Skip to main content
Advertisement
  • Neurology.org
  • Journals
    • Neurology
    • Clinical Practice
    • Genetics
    • Neuroimmunology & Neuroinflammation
    • Education
  • Online Sections
    • Neurology Video Journal Club
    • Inclusion, Diversity, Equity, Anti-racism, & Social Justice (IDEAS)
    • Innovations in Care Delivery
    • Practice Buzz
    • Practice Current
    • Residents & Fellows
    • Without Borders
  • Collections
    • COVID-19
    • Disputes & Debates
    • Health Disparities
    • Infographics
    • Null Hypothesis
    • Patient Pages
    • Topics A-Z
    • Translations
  • Podcast
  • CME
  • About
    • About the Journals
    • Contact Us
    • Editorial Board
  • Authors
    • Submit a Manuscript
    • Author Center

Advanced Search

Main menu

  • Neurology.org
  • Journals
    • Neurology
    • Clinical Practice
    • Genetics
    • Neuroimmunology & Neuroinflammation
    • Education
  • Online Sections
    • Neurology Video Journal Club
    • Inclusion, Diversity, Equity, Anti-racism, & Social Justice (IDEAS)
    • Innovations in Care Delivery
    • Practice Buzz
    • Practice Current
    • Residents & Fellows
    • Without Borders
  • Collections
    • COVID-19
    • Disputes & Debates
    • Health Disparities
    • Infographics
    • Null Hypothesis
    • Patient Pages
    • Topics A-Z
    • Translations
  • Podcast
  • CME
  • About
    • About the Journals
    • Contact Us
    • Editorial Board
  • Authors
    • Submit a Manuscript
    • Author Center
  • Home
  • Latest Articles
  • Current Issue
  • Past Issues
  • Residents & Fellows

User menu

  • Subscribe
  • My Alerts
  • Log in

Search

  • Advanced search
Neurology
Home
The most widely read and highly cited peer-reviewed neurology journal
  • Subscribe
  • My Alerts
  • Log in
Site Logo
  • Home
  • Latest Articles
  • Current Issue
  • Past Issues
  • Residents & Fellows

Share

January 08, 2019; 92 (2) Global Perspectives

Barriers to diagnosis and management of CNS infections in Indonesia

Darma Imran, Sekar Satiti, Paulus Sugianto, Riwanti Estiasari, Kartika Maharani, David Pangeran, Putri Widya Andini, Badrul Munir, Arthur H.P. Mawuntu, Ni Made Susilawathi, Kiking Ritarwan, O.S. Hartanto, Meity Frida, Ahmad Rizal Ganiem, Dede Gunawan, Sofiati Dian, A.A.R. Sudewi, Reinout van Crevel
First published January 7, 2019, DOI: https://doi.org/10.1212/WNL.0000000000006732
Darma Imran
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sekar Satiti
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Paulus Sugianto
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Riwanti Estiasari
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kartika Maharani
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David Pangeran
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Putri Widya Andini
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Badrul Munir
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Arthur H.P. Mawuntu
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ni Made Susilawathi
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kiking Ritarwan
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
O.S. Hartanto
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Meity Frida
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ahmad Rizal Ganiem
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Dede Gunawan
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sofiati Dian
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
A.A.R. Sudewi
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Reinout van Crevel
From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Full PDF
Citation
Barriers to diagnosis and management of CNS infections in Indonesia
Darma Imran, Sekar Satiti, Paulus Sugianto, Riwanti Estiasari, Kartika Maharani, David Pangeran, Putri Widya Andini, Badrul Munir, Arthur H.P. Mawuntu, Ni Made Susilawathi, Kiking Ritarwan, O.S. Hartanto, Meity Frida, Ahmad Rizal Ganiem, Dede Gunawan, Sofiati Dian, A.A.R. Sudewi, Reinout van Crevel
Neurology Jan 2019, 92 (2) 104-106; DOI: 10.1212/WNL.0000000000006732

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Permissions

Make Comment

See Comments

Downloads
676

Share

  • Article
  • Figures & Data
  • Info & Disclosures
Loading

Little is known about the management and outcome of CNS infections in Indonesia (population: approximately 261 million), and the burden of CNS infections is increasing as result of a rapidly growing HIV epidemic. Indeed, in a recent study in Jakarta,1 54% of patients with a CNS infection were HIV-infected, vs 25% in a similar study conducted in Bandung, the second largest city on Java.2 Establishing the etiology of CNS infections is important for clinical management and outcome, but anecdotal evidence suggests that there are major gaps in clinical management, including a failure to recognize CNS infections, perform appropriate diagnostics, or initiate necessary drug treatment. In this study, we address some of these barriers by interviewing a group of Indonesian neurologists.

On behalf of the Indonesian Neurologic Association, neurologists who attend the National Neurology Conference (July 27–30, 2017, Yogyakarta) were given questionnaires to complete with respect to the frequency and type of CNS infections and possible barriers in diagnosis and treatment. The questionnaire was developed and piloted in Cipto Mangunkusumo Hospital, Jakarta, and adjusted with feedback from the neuroinfection working group.

The anonymous paper questionnaire (available as supplementary material, links.lww.com/WNL/A775) was completed by 288 neurologists (median age 41 years, 56% female) from tertiary (19%), regional (48%), or district (30%) hospitals in Java/Bali (62%), Sumatra (22%), Sulawesi (7%), Kalimantan (6%), and the eastern islands including Papua (3.2%). Most (67%) had worked fewer than 10 years since their neurology training. Almost all neurologists (93%) had seen presumptive CNS infections in the last 3 months; however, only 15% had performed lumbar puncture (LP) during this same period. More recently qualified neurologists and those working in regional hospitals reported a higher number of CNS infections and LPs.1 Neurologists' considerations not to perform LP included “unfavorable condition of the patient,” logistical issues like lack of LP kits, and concerns regarding possible blame from the family if complications would occur (table). Fear of complications, such as pain, paralysis, and death, was also reported as a reason for patient reluctance to undergo LP. Most neurologists mentioned shock (90%), raised intracranial pressure (89%), brain herniation (87%), and papilledema (86%) as contraindications for LP, but 35% also mentioned HIV infection as contraindication for LP. When asked what blood examinations they would like to order in approaching suspected CNS infection cases, only 15 (5%) spontaneously mentioned HIV testing.

View this table:
  • View inline
  • View popup
Table

Experience of Indonesian neurologists (n = 288) regarding diagnosis and management of CNS infection

With regard to specific diagnosis and treatment, serious barriers were identified. The majority of neurologists reported working in a hospital where CT scans (81%) and routine CSF examination (73%) are available. However, only a small number mentioned having access to specific microbiological testing for tuberculous meningitis, cryptococcal meningitis, and viral encephalitis (table). Similarly, many reported a lack of drug treatment for cerebral toxoplasmosis or cryptococcal meningitis (table). In daily practice, the situation might be even more difficult, as supply of certain tests (e.g., Xpert MTB/RIF cartridges) or medication (e.g., amphotericin B) is often interrupted, or costs are not covered by patients' insurance.

Based on our findings, several conclusions can be drawn. First, it seems that neurologists in Indonesia frequently encounter patients with suspected CNS infections, but often fail to do LP. A previous report from Uganda described how educational material helped decrease patient refusal to undergo LP.3 Our data suggest that it may be at least as important to improve doctors' knowledge and skills. Experienced groups with an interest in CNS infections in Bandung and Jakarta who have reported high rates of large-volume LPs, with <5% refusal rate, might take the lead in educating other neurologists in Indonesia.1,2 Second, many neurologists mentioned having no access to appropriate diagnostics and specific microbiological testing, something that could be defined as a health systems constraint. WHO has defined 6 building blocks of a health system (service delivery, health workforce, information, medical products and technologies, financing, and leadership), which were used recently for constraints analysis for neurologic disease in Timor-Leste, a low-income country neighboring Indonesia.4 One could apply a similar approach specifically for CNS infections. Our third conclusion is that HIV testing does not seem standard for patients with suspected CNS infection, even though a patient's HIV status is relevant in terms of the etiology and management of CNS infections, and that many neurologists consider HIV infection as a contraindication for doing LP. This is worrying, as in a recent cohort study in Jakarta we found that 54% of adult patients with CNS infections were HIV-infected, with half of this group diagnosed with HIV infection previously, but only a minority receiving antiretroviral therapy, and with a median CD4 cell count of 30 μL both among newly and previously diagnosed patients.1 These findings and those of the present study underscore the urgent need to address the many barriers to providing good care for patients with suspected or proven CNS infections in Indonesia, as in many low- or middle-income countries. We have reported our findings to the Indonesian Ministry of Health and National Neurology Association. As a next step, based on our findings, we intend to perform a more detailed qualitative and quantitative assessment to prioritize and address amendable gaps in care for patients with CNS infections, as was previously done for management of child contacts of tuberculosis patients in Indonesia.5

Author contributions

Darma Imran: study concept and design, acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content, study supervision. Sekar Satiti: study concept and design, acquisition of data. Paulus Sugianto: study concept and design, acquisition of data. Riwanti Estiasari: study concept and design, critical revision of the manuscript for important intellectual content, study supervision. Kartika Maharani: analysis and interpretation, critical revision of the manuscript for important intellectual content. David Pangeran: acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content. Putri Widya Andini: analysis and interpretation, critical revision of the manuscript for important intellectual content. Badrul Munir: study concept and design, acquisition of data. Arthur H.P. Mawuntu: study concept and design, acquisition of data. Ni Made Susilawati: study concept and design, acquisition of data. Kiking Ritarwan: study concept and design, acquisition of data. O.S. Hartanto: study concept and design, acquisition of data. Meity Frida: study concept and design, acquisition of data. Ahmad Rizal Ganiem: study concept and design, acquisition of data, critical revision of the manuscript for important intellectual content, study supervision. Dede Gunawan: study concept and design. Sofiati Dian: study concept and design, acquisition of data. A.A.R. Sudewi: study concept and design, acquisition of data, study supervision. Reinout van Crevel: study concept and design, analysis and interpretation, critical revision of the manuscript for important intellectual content, study supervision.

Study funding

The study was supported by the Indonesian Neurological Association.

Disclosure

D. Imran received a grant from the Indonesian Neurological Association. S. Satiti, P. Sugianto, R. Estiasari, K. Maharani, D., P. Widya Andini, B. Munir, A. Mawuntu, N. Susilawati, K. Ritarwan, O. Hartanto, M. Frida, A. Rizal Ganiem, D. Gunawan, S. Dian, A. Sudewi, and R. van Crevel report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • © 2019 American Academy of Neurology

References

  1. 1.↵
    1. Imran D,
    2. Estiasari R,
    3. Maharani K, et al
    . Presentation, etiology and outcome of brain infections in an Indonesian hospital: a cohort study. Neurol Clin Pract Epub 2018 Sep 13.
  2. 2.↵
    1. Ganiem AR,
    2. Parwati I,
    3. Wisaksana R, et al
    . The effect of HIV infection on adult meningitis in Indonesia: a prospective cohort study. AIDS 2009;23:2309–2316.
    OpenUrlPubMed
  3. 3.↵
    1. Thakur KT,
    2. Mateyo K,
    3. Hachaambwa L, et al
    . Lumbar puncture refusal in sub-Saharan Africa: a call for further understanding and intervention. Neurology 2015;84:1988–1990.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    1. Mateen FJ,
    2. Martins N
    . A health systems constraints analysis for neurologic diseases: the example of Timor-Leste. Neurology 2014;82:1274–1276.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Rutherford ME,
    2. Ruslami R,
    3. Anselmo M, et al
    . Management of children exposed to Mycobacterium tuberculosis: a public health evaluation in West Java, Indonesia. Bull World Health Organ 2013;91:932–941A.
    OpenUrl

Disputes & Debates: Rapid online correspondence

No comments have been published for this article.
Comment

REQUIREMENTS

If you are uploading a letter concerning an article:
You must have updated your disclosures within six months: http://submit.neurology.org

Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment.

If you are responding to a comment that was written about an article you originally authored:
You (and co-authors) do not need to fill out forms or check disclosures as author forms are still valid
and apply to letter.

Submission specifications:

  • Submissions must be < 200 words with < 5 references. Reference 1 must be the article on which you are commenting.
  • Submissions should not have more than 5 authors. (Exception: original author replies can include all original authors of the article)
  • Submit only on articles published within 6 months of issue date.
  • Do not be redundant. Read any comments already posted on the article prior to submission.
  • Submitted comments are subject to editing and editor review prior to posting.

More guidelines and information on Disputes & Debates

Compose Comment

More information about text formats

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
NOTE: The first author must also be the corresponding author of the comment.
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g. higgs-boson@gmail.com
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Publishing Agreement
NOTE: All authors, besides the first/corresponding author, must complete a separate Publishing Agreement Form and provide via email to the editorial office before comments can be posted.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

You May Also be Interested in

Back to top
  • Article
    • Author contributions
    • Study funding
    • Disclosure
    • Footnotes
    • References
  • Figures & Data
  • Info & Disclosures
Advertisement

Related Articles

  • No related articles found.

Topics Discussed

  • All global neurology
  • Encephalitis
  • Meningitis
  • HIV

Alert Me

  • Alert me when eletters are published
Neurology: 98 (24)

Articles

  • Ahead of Print
  • Current Issue
  • Past Issues
  • Popular Articles
  • Translations

About

  • About the Journals
  • Ethics Policies
  • Editors & Editorial Board
  • Contact Us
  • Advertise

Submit

  • Author Center
  • Submit a Manuscript
  • Information for Reviewers
  • AAN Guidelines
  • Permissions

Subscribers

  • Subscribe
  • Activate a Subscription
  • Sign up for eAlerts
  • RSS Feed
Site Logo
  • Visit neurology Template on Facebook
  • Follow neurology Template on Twitter
  • Visit Neurology on YouTube
  • Neurology
  • Neurology: Clinical Practice
  • Neurology: Genetics
  • Neurology: Neuroimmunology & Neuroinflammation
  • Neurology: Education
  • AAN.com
  • AANnews
  • Continuum
  • Brain & Life
  • Neurology Today

Wolters Kluwer Logo

Neurology | Print ISSN:0028-3878
Online ISSN:1526-632X

© 2022 American Academy of Neurology

  • Privacy Policy
  • Feedback
  • Advertise