Ppt Lapkas Meningitisa

7/28/2019 Ppt Lapkas Meningitisa

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MENINGITIS

Presenters : Shella Novita

Wizni Nadra Lubis

Supervisor : dr. Tina C. L. Tobing, Sp. A (K)


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Definisi

Meningitis is a disease caused by the inflammation

of the protective membranes covering the brain andspinal cord known as the meninges.


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Etiologi

Meningitis

Bacterial

Viral

Fungal

Parasitic

Non

Infectious


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Pathogenesis

causative agent

Invasion of the central nervous system via the blood

stream

Migrate to Subarachnoid

The inflammatory response in

piamater

,

arachnoid

,

cerebrospinal fluid, and ventricular

Exudate

spread across the cranial nerves and spinal

nerves

neurological damage


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Pathogenesis and Pathophysiology


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Pathogenesis of Tuberculous

Meningitis

BTA enter the body

Common through

inhalation, rare in the skin,

gastrointestinal tract

multiplication

Pulmonary infection /

other focus of infection

Spread homogeneous

Meningens

forming tubercles

BTA is inactive / dormant


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When theimmune

system is weak

Rupture ofmeningeal

tubercles

The release ofBTA into the

subarachnoidMeningitis


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Diagnosis

fever, anorexia and poor feeding,

headache, symptoms of upperrespiratory tract infection,myalgias, arthralgias, tachycardia,hypotension

nonspecificfindings

nuchal rigidity, back pain, Kernigsign and Brudzinski sign

Meningealirritation

Sign and Symptoms


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Lumbar Puncture

Latex Agglutination Tests

PCR

sTREM-1

Blood Culture


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Management


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Antibiotic

Glucocorticoid

Therapy


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MEDICAL RECORD

Name AK

Age 14 years 7 months oldSex Male

Address Namo Rambe

No.RM 54.33.40

Date of hospitaladmission January 05th 2013


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History Taking

AK, 14 years 7 months old, male, weight 35 kg, height 158 cm,was admitted to Haji Adam Malik Hospital at the Infection UnitPediatric Department on January 05th 2013 with main complaintaltered level of consciousness at admission to the ER. It started

seven days ago starting from seizure once, with duration less than 5minute and frequency less than 3 times a day. Seizure generalized,with eyes rolling up, jerking extremities, and patient fall to sleepafter seizure over. Patient experienced fever since three weeks ago.Fever is fluctuating without chills, and decreased with antipiretic

drugs. Headache was found since three weeks ago. Cough was notfound. History of contact with an infected person with chroniccoughs was not found. No history of trauma was found. Theres nohistory of complete immunization and BCG scar.


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History ofBirth

Appropriate for gestation age (40 weeks),spontaneously, crying immediately and loudly,

history of cyanotic (-), birth weight = 3700 grHistory ofDevelopment

6 months old : sitting 10 months old : standing 14 months old : walking

History ofFeeding

0-3 months old : breast milk 3-18 months old : breast milk + rice porridge 18 months old until now : family food

History of

Immunitation

DPT : (-)

Polio : 1 times BCG : (-) Measles : (-) Hep. B : (-)


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History ofprevious illness

Varicella at the age of 10 years oldThypoid fever 2 months ago Patient was treated for three day in RSHerna by neurologist and diagnosed as

meningitis tuberculosis.

History ofpreviousmedication

Injection of Meropenem, Dexamethasone,Ranitidine and Dilantin


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Physical Examination

Presence

Status

Sensorium : GCS7 (E2V1M4), temperature:

37,8C. Anemic (-), dyspnea (-), cyanotic (-),edema (-), icteric (-).Body weight (BW): 35 kg, body length (BL): 158cm, BW/BL : 97.8%

Head Eye: Light reflexes (+/+), anisochoric pupil, right = 2 mm, left = 3 mm, pale inferior conj.palpebra (-/-). Ear/ mouth: normal. Nose: nasalecanule and NGT (+)

Neck Lymph node enlargement (-), nuchal rigidity (+)

Thorax Symmetrical fusiform , retraction (-)HR: 90 bpm, regular, murmur (-)RR : 18 bpm, regular, rales (-)


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Abdominal Soepel, peristaltic (+), liver and spleen not

palpable

Extremities Pulse = 90 bpm, regular, adequatepressure/volume. Warm acral, CRT < 3 seconds.

Physiologic Reflex : Right APR/KPR (+ /+),

Left APR/KPR (+/+)Pathologic Reflex : Babinsky (-), Chaddock (-),

Schuffner (-),Oppenheim (-/-)

Meningeal Reflex : Brudzinsky I/II (-/-)Genitalia Male, within normal limit


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Laboratorium:

Test(03-1-2013) Results Normal ValueComplete Blood CountHemoglobin (Hb) 11.40 g % 13.018.0 g %Erytrocyte (RBC) 5.09 x 106/mm3 4.56.5 x106/mm3Leukocyte (WBC) 19.80 x 103/mm3 4.510.0 x103/mm3Hematocrite 35 % 38 - 52 %Trombocyte (PLT) 217 x 103/mm3 150450 x103/mm3MCV 70.00 fL 76 - 96 fLMCH 22.00 pg 27 - 32 pgMCHC 31.00 g % 3050 g %ESR 35 mm/h 010 mm/h

Cell Count:

Neutrofil 82 % 4060 % Limfosit 11 % 2040 % Monosit 5 % 48 % Eosinophil 1 % 13 % Basophil 0% 01 %

Renal Function Test:


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Renal Function Test: Ureum CreatinineElectrolyte: Na K ClSerology:IgM Salmonella typhi

30 mg/dL0.71 mg/dL135 mEq/L4.3 mEq/L

100 mEq/L

+6

15-45 mg/dL0.7-1.2 mg/dL

135-148 mEq/L3.8-5.4 mEq/L

94-111 mEq/L 2 : Negative

Test (05-1-2013) Results Normal ValueANALYSIS OF CEREBROSPINAL FLUIDColor Clear ClearLDH 200 U/L < 200 U/LTotal Protein 103.20 mg/dL < 45Leukocyte Count 0.56 x 103/uL < 32 x103/uLErytocyte Count 0.002 x 106/uLGlucose 20.2 mg/dL 4076 mg/dLpH 8 78MN Cell 89.5 %PMN Cel 10.5 %


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Workingdiagnose

Meningitis Serous

Management Nasale canule oxygen 0.5-1 L/minute

30 Head elevationIVFD D5% NaCl 0,9% 25 gtt/minute microdripsMannitol 20% injection 125cc/8 hours/IV (donewithin 1 hour)

Dexamethasone injection 4mg/6 hours/IVRifampicin 1x525 mgINH 1x350 mgPyrazinamid 1x875 mgEthambutol 1x525 mg

Sonde voiding diet 1800 kkal with 70 gramprotein

Investigationplanning

Consult to neurology divisionConsult to respirology division


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Chest X-ray (3-1-2013)

Conclusion : Normal chest x-ray


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Head CT-Scan (3-1-2013)

Conclusion : Mild Dilatation Pan Ventricle


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Brain MRI (3-1-2013)

Conclusion : Meningitis with inflamation process in dorsal

midbrain and right portion of cerebellum and hydrocephalus and

cerebral infarct in right basal ganglia


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FOLLOW UP

F ll U J 6th 2013


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Follow Up January 6th 2013

S : Altered level of consciousness (+)O: Sensorium : GCS 7 (E2V1M4), weight = 35 Kg, Temperature = 37,2

0CHead : Eye: Light reflexes (+/+), anisochoric pupil, right = 2 mm, left = 3 mm,

pale inferior conj. palpebra (-/-). Ear/ mouth: normal. Nose: nasale canule and

NGT (+)Neck : Lymph node enlargement (-), nuchal rigidity (+)Thorax : Symmetrical fusiform , retraction (-)

HR: 90 bpm, regular, murmur (-)RR : 28 bpm, regular, rales (-)

Abdominal : Soepel, peristaltic (+), liver and spleen not palpableExtremities : Pulse = 90 bpm, regular, adequate pressure/volume. Warm acral, CRT

< 3 seconds. Blood pressure = 90/40 mmHgPhysiologic Reflex : Right APR/KPR (+ /+), Left APR/KPR (+/+)Pathologic Reflex : Babinsky (-), Chaddock (-), Schuffner (-),

Oppenheim (-/-)

Meningeal Reflex : Brudzinsky I/II (-/-)


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A : Meningitis SerousP :

Nasale canule oxygen 0.5-1 L/minute 30 Head elevation IVFD D5% NaCl 0,9% 25 gtt/minute microdrips Ceftriaxone injection 1g/12 hours/IV (H2) Mannitol 20% injection 125cc/8 hours/IV (done within 1 hour) Dexamethasone injection 4mg/6 hours/IV Rifampicin 1x525 mg INH 1x350 mg Pyrazinamid 1x875 mg Ethambutol 1x525 mg Sonde voiding diet 1800 kkal with 70 gram protein



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Pediatric Neuorologist Consultation:Diagnose : Meningitis SerousTreatment : Phenytoin 700 mg injection in 70 cc NaCl (done within 20 minutes), for

next 12 hours phenytoin 90 mg in 9 cc NaCl 0.9%/ 12 hoursMantoux test done in left volar (lower arm). Read at Thursday, January 10th

2013.Ophtalmologist Consultation:

Diagnose : Conjunctivitis OSTreatment : C. floxa 4x1 gtt (OS)

C. lyteers 4x1 gtt (ODS)Eyes covered by wet (by RL) sterile gauze

Electrolyte Check Result: Hyponatremia (Na = 125 mEq/L).Corrected by NaCl 3% 420 cc (105 gtt/minute microdrips)Balance :Input = 845cc Different = - 255cc Output = 1100cc

F ll U J 8th 2013


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S : Altered level of consciousness (+), Fever (+)

A : Meningitis Serous + Conunctivitis OS

P :

Ceftriaxone injection 1g/12 hours/IV aff IVFD NaCl 3% 350cc/12 hours (done within 2 hours) electrolyte recheck

Diamox pulvers 3x250 mg

Ibuprofen pulvers 4x400 mg

Phenytoin injection with maintenance dose 90 mg/12 hour/iv diluted in 9 cc NaCl 0.9%

is given over in 20 minute

Eyes cover with wet (RL) sterile gauze

Balance :

Input = 1440cc Different = - 485cc Output = 1925cc

Urine Dipstic:

LEU NIT URO PRO pH BLO SG KET BIL GLU

- - 0.2 - 6.0 +++ 1.005 - - -


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Test(8-1-2013) Results Normal Value

Electrolyte: Na K Cl Ca P Mg

133 mEq/L4.9 mEq/L102 mEq/L8.3 mEq/L2.8 mEq/L2.27 mEq/L

135-155 mEq/L3.6-5.5 mEq/L96-106 mEq/L9.2-11 mEq/L3.4-6.2 mEq/L1,3-1,8 mEq/L


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S : Altered level of consciousness (+), Blood in NGT (+), Fever (-)


P : Sonde voiding diet 1800 kkal with 70 gram protein fasting for cooling spooling

Balance :

Input = 775cc Differernt = - 425cc Output = 1250cc

Urine Dipstic:


- - 0.2 7.0 ++ 1.005 - - -


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S : Altered level of consciousness (+), Clear NGT (+)


P :

Nebule of NaCl 0.9% 2.5cc + Ventolin

Suction regularly every 2 hours

Sonde voiding diet 1800 kkal with 70 gram protein

Balance :


Urine Dipstic:

LEU NIT URO PRO pH BLO SG KET BIL GLU- - 0.2 5.0 + 1.025 - + -


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Test(8-1-2013) Results Normal ValueBlood Gases: pH pCO2 pO2 HCO3 Total CO2 BE SaO2

7.42918.4 mmHg107.3 mmHg11.9 mmol/L12.5 mmol/L-10.0 mmol/L

98%

7.35-7.4538-42 mmHg

85-100 mmHg22-26 mmol/L

19-25 mmol/L

(-2)(+2) mmol/L95-100%


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S : Altered level of consciousness (+)


Balance :

Input = 1430cc Differernt = 95cc Output = 1325cc

Urine Dipstic:LEU NIT URO PRO pH BLO SG KET BIL GLU

- - 0.2 + 6.0 - 1.015 - -


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S : Altered level of consciousness (+) , vesicles on left side of neck (+), blood in urinary

cathteter (+)

O : Head : OFT (+)

Neck : vesicle (+) multiple on left side of neck, ulcer (+) on back side of neck

A : Meningitis Serous + Conjunctivitis OS + Susp. Herpes Zooster + Hematuria ec Susp.

UTI + Pressure ulcer

P :

Zinc 1x10 mg

Chest physiotherapy

Balance :



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Test(12-1-2013) Results Normal ValueElectrolyte: Na K Cl Ca P Mg

132 mEq/L4.0 mEq/L107 mEq/L7.5 mEq/L3.6 mEq/L

1.95 mEq/L

135-155 mEq/L3.6-5.5 mEq/L96-106 mEq/L9.2-11 mEq/L3.4-6.2 mEq/L

1,3-1,8 mEq/L

Hypocalcemia Correction: 0.5xBB = 0.5x35 = 17.5 cc Ca gluconas in 17.5 cc Dextrose 5%

(done within 20 minutes)


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Test(12-1-2013) Results Normal ValueUrinalysis Color Glucose Bilirubin Keton SG pH Protein Urobilinogen Nitrit Blood

Yellow

NegativeNegativeNegative

1.0256.0

NegativeNegativeNegativePositive

YellowNegativeNegativeNegative

1.005-1.0305-8


Urine Sediment: Eritrocyte 10-15 < 3 Leucocyte 3-5 < 6 Epitel 0-1 Cast Negative Negative Cristal Negative


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S : Altered level of consciousness (+), vesicles on left side of neck (+), blood in urinary

cathteter (+)



Balance :


Urine Dipstic:


- - 0.2 5.0 - 1.015 - - -



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Follow Up January 14 2013


cathteter (+)



P :

Gentamycin cream

Acyclovir cream

Acyclovir 5x800 mg

Blood Cultur : No micoorganisme growth

Balance :

Input = 1400cc Differernt = -100cc Output = 1500cc

Urine Dipstic:


- - 0.2 ++ 6.0 - 1.015 - -



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o ow Up J u y 5 0 3


cathteter (-)

A : Meningitis Serous + Conjunctivitis OS + Susp. Herpes Zooster + Susp. UTI +

Pressure ulcer

Balance :


Urine Dipstic:


- + 0.2 - 6.0 1.010 - - -


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Yellow


1.0205.0



1.005-1.0305-8


Urine Sediment: Eritrocyte 1-3 < 3 Leucocyte 0-1 < 6 Epitel 0-1 Cast Negative Negative Cristal Negative Others Yeast (+)


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Nephrology Division Consultation : Repeat Urinalysis and urine culturMedical Rehabilitation Consultation : Treatment every 3 days as IR, Chest FR

and Body moving


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S : Altered level of consciousness (+), vesicles on left side of neck (+)

A : Meningitis Serous + Conjunctivitis OS + Susp. Herpes Zooster + Susp. UTI + Pressure

ulcer

Balance :


Urine Dipstic:


- + 0.2 - 6.0 1.010 - - -

Test(16-1-2013) Results Normal Value


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Complete Blood CountHemoglobin (Hb) 10.00 g % 12.014.4 g %Erytrocyte (RBC) 4.31 x 106/mm3 4.204.87 x106/mm3Leukocyte (WBC) 18.07 x 103/mm3 4.511.0 x103/mm3Hematocrite 31.70 % 43 - 49 %Trombocyte (PLT) 378 x 103/mm3 150450 x103/mm3MCV 73.50 fL 85 - 95 fLMCH 23.20 pg 28 - 32 pgMCHC 31.50 g % 3335 g %RDW 23.40 % 11,614,8 %MPV 7.90 fL 7,210,2 fLPCT 0.30 %PDW 7.6 fLESR 44 mm/h < 15 mm/hCell Count: Neutrofil 86.80 % 3780 % Limfosit 5.30 % 2040 % Monosit 4.10 % 28 % Eosinophil 3.70 % 16 % Basophil 0.100 % 01 % Neutrophil absolute 15.68x103/L 2.47.3 x103/L Limfosit absolute 0.96x103/L 1.75.1 x103/L Monosit absolute 0.74x103/L 0.20.6 x103/L

Eosinophil absolute

0.67x10

3

/L

0.100.30 x10

3

/L

Basophil absolute 0.02x103/L 00,1 x103/L


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Liver Function: Total Bilirubin Direct Bilirubin ALP SGOT SGPTRenal Function: Ureum

Creatinine

Uric acidElectrolyte: Na K

Cl

Ca P Mg

0.56 mg/dL0.19 mg/dL

96 U/L43 U/L45 U/L

24.70 mg/dL0.36 mg/dL

3.9 mg/dL


< 1 mg/dL0-0.2 mg/dL< 390 U/L< 38 U/L< 41 U/L

< 50 mg/dL0.57-0.87 mg/dL

< 7.0 mg/dL



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S : Altered level of consciousness (+), vesicles on left side of neck(+)

A : Meningitis Serous + Conjunctivitis OS + Cristalina Miliaria + Susp. UTI + Pressure

ulcer

P :

Acyclovir cream 2x1 aff Acyclovir 5x800 mg aff

Urine Cultur : Fungal (+)

Dermatologist Consultation : Diagnose : Cristalina Miliaria

Treatment : Hydrocortisone 2.5% sue 2x1

Balance :



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A : Meningitis Serous + Conjunctivitis OS + Cristalina Miliaria + Susp. UTI + Pressure

ulcer

P :

Hydrocortisone 2.5% cream 2x1

Balance :


Urine Dipstic:


+ - 0.2 - 6.0 - 1.015 - - -


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Test(18-1-2013) Results Normal ValueElectrolyte: Na K Cl Ca P Mg



Hyponatremia Correction : (135-118) x 0.6 x 35 = 357 mEq/L

Corrected by : NaCl 3% = (357/513) x 1000 = 695 L (done within 4 hours)

174 gtt/i microdrips = 56 gtt/i macrodripsHypocalcemia Correction : 0.5 x 35 = 17.5 cc Ca gluconas in 17.5 D5% IV Bolus

(done within 20 minutes)

T (18 1 2013) Results Normal Value


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Yellow


1.0206.0



1.005-1.0305-8


Urine Sediment: Eritrocyte 5-10 < 3 Leucocyte 10-15 < 6 Epitel 0-1 Cast Negative Negative Cristal Oxalat 1-2 Others Yeast (+), hifa (+)


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A : Meningitis Serous + Conjunctivitis OS + Cristalina Miliaria + Susp. UTI +

Pressure ulcer

P :

Fluconazole injection loading dose 12 mg/kgBB/IV (400 mg IV)

maintenance dose 6 mg/kgBB/IV (100 mg IV)

Balance :



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Pressure ulcer

Balance :Input = 1550cc Differernt = 150cc Output = 1400cc

Urine Dipstic:


- - 0.2 - 6.0 ++ 1.030 - - -


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Pressure ulcer

Balance :Input = 2100cc Differernt = 800cc Output = 1700cc

Urine Dipstic:


- - 0.2 - 6.0 - 1.015 - - -


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DISCUSSION

Theor Case


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Theory CaseSymptoms often appear are fever,headache, and stiff neck and someaccompanying symptoms such as

nausea, vomiting, photophobia,impaired mental status, severemeningitis symptoms that may occur isa seizure until coma.

Some of the symptoms above can befound on the case, i.e., fever,headache, stiff neck accompanied by

weight of the seizure symptoms ofmeningitis.

Diagnosis is confirmed by examination

of cerebrospinal fluid (CSF) andidentification of bacteria, viruses orfungi, by culture or detection antigen.

Lumbar puncture performed on the

patient. Examination showed thatthere was no increase in the amount ofprotein CSF. CSF normal protein levels,a slight increase, or decrease can befound in meningitis viral.

For tuberculous meningitis, thediagnosis is confirmed based on clinicalfeature and ziehl-neelsen gramstaining.

In this case, the patient show alteredlevel of consciousness, seizure,recurrent fever and headache thatindicates sign of central nervoussystem infection.


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Theory CaseOn acute bacterial meningitis and thechronic decline in glucose levels (< 40mg/dL) and high protein (usually 100-500 mg/dL)8. In some studies, theanalysis of culture fluid CSS with

negative bacterial colonies are oftencaused because the patient hasreceived antibiotic therapy before LP.

CSF fluid analysis results of thepatients showed clear color with a lowin glucose levels (20.2 mg/dl normalvalue 40-76 mg / dl) and high proteinlevels (103.20 mg/dL normal


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Summary

Patients, M, a 14 days old baby wasdiagnosed with meningitis ec Staphylococcusepidermidis. A comprehensive treatment to

manage meningitis has been conducted tothis patient. He has been stabilized, and thenhe discharge by his own request.


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Documents

Ppt Lapkas Meningitisa