atypical presentation of tubercular meningitis
TRANSCRIPT
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Dr. Md Rashedul Islam FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM
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A 56 years old diabetic right handed gentleman,
hailing from Gazipur, got admitted in BIRDEM
General Hospital on 10th October,14 with the
complaints of-
• Drooping of eyelid for 2 months
• Headache for 3 months
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According to the statement of the patient, he was reasonably well 3 monthsback. Then he developed headache which was gradual on onset, global, dull aching in nature, mild in severity. It was not associated with radiation, vomiting, eye ache, exaggerated at morning & coughing. It was relieved with medication.
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H/O Present illness
He also has complaints of drooping of both eyelid which was gradual on onset, asymmetrical, double vision, eye ache. On detailed query he gives h/o fever for 3 months which was low grade, intermitted, associated with generalized weakness. It was not associated with chill & rigor, night sweating, diurnal variation, cough, weight loss.
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H/O Present illness
With the above complaints, he visited opthalmologist & neurologist outside BIRDEM & investigated. He was diagnosed as bilateral opthalmoplegia due to mononeuritis multiplex due to diabetes mellitus. He was referred to Neurology, BIRDEM for further investigation & management.
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CT Scan of Brain
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CT Scan of Brain
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H/O past illness: Nothing contributory Socioeconomic history: He belongs to a middle class family
Personal history:
He is non alcoholic, non smoker
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Family history:
Nothing significant
Treatment history:
Tab. Glimiperide
Tab. Vit B complex
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General examination:
Appearance: ill looking, bilateral ptosisBuilt: average Decubitus: on choiceAnaemiaJaundiceCyanosisOedemaDehydrationClubbingKoilonychiaLeukonychia
Absent
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General examination:
Neck vein: not engorged
Thyroid: not enlarged
Lymph node: not palpable
Skin pigmentation & body hair distribution: normal
Pulse: 86 b/min
BP: 130/80 mmHg
Temp:98 F
RR: 16 breaths/min
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• Higher psychic function : Conscious, Oriented• Speech: Normal• Cranial nerves :
Complete opthalmoplegia on right eye
3rd, 4th & partial 6th nerve palsy on left eye• Fundus: Normal• GCS: 15/15
NERVOUS SYSTEM EXAMINATION
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Video clips
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Muscle Rt. UL Lt. UL Rt. LL Lt. LL
Bulk Normal Normal Normal Normal
Tone Normal Normal Normal Normal
Power Normal Normal Normal Normal
Involuntary movement
Absent Absent Absent Absent
MOTOR FUNCTION:
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Reflex B T S K A Abd Plantar
Right ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ Present Flexor
Left ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ Present
Flexor
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Sensory system:
Pain Temp Touch Vibration
Position sense
Right upper limb
Intact
Right lower limb
Left upper limb
Left lower limb
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• Sign of Meningeal irritation - Absent
• Cerebellar sign : Absent
• Gait: Absent
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Systemic examinations
Other systemic examination was normal
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A 56 years old gentleman hailing from Gazipur got admitted in Neurology with the complaints of headache which was gradual on onset, global, dull aching in nature, mild in severity. It was not associated with radiation, vomiting, eye ache, exaggerated at morning & coughing.
Salient feature
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Salient feature
He also has complaints of drooping of both eyelid which was gradual on onset, asymmetrical, double vision, eye ache. On detailed query he gives h/o fever for 3 months which was low grade, intermitted, associated with generalized weakness. It was not associated with chill & rigor, night sweating, diurnal variation, cough, weight loss.
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Salient feature
On examination , he is ill looking, Conscious, Oriented, Complete opthalmoplegia on right eye, 3rd, 4th & partial 6th nerve palsy on left eye. Fundoscopy & other systemic examination is normal. There is no sign of meningeal irritation.
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Provisional diagnosis
• Diabetes Mellitus Type 2
• Basal meningitis
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Differential diagnosis
• Myaesthenia gravis
• ICSOL involving brain stem
• Mononeuritis cranial multiplex
• Cavernous sinus thrombosis
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Investigations
CBC:
Hb % - 13.2
WBC -7000 cu/mm
Neu-45 %
Lymph- 47 %
Mono -5.9 %
Eosino- 1.1%
Platelet- 195000
ESR- 82mm in 1st hour
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S. Electrolytes
Na-136 mmol/l
K-4.5 mmol/lCl: 106 mmol/lHCO3: 25 mmol/lCa- 9.2 mmol/lMg- 0.8 mmol/lPhosphate-3.8
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Lipid profile:
TG: 166 mg/dl
T. Chol : 144 mg/dl
LDL: 85 mg/dl
HDL: 40 mg/dl
LFT:
ALT: 28 iu/L
AST: 36 iu/L
RFT:
S. Creatinine: 0.8mmol/l
S Urea: 31 mmol/l
HbA1c: 6.2%
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Sugar - Nil
Albumin – Nil
Ketone- Nil
Epi. cell: A few /HPF
Pus cell: 1-2 /HPF
RBC: Nil
URINE R/M/E
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Chest X-Ray
NORMAL
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ECG
Normal
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MRI of Brain
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MRI of Brain
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MRI of Brain
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MRI of Brain
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MRI of Brain
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MRI of Brain
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Special investigations
ANA: Negative
P-ANCA: Negative
C-ANCA: Negative
VDRL: non- reactive
TPHA: non- reactive
CRP: 46 mg/l
MT: 6mm
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CSF study
• Appearance: clear
• Protein: 136g/L
• Sugar: 3.2mmol/L( Corresponding blood glucose-12mmol/l)
• Cell count: Total WBC 350 cells/cmm
• Lymphocytes: 99%
• Total RBC: 25cells/cmm
• Bacterial antigen: Negative
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Final diagnosis:
• Diabetes mellitus type 2
• Tubercular meningitis
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Treatment:
Short acting insulin
Anti TB drugs
Tab. pyridoxine
Tab. Prednisolone
Supportive treatment
Patient was counseled about Course and prognosis of the disease
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Follow UP
Patient was advised to follow up in Neurology after 2 weeks for further clinical evaluation & management
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Video clip
• Oculoparesis is improved along with ptosis
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Acknowledgement :
Department of Ophthalmology
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