Acta Medica Indonesiana

Short-Chain Fatty Acids in the Gut-Brain-Liver Axis: Implications for Hepatic Encephalopathy

Irsan Hasan — 2025-12-23

Hepatic 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.

Performance of Tokyo Guidelines 2018 and Predictors of Mortality in Acute Cholangitis Patients in Indonesia

Vesri Yoga — 2025-12-23

Background: Acute cholangitis is associated with high mortality, necessitating prompt diagnosis and intervention. The Tokyo Guidelines 2018 (TG18) are a crucial diagnostic tool, but their sensitivity and specificity require evaluation. Moreover, factors influencing acute cholangitis mortality in Indonesia remain unidentified. This study evaluates the diagnostic accuracy of TG18 and identifies mortality predictors in adult patients with acute cholangitis in Indonesia. Methods: A retrospective cohort study was conducted using the medical records of acute cholangitis patients at Cipto Mangunkusumo Hospital from 2019 to 2022. TG18 was compared with endoscopic retrograde cholangiopancreatography (ERCP). Bivariate and multivariate analyses were employed to identify mortality predictors. Results: The study involved 163 individuals (male: 51.5%; mean age: 51.0 ± 12.81 years). The in-hospital mortality rate was 11.6%. TG18 demonstrated a sensitivity and specificity of 84.05% (95% confidence interval (CI):77.51%–89.31%) and 95.65% (95%CI: 78.05%–99.89%), respectively, compared with ERCP. Significant mortality predictors in univariate analysis included TG18 grade III (risk ratio (RR): 13.85; 95%CI: 3.31–57.89; p<0.001), history of malignancy (RR: 4.40; 95%CI: 1.52–12.68; p=0.006), noncompliance with antibiotic guidelines (RR: 3.27; 95%CI: 1.36–7.85; p=0.008), and procalcitonin levels ≥ 2.0 ng/dL (RR: 2.44; 95%CI: 1.056–5.63; p=0.037). Multivariate analysis revealed that significant predictors included TG18 grade III (RR: 10.67; 95%CI: 2.50–45.56; p<0.001), non-compliance with antibiotic guidelines (RR: 2.92; 95%CI: 1.34–6.36; p=0.007), and procalcitonin levels
≥ 2.0 ng/dL (RR: 2.37; 95%CI: 1.18–4.75; p=0.015). Conclusion: TG18 demonstrates favorable sensitivity for diagnosing acute cholangitis. Independent predictors of acute cholangitis mortality include TG18 grade III, noncompliance with antibiotic guidelines, and procalcitonin levels ≥ 2.0 ng/dL.

Coronary Artery Calcium Score as a Potential Non-Invasive Marker for Pulmonary Artery Hypertension

Shahin Mirzamohammadi — 2025-12-23

Background: Early prediction of cardiac dysfunction is crucial in preventing the progression to heart failure and associated complications. To achieve this, the utilization of clinical indicators, molecular and pathological markers, and non-invasive evaluation methods has gained significant interest. One potential predictive tool that can be measured through non-invasive imaging modalities is the coronary artery calcium (CAC) score. Recent studies have extensively examined the correlation between coronary atherosclerotic plaque calcium score and cardiac dysfunction. However, data are scarce regarding the usefulness of the calcium score in predicting pulmonary artery hypertension, which is a known consequence of ventricular dysfunction. Methods: A total of 167 patients with suspected coronary artery involvement were included in the study. Before performing CT angiography, the score of CAC was measured in all patients based on their CT results. The CAC value was calculated using Vitrea software. The CAC score of each coronary artery, as well as the total CAC score (by summing the scores of each artery), was determined based on the Agatston method. Then the patients were subjected to CT angiography, and the value of pulmonary artery pressure or PAP, as well as the pulmonary artery dilatation, was measured based on the results of CT angiography. Results: The average CAC score in the two groups with and without PAH was 107.57 ± 268.60 and 35.47 ± 93.98, respectively, which indicated a significant difference between the two groups (P value 0.011). Accordingly, the number of cases with a positive CAC score in the two groups with and without PAH was 24 (49.0%) and 47 (39.8%), respectively, which showed a significant difference between the two groups (P = 0.046). There was a significant correlation between CAC score and PAH. Based on the analysis of the area under the ROC curve, CAC score evaluation had a high ability to predict PAH in women and in patients over 50 years old. Conclusion: The measurement of CAC score could be incorporated as a predictive index for the increase of pulmonary artery pressure and the occurrence of PAH. However, this predictive value is more evident in women and in older patients.

The Role of Changes in the Proportion of Fecal Short-Chain Fatty Acids on the Severity of Hepatic Encephalopathy in Cirrhosis Patients

Mochamad Anief Ferdianto — 2025-12-23

Background: Short-chain fatty acids (SCFA) are the main metabolites of the intestinal microbiota, which play a role as colonocyte trophic factors and maintain the integrity of the gastrointestinal tract and blood-brain barrier. Microbiota dysbiosis that occurs in cirrhosis reduces SCFA production and plays a role in the pathogenesis of hepatic encephalopathy (HE). This study aims to compare the amount and composition of fecal SCFA in patients with cirrhosis, with and without HE. Methods: This research is a cross-sectional study at the Hepatobiliary Clinic and Integrated Procedure Room, Dr. Cipto Mangunkusumo Hospital, Jakarta, in 2023. Patients with cirrhosis underwent a flicker or Stroop test, fecal SCFA examination (acetate, butyrate, and propionate), and a questionnaire with a food recall technique to assess dietary patterns. Results: A total of 86 patients with cirrhosis participated in this study, with a mean age of 53 ± 8.10 years, and the majority were male (68.6%). Hepatic encephalopathy (HE) was identified in 20 patients (23.25%). Multivariable analysis of SCFA profiles showed no statistically significant associations with HE. The absolute SCFA proportion had an adjusted prevalence ratio (PR) of 1.98 [95% CI: 0.75–5.24; p = 0.171], the absolute acetate proportion had an adjusted PR of 2.06 [95% CI: 0.40–10.62; p = 0.388], and the butyrate proportion had an adjusted PR of 2.02 [95% CI: 0.76–5.39; p = 0.158]. Conclusion: Changes in SCFA composition may be associated with the presence of HE in patients with cirrhosis. Although no statistically significant relationships were found, these findings suggest that SCFA profiles warrant further investigation concerning dysbiosis and HE in cirrhosis.

Efficacy of Exercise in the Sitting Position Compared with Exercise in the Standing Position in Obese Patients with Knee Osteoarthritis

Tirza Zainuddin Tamin — 2025-12-23

Background: Knee osteoarthritis (OA) is a degenerative condition that causes pain, swelling, and stiffness, affecting a person’s ability to move freely. Non-weight-bearing therapeutic exercise programs provide better pain reduction and improve joint function compared with conventional exercise programs. This study compared the effectiveness of therapeutic exercises in sitting versus standing positions in reducing pain, improving knee function, and enhancing quality of life in obese patients with OA. Methods: Fifty-four obese women aged 50–80 years were randomly assigned to one of two exercise program groups, either sitting or standing. Members of each group participated in a 12-week intervention consisting of aerobics, hip stretching and strengthening, and balance exercises. Sessions lasted 45 minutes, three times per week, increasing by 30 minutes every four weeks. Pain was assessed using the Numerical Rating Scale, knee function was measured with the Knee Injury and Osteoarthritis Outcome Score, and quality of life was assessed with the 12-Item Short Form Survey. Measurements were taken at baseline and every four weeks during the intervention. Results: When compared with the standing position group, the sitting position group showed significantly less pain and better knee function as determined by NRS and KOOS, as well as better physical quality of life (p<0.05). In contrast, the standing position group had a better mental quality of life. Conclusion: Therapeutic exercises in a sitting position are more effective in reducing pain, improving knee function, and enhancing physical quality of life in OA. However, standing exercises contribute more to mental well-being.

Predictors of Technical and Clinical Success of ERCP in Patients with Biliary Obstruction: A Study from a Tertiary Referral Center in Indonesia

Tony Darmadi — 2025-12-23

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a primary therapeutic modality for managing malignant and benign biliary obstruction. Technical success (TS) and clinical success (CS) of modality are essential indicators of procedural efficacy, which is influenced by various patient- and procedure-related factors. Therefore, this study aims to evaluate the TS and CS rates of ERCP and identify their predictors in patients with biliary obstruction at a tertiary referral center in Indonesia. Methods: A retrospective analysis was conducted on patients with biliary obstruction who underwent therapeutic ERCP at Cipto Mangunkusumo Hospital between January 2022 and December 2024. Patients with diagnostic ERCP or prehepatic/parenchymal jaundice were excluded. Results: A total of 259 patients were included (49.4% female, mean age 50.6 years) in this study. The results show that the TS rate is 96.5%, with multivariate analysis identifying ulcerative fragile papillary mass (AOR 0.075; P=0.001) as an independent negative predictor. Meanwhile, the CS rate is 88%, with pre-ERCP bilirubin >3 mg/dL (AOR 8.545; P<0.001) and previous ERCP stenting/pre-cutting (AOR 0.330; P=0.037) being independent predictors. Distal malignant obstruction causes a higher pre-ERCP bilirubin level (P=0.025) of >3 mg/dL (OR 6.116; P=0.011). Conclusion: ERCP showed high technical and clinical success rates in managing biliary obstructions. TS was negatively predicted by ulcerative fragile papillary mass. CS was positively predicted by pre-ERCP bilirubin >3 mg/dL and negatively by prior stenting or pre-cutting. These findings should be taken into consideration when planning and delivering ERCP to achieve better outcomes.

The Role of Probiotics in Depression and Quality of Life in Patients with Irritable Bowel Syndrome

Diana Erlita — 2025-12-23

Background: 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.

Temporal Changes in Inflammation, Oxidative Stress, Apoptosis, and Endothelial Glycocalyx Degradation in Correlation to Organ Function Assessment Following On-Pump Coronary Artery Bypass Graft Surgery

Arif Mansjoer — 2025-12-23

Background: A coronary artery bypass graft is a complex procedure that can cause various physiological responses, including inflammation, oxidative stress, apoptosis, and endothelial dysfunction. Nevertheless, the correlation between these responses and organ function after CABG has not yet been established. This study aims to investigate the correlation between inflammation, oxidative stress, apoptosis, endothelial dysfunction markers, and postoperative organ function assessment as evaluated by the Cardiac Surgery Score (CASUS). Methods: A prospective cohort study was conducted on patients undergoing coronary artery bypass graft from two hospitals in Jakarta. IL-6, MDA, caspase-3, and syndecan-1 levels were measured at three points in time: before surgery, on ICU Day-1, and ICU Day-2. Postoperative organ function was assessed on ICU Day 2 by Cardiac Surgery Score (CASUS). Results: Fifty-one patients were included in the study. There was a positive correlation between IL-6 measured before surgery (r = 0.325, p = 0.020) and at the time of admission to the ICU (r = 0.374, p = 0.007). Positive correlation was also found between syndecan-1 levels on ICU day 1 (r = 0.304, p = 0.030) with CASUS. MDA correlated with CASUS on ICU day 2 (r = 0.392, p = 0.004); meanwhile, no significant association was found between caspase-3 and postoperative organ function assessment. Conclusion: Interleukin-6 levels pre-surgery and on ICU day 1, syndecan-1 levels on ICU day 1, and MDA levels on ICU day 2 were correlated with CASUS.

Typhoid Fever in Indonesia: Pitfalls in the Diagnosis of Typhoid Fever

Eric Ricardo Yonatan — 2025-12-23

Typhoid 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.

Continuous Glucose Monitoring Use in Rural Area: An Evidence-Based Case Report

Ekvan Danang Setya Pramudito — 2025-12-23

Continuous Glucose Monitoring (CGM) provides real-time glycemic variability data, surpassing traditional methods like HbA1c. CGM data, also known as glucometrics, provide a comprehensive assessment of glycemic variability rather than a single point estimate like HbA1c, CGM data, or glucometrics. It provides a comprehensive assessment of glycemic variability rather than a single point estimate like HbA1c. CGM enables clinicians to understand dysglycemia patterns better by continuously tracking the patient’s glucose levels, therefore allowing for individualized adjustments to antidiabetic therapy. By continuously tracking glucose levels, a CGM enables clinicians to understand dysglycemia patterns better, allowing for individualized adjustments to antidiabetic therapy. While costly, CGM enables long-distance monitoring, addressing healthcare inaccessibility in remote rural areas. This case reportstudy examines a 24-year-old Indonesian female patient diagnosed with young-onset diabetes with limited access to specialized care, a history of macrosomia at birth, high blood glucose, and a body mass index (BMI) of 27.7. The patient's abdominal circumference was 86 cm, which is above normal for women and within the range of obesity. In this patient, CGM recorded a mean glucose level of 145 mg/dL. Studies indicate that when at least 70% of CGM data is available over a 10–14-day period, an estimated HbA1c can be calculated. CGM is vital for diabetes management in rural settings. Further, integrating telemedicine can help bridge healthcare gaps. Expanding access to CGM and genetic testing is crucial for improving outcomes in underserved communities.

Benefit of Influenza Vaccination in Patients with Cardiovascular Disease

Anshari Saifuddin Hasibuan — 2025-12-23

Influenza 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 diseases

Perspective of Muslims on Kidney Transplantation in Indonesia: A Narrative Review

Maruhum Bonar Hasiholan Marbun — 2025-12-23

The prevalence of end-stage renal disease patients in Indonesia is predicted to increase by the end of 2025. Kidney transplantation is the preferred treatment for end-stage renal disease, and the demand for kidney transplants is steadily increasing globally, including in Indonesia. However, organ transplantation and donation are debatable issues in the medical field, particularly when considered in conjunction with religious views. The Qur'an and Hadith do not directly discuss transplantation in Islam, prompting several interpretations and fatwas. Diverse ideologies, cultures, and beliefs also result in prospective differences. To address these differences, fatwas regarding the permissible conditions for transplantation have been issued by the Indonesian Ulema Council. This study aimed to explore the perspectives of Muslims and Islamic law on kidney transplantation in Indonesia. The study also includes comparative studies of Muslim perspectives from different countries. The findings provide an overview of Islamic law, the perspectives of religious scholars, and the perspectives of Muslims residing in Indonesia, as well as in other countries.

Complicated Thoracic Empyema of Serotype 23F Streptococcus pneumoniae in an Adult Patient

Indra Yovi — 2025-12-23

We report a case of thoracic empyema in a 61-year-old male patient, a heavy smoker with malignancy undergoing chemotherapy. The patient’s clinical symptoms included shortness of breath, productive cough, fever, and chest pain. This patient had never received antibiotics before. Streptococcus pneumoniae was isolated from a bedside culture of empyema fluid collected through thoracentesis. The empyema fluid was cultured on chocolate agar plates and in aerobic and anaerobic culture bottles. The isolate was identified as serotype 23F, a vaccine strain with sequence type 17532. The isolate was resistant to chloramphenicol, tetracycline, and cotrimoxazole. The patient clinically improved with the administration of combined intravenous ceftriaxone and levofloxacin antibiotics, along with chest tube drainage via thoracostomy. This is the first report of thoracic empyema caused by S. pneumoniae in an adult in Indonesia. Serotype 23F is multi-resistant with low invasiveness, typically causing infections in patients with underlying health conditions. The pneumococcal conjugate vaccine covers it; thus, it usually occurs in areas with low vaccine coverage. Our findings support the importance of improving adult pneumococcal vaccination coverage in Indonesia.

Complicated Pregnancy in a Patient with Distal Renal Tubular Acidosis, Systemic Lupus Erythematosus, and Antiphospholipid Syndrome: A Rare Case and Management Strategies

I Gede Yasa Asmara — 2025-12-23

Distal renal tubular acidosis (dRTA) is a rare disorder characterized by impaired acid excretion leading to metabolic acidosis and hypokalemia. Its occurrence during pregnancy, particularly alongside systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), poses significant challenges for both maternal and fetal outcomes. This case report describes the successful management of a 23-year-old woman with secondary dRTA, SLE, and APS during pregnancy. The patient, with a history of recurrent hypokalemia and previous preterm deliveries, was closely monitored by a multidisciplinary team. Throughout her pregnancy, she required significant potassium and bicarbonate supplementation to maintain electrolyte and acid-base balance. Additionally, hydroxychloroquine, methylprednisolone, aspirin, and unfractionated heparin were continued to manage SLE and APS. Despite the complexity of her condition, she delivered a healthy baby girl at 37 weeks via cesarean section. This case provides valuable insights into managing dRTA during pregnancy, highlighting the importance of customized approaches to the management of electrolyte and acid-base abnormalities, as well as that of autoimmune disease.

The Role of Mesenchymal Stem Cells for Hemorrhagic Stroke Management

Mohammad Kurniawan — 2025-12-23

Stroke is ranked as the second-leading cause of death worldwide. As a result, the long-term sequelae of motor and cognitive abnormalities, such as hemiparesis, paralysis, psychomotor, chronic pain, and behavioral symptoms, can delay the patient's full recovery and function in society. In this context, stem cell-based treatment for stroke has been proven effective due to the potential to provide neurorestorative benefits. This study presented a case of a 50-year-old patient admitted to Cipto Mangunkusumo National General Hospital, Jakarta, in 2022 with intracerebral hemorrhage in the left thalamus, surrounding perifocal edema, and left lateral intraventricular hemorrhage. The patient was given mesenchymal stem cells (MSCs) treatment three times through Digital Subtraction Angiography (DSA). The patient achieved good outcomes in terms of body mobility, balance, and voluntary movement of the upper and lower right limbs.

The Emergence of Drug Resistance in Extrapulmonary Tuberculosis: A Case Series

Herikurniawan Herikurniawan — 2025-12-23

Drug-resistant extrapulmonary tuberculosis (DR-EPTB) represents an escalating global health challenge, complicated by rising rates of rifampicin-resistant (RR-TB) and multidrug-resistant tuberculosis (MDR-TB). Despite growing awareness, DR-EPTB remains underdiagnosed and underreported, often due to presumptive assumptions of drug sensitivity. This case series describes three distinct cases of DR-EPTB: a 34-year-old woman diagnosed with primary MDR-TB involving the lungs and colon; a 41-year-old man with RR-TB-associated arthritis of the elbow joint, following a previous history of pulmonary TB; and a 63-year-old immunosuppressed woman presenting with primary laryngeal and pulmonary RR-TB. These cases highlight the diagnostic complexities and emphasize the necessity of prompt and precise diagnosis facilitated by molecular diagnostics, particularly GeneXpert MTB/RIF. Increased awareness and vigilance for DR-EPTB among clinicians are critical for early detection, effective management, and curbing the spread of drug-resistant strains.

Conn Syndrome with Hyperthyroidism and Refractory Hypokalemia: A Case Report

Tamara Audrey Kadarusman — 2025-12-23

Conn 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.

Dual Anti-HER2 Combination with Chemotherapy as First-line Treatment for HER2-positive Metastatic Breast Cancer

Wulyo Rajabto — 2025-12-23

HER2-positive metastatic breast cancer is an aggressive subtype of breast cancer associated with poor prognosis due to high recurrence and mortality rates. The introduction of dual anti-HER2 therapy combined with chemotherapy has significantly improved treatment outcomes.

A 50-year-old woman with a history of left mastectomy in 2019 who initially declined adjuvant chemotherapy and radiotherapy. Three years later, she presented to the clinic with erythematous skin changes, a nodule at the mastectomy site, and left-arm lymphedema. A biopsy confirmed recurrent HER2-positive breast cancer with metastases to lymph nodes, liver, and bones (cT4cN3cM1 ER−, PR−, HER2+). She received initial treatment with dual anti-HER2 (Pertuzumab, Trastuzumab) and Docetaxel every 3 weeks for six cycles, followed by maintenance therapy with Pertuzumab and Trastuzumab. PET scan evaluations showed an excellent response, with complete resolution of the primary lesion and substantial regression of metastases. The CLEOPATRA trial supports the efficacy of a combination of dual anti-HER2 and Docetaxel, showing prolonged progression-free and overall survival. The combination of dual anti-HER2 enhanced antitumor efficacy by providing dual inhibition of HER2. This case highlights the pivotal role of dual anti-HER2 therapy combined with chemotherapy in improving survival outcomes of patients with metastatic HER2-positive breast cancer.