successful Ultrasound-Guided Dry Needling for Treatment of Piriformis Syndrome

Guntur Darmawan — 2025-07-08

Piriformis syndrome is an often overlooked cause of chronic buttock or low back pain, sometimes radiating to the posterior thigh. Despite various treatment options, a definitive standard therapy has not been established. Dry needling has recently gained attention as a non-pharmacological intervention, especially when guided by ultrasound to enhance accuracy and safety.

A 69-year-old woman presented with a 9-month history of fluctuating right gluteal pain, aggravated by prolonged sitting and movements. Physical examination revealed tenderness in the piriformis area and positive provocative tests, with no neurological deficits. After failure of previous pharmacological and physiotherapeutic interventions, the patient underwent ultrasound-guided dry needling of the piriformis muscle. The procedure was performed using an in-plane technique with a 0.3 x 75 mm needle and elicited a twitch response. After two sessions, the patient reported a significant reduction in pain intensity from 7/10 to 2/10.

Ultrasound-guided dry needling offers several benefits, including precise targeting of the piriformis muscle, avoidance of chemical agents, and reduced risk of adverse effects. The analgesic effect is attributed to inactivation of myofascial trigger points and neuromodulation involving reduced levels of substance P and calcitonin gene-related peptide. We conclude that ultrasound-guided dry needling appears to be a safe, effective, and minimally invasive option in the management of piriformis syndrome, particularly when conventional therapies fail.

Risk Factors of Coronary In–Stent Restenosis in Drug-Eluting Stent: A Systematic Review and Meta-Analysis

Hotmauli Siahaan — 2025-07-08

Background: In-stent restenosis (ISR) is an event of coronary atherosclerosis re-budling following the stent implantation in percutaneous coronary intervention. The events of ISR have been significantly reduced since the introduction of drug-eluting stents. However, ISR could still occur, and factors affecting the incident have not yet been discovered. This study aims to evaluate the risk factors of coronary in-stent restenosis in drug-eluting stents. Methods: Studies on the factors and risks of ISR in patients with drug-eluting stents were systematically searched in databases (PubMed, ScienceDirect, Springer, Google Scholar, and ProQuest) on September 20th, 2023. The odds ratio (OR) and mean difference (MD) were analyzed using Review Manager 5.4. Results: Diabetes mellitus (OR 1.73 [95%CI 1.56, 1.91] p < 0.00001) and smoking (OR 1.24 [95%CI 1.13, 1.36] p<0.0001) are the patients' clinical characteristics that are associated with ISR in DES. It is closely related to the contribution of diabetes mellitus in promoting platelet adhesion and smoking in enhancing intimal hyperplasia. As in the angiography characteristics, stent lesion at LAD (OR 1.20 [95%CI 1.07, 1.35] p = 0.002) and stent length (MD 3.61 [95%CI 1.81, 5.42] p < 0.0001) are correlated with the events of ISR. Every millimeter excess of stent length significantly increases the risk of ISR. Therefore, reducing the excess stent length may contribute to the reduced risk of ISR in DES. Conclusion: The identification of risk factors contributing to ISR in DES may help cardiologists modify the attributable factors and prevent the occurrence of ISR.

Correlation of Short Chain Fatty Acid (SCFA) Levels with Transient Elastography Values and Controlled Attenuation Parameters in Patients with Non-Alcoholic Fatty Liver Disease (NAFLD)

Desi Astari — 2025-07-08

Background: The current hypothesis regarding the mechanism of Non-Alcoholic Fatty Liver Disease (NAFLD) is the multiple hit theory, where one of the factors involved is gut microbiota. Short-chain fatty acid (SCFA) is the main metabolite of gut microbiota and is suspected to play a role in the development of NAFLD. This study aims to determine the correlation between SCFA levels (acetate, propionate, butyrate) and the degree of fibrosis and steatosis in patients with NAFLD assessed by controlled attenuation parameter (CAP) and transient elastography (TE). Methods: A cross-sectional study that included 33 consecutively selected patients at Cipto Mangunkusumo Hospital was conducted from January to August 2023. Fecal sample collection was performed for SCFA examination using GC-MS (Gas Chromatography-Mass Spectrometry). Absolute fecal SCFAs were analyzed for correlation with steatosis and fibrosis based on controlled attenuation parameter (CAP) and transient elastography (TE) values. Results: Subjects were predominantly female (51.5%), with an average age of 49 years, an average CAP value of 296 dB/m, and a median transient elastography value of 6.1 kPa. The ratio of acetate, propionate, and butyrate values in the subjects was 59:24:17. A moderate negative correlation was observed between the absolute butyrate and CAP values (r=-0.522; p=0.002). Conclusion: There is no correlation was identified between short-chain fatty acid levels and transient elastography values.

The Diagnostic Utility of Brain Natriuretic Peptide in Heart Failure Patients Presenting with Acute Dyspnea: A Systematic Review and Meta-analysis

Mohammad Amin Karimi — 2025-07-08

Background: Patients with heart failure are often diagnosed based on clinical signs and serological markers. Finding biomarkers with greater sensitivity and specificity for heart failure patients who also have episodic dyspnea is a challenge for researchers. Thus, we conducted a systematic review and meta-analysis of previous research to determine the diagnostic value of B-type natriuretic peptide as a potential biomarker in heart failure patients experiencing acute dyspnea. Methods: By searching PubMed/Medline, Scopus, and Google Scholar up to March 2023, all cross-sectional and cohort studies were selected according to the PRISMA guidelines and assessed by the Deeks’ funnel plot asymmetry test for bias. Results: A total of thirty-five qualifying studies had their data extracted. In 26 investigations (n=16002), the precision of B-type natriuretic peptide was evaluated. There were significant differences in the reported sensitivity and specificity between trials. One research study yielded the lowest sensitivity of 0.76 (0.68, 0.82), with a prevalence of 46% for heart failure and a BNP level of ≥500 pg/ml. Specificity grew but stayed variable as the threshold rose, whereas sensitivity declined. A diagnostic meta-analysis was carried out on 14 trials (n=6313) to determine the accuracy of N-terminal probrain natriuretic peptide. When the threshold is raised, the pattern in NTproBNP is similar to that of B-type natriuretic peptides, with sensitivity falling and specificity increasing. Following the final analysis, the confidence areas surrounding the pooled sensitivity and specificity for BNP vs NTproBNP showed a distinct overlap. The overlap indicated that there was no statistically significant difference between the tests at the <100 pg/ml and ≤300 pg/ml rule-out levels, respectively (P>0.05). Conclusion: The meta-analysis reveals a substantial degree of congruity in the sensitivity and specificity between the levels of BNP and NTproBNP as biomarkers. Nevertheless, it's worth noting that, in the end, there exists a potential for overlooking heart failure diagnoses. Larger future studies, overcoming past limitations, could likely establish a consensus.

Diagnostic Performance of INA-FRAIL and Study of Osteoporotic Fractures (SOF) Index Compared to Cardiovascular Health Study (CHS) in Diagnosing Frailty Syndrome in Older Adults with Heart Failure

Eka Ginanjar — 2025-07-08

Background: There is currently no gold standard for assessing frailty syndrome in older adults with heart failure. The Cardiovascular Health Study (CHS) is a reference standard for evaluating frailty in older adults with heart failure. Still, it requires a dynamometer and a spacious space, rendering it impractical in daily practice. The INA-FRAIL and Study of Osteoporotic Fractures (SOF) Index can often be easy to use; however, it has not been evaluated for diagnostic performance on older adults with heart failure in Indonesia. This study aimed to assess the diagnostic performance of INA-FRAIL and SOF-Index in diagnosing frailty in older adults with heart failure. Methods: This cross-sectional study evaluated the diagnostic performances of INA-FRAIL and SOF-Index compared to CHS as the gold standard in this study. The population was heart failure patients aged > 60 at Cipto Mangunkusumo Hospital. Results: Analysis from 81 samples shows the prevalence of frailty based on CHS (35.5%), INA-FRAIL (23.5%), and SOF-Index (8,6%). Diagnostic performance analysis of INA-FRAIL showed a sensitivity of 55,17% (95% CI 35.69–73.55), specificity 94.23% (95% CI 84.05– 98.79), and AUC 0.805 (95% CI 0.698–0.912). Diagnostic performance analysis of SOF showed 20,69% sensitivity (95% CI 7.99 – 39.72), 98.08% specificity (95% CI 89.74 – 99.95), and AUC 0.719 (95% CI 0.595 – 0.843). Conclusion: INA-FRAIL and SOF-Index had a significant association with CHS. The cut-off point of INA-FRAIL ≥1 showed the highest sensitivity, while INA-FRAIL ≥2 showed the highest Youden index. The cut-off point of SOF ≥1 showed the highest sensitivity and the highest Youden index.

The Impact of Palliative Care on Quality of Life and Cortisol Levels in HIV/AIDS Patients with Anxiety

Wiwiek Indriyani Maskoep — 2025-07-08

Background: Individuals with HIV/AIDS often experience significant physical and mental burdens. Palliative care has emerged as a means to improve the quality of life for people living with HIV/AIDS (PLWHA). This study aims to determine the effect of palliative care on the quality of life and psychoneuroimmunoendocrine aspects in PLWHA, particularly those suffering from anxiety, as indicated by cortisol hormone levels. Methods: A total of 30 PLWHA with anxiety were selected based on inclusion and exclusion criteria. This study employed a quantitative design with a quasi-experimental one-group pre-test and post-test approach. The data were analyzed using descriptive statistics and a paired t-test to assess the impact of the intervention on quality of life and cortisol hormone levels. Results: The findings indicated a significant improvement in quality of life following palliative care (p = 0.000, p < 0.05). The cortisol levels in PLWHA with anxiety decreased following palliative care; however, the reduction was not statistically significant, suggesting that palliative care had no measurable impact on cortisol levels post-intervention (p = 0.845, p > 0.05). Conclusion: Palliative care significantly enhances the quality of life in PLWHA. However, it does not lead to a statistically significant reduction in cortisol hormone levels before and after the intervention. Factors such as patient compliance with the palliative care plan and the influence of efavirenz on cortisol levels in PLWHA are likely contributing to these results.

The Correlation Between Angiotensin II Levels and Homeostatic Model Assessment of Insulin Resistance in Normotensive Young Adults with a Family History of Essential Hypertension

Stella Palar — 2025-07-08

Background: A family history of hypertension increases the risk of renin–angiotensin–aldosterone system activation, insulin resistance, and vascular inflammation, contributing to cardiovascular disease. Early vascular disturbances, marked by angiotensin II and insulin resistance assessed through the homeostatic model assessment of insulin resistance (HOMA-IR), play crucial roles in hypertension development. This study aims to determine the comparison and correlation between Ang II levels and HOMA-IR in normotensive young adults with or without offspring hypertension. Methods: We conducted this cross-sectional study by recruiting fifty normotensive participants, who were categorized into two groups: normotensive young adults who are offspring of parents with essential hypertension (case) and those who are not (control). The serum Ang II and HOMA-IR were measured. The comparative analysis was conducted using the Mann-Whitney test, and correlations were evaluated using Spearman’s test. Results: Among the 50 subjects (25 cases and 25 controls), a significant difference was observed in Ang II levels (p = 0.010), whereas HOMA-IR (p = 0.206) showed no notable difference between case and control. Notably, a positive correlation between Ang II and HOMA-IR (r = 0.554; p = 0.004) was observed in the case group, while the control group exhibited an insignificant correlation (r = –0.089; p = 0.671). Conclusion: There are marked differences in Ang II levels between normotensive young adults with a family history of essential hypertension and those without such history. Additionally, a significant correlation was found between Ang II and HOMA-IR in normotensive young adults who have a family history of essential hypertension.

Effect of Ramadan Fasting on Malondialdehyde, Poly (ADP-Ribose) Polymerase, Sirtuin 1, Nuclear Receptor Subfamily 1 Group D Member 1, and Transforming Growth Factor Beta in Chronic Kidney Disease: A Prospective Cohort Study

Drajad Priyono — 2025-07-08

Background: Chronic kidney disease (CKD) is a global health problem with increasing prevalence. This study aims to analyze the effect of Ramadan fasting on important biomarkers in CKD patients. Methods: A prospective cohort study was conducted on 30 CKD patients with stages 1, 2, and 3A who underwent Ramadan fasting. Measurements of MDA, PARP, SIRT1, NR1D1, and TGF-β levels were carried out before fasting, 2 weeks during fasting, and after fasting using the Enzyme-linked immunosorbent assay (ELISA) method. Results: There were significant decreases in urea, fasting blood glucose, HbA1C, and uric acid levels (p<0.05). MDA and SIRT1 decreased significantly (p<0.001), while PARP and NR1D1 increased significantly (p<0.001). TGF-β also showed a decrease. There were no significant changes in lipid profiles, creatinine, and albumin. Conclusion: Ramadan fasting has significant effects on several biochemical parameters and biological markers in early-stage CKD patients. These changes indicate potential improvements in oxidative stress, cell autophagy, inflammation regulation, and circadian rhythm. Further studies are needed to evaluate the long-term effects and clinical implications of these findings in CKD management.

Early Enteral Feeding Versus Total Parenteral Feeding After Surgery in Severe Acute Pancreatitis: An Evidence-Based Case Report

Roy Akur Pandapotan — 2025-07-08

Background: Acute pancreatitis is a self-limiting inflammatory disease that in some cases may lead to severe acute pancreatitis. To prevent this development, multimodal management, including nutritional management, is used in treating acute pancreatitis patients. The controversy between parenteral and enteral feeding has led to major debate. This case report aims to assess which method has better outcomes based on multiple cases of organ failure, inflammatory response, and length of hospital stay. Methods: A 46-year-old male presented to the Emergency Department of our hospital with acute abdominal pain, nausea, and vomiting, 12 h before admission. Based on physical and further examination, the patient was diagnosed with severe acute pancreatitis and underwent a necrotomy procedure. Articles from multiple databases were obtained and assessed using the Cochrane Collaboration Risk of Bias tool. The articles were analyzed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and a forest plot model. Effect size quantification for continuous and categorical variables was analyzed using continuous and binary random effect models, respectively. Results: Seven articles were obtained after exclusion and review. A total of 491 patients with acute/severe acute pancreatitis were assessed. These seven articles conclude that enteral nutrition has advantages over parenteral nutrition. Conclusion: Our study concluded that early enteral feeding provides better clinical improvement, reduced lipase enzyme levels, and shortened length of hospital stay.

Bridging Palliative Care and HIV/AIDS: A Call for Integrated Approaches

Rudi Putranto — 2025-07-08

Human Immunodeficiency Virus (HIV) and acquired immunodeficiency syndrome (AIDS) remain significant global health challenges. Beyond the physical manifestations, individuals living with HIV/AIDS often grapple with psychological burdens, notably anxiety, which can adversely affect their quality of life (QoL) and physiological stress markers, such as cortisol levels. Palliative care, traditionally associated with end-of-life support, has evolved to address the multifaceted needs of chronic illness patients, including those with HIV/AIDS. In the world, 1.89 million individuals require palliative care due to pain, and around 2.7 million people have HIV. This editorial explores the role of palliative care in enhancing QoL and modulating cortisol levels among HIV/AIDS patients experiencing anxiety.

Palliative care is holistic, addressing physical, emotional, social, and spiritual needs. In the context of HIV/AIDS, palliative interventions have demonstrated efficacy in alleviating symptoms, reducing psychological distress, and improving overall well-being. A systematic review highlighted that home-based palliative care and inpatient hospice services significantly improved patient outcomes in pain management, symptom control, anxiety reduction, and spiritual well-being. Palliative care emerges as a vital component in the comprehensive management of HIV/AIDS, particularly for patients grappling with anxiety. By enhancing quality of life and potentially modulating stress-induced hormonal imbalances, palliative interventions offer a holistic approach that addresses both psychological and physiological aspects of the disease. Future research should focus on elucidating the mechanisms by which palliative care influences cortisol levels and exploring its long-term benefits on disease progression and patient well-being.

Subphenotypic Classification of Immune Response in Sepsis: Predicting Mortality and Guiding Future Personalized Immunotherapy

Velma Herwanto — 2025-07-08

The most recent definition of sepsis highlights the dysregulation of the host’s immune response to infection, which varies between individual hosts, with patients predominantly presenting with either hyperinflammation, immunoparalysis, or a combination of both states. Therefore, management strategies must be tailored to accommodate the heterogeneity of patients with sepsis, as these conditions are associated with distinct prognoses and therapeutic approaches. Identification of the immune response in patients with sepsis can be achieved through advanced techniques, such as gene expression profiling or, more simply, through a subphenotypic approach. This article introduces a subphenotypic classification of the sepsis immune response into macrophage activation-like syndrome (MALS), where pathological macrophage activation leads to excessive hyperinflammation, immunoparalysis, or neither. Patients are classified using serum ferritin levels and monocyte HLA-DR expression, which is assessed using peripheral blood. This classification demonstrates significant differences in survival across groups, which is attributed to their distinct underlying biological processes. Immunotherapeutic options also differ for these three groups. In the future, such immune response classifications will be valuable in sepsis management algorithms for personalized prognostication and therapy.