Acta Medica Indonesiana – The Indonesian Journal of Internal Medicine
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Short-Chain Fatty Acids in the Gut-Brain-Liver Axis: Implications for Hepatic Encephalopathy
Full text linkHepatic encephalopathy (HE) is one of the serious complications of liver cirrhosis, characterized by a broad spectrum of neuropsychiatric symptoms, ranging from subtle cognitive impairment to coma, due to brain dysfunction associated with acute or chronic liver failure and/or portosystemic shunting. Globally, the prevalence of hepatic encephalopathy (HE) is reported to range from 20% to 80% in patients with liver cirrhosis, depending on whether the assessment includes minimal (MHE) or overt (OHE) forms. In Indonesia, determining the true prevalence of HE is challenging due to diagnostic difficulties, with estimates ranging from 30% to 84%. At Cipto Mangunkusumo General Hospital, the prevalence of HE in 2009 was 63.2%. In recent years, evidence has highlighted the role of the gut microbiota in the pathogenesis of hepatic encephalopathy (HE), a concept now widely referred to as the “gut–liver–brain axis.” Short-chain fatty acids (SCFAs) are gut microbial-derived metabolites that provide numerous health benefits. SCFA has been demonstrated to impact gut barrier function, immunomodulation, and glucose homeostasis.
In this issue, Ferdianto et al. conducted a cross-sectional observational study comparing the amount and composition of fecal SCFA in cirrhotic patients with and without HE. The study revealed no significant difference in SFA levels between HE and non-HE groups; however, the HE groups demonstrated higher levels of total SCFA, acetate, and butyrate compared to the non-HE groups. While this study contributes valuable early evidence from an Indonesian cohort, several important limitations should be acknowledged. First, the diagnostic approach for covert or minimal HE requires clarification. The authors did not explicitly state the neuropsychological tools and specific criteria used. Clear definitions are essential, as minimal and covert HE is susceptible to the choice of diagnostic method and can substantially influence group classification. Second, although SCFAs represent key microbial metabolites, the study did not explore the underlying microbiome composition. Without bacterial taxonomy or species-level data, it remains difficult to determine whether differences in SCFA levels truly reflect gut dysbiosis or altered microbial diversity. SCFA concentrations may be influenced by multiple factors, and therefore, inclusion of metagenomic or sequencing data would strengthen the mechanistic interpretation and allow linking specific bacterial taxa with cognitive impairment. Future studies that include larger and more heterogeneous cohorts, alongside integrated analyses of microbiome composition and validated neurocognitive testing, will be crucial to validate the role of SCFAs in HE development
Conn Syndrome with Hyperthyroidism and Refractory Hypokalemia: A Case Report
Full text linkConn syndrome is an adrenal gland adenoma that causes primary hyperaldosteronism, with a prevalence of <1% in the world population. Therefore, this case report presents a patient with Conn syndrome co-existing with hyperthyroidism. A 26-year-old female was admitted with muscle spasms in the left arm and muscle weakness in both legs for a day, palpitations, excessive sweating, nocturia, polyuria, and polydipsia. The patient had a history of hyperthyroidism for 10 years and routinely took anti-hypertension (Nifedipine), anti-thyroid, and potassium supplements. Physical examination showed the presence of hypertension. In addition, laboratory examinations revealed hypokalemia, slightly elevated FT4. The patient showed a high level of ARR (Aldosterone-Renin ratio; >30 ng/dL), consistent with primary hyperaldosteronism. Since abdominal USG revealed no abnormality, abdominal MRI with contrast was performed and showed an adenoma in the left adrenal gland. During admission, the patient had refractory hypokalemia despite various efforts to correct the defect. An anti-hypertension drug was then administered, particularly a mineralocorticoid antagonist receptor (Spironolactone). After the treatment, the patient had manageable hypertension and a normal potassium serum level, with no symptoms. Subsequently, discharge was then granted after 9 days of treatment, with a surgery schedule.Conn syndrome with hyperthyroidism can cause refractory hypokalemia, which transforms into a challenge in patient management. With early detection and management, the outcome of this case is manageable
Axillary Lymph Node Metastasis in Papillary Thyroid Carcinoma at Early Perioperative Period: Report of a Case and Review of the Literature
Full text linkA 36-year-old woman with a history of neck swelling was diagnosed with papillary thyroid carcinoma, a common but typically slow-growing thyroid cancer with a good prognosis. Despite frequent lymph node metastasis, mortality rates are low. This cancer can rarely spread to unusual areas like the axillary region. The patient had multiple nodules in her thyroid and metastasis to cervical lymph nodes. After a total thyroidectomy and neck dissection, 14 metastatic lymph nodes were found. Post-surgery, radioactive iodine treatment and a whole-body scan revealed axillary lymph node involvement, confirmed as metastasis from the thyroid cancer.Papillary thyroid carcinomas usually have an excellent survival rate, but some can be aggressive. Risk factors for poor outcomes include larger tumors, extracapsular spread, older age, specific variants, and distant metastasis. Surgical removal is the primary treatment, aiming to eliminate local and regional spread. However, metastasis to atypical regions like the axilla is rare and not well understood due to limited data. It’s thought to spread retrograde from the neck or due to abnormal lymphatic flow caused by surgery.Axillary metastasis is often found during or after surgery and may indicate systemic disease. Imaging techniques are used for detection. While it’s usually a sign of poor prognosis, isolated cases without distant metastasis exist. Aggressive thyroid cancer treatment should consider the potential for distant metastases
Cutaneous Anthrax: What is the Hallmark?
Full text linkA 71-year-old man complained of a blackish wound under his left eye, which began with fever and reddish spots after helping to slaughter a cow and cut its meat. The fever occured especially in the afternoon to evening, and is not accompanied by chills and sweating. On day 4 of fever onset, the fever diminished and the spots progressively widened with swelling. On day 7, the lesions on the skin became open wounds that were not purulent and did not bleed. On day 9, a blackish, painless layer appeared over the wounds and widened, further covering their surface. Upon presentation, the patient’s general condition was good, with normal vital signs and temperature. He presented with a solitary ulcer accompanied by edema, sized 1 cm x 3 cm, not hyperemic, firm border, flat edge, and covered with blackish eschar. Blood tests revealed normal levels of hemoglobin, leukocyte, platelets, kidney and liver function. The anti-anthrax protective antigen (anti-PA) IgG level is found to be seropositive with a level of 85 U/ml. Gram staining of the tissue underneath the eschar found Gram-positive rod bacteria in reddish-purple color. The patient was clinically diagnosed with probable cutaneous anthrax, and was treated with amoxicillin 500 mg orally t.i.d. for three days and paracetamol 500 mg if fever developed. The tissue sample was sent to a laboratory with Bio Safety level 3 facilities for microbiological culture, with the results of Bacillus anthracis growth. On day three after antibiotic administration, the wound was smaller (0.5 cm x 1.5 cm), firm border, flat edge, with a bit of edema above it. The eschar was thickened, painless, not purulent nor bleeding. Antibiotic administration is continued for another three days with amoxicillin 500 mg orally t.i.d. On day 6 of antibiotic administration, the eschar began to peel off, and antibiotics were stopped. On the 10th day, the eschar peeled off entirely without leaving a mark. Early diagnosis is crucial in preventing the spread that may lead to more cases. Clinical and serological examinations are the spearheads of early detection of anthrax cases. Prompt and appropriate management largely determines the success of therapy
Prevalence and Risk Factors of Malaria in Iwaka District, Mimika, Papua
Full text linkBackground: Papua is a high-endemic region for malaria in Indonesia. Malaria transmission is heavily influenced by environmental factors, particularly those related to vector breeding habitats and the homes of infected individuals. Communities in high-endemic areas also exhibit risk behaviors that can increase the likelihood of malaria transmission. Methods: This cross-sectional study was conducted in Iwaka District, Mimika, Papua, and included residents aged 18 years and older who had lived in the district for at least six months and exhibited symptoms of malaria. Subjects with a history of malaria or those under antimalarial treatment in the last two weeks were excluded. We collected demographic characteristics, malaria history, environmental factors, and behavioral components using a structured questionnaire. Each subject underwent a malaria examination using a rapid diagnostic test (RDT). Data were analyzed using STATA software. Results: A total of 863 subjects met the inclusion and exclusion criteria. Of these, 429 (49.7%) were diagnosed with malaria. Malaria cases were predominantly found among males, individuals aged 21– 40 years, those with secondary education, and those working as farmers. Malaria incidence was associated with having family members who had malaria, living near stagnant water, and residing within 100 meters of forests or fields (p < 0.05). The use of bed nets, mosquito repellents, and long-sleeved clothing was low, and most houses had wooden walls without wire mesh protection. Conclusion: Malaria prevalence in Iwaka District is extremely high, with risk factors including age, gender, proximity to stagnant water and forests/fields, and family history of malaria
Circulating Free RNA as a Therapeutic Evaluation in Diffuse Large B-cell Lymphoma: A Case Series from the Indonesian Cancer Center
Full text linkCancer is still the leading cause of death worldwide. Despite advances in diagnosis, management with the rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone (R-CHOP) chemotherapy regimen, and careful clinical and radiologic evaluation, diffuse large B-cell lymphoma (DLBCL) still carries high recurrence in clinical practice. This case series aims to assess the potential of circulating free RNA as a biomarker for evaluating therapeutic responses in DLBCL. This case series was conducted at Dharmais National Cancer Center Hospital in Jakarta in 2020. The subjects were 13 DLBCL patients who came for treatment to our hospital in 2020. Sampling was carried out by taking peripheral blood, which was taken 7–14 days after the patient underwent the 3rd and 6th cycles of chemotherapy or before and 7–14 days following the 3rd cycle of chemotherapy. Circulating free RNA (cfRNA) was extracted and assessed. The quantity of cfRNA was subsequently examined twice as matching samples from each patient, with the following results – (1) no mutations detected; (2) mutation detected solely in the second examination; (3) mutation only detected in the first examination; and (4) changes in gene mutations and mutation types. Statistic tabulation neither showed an association between recurrency and clinical variables nor detected cfRNA from the matching samples. This case series underscores the challenges in utilizing cfRNA as a biomarker for therapeutic evaluation in DLBCL due to heterogeneity and increased mutations in post chemotherapy conditions. Further research with larger sample sizes is needed to emphasize the role of cfRNA in DLBCL disease monitoring
The Role of Probiotics in Depression and Quality of Life in Patients with Irritable Bowel Syndrome
Full text linkBackground: Irritable Bowel Syndrome (IBS) is a functional gastrointestinal disorder frequently accompanied by psychological disturbances such as depression and reduced quality of life. Probiotic intervention has been studied as a potential adjunct therapy to address psychological symptoms and improve the quality of life in IBS patients. This study aims to evaluate the effect of probiotic supplementation on depressive symptoms and quality of life in IBS patients at Dr. Cipto Mangunkusumo National General Hospital using the Beck Depression Inventory-II (BDI-II) and SF-36 instruments. Methods: This study was a double-blind randomized controlled trial with a pre-post intervention design. A total of 70 participants were randomly assigned into two groups: the intervention group (n=35), which received probiotics, and the control group (n=35), which received a placebo. Depressive symptoms were assessed using the BDI-II, while quality of life was measured using the SF-36 questionnaire, both before and after the intervention. Statistical analysis was performed using the Mann-Whitney test and independent t-test, with a significance level of p<0.05. Results: After the intervention, the probiotic group showed a significant reduction in BDI-II scores compared to the placebo group (p<0.0001). In addition, the probiotic group demonstrated significant improvements in almost all domains of the SF-36 compared to the placebo group, including physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional well-being, and mental health (p<0.0001). Conclusion: Probiotic supplementation significantly reduces depressive symptoms and improves quality of life in IBS patients. These findings support the potential of probiotics as an adjunct therapy in the comprehensive management of IBS
Typhoid Fever in Indonesia: Pitfalls in the Diagnosis of Typhoid Fever
Full text linkTyphoid fever remains a major public health issue in Indonesia, with its true burden likely underreported due to diagnostic challenges. The clinical manifestations of typhoid fever are often nonspecific and overlap with other endemic febrile illnesses such as dengue, leptospirosis, and rickettsial infections, leading to frequent misdiagnosis. Although blood culture and PCR are the gold standards, their limited accessibility in Indonesia has resulted in reliance on suboptimal diagnostic tools such as the Widal test and TUBEX TF. Recent advances, including the Nelwan Score and CRP-based differentiation, have shown promise in improving early clinical screening. Furthermore, antibody-based proteomic diagnostics offer enhanced accuracy but remain largely confined to research settings. A combined approach utilizing validated clinical scores, affordable biomarkers, and selective use of serological tests is essential to improve diagnostic accuracy and patient care. Misdiagnosis not only endangers patient outcomes but also contributes to inappropriate antibiotic use, accelerating the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) Salmonella Typhi. Resistance to first-line antibiotics and fluoroquinolones has been increasingly reported in Indonesia, although some regions still demonstrate preserved susceptibility. Cautious and evidence-based antibiotic prescribing is therefore critical to mitigating resistance. This article underscores the urgent need to strengthen diagnostic strategies and antimicrobial stewardship to address the persistent challenge of typhoid fever in Indonesia
Benefit of Influenza Vaccination in Patients with Cardiovascular Disease
Full text linkInfluenza remains a significant global health problem. The risks of complication and death from influenza are greater in comorbid groups, such as those suffering cardiovascular diseases. The true economic and social costs of influenza are far greater in these groups compared to healthy ones as these groups are vulnerable to complications and even death. Cardiovascular disease is the leading cause of death, both globally and in Indonesia. The relationship between cardiovascular events and seasonal influenza has been established. Influenza vaccination is one of the prevention methods that has proven effective in preventing influenza infection and reducing the risk of major cardiovascular events. In addition to being effective, influenza vaccination is also safe and well-tolerated by adults and the elderly. This review outlines the impacts of influenza and the benefits of influenza vaccine in groups with cardiovascular disease.
Key words: influenza, vaccine, cardiovascular disease
Anuric Acute Kidney Injury in Chronic Myeloid Leukemia: A Rare Complication Case
Full text linkThis report describes a rare case of anuric acute kidney injury related to suspected urate nephropathy in a 23-year-old male with chronic phase of Chronic Myeloid Leukemia (CML). The patient presented with anuria and limb edema, with a history of imatinib-treated CML. Investigations revealed probable urate crystals causing bilateral hydronephrosis and hydroureters. Management included fluid restriction to maintain euvolemic status, hypouricemic agents, urinary alkalinization, urgent hemodialysis for acute kidney injury, and blood product transfusions to address haematological imbalances. The continued use of imatinib and aforementioned treatments resulted in the restoration of renal function depicted through normalization of serum urea, creatinine and uric acid levels. This case highlights the importance of meticulous assessment and management of anuric acute kidney injury in CML patients to ensure a positive outcome