presentasi meningitis tebe

Case report

TUBERCULOUS MENINGITIS

By:Indah Edilla

NIM. 0608114174

Preceptor:dr. Harry Mangunsong, Sp.A

CLERKSHIPDEPARTMENT OF PEDIATRIC

MEDICAL FACULTY UNIVERSITY OF RIAUARIFIN ACHMAD HOSPITAL PEKANBARU

PEKANBARU2012

Definition

• Tuberculous meningitis is inflamation of meningens caused by complication of primary M. tuberculosis infection.

How M. tuberculosis reach the meningen

• First M. tuberculosis get into the body via droplet lung (tubercle)Broken of tubercleM.tb spread to the regional limph nodesand then to the vascular systemmakes other infection focus in other areas of the body, include brain, bone marrow or vertebrae.

Sign and symptoms

• Headache • Back pain• Subfebrile fever• Photofobia• Malaise, agitated

or feeling unwell

At the beginning sometimes the sign and symptoms have not occurred yet, but the meningen has been infected

• Nausea and vomitus• Somnolent and dizy• Epileptic seizures• Meningeal sign• Peripheral nerve

disorders

Staging

1. Stage I - Prodromal stage (early)2. Stage II - Meningeal irritation (intermediate)3. Stage III - Cerebral involvement (advanced)

How to diagnose ?

• Diagnosis of TB meningitis is made by analysing cerebrospinal fluid collected by lumbar puncture.

• From the anamnesis we ask sign of prodromal stage, such as headache, anorexia, vomite and nausea, subfebrile fever, clouding of consciousness, focus infection, sosio-economic state, imunization and history contact to patient with TB.

• From the physical assesment:1. meningeal reflexes and nuchal rigidity are almost always present

2. disorder of the cranial nerve such as N III, N IV, N VI, N VII, N VIII often be found

• Laboratory investigation1.Complete examination of peripheral blood,

glucose, electrolyte2.Lumbal puncture3.Imaging (CT SCAN or MRI)4.Chest X-Ray5.Tuberculin test6.PCR, ELISA and latex particle agglutination

can detect mycobacterium in the CSF7.Electroencephalography

Complication

Complications of meningitis can occur as a result of incomplete treatment or delayed treatment

1. Hydrocephalus2. Cranial nerve paralyze3. Subdural effusion4. Subdural empyema5. Cerebral abscess6. Epilepsy

Prognosis

• Without medication of antituberculosis the mortality is almost 100%

• With medication of antituberculosis the mortality is about 10-50%

Treatment

1. Causal therapy: a combination of OAT2. Corticosteroid3. The symptomatic treatment of seizure and

fever4. Correction of dehydration5. Asetazolamid or furosemid for hydrocephalus6. KCl for hipocalemia

CASE ILLUSTRATION• IDENTITY

Name : SAge : 3 yrs oldGender : MaleAddress : Banglas street, Merbau, Kp. MerantiDate : Januari 22nd 2012

• ALLOANAMNESIS

Given by: Patient’s mother

• Chief complaintbeing unconscious since 9 days before his admission to the hospital

Present Illness History

Since 2 weeks before his admission to the hospital the patient get fever, it is not so high, it’s been higher at night, and it got better when he was given an antipiretic agent by general practitioner. Patient also cough with a little phlegm, sputum cannot be carried out, night sweats even if it’s a cold night, decreased of appetite, the patient looks thinner, no seams. There were no headache, nausea, vomiting, diarrhoea, no pain when he swallowing, pain or secrets out from his ear, nyeri saat buang air kecil, maupun nyeri sendi.

• He was lived with his father and grandfather who had chronic cough. His father have had a bloody cough and still eat drugs from center public health that he had to eat for 6 month.

• Since 9 days before his admission to the hospital the fever become higher and occurs all day. Then he got seizure 4 hr later, spasms through out the body, eyes staring upward, while seizure the patient does not respond when called, seizure was occur in 15 minutes, after a seizure patients was unconscious. It happened repeatedly, with app. 15 min -2 hr between each seizure. Because the patient is unconscious and seizures occur repeatedly, the patient's parents then brought the patient to Selat Panjang hospital.

• The patient was then treated for 9 days by child specialist. At the 2nd hospitalized day patient was conscious, but the patient got seizure again, and after seizure patients become unconscious again. The body of the patient were rigid, and the patient's eyes always staring upward. Because there was no improvement, the patient then referred to Arifin Achmad Hospital.

Past Illness History

• When he was 9 month’s old, he had a seizure, seizure was preceded by a fever, spasms through out the body, eyes staring upward, while seizure the patient does not respond when called, seizure was occurred in 15 minutes, after a seizure patients was still aware of but limp and then fall asleep. After that the patient never strain again

• Asthma history (-)• Campak (-)

Family Disease History• his father and grandfather had chronic cough. • His father have had a bloody cough and still

consume drugs from center public health that he had to eat for 6 month.

• asthma history (-)

Pregnancy History

• Born quite months with weight born 3200 grams

• Born normally, helped by midwife• ANC was regular. • during pregnancy, the patient's mother never

suffer certain illnesses, never smoked nor drunk herbal drink or alcoholic.

PHYSICAL EXAMINATION• General state: Looks severe sick

Awareness: soporocomatous

Vital Signpulse : 90/60 mmHgTemperature : 38,8 ° CHR : 120 × / minBreath : 30 × / min

Nutritional statusPB: 88 cmBB: 12 kgNutritional status: 12 / 14 x 100% = 85% (mild malnutrition)Head circumference: 48 cm (normocephaly)

• Head: UUB closed, normosefaliEye: Conjunctiva is not pale, no jaundiced scleraEars: There is no congenital abnormalities.Nose: symmetrical shape, secretions (-), nostril breathing (-).Mouth: lips was dry, mucous membranes was not hiperemisNeck: nuchal rigidity (+), enlarged lymph nodes (-)

ChestInspection: symmetrical chest wall movement, retraction (+).Percussion: sonorAuscultation: crackles (+/+), Wheezing (-/-)

• abdomenInspection: flatPalpation: sociable, no enlarge of hepar and spleen, good turgorPercussion: timpaniAuscultation: Intestinal sound (+) normal

Extremities • warm acral• Physiological reflexes (biseps, triseps, patella) was raising• Pathological reflexes (babinski, chaddock) (+)• Meningeal reflexes (lasegue, kernig, brudzinsky 1 and 2) (+)

• ADDITIONAL EXAMINATIONRoutine blood examination (22 Januari 2012)Hb : 12 gr%WBCs: 18,400 / mm3Platelets : 149,000 / mm3Ht : 34,2 vol%GDS : 124 mg/dlBUN : 14 mg / dlCR-S : 0.03 mg / dlAST : 60 IU / lALT : 40 IU / lU : 30 mg / dlNa+ : 133 mmol/LK+ : 4,2 mmol/LCa++ : 0,76 mmol/L

ADDITIONAL EXAMINATION• Urine examination

macroscopic view: yellow, jernih, BJ 1,010, no protein, no reductionmicroscopic view: Eritrosit 0-1/LPB, Leukosit 1-2/LPB

• Fecal examinationpH : 7macroscopic view: yellowish green, smooth, no cacingmicroscopic view: cacing egg (-), amoeba (-), eritrosit 0-1/LPB, leukosit 1-2/LPBChemical rx : protein (-), reduction (-), bilirubin (-), urobilin (N), nitrit (-), keton (-), blood (-)

• X-Ray examination

Koch Pulmonum appearance

SIGN AND SYMPTOMS

Anamnesis• decreased consciousness• Repetation of seizures• Fever in 2 weeks, following by cough with phlegm• Rigidity of the neck, lower and upper extremities• The eyes always looking upward• Patient’s father have a prolong cough, even bloody cough,

and consume drugs for 6 month from center public helath and patient’s grandfather have a prolong cough too (high risk TB)

SIGN AND SYMPTOMSPhysical examination • Decreased consciousness• Hyperthermia• Nuchal rigidity• Spastic tetraparese• Increasing physiological reflexes• Presenting of pathological reflexes (babinski and chaddock)

SIGN AND SYMPTOMS

Laboratory examination• leucocytosis

Chest X-Ray• Koch Pulmonum appearance

• Working Diagnosis:Suspect tuberculous meningitis

• Differential diagnosis:viral meningitisnon-specific bacterial meningitis

MANAGEMENT

• IVFD D 5% + NaCl 0,145% + KCl 7,5 meq 12 gtt/min (macro)• ATD : INH 1 x 100 mg

Rifampisin 1 x 150 mgPirazinamid 1 x 300 mgEtambutol 1 x 200 mg

• Prednison 3x4 mg• Inj. Piracetam 3x200 mg• Inj. Furosemid 1x15 mg• Diet : 600 kkal 7,5 gr protein in 600 ml solution, given in 4-

6 times per day.

Prognosis

Quo ad Vitam : dubia ad malamQuo ad functionam : dubia ad malam

Date Follow up Teraphy

23-1-2012 S: fever (+), seizures (+) whole body was rigid, eyes

staring upward, 2x, 20 minutes, he still

unconscious after the seizures

O : consciousness: soporocomatous

HR : 100 x/min

RR : 28 x/min

T : 38,5° C

nuchal rigidity (+), spastic tetraparese (+),

increasing physiological reflexes, pathological

reflexes: babinski dan chaddock (+).

A: susp. Tuberculous meningitis

Same as yesterday

Fenitoin 240 mg in 50 cc NaCl 0,9%

15 gtt/ menit (when seizure), 12 hr

later: fenitoin 120 mg in NaCl 0,9%

50 cc



staring upward, 1x, 15 minutes, he still



N : 110 x/min

RR : 28 x/min

T : 38,7° C


increasing phusiological reflexes, pathological



Same as yesterday

Fenitoin 60 mg in 50 cc NaCl 0,9%

15 gtt/ min (when seizure), 12 hr

later: fenitoin 30 mg in NaCl 0,9%

50 cc


25-1-2012 S: fever (+), seizures (-)


N : 100 x/min

RR : 28 x/min

T : 38,9° C


increasing phusiological reflexes, patohlogical



Same as yesterday

Fenitoin 2x30 mg in 50 cc NaCl

0,9% 15 gtt/min


26-1-2012 S: fever (+), seizures (-)


HR : 98 x/min

RR : 30 x/min

T : 38,6° C


increasing phusiological reflexes, pathological



Same as yesterday



staring upward, 20 minutes, he still unconscious

after the seizures


HR : 100 x/min

RR : 28 x/min

T : 39° C





Same as yesterday

Increasing diet to 800 kkal and 10

gram protein in 800 cc solution,

given 4-6 times/day



staring upward, 3x, 15 minutes, there was

approximately 5 min between every seizure.

He still unconscious after the seizures


HR : 100 x/min

RR : 28 x/min

T : 38,8° C





Same as yesterday


29-1-2012 S: fever (+), seizures (-)


HR : 98 x/min

RR : 30 x/min

T : 38,6° C





Same as yesterday



staring upward, over and over in 1 hour, he still



HR : 96 x/min

RR : 24 x/min

T : 39,6° C




pupil was anisochor 4mm/3mm


12.10 wib – the patient was dead.

DISCUSSION

Working diagnosis was established based on patient history and physical examination.

• From anamnesis: fever with progressive clinical sign,

started with cough, night sweating, decreased appetite, loss 10% of BW, then seizures and uncounscious. Patient was lived with 2 persons who had chronic cough, his father and his grandfather. His father have had bloody cough, and still consumed drug from the center public health which he have to eat for 6 month.

• From physical examination: decreased consciousness, hyperthermia, nuchal rigidity, spastic tetraparesis, increasing phisiological reflexes, present of pathological reflexes (babinski and chaddock)

• From chest X-Ray: KP appearance

• It needs LP and CSF analysis to ensure the diagnosis of tuberculous meningitis. But unfortunately there was an ulcus at his posterior truncus so that we’re unable to do that.

• Head CT scan also can be used to find the sign of hydrocephalus and cerebral infarct.

• We manage this patient by giving OAT, corticosteroid and furosemid.

• Piracetam is giving as a neuroprotector.

presentasi meningitis tebe

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