TBM Case Report (tuberculose meningitis)

8/13/2019 TBM Case Report (tuberculose meningitis)

http://slidepdf.com/reader/full/tbm-case-report-tuberculose-meningitis 1/43

TUBERCULOUS MENINGITIS

Supervisor:

dr. Ridwan M Daulay, Sp.A(K)

Presentator:

Lee Wei Lun 080100419

CASE REPORT

PEDIATRICS DEPARTMENT

FACULTY OF MEDICINE

UNIVERSITY OF NORTH SUMATERA

HAJI ADAM MALIK GENERAL HOSPITAL CENTER

MEDAN 2013



Definition

The disease caused by the inflammation of

the protective membranes covering the

brain and spinal cord known as the

meninges

EtiologyBacterial, Viral, Fungal, Parasitic,

Noninfectious

Risk Factor

- Immunodeficiency associated with young age,aging, malnutrition etc

- Immunosuppressed individuals

- Defect complemen system (C5-C8) in Eskimos.

- Congenital or acquired CSF leakage (may be

due to trauma)

Definition, Etiology and Risk Factors

of meningitis



Tuberculous

Meningitis

Infection of the meninges by

Mycobacterium tuberculosis.



Pathogenesis



Pathophysiology

Bacterialseeding

Increasedpearmeability BBB

Cerebraledema

Presenceof toxic

mediator s

Inflammationof spinal

nerves androots

Meningeal signs

Inflammationof cranialnerves

Cranialneurophatie

s



Diagnosis

Nonspecific

symptoms:Fever, Irritability,

Drowsiness, and

Malaise

Confusion,

meningeal

signs,

seizures

Coma,

Hemiparesis,

Nerves palsies

Lumbal Puncture Blood Culture

Radiology



Lumbal Puncture

PCR

CSF culture

CSF Staining

CSF Analysis

• Lymphocytic-predominant pleiocytosis• Elevated protein levels 100-500mg/dL

• Low glucose <45mg/dL



Radiology

• Suggesting active or previous

pulmonary tuberculosis

• 10% have milliary disease

Brain CT-Scan

Chest X-ray

• Hydrocephalus

• Tuberculomas

• Infarctions



Management

Antibiotic

Glucocorticoid

• Evidence thatinflammatorycytokines

• Adjunctivetherapy was

reducedaudiologic andneurologicsequelae

Antituberculousdrugs

• INH ( 10 mg/kgBB/day)

• Rifampicin (10-20mg/kgBB/day)

• Pyrazinamide (15-30mg/ kgBB /day

• Ethambutol (15-25mg/ kgBB/day)

• Streptomycin (20-40mg/ kgBB/day)





CASE REPORT

Name : PF

Age : 1 year 10 months Sex : Female

MR : 54.33.98

Address : Desa Batu Lapan, Deli

Serdang

Date of Admission : January 06th 2013



CHIEF COMPLAINT:

Altered level of consciousness

HISTORY:

It started 2 days ago and was preceded by an episode of seizure. Theseizure was generalized, with stiffening and rigidity of all four extremitiesand the patient’s eyeballs appeared to be rolled upwards. The seizure onlyoccurred once with duration of 1 hour and the patient was unconscioussince then. The patient does not have any history of seizure before this.

Fever(+) for the past 1 week with fluctuating body temperature, bodytemperature tends to decrease with consumption of antipyretic drugs.

Cough(+) for the past 1 week, unproductive. History of coming into contactwith any person with chronic coughs was not found.

2 days ago, before the seizure occurred, the patient experienced 2episodes of vomit. Contents of the vomits are the foods and drinks

ingested.Previous traumatic event was not found.



Pregnancy history : 2nd child of the family,

history of sickness during pregnancy (-), diabetes (-),

hypertension (-), consumption of medications (-),

consumption of herbal drinks (-).

Delivering history : Born at home with the helpof a midwife, aterm, cried immediately, birth weight:

3000gram and body length: 50cm. bluish appearance

(-), seizures (-) .



History of Growth &Development:

Sitting : 8 month

Walking : 1 yearCurrently patient can mention certain words like:‘mama’, ‘bapak’, ‘kakek’ and ‘nenek’

History of Feeding:

Birth – 5 mo : Breast milk only

5 mo – 1 yr : Breast milk + conventional

milk + porridge

1 year – present : conventional milk + soft rice

History of Immunization: Unclear



History of previous illness:

Patient was initially treated in Kabupaten A.Tamiang General Hospital for two days with thediagnosis: Encephalitis with bronchopneumonia.

History of previous medications:

Injection of Metamizole Sodium, Ampicillin,Gentamycin and Phenytoin



Age: 1 years 10 months, girl

Body weight (BW): 9 kg, Body length: 81 cm,

Body weight in 50th percentile according to age:11.8 kg

Body length in 50th percentile according to age:

84.0 cm

Body weight in 50th percentile according to body

length: 11.1 kg

BW/BL : 9/11.1 x 100% = 81.08%

BW/age : 9/11.8 x 100% = 76.27%

BL /age : 81/84 x 100% = 96.42%



Presence Status:

Sensorium: GCS 9 (E3V2M4)

BP = 90/60 mmHgHR = 120 x/i

RR = 26 x/i,

T = 38.5°C

Body weight (BW) : 9.0 kg

Body length (BL) : 81 cm

Head Circumference (HC): 43 cm

Anemic (-), icteric (-), dyspnea (-)cyanotic (-), edema (-).



Physical Examination

Head Eyes: light reflex (+/+), isochoric pupil 3 mm, pale conjuctiva palpebra

inferior, icteric sclera (-/-)

Nose / Ears / Mouth : within normal limits

Neck lymph node enlargement (-), stiff neck (-)

Thorax symmetric fusiform, retraction (-)

HR: 120 bpm, regular, murmur (-),RR: 26 x/i, reguler, ronchi (-/-)

Abdomen soepel, normoperistaltic; liver, spleen: not palpable

Extremities pulse 120 bpm, regular, adequate pressure/volume

warm axilla, capillary refill time <3s

Physiologic reflexes : APR (+↑), KPR (+↑)

Pathologic reflexes : Babinsky (+/+), Chaddock (+/+), Gordon (+/+),

Oppenheim (+/+)

Spasticity of right leg (+)

Genitalia female, normal



Laboratory Findings:

Complete Blood Coun t

Test Result Normal Value Unit

Hb 9.20 11.3 –

14.1 g %

RBC 4.26 4.40 – 4.48 106/mm3

WBC 13.10 6.0 – 17.5 103/mm3

Hematocrite 30.70 37 – 41 %

PLT 487 217 - 497 103/mm3

MCV 72.10 81 – 95 fL

MCH 21.60 25 – 29 Pg

MCHC 30.00 29 – 31 g %

RDW 16.60 11.6 – 14.8 %

MPV 8.30 7.2 –

10 fL

PCT 0.41 %

PDW 8.8 fL



Test Result Normal Value Unit

Neutrophil 70.20 37 –

48 %

Lymphocyte 21.00 20 – 40 %

Monocyte 8.50 2 – 8 %

Eosinophil 0.10 1 – 6 %

Basophil 0.200 0 – 1 %

Neutrophil absolute 9.20 1.9 – 5.4 103/µL

Limfosit absolute 2.75 3.7 – 10.7 103/µL

Monosit absolute 1.12 0.2 – 0.6 103/µL

Eosinophil absolute 0.01 0.20 – 0.50 103/µL

Basophil absolute 0.02 0 – 0.1 103/µL



Carbohydrate metabolism

Blood glucose level (ad random) 59.50 < 200 mg/dL

Renal

Ureum 10.90 < 50 mg/dL

Creatinine 0.20 0,24 – 0.41 mg/dl

Electrolytes

Sodium (Na) 140 135-155 mEq/L

Pottasium (K) 4.0 3.6-5.5 mEq/L

Chloride (Cl) 106 96-106 mEq/L





Radiology (Chest X-ray)

[6/1/2013]



Differential Diagnosis:

Encephalitis

Meningoencephalitis

Meningitis



Management:

- Bed rest with 30º head elevation

- O2 1 liter/minute via nasal canule

- IVFD D5% NaCl 0,45% 19 gtt/i (micro)- Diet SV 900 kcal with 18g protein

- Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes

- Inj. Ceftriaxone 450 mg/12 hours/IV

- Inj. Ampicillin 450 mg/6 hours/IV

- Paracetamol 3x100 mg

Diagnostic Planning:

Consult Neurology Division

Head CT-Scan Mantoux test done on left volar, read on 9th January

Blood culture

J 7th 2013



January 7th 2013

S Decreased level of consciousness (+), fever(+)

O

Sens: GCS 9 (E3V2M4), T= 38.3°C

Head: Eyes: light reflex (+/+), isochoric pupil 3 mm, pale

conjuctiva palpebra inferior, icteric sclera (-/-)

Nose: nasal canule (+)

Ears / Mouth : within normal limits

Neck : lymph node enlargement (-), stiff neck (-)

Thorax: symmetric fusiform, retraction (-), HR: 110 bpm,

regular, murmur (-)

RR: 24 x/i, reguler, ronchi (-/-)Abdomen: soepel, normoperistaltic; liver, spleen, and

renal are not palpable

Extremities: pulse 110 bpm, regular, adequate

pressure/volume, warm acral, capillary refill time <3’’


Pathologic reflexes : Babinsky (+/+), Chaddock

(+/+), Gordon (+/+), Oppenheim (+/+)

A DD: 1. Encephalitis

2. Meningoencephalitis

3. Meningitis

P

Management:


- O2

1 liter/minute via nasal canule

- IVFD D5% NaCl 0,45% 19 gtt/i (micro)

- Diet SV 900 kcal with 18g protein

- Inj. Phenytoin 25mg/12hours in 5cc D5% in 20minutes

- Inj. Ceftriaxone 450 mg/12 hours/IV (H1)

- Inj. Ampicillin 450 mg/6 hours/IV (H1)

- Inj. Dexamethasone 9mg/6hours/IV

- Paracetamol 3x100 mg

Pediatric Neurologist Consultation:

Working Diagnosis: Encephalitis

Treatment: IVFD NaCl 3%/12 hours done in 2 hours

time

Liver Function Test

AST/SGOT: 45U/L (N: <32)

ALT/SGPT: 17 U/L (N: <31)

Ferritin: results pending

Iron (Fe): 25 mg/dL (N: 61 – 157)

TIBC: 153 mcg/dL (N: 112 – 346)

January 8th 2013



January 8th 2013


O

Sens: GCS 9 (E3V2M4), T= 38.6°C







regular, murmur (-)








A DD: 1. Encephalitis


3. Meningitis

P

Management:



- IVFD D5% NaCl 0,45% 19 gtt/i micro

- IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours





- Inj. Dexamethasone 9mg/6hours/IV- Paracetamol 3x100 mg

Gastric Aspiration was done and samples taken for

microbiology and acid-fast test.

Results from blood culture using Bactec:

Staphylococcus saprophyticus

Balance: I: 850cc; O:670cc = 180cc

Urine Dipstick:

Leu Nit Uro Prot pH Blo Sg Ket Bil Glu

- - 0.2± 5.0 - 1.005 - - -

January 9th 2013



January 9th 2013


O

Sens: GCS 9 (E3V2M4), T= 38.5°C







regular, murmur (-)








A DD: 1. Encephalitis + Suspect Sepsis


3. Meningitis

P

Management:



- IVFD D5% NaCl 0,45% 19 gtt/i micro- IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours





- Inj. Dexamethasone 9mg/6hours/IV- Paracetamol 3x100 mg

Results of Mantoux Test: negative

Results from microbiology on gastric aspirates:

Epithelial: 0-1/lpbLeucocytes: 0-1/lpb

BTA: negative

Fungal: negative

Gastric Aspiration was repeated.

Immunoserology

Qualitative CRP: positive

Procalcitonin: 1.24ng/mL (N:<0.05)

January 10th 2013



January 10th 2013


O

Sens: GCS 9 (E3V2M4), T= 37.9°C

Head:

Eyes: light reflex (+/+), isochoric pupil 2 mm, pale






regular, murmur (-)

RR: 26 x/i, reguler, ronchi (-/-)

Abdomen: soepel, normoperistaltic; liver, spleen, andrenal are not palpable






A DD: Tuberculous Meningitis + suspect sepsis

P

Management:









- INH 1 x 90mg (H1)

- Rifampin 1 x 90mg (H1)

- Pyrazinamid 1 x 180mg (H1)

- Ethambutol 1 x 135mg (H1)

- Prednisone 3 x 3mg (H1)- Paracetamol 3x100 mg

Results from microbiology on gastric aspirates:

Epithelial: 0-1/lpb

Leucocytes: 5 - 10/lpb

BTA: positive 1 (+)

Fungal: negative

Results from Brain

CT Scan:

Right Frontal

periventricular

infarct+

communicating

hydrocephalus



Results from

Brain

CT Scan:Right Frontal

periventricular

infarct+

communicating

hydrocephalus

January 11th 2013



January 11 2013


O

Sens: GCS 9 (E3V2M4), T= 38°C

Head:

Eyes: light reflex (+/+), isochoric pupil 2 mm, pale






regular, murmur (-)

RR: 26 x/i, reguler, ronchi (-/-)







A DD: Tuberculous Meningitis + suspect sepsis

P

Management:









- INH 1 x 90mg (H2)






Urine Dipstick:Leu Nit Uro Prot pH Blo Sg Ket Bil Glu

- - 0.2 ± 5.0 + 1.015 - - -

January 12th 2013



January 12 2013

S Decreased level of consciousness (+), fever(+), breathlessness (+), gasping (+) with risk

of respiratory failure

O

Sens: GCS 5 (E1V2M2), T= 38.4°C BP: 60/20 mmHg

Head: Eyes: light reflex (+/+), mydriasis (+), pale conjuctiva

palpebra inferior (+/+)


Ears / Mouth : gasping (+)


Thorax: symmetric fusiform, epigastrium retraction(+),

HR: 160 bpm, regular, murmur (-)








A DD: Tuberculous Meningitis + suspect sepsis + Anemia ec DD/ Iron deficiencyChronic disease

P

Management:









- INH 1 x 90mg (H3)




- Prednisone 3 x 3mg (H3)

- Paracetamol 3x100 m

Results from complete blood test:

Haemoglobin: 9.70%

RBC: 4.40 x 106/mm3

MCV: 66.80 fL

MCH:22.00 pg

Leucocyte: 29.40 x 103/mm3

Thrombocyte: 42 x 103/mm3

Hypochromic microcytic anemia + leucocytosis +

thrombocytopenia

Patient’s condition worsen, transferred to HCU

Respiratory distressed were seen with RR 10x/i.

intubation was done on patient and ETT was

inserted. VTP 30/minute with oxygen 10L/i.



Blood Gas Analysis

pH 7.4 7.35 – 7.45

pCO2 22 38 – 42 mmHg

pO2 265 85 – 100 mmHg

Bicarbonate 13.6 22-26 mmol/L

Total CO2 14.3 19 –

25 mmol/L

Base Excess (BE) -11.2 (-2) – (+2) mmol/L

SaO2 100 95 – 100 %

Electrolytes

Calcium (Ca) 6.0 8.4 – 10.4 mg/dL

Sodium (Na) 120 135-155 mEq/L

Potassium (K) 2.5 3.6-5.5 mEq/L

Chloride (Cl) 97 96-106 mEq/L

[12/1/2013]

January 13th 2013



January 13 2013


O

Sens: GCS 4 (E1V1M2), T= 38°C BP: 80/40 mmHg

Head:

Eyes: light reflex (+/+), mydriasis (+), pale conjuctiva


Nose: NGT (+)

Ears / Mouth : ETT (+)


Thorax: symmetric fusiform, epigastrium retraction(-),

HR: 168 bpm, regular, murmur (-)

RR: 30 VTP/i, reguler, ronchi (-/-)

Abdomen: soepel, normoperistaltic; liver, spleen, and


Extremities: pulse 168 bpm, regular, inadequate

pressure/volume, cold acral, capillary refill time >3’’

A

DD: Tuberculous Meningitis + suspect sepsis + Anemia ec DD/ Iron deficiency

Chronic disease

P

Management:









- INH 1 x 90mg (H4)





Correction of hypocalcemia: with 4.5cc calcium

gloconate in 4.5cc NaCl 0.9% in 15 minutes

Correction of hypokalemia: with 4.5 mEq in 24cc

D5% in 1 hour

Correction of hyponatremia: with 210cc Nacl 0.9%D5% in 4 hours and followed by 13cc/hour for the

next 20 hours.

Patient was consulted to anaesthesia department for

the insertion of CVC line. CVC line inserted at left

thorax.

January 14th 2013



January 14 2013


O

Sens: GCS 4 (E1V1M2), T= 38.5°C BP: 80/40 mmHg

Head: Eyes: light reflex (+/+), mydriasis (+), pale conjuctiva


Nose: NGT (+)

Ears / Mouth : ETT (+)


Thorax: symmetric fusiform, epigastrium retraction(-),

CVC line (+), HR: 148 bpm, regular, murmur (-)

RR: 30 VTP/i, reguler, ronchi (-/-)


Extremities: pulse 148 bpm, regular, inadequate

pressure/volume, cold acral, capillary refill time >3’’

Physiologic reflexes : APR (+), KPR (+)

Pathologic reflexes : Babinsky (-/-), Chaddock (-/-),

Gordon (-/-), Oppenheim (-/-)

A DD: Tuberculous Meningitis + suspect sepsis + Anemia ec DD/ Iron deficiencyChronic disease

P

Management:









- INH 1 x 90mg (H5)





Urine catheter was inserted


Urine Dipstick:

Leu Nit Uro Prot pH Blo Sg Ket Bil Glu

- - 0.2 ++++ 5.0 ++ 1.025 ++ - -



January 14th 2013

At 0945 hours patient fell into apnoea with a GCS score of 3

delayed light reflexes, dilated pupil right = left ϕ 6 mm

pulse and blood pressure were unmeasurabletemperature fell to 35,10C

dirty red fluid was seen in the NGT and urine was stained red.

A : Respiratory failure + Shock Septic + Tuberculous Meningitis + Anemia

P :

- VTP 30x/minute with oxygen of 10/L was administered continuously but oxygen

saturation was failed to be measured using pulse oxymetry.

- Fluid challenge with IVFD NaCl 0.9% 10cc/kg/hour (90cc/hour) at 30 gtt/minute

from 0945 to 1045 hours. Patient’s last recorded blood pressure was 60/20 mmHg

during re-evaluation at 1015 hours.

- Blood glucose level was 50mg/dL and 2cc/kg Dextrose 10% (20cc) was given as

bolus.

- Adrenaline of 0.1cc.kg (10cc) was injected intravenously followed by dobutamine

0,5cc/hour.

Patients failed to response to the emergency intervention given and remained in

shock. At 1100 hours patient was declared decease based on maximal dilation of

pupil.





DISCUSSION

THEORYIn tuberculous meningitis, a prodromal phase of low-grade fever, malaise,

headache, dizziness and vomiting may persist for a few weeks, after whichpatients can then develop more severe headache, altered mental status,

stroke, hydrocephalus, and cranial neuropathies. Seizures occurs in about

50% of child tuberculous meningitis.

CASE

PF, was admitted with the chief complain of altered mentalstatus. Symptoms that preceded the decrease of

consciousness includes fever, vomiting and an episode ofseizure.



DISCUSSION

THEORYCharacteristic CSF findings of tuberculous meningitis include:

(i) Clear fluid

(ii) Lymphocytic-predominant pleiocytosis. Total white cell counts are

usually between 100 and 500 cells/ μ L. MN>PMN

(iii) Elevated protein levels, typically between 100 and 500 mg/dL,

(iv) Low glucose, usually less than 45mg/dL or CSF: plasma ratio <50%

CASE

CSF analysis shows a clear colored fluid, slight increase in proteins level: 56mg/dLand decrease level of CSF glucose: 24mg/dL. Pleiocytosis was not found. MN 52%,

PMN 58%.Atypical CSF findings are well described, particularly in immune-suppressed

patients, and the CSF can be acellular or contain a predominance of neutrophils .



DISCUSSION

THEORY

Gastric aspirates and bone marrow aspirates may assist indetecting extra-neural tuberculosis in children

CASE

Gastric aspiration was done twice. On the second time, resultsshows that acid-fast bacilli was found to be positive 1 (+1) on

smear.



DISCUSSION

THEORYThe commonest cerebral CT features of tuberculous meningitis are

hydrocephalus and basal contrast enhancing exudates. Both features are

more common in children ( 80%). Infarctions as a result of ongoingvasculitis or tuberculoma are found in approximately 20% of patients.

CASE

results of CT-scan from the radiologist: Right frontalperiventricular infarct with communicating hydrocephalus

possibly due to meningitis



PF, 1 year 10 months, female who first entered with thediagnosis of encephalitis was diagnosed withtuberculous meningitis with sepsis.

The diagnosis was established based on history taking,

clinical manifestations, laboratory and radiologicalfindings.

Patient was treated for 9 days.

The condition of the patient worsen after 2 days intoantituberculosis drugs and finally pass away on the 5th day of antituberculosis therapy due to respiratory failure.



hank you

Documents

TBM Case Report (tuberculose meningitis)