Acta Medica Indonesiana

When More Becomes Harm: The Art of Managing Multimorbidity and Multicomplexity in Older Adults

Siti Setiati — 2026-07-03

Multimorbidity and multicomplexity are increasingly becoming the norm in geriatric clinical practice, with a recent Indonesian multicentre study revealing that 80.7% of older outpatients present with multiple coexisting conditions. This editorial discusses the limitations of conventional single-disease guidelines when applied to complex older adults, where simultaneous treatments often lead to polypharmacy, cumulative anticholinergic burdens, and potential adverse outcomes. Highlighting findings from a recent study in Acta Medica Indonesiana, which found polypharmacy in 43.9% of Indonesian geriatric outpatients but a low rate of high anticholinergic burden (1.8%), the editorial underscores the concept of "appropriate polypharmacy" under close clinical monitoring. To effectively navigate multicomplexity defined by the intricate interactions between pathophysiology, treatment effects, functional status, and social context, clinicians must look beyond rigid numerical targets and adopt patient-centered frameworks such as the Geriatrics 5Ms. Central to this approach is the art of judicious deprescribing, utilizing validated criteria like the AGS Beers or STOPP/START to optimize care and minimize harm. Ultimately, modern geriatric care requires a fundamental shift from merely extending lifespan to enhancing health span, focusing on "What Matters Most" to the patient. Integrating these competencies into medical education is vital to prepare future frontline clinicians for the realities of aging populations.

Successful Conservative Management of Right Ventricular Perforation Caused by Temporary Pacemaker Placement during Complex Percutaneous Coronary Intervention: A Case Report

Fadhil Pratama Apriansyah — 2026-07-03

Cardiac tamponade is a critical condition that can result from complications during invasive cardiac procedures. This case report describes a 67-year-old male who developed right ventricular perforation leading to cardiac tamponade following elective complex percutaneous coronary intervention with rotational atherectomy and temporary pacemaker placement. By performing emergent pericardiocentesis and using a pigtail catheter with sustained negative pressure, we successfully managed a massive pericardial effusion of 2,600 cc. The patient stabilized without requiring surgical intervention, demonstrating favorable outcomes. This case underscores the importance of timely recognition and personalized management strategies in the conservative treatment of cardiac tamponade secondary to right ventricular perforation.

Complete Recovery of Thyrotoxicosis Cardiomyopathy After Antithyroid and Corticosteroid Therapy: A Case Report

Kyra Adiavira — 2026-07-03

Thyroid storm (TS) is an extreme hypermetabolic state due to thyrotoxicosis. TS may manifest as cardiovascular symptoms, including atrial fibrillation (AF) (9 – 23%) and heart failure (HF). Dilated cardiomyopathy (DCM) and HF develop at a later stage in approximately 1% of thyrotoxicosis patients. A 46-year-old man presented to the emergency department with a chief complaint of severe dyspnea and rapid AF. Blood test examination showed overt thyrotoxicosis. The Burch-Wartofsky point scale is 60 (highly suggestive of TS). Echocardiography showed severely reduced left ventricular (LV) systolic function. The patient was diagnosed with TS, rapid AF with DCM, probably due to thyrotoxic cardiomyopathy. After 3 months of antithyroid therapy, corticosteroids, and optimal HF management, we observed complete recovery of his ventricular function, along with spontaneous conversion to sinus rhythm. LV systolic dysfunction is described in a small percentage of thyrotoxicosis patients. In later stages of thyrotoxicosis cardiomyopathy (TCM), HF phenotype of DCM will develop, characterized by progressive reduction of myocardial systolic function that marks advanced stages of TCM. This report highlighted the importance of thyroid investigation as an integral part of HF etiological work-up due to its reversibility.

Beyond the Irregular Beat: An Unexpected Case of Raynaud’s Phenomenon in a Patient with Atrial Fibrillation

Ni Putu Widyanti Suastiari — 2026-07-03

Raynaud's phenomenon is characterized by episodic vasospasm of the extremities, often triggered by cold or stress. It is a hallmark of systemic sclerosis (SSc) and is frequently associated with pulmonary arterial hypertension (PAH). PAH may cause right atrial dilatation, predisposing to atrial fibrillation (AF). While Raynaud’s and PAH are well-documented, their coexistence with AF is rarely reported. A 71-year-old male presented with rapid AF and pulmonary oedema. On admission, vital signs were stable, but he developed symmetrical discoloration of the fingers, palms, and feet after cold exposure in the ICU, accompanied by numbness and pain. Laboratory tests revealed prolonged PT, high ESR (65/121 mm/hr), and positive ANA (44.8 IU/mL). ECG showed rapid AF with left ventricular hypertrophy. Chest X-ray demonstrated pulmonary artery dilatation and cardiomegaly. Echocardiography revealed moderate tricuspid regurgitation and severe PAH. This case illustrates a rare combination of Raynaud’s phenomenon, PAH, and AF, likely secondary to autoimmune vascular dysfunction. PAH-induced atrial dilatation may trigger AF, while endothelial dysfunction may worsen Raynaud’s symptoms. A positive ANA suggests underlying SSc or SLE. Early recognition and multidisciplinary management targeting pulmonary pressure, arrhythmia control, and vasospasm are crucial to prevent complications. Long-term outcome was not assessed due to loss to follow-up.

Outcomes of Tranexamic Acid Treatment in Patients with Upper Gastrointestinal Bleeding: An Overview of Reviews

Aurel Feodora Tantoro — 2026-07-03

Background: Upper gastrointestinal bleeding (UGIB) is a life-threatening emergency requiring prompt management. Standard treatments include endoscopic intervention, blood transfusions, and pharmacological therapies such as proton pump inhibitors (PPIs) and antifibrinolytics like tranexamic acid (TXA). However, the efficacy of TXA in UGIB remains controversial due to mixed findings. This systematic review analyzed six systematic reviews covering 34,351 patients. The objective is to assess TXA’s effectiveness in reducing mortality, rebleeding, and thromboembolic events, as well as secondary outcomes such as transfusion requirements, surgery, hospital stay, and adverse events. Methods: Studies on non-GI bleeding, pediatric populations, and non-peer-reviewed articles were excluded. A comprehensive search across PubMed, Cochrane Library, ScienceDirect, and DOAJ (2014–2024) identified 157 records, with six systematic reviews/meta-analyses (34,351 participants) meeting inclusion criteria. Risk of bias was assessed using AMSTAR 2, with two studies rated as high confidence and four as moderate confidence. Results: Current high-quality evidence does not support routine TXA use for mortality reduction in UGIB. Safety remains uncertain, particularly with prolonged high-dose administration. Conclusion: These findings are consistent with the 2022 Indonesian national consensus, which advises against routine TXA use in UGIB. Future research should focus on optimized dosing strategies, timing of administration, and identification of clinically relevant subgroups to clarify its therapeutic role.

Anticholinergic Burden, Falls, and the Concept of Appropriate Polypharmacy in Indonesian Geriatric Clinics: A Multicentre Observational Study

Siti Setiati — 2026-07-03

Background: A high anticholinergic burden (ACB) scale score (≥3) and polypharmacy have been viewed negatively due to possible adverse events. As Indonesian multicentre data in this field are lacking, this study aimed to provide regional data related to ACB, polypharmacy, and falls, and to analyse factors potentially linked to falls. Methods: Data from community-dwelling older adults aged ≥60 years were collected in 12 geriatric care centres through history taking and medical records. Bivariate and multivariate analyses were conducted to evaluate the association between covariates and falls. Results: Polypharmacy and high ACB (score ≥3) were observed in 43.9% and 1.8% of 626 older adults, respectively. The five most prescribed drug classes were calcium-channel blockers, angiotensin receptor blockers, statins, beta blockers, and proton pump inhibitors. The three most prescribed drugs with possible anticholinergic activity were furosemide, isosorbide dinitrate, and cetirizine. The prevalence of past-year falls was 16.8%. Falls were associated with age ≥80 years (odds ratio [OR] 2.44, 95% confidence interval [CI] 1.31-4.53), female sex (OR 2.08, 95% CI 1.30-3.31), transient ischaemic attack and cerebrovascular accident (OR 1.97, 95% CI 0.94-4.10), multimorbidity (≥3 co-morbidities) (OR 1.80, 95% CI 1.07-3.03), depression (OR 1.79, 95% CI 1.00-3.23), and polypharmacy (OR 0.65, 95% CI 0.40-1.05). Conclusion: The prevalence of a high ACB score and falls were 1.8% and 16.8%, respectively. Approximately one in two older adults had polypharmacy. We observed a non-significant inverse relationship between polypharmacy and falls. This may possibly suggest appropriate polypharmacy and closer monitoring applied in geriatric settings, which requires further investigation.

Prognostic Performance of Prognostic Nutritional Index, Subjective Global Assessment, and Nutritional Risk Screening 2002 as Predictors of Inpatient Sepsis Mortality: a Prospective Cohort Study

Yongkie Iswandi Purnama — 2026-07-03

Background and Aim: Sepsis is a leading cause of infection-related mortality. Various factors contribute to sepsis-related mortality, including age, comorbidities, Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) score, serum lactate levels, and nutritional status. Several parameters are available to assess nutritional status, including the Prognostic Nutritional Index (PNI), Subjective Global Assessment (SGA), and Nutritional Risk Screening 2002 (NRS 2002). The SGA and NRS 2002 parameters are standard tools for evaluating nutritional status, while the PNI is very simple and objective. This study aimed to evaluate the accuracy of these three nutritional parameters as predictors of in-hospital mortality in patients with sepsis and to analyze the extent to which malnutrition contributes to sepsis-related mortality among other factors.

Methods: This was a prospective cohort study. The inclusion criteria were patients aged 18 years or older who were hospitalized with a diagnosis of sepsis. The exclusion criteria were patients who could not be interviewed or those who were pregnant. Dropout criteria included patients who were discharged against medical advice. Sampling was conducted using consecutive sampling. Nutritional status and other clinical parameters were assessed within the first 48 hours of sepsis diagnosis. In-hospital outcomes were recorded as either mortality or survival. Cut-off points for numerical variables were determined using ROC curves. Bivariate analysis was performed using Chi-square or Fisher’s exact test, and multivariate analysis was conducted using binary logistic regression.

Results: A total of 158 subjects were included in the study. The mortality rate was 62.7%. As predictors of mortality, PNI had a positive predictive value (PPV) of 72.7% and a negative predictive value (NPV) of 54.2% with a cut-off point of 30.55, while SGA had a PPV of 70.4% and an NPV of 54.0%, and NRS 2002 had a PPV of 64.7% and an NPV of 75.0%. Regarding sepsis mortality, malnutrition status based on PNI had an aRR 3.0 (95% CI 1.4-6.6), SGA had an aRR 2.4 (95% CI 1.1-5.3), and NRS 2002 had an aRR 1.6 (95% CI 0.2-10.1). Other variables that were also significantly associated with sepsis mortality included comorbidity score, SOFA score, and serum lactate level. Pathogen resistance was not identified as a significant factor contributing to sepsis-related mortality in this study.

Conclusion: Malnutrition was significantly associated with in-hospital sepsis mortality. Both PNI and SGA are equally effective in predicting sepsis mortality. The NRS 2002 is the least predictive to both PNI and SGA in predicting sepsis mortality. Other factors that also have significant association with in-hospital sepsis mortality are Charlson Comorbidity Index (CCI) score, SOFA score, and serum lactate level.

Keywords: Sepsis, mortality, malnutrition, Prognostic Nutritional Index, Subjective Global Assessment, Nutritional Risk Screening 2002

Socio-Demographic Characteristics, Income, and Lifestyle of Internists Across Indonesia: A National Cross-Sectional Survey

Lugyanti Sukrisman — 2026-07-03

Background: Internal medicine specialists have always been one of the pillars that support the health of Indonesian people. Currently, there is no available survey regarding the socio-demography, lifestyle, and income of any medical specialist in Indonesia. This study aims to report this gap in knowledge amongst internists across Indonesia. Methods: This study was a nationwide cross-sectional study and was conducted via online questionnaires by The Indonesian Society of Internal Medicine Specialists (INASIM) between December 2023 and March 2024. Participants from the existing 39 INASIM branches were selected using cluster random sampling, with a target of 20% of registered internists per branch. Of 1,568 internists invited, 1,082 (69.0%) completed the questionnaire and were included. Results: A total of 1,082 internists participated in this study, mostly male (57.7%), aged 35-49 years (57.7%), non-academic staff (64.3%), practicing as general internists (76.3%) in 3 locations (70.9%). Distribution discrepancy was observed with 58.0% of general internists and 71.5% of subspecialists practicing in urban areas only. Income analyses showed significant positive correlations with age, working years, working hours, and number of practices. Male internists had higher income than their counterparts, indicating a gender-related income gap. The location of practice did not affect income significantly. Amongst internists, there were approximately 11.1% with a history of smoking, 55.9% with daily coffee consumption, 62.9% with sleep deprivation, and more time spent being sedentary. Conclusion: This study identified distribution discrepancy, a gender-related income gap, and unhealthy lifestyle patterns among Indonesian internists, which are issues that warrant targeted policy responses. Nevertheless, these findings may support future policies on equitable workforce distribution, appropriate incentive systems, and physician wellness programs in Indonesia.

Exploring the Treatment Outcomes and Safety of Elobixibat for Chronic Constipation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Maggie Liberty — 2026-07-03

Background: Currently available laxatives usage in chronic constipation (CC) has been reported to cause various adverse events, notably melanosis coli and colonic neuromuscular disorder. Elobixibat, an ileal bile acid transporter inhibitor, appears to be a promising option for chronic constipation to counteract this challenge. This study aims to evaluate the treatment outcome and safety of elobixibat for chronic constipation. Methods: This systematic review and meta-analysis were performed on 3 search engines: PubMed/MEDLINE, ScienceDirect, and Cochrane Database of Systematic Reviews. Randomized controlled trials (RCTs) comparing elobixibat 10 mg with placebo in patients with functional chronic constipation were included. The quality of studies was assessed using the Cochrane risk of bias 2.0 tool. Statistical analyses were conducted using RevMan 5.4.1 software. Results: A total of six RCTs that met the inclusion criteria were included in this study. Results demonstrated that elobixibat markedly improved bowel movement with a significant change in spontaneous bowel movement (SBM) (MD 2.91, 95% CI 2.81 to 3.01, p<0.00001) and complete spontaneous bowel movement (MD 0.61, 95% CI 0.38 to 0.83, p<0.00001). The percentage of patients experiencing first SBM in 24 hours was significantly higher in the elobixibat group compared to the placebo group (RR 1.49, 95% CI 1.21 to 1.84, p=0.0002). Stool consistency was improved significantly in the elobixibat group (MD 1.40, 95% CI 1.09 to 1.71, p<0.00001). Moreover, the elobixibat group reported favourable safety with no serious adverse events. Conclusion: Elobixibat shows promising therapeutic efficacy in the treatment of functional chronic constipation. Elobixibat is safe and well-tolerated with minimal adverse events.

Prognostic Performance of the Clinical Frailty Scale for Predicting 30-Day Mortality in Hospitalised Indonesian Older Adults

Ressy Hastopraja — 2026-07-03

Background: Frailty is common among hospitalized elderly patients, with prevalence rates ranging from 27% to 80%. Frail individuals have a higher risk of mortality than non-frail individuals do. The Clinical Frailty Scale (CFS), developed by the Canadian Study of Health and Aging (CSHA), is a widely used tool for assessing frailty and clinical outcomes in older adults. This study aimed to evaluate the prognostic performance of the CFS in predicting 30-day mortality among elderly inpatients. Methods: This prospective cohort study included patients aged ≥ 60 years admitted to the Haji Adam Malik Central General Hospital in Medan, Indonesia. Discrimination and calibration of the CFS were evaluated using the ROC curve and Hosmer-Lemeshow tests, while logistic regression identified factors independently associated with mortality. Discrimination and calibration of the CFS were evaluated using the ROC curve and Hosmer-Lemeshow tests, while logistic regression identified factors independently associated with mortality. Results: Among 120 patients, the 30-day mortality rate was 43.3%. The Hosmer–Lemeshow test indicated good calibration (p = 0.661), and ROC curve analysis showed good discrimination (AUC = 83.2%, 95% CI 76%–90.4%). Multivariate analysis identified the C-reactive protein level, CFS score, and nutritional status as independent predictors of 30-day mortality. Conclusion: Clinical Frailty Scale (CFS) demonstrates good prognostic performance for predicting 30-day mortality among elderly inpatients, with elevated CRP, higher CFS scores, and malnutrition serving as independent predictors of death.

The Role of Group Supportive Psychotherapy on Quality of Life and Its Relationship with Heart Rate Variability and Blood Serotonin Levels in End-Stage Renal Disease (ESRD) Patients Undergoing Chronic Hemodialysis

Dian Pritasari Jeger — 2026-07-03

Background: Patients with end-stage renal disease (ESRD) undergoing chronic hemodialysis often experience reduced quality of life and autonomic dysregulation. Group supportive psychotherapy may improve psychological well-being through biopsychosocial mechanisms. This study evaluated the effects of group supportive psychotherapy on quality of life and its association with heart rate variability (HRV) and blood serotonin levels. Methods: This randomized, parallel-group, single-blind controlled trial was conducted at the Hemodialysis Unit of Dr. Cipto Mangunkusumo National General Hospital, Jakarta, from November 2024 to January 2025. Fifty-two eligible patients were randomly assigned to an intervention group receiving group supportive psychotherapy plus standard care (n = 26) or a control group receiving standard care alone (n = 26). Outcomes were assessed at baseline and post-intervention using Kidney Disease Quality of Life-36 (KDQOL-36), HRV measured by standard deviation of normal-to-normal intervals (SDNN), and plasma serotonin levels measured using enzyme-linked immunosorbent assay (ELISA). Statistical analyses included an independent t-test or Mann-Whitney test, with effect size calculation and ANCOVA adjustment for baseline values. Results: The intervention group demonstrated significantly greater improvement in KDQOL-36 scores compared with control (mean change 8.46-16.92 vs 0.27-11.36; p=0.046). After adjustment, the between-group difference remained statistically significant (p<0.001), with a large effect size (Cohen’s d = 1.16). Plasma serotonin levels were significantly higher in the intervention at post-intervention (p=0.028; r=0.30). However, no significant differences were observed in HRV (SDNN) either between groups (p=0.805) or within groups over time (p>0.05). Conclusion: Group supportive psychotherapy significantly improves quality of life and is associated with higher plasma serotonin levels in ESRD patients undergoing chronic hemodialysis. However, no significant autonomic modulation, as measured by HRV, was demonstrated.

Quality of Life Research in Cardiovascular Disease in Indonesia: A Scoping Review

Simon Salim — 2026-07-03

Background: Cardiovascular (CV) disease remains the leading cause of mortality and disability worldwide, particularly in developing countries. Beyond mortality, health-related quality of life (HRQoL) is increasingly recognized as a key outcome and is commonly assessed using patient-reported measures. In Indonesia, cultural and linguistic diversity poses challenges, as most HRQoL instruments have been developed in other contexts. This scoping review aimed to map HRQoL research in Indonesian cardiovascular disease populations by identifying validated instruments, describing study designs and measurement tools, and summarizing HRQoL outcomes. Methods: This review was registered on Figshare (DOI: 10.6084/m9.figshare.29218991) and conducted following the Joanna Briggs Institute methodology and PRISMA-ScR guidelines. Literature searches were performed in PubMed, ScienceDirect, Google Scholar, and included grey literature. Studies reporting HRQoL measurement in Indonesian populations were included. Results: A total of 54 studies were included. Both generic and disease-specific HRQoL instruments were identified. Common generic tools included SF-36, SF-12, WHOQOL-BREF, and PedsQL, while disease-specific instruments included MLHFQ, KCCQ, Seattle Angina Questionnaire, AFSS, ASTA, AFEQT, MacNew, and AQUAREL. Only several instruments have been culturally validated, while others were used without prior validation, and some validated tools remained underutilized. HRQoL was influenced by clinical, psychological, behavioral, and social factors. Conclusion: HRQoL research in Indonesia is growing but remains heterogeneous. This mismatch highlights a critical gap between research capacity and real-world implementation in Indonesia. Greater use of standardized tools and longitudinal designs is needed to strengthen patient-centered cardiovascular care.

Effect of Listening to Quran Recitation on the Quality of Life of Systemic Lupus Erythematosus Patients: A Quasi-Experimental Study

Karina Wijayanti — 2026-07-03

Background: Quality of life (QoL) is not sufficiently considered in current systemic lupus erythematosus (SLE) treatment targets, even though it’s significantly impaired. Studies have shown that higher religiousness is associated with a higher QoL. This study aimed to determine the effect of listening to Quran recitations on the QoL of SLE patients. Methods: A quasi-experimental study with a pretest-posttest study design was conducted at Cipto Mangunkusumo Hospital, Jakarta. Participants were females aged 18 years or older with SLE, Muslim, and not experiencing hearing loss. Those who didn’t regularly listen to the Quran were assigned to the control group. The intervention group consisted of patients who had previously listened to the Quran on a more regular basis, as well as those who had not. The intervention group listened to a Quran (QS. Ar-Rahman) for a minimum duration of 15 minutes, twice daily, for 40 days. A comparison of the effects of listening to the Quran within the group was conducted using a paired T-test, with a Wilcoxon test applied when necessary. p-values of less than 0.05 were considered statistically significant. Results: A total of 65 participants were included in the study, with 32 in the intervention group and 33 in the control group. The results indicated a significant increase in QoL in the intervention group (p=0.023). Additionally, there was a reduction in anxiety levels within the intervention group (p=0.030). Conclusion: Listening to Quran recitation can enhance QoL, while also decreasing anxiety in patients with SLE.

Small-Bowel Lymphoma: The Hidden Cause of Obscure Gastrointestinal Bleeding

Amanda Pitarini Utari — 2026-07-03

Obscure gastrointestinal bleeding (OGIB) accounts for approximately 5% of all gastrointestinal bleeding cases, with the small intestine being the most common source of origin. Primary small-bowel lymphoma is a rare malignancy that can present as intestinal bleeding in 2% to 22% of cases.

A 67-year-old male presented with a four-day history of diarrhea and melena, accompanied by severe anemia with a hemoglobin level of 5 g/dL. While a colonoscopy only revealed internal hemorrhoids and an ascending colon polyp, a subsequent non-contrast whole-abdomen CT scan demonstrated a 6-cm segmental small bowel wall thickening involving the proximal and distal ileum, accompanied by mesenteric fat stranding and aggressive aneurysmal dilatation. Further evaluation using antegrade enteroscopy identified a mass with central ulceration in the proximal ileum. Histopathological analysis of the ileal biopsy specimens revealed small intestinal mucosa heavily infiltrated by a diffuse, highly cellular tumor with small-to-medium neoplastic cells, confirming a malignant round cell neoplasm highly suspicious for non-Hodgkin lymphoma. This case highlights the critical clinical challenge of managing OGIB and underscores the importance of early diagnostic interventions. Utilizing CT imaging alongside device-assisted enteroscopy is vital for the prompt recognition of hidden small bowel disorders like lymphoma, enabling timely treatment, preventing life-threatening hemorrhagic complications, and improving the overall patient prognosis.

Transition from Quadrivalent to Trivalent Influenza Vaccination Compared with Continued Quadrivalent Vaccination for Preventing Severe Influenza Outcomes in Populations in Indonesia: Implications from the 2025–2026 Epidemiological Landscape

Sukamto Koesnoe — 2026-07-03

Seasonal influenza remains a global public health challenge, with an estimated 1 billion infections and 290,000-650,000 respiratory deaths each year. The 2024-2025 season recorded a high disease burden in the United States, with tens of millions of symptomatic cases and hundreds of thousands of hospitalizations, as well as the highest hospitalization rates in the FluSurv-NET surveillance era. Entering the 2025-2026 season, a shift in dominance toward influenza A(H3N2) has been observed in various regions, including the emergence of subclade K (J.2.4.1), which has spread globally and become the dominant variant in several regions. In Indonesia, surveillance data indicate an increase in influenza activity in late 2025, followed by a decline in early 2026, with the positivity rate peaking during this period before returning to low activity levels. Subclade K has been detected across multiple provinces with wide geographic distribution, and most cases present with mild to moderate clinical manifestations. Serological studies have shown reduced antigenic reactivity between the vaccine and circulating viruses; however, real-world vaccine effectiveness data indicate that protection against severe disease remains preserved, with higher effectiveness observed in children compared to adults. The World Health Organization has recommended transitioning from quadrivalent to trivalent vaccines since 2023, following the absence of the B/Yamagata lineage in global circulation since 2020. This study presents an updated overview of global and national influenza epidemiology and its implications for vaccination policy, providing a scientific basis to support consideration of transitioning to trivalent vaccines in Indonesia.

Hantavirus Infection: Review of Clinical Management

Robert Sinto — 2026-07-03

Hantavirus infection is a rodent-borne zoonotic disease that can present as Hemorrhagic Fever with Renal Syndrome (HFRS) or Hantavirus Cardiopulmonary Syndrome (HCPS). Both diseases are associated with substantial morbidity and mortality. The rise of new Hantavirus species and recurrent outbreaks worldwide has renewed interest in the epidemiology, pathogenesis, diagnosis, and management of this viral infection.
A narrative literature review was conducted using published articles, review papers, epidemiological reports, and clinical studies on Hantavirus up to 2026. Relevant evidence regarding epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, treatment, complications, and prevention was analyzed and synthesized.
Hantaviruses primarily infect endothelial cells, leading to increased vascular permeability, thrombocytopenia, and capillary leakage through immune-mediated mechanisms. HFRS affects the kidneys, and HCPS is characterized by severe cardiopulmonary symptoms, although overlap between the two syndromes has increasingly been observed. Diagnosis is based on clinical suspicion supported by epidemiological exposure history, serological testing, and virological confirmation from reverse transcription polymerase chain reaction (RT-PCR). Current management remains largely supportive, including hemodynamic stabilization, respiratory support, and renal replacement therapy when indicated. Ribavirin may provide benefit in selected HFRS cases when given early, but evidence remains inconclusive, especially for HCPS. Favipiravir has demonstrated promising antiviral activity in vitro and in animal studies, yet clinical data in humans are still lacking. Preventive measures focus primarily on minimizing exposure to infected rodents and contaminated environments, while vaccine development remains ongoing. Hantavirus infection continues to represent an important global public health concern due to its potential for severe disease and high mortality. Improved understanding of disease pathogenesis, advances in diagnostic methods, and ongoing research into antiviral therapies and vaccines are essential to improve patient outcomes and strengthen future prevention strategies.

Local Crude House Dust Extracts as a Substitute for Standardized House Dust Mite Extracts in Allergy Diagnostic and Immunotherapy

Odhi Anggani — 2026-07-03

Allergic diseases are a significant global health issue commonly triggered by house dust mite (HDM) allergens. Standardized HDM extracts are currently widely used in allergen immunotherapy (AIT) and diagnostic tests. However, in several tropical regions, such as Indonesia, these standardized extracts were either expensive, difficult to obtain, or did not represent local allergen exposure. Previous studies examined crude house dust extracts (CHDE) derived from locally collected dust as a possible substitute because they reflected the complex allergenic and other composition of the local environment. Therefore, this study aimed to review the potential of Local Crude House Dust Extracts (LCHDE) as a regionally relevant substitute source of allergens for both diagnostic and therapeutic applications. LCHDE reflects real environmental exposure, including region-specific mite, fungal, and bacterial components, which could better represent local allergen profiles. LCHDE offered a promising, cost-effective, and contextually relevant option for allergy diagnosis in developing regions. However, its application in immunotherapy necessitated rigorous allergen profiling, and regional collaboration was crucial to establish a CHDE suitable for clinical use.

Midwall Late Gadolinium Enhancement and Native T1 Elevation in Chronic Myocarditis-Related Dilated Cardiomyopathy: An Evidence-Based Case Report

Praveen Septian Hadi — 2026-07-03

Background: Cardiovascular magnetic resonance (CMR) is the reference standard for non-invasive myocardial tissue characterization, with proven value in diagnosing and prognosticating myocarditis and non-ischemic dilated cardiomyopathy (DCM). This study aimed to present a case of chronic myocarditis/DCM phenotype and integrate it with evidence from high-quality studies on CMR diagnostic and prognostic utility. Methods: An evidence-based case report (EBCR) framework was applied. Literature was systematically searched across PubMed, Cochrane Library, and ScienceDirect for studies evaluating CMR in myocarditis or DCM using the 2018 Lake Louise Criteria or equivalent multiparametric protocols. Results: A 45-year-old female presented with mild exertional dyspnea. CMR revealed midwall late gadolinium enhancement (LGE) in the basal-to-mid interventricular septum, elevated native T1 values, and no T2 elevation. These findings fulfilled the T1-based criterion for chronic myocardial injury but not the T2-based edema criterion, indicating prior inflammation and residual fibrosis. Across the included studies, midwall LGE correlated with histopathology-confirmed myocarditis, predicted all-cause mortality and sudden cardiac death, and signaled risk of progressive ventricular dysfunction. Native T1 mapping improved sensitivity for detecting diffuse fibrosis even in the absence of widespread LGE. The patient’s imaging profile aligns with chronic myocarditis, carrying a heightened arrhythmic and heart failure risk. Evidence supports intensified surveillance and consideration for device therapy in such profiles. Conclusion: CMR, through combined LGE and mapping techniques, offers essential diagnostic clarity and prognostic stratification in chronic myocarditis/DCM, enabling precise and individualized clinical management.