Tuberculous Meningitis

Neurology PresentationDavid Paraide & Marsha DanielPhysiotherapy 2

Content

• Objective• Introduction• Anatomy of the CNS affected• Definition• Pathophysiology• Systemic involvement• Etiology• Clinical features• Investigation & diagnosis• Medical management• Physiotherapy management• Prognosis • Prevention• Complication• Summary• reference

Objective

To knowo What is Tuberculosis Meningitiso Anatomy of the Body parts affected by Tb meningitiso Pathophysiology / Etiologyo Signs and symptomso Diagnosiso Management/ treatment-both medical and physiotherapy.o Prognosiso Preventiono Complication

Introduction

• Tuberculosis Meningitis also known as TB Meningitis is a serious inflammatory disease of the CNS affecting about 1-2 % of all Tuberculosis infection.

• The tissue surrounding the brain and spinal cord, and is defined by an abnormal number of white blood cells in the cerebrospinal fluid (CSF).

• The main part of the brain affected is the meninges• The meninges consist of three parts: the pia, arachnoid, and dura maters.• Bacterial meningitis reflects infection of the arachnoid mater and the CSF in

both the subarachnoid space and the cerebral ventricles.

Introduction; Anatomy

Introduction; Anatomy

Definition

• What is Tuberculous Meningitis? Tuberculosis Meningitis is an infectious disease that causes inflammation of the membranes

(leptomeninges) that surround the brain.

PathophysiologyPathophysiologyMycobacterium Tuberculous bacilli enter the host by droplet inhalation.Immunologically directed inflammatory reaction to the infection is the main cause of the many

signs and symptoms of TBM.There are three stages of TB Meningitis:

I. Stage One;Alveolar macrophages are the initial point of infection. Localized infection escalates within the lungs, with dissemination to the regional lymph nodes to produce the primary complex.*During this process a short but significant bacteremia is present, and it can seed tubercle bacilli to other organs

II. Stage Two;The second step in the development of TBM is an increase in size of a Rich focus until it ruptures into the subarachnoid space. The location of the expanding tubercle (i.e., Rich focus) determines the type of CNS involvement. Tubercles rupturing into the subarachnoid space cause meningitis.

III. Stage Three; Represents advanced illness with delirium, stupor, comma, multiple cranial nerve palsies, and death usually occurs

Cont.…

Systematic involvement

Nervous• Inflammation of subarachnoid space• Spread of inflammation to parenchyma• Focal ischemic lesions• Hydrocephaly• Impaired consciousness

Stages include irritability, confusion, drowsiness, stupor, and coma

• Hemiparesis• Seizures• Cranial nerve palsy• Hypothalamic dysfunction in children

Vascular• Inflammation of small subarachnoid vessels (especially veins)• Thrombotic obstruction of vessels

Cont…

Musculoskeletal• Opisthotonic posture• Infectious spread to jointsSensory• Impaired hearing• Loss of visionMetabolic• Dehydration• HyponatremiaGastrointestinal• VomitingIntegumentary• • Petechial rash of skin (usually associated with bacterial meningitis

Etiology

The main cause of Tuberculous Meningitis is the bacteria MICOBACTERIUM TUBERCULOSIS.

Inflammation is concentrated towards the base of the brainCranial nerves may be affected when the inflammation is in the Brainstem subarachnoid

area

Clinical features

Adult• Vomiting• drowsiness• severe Headache• Joint stiffness• Joint pain• Seizures• Malaise• Nuchal rigidity (neck stiffness)• photophobia (intolerance of bright

light)• Confusion• Muscle atrophy• flacidityIn children• Frontanelle• Irritable and unwell (malaise)• Pale, blotchy skin color

Clinical features

Investigation & diagnosis

• History and examination• EMG• MRI• CT scan Special test• Lumber puncture• Biopsy of the meninges

Lab test• Glucose• Protein• White blood cell

Investigation and Diagnosis

Medical Management

Medical Treatment of TBM includes;• Isoniazid• Rifam picin• Pyrazinamide• Ethambuthol

*These medication will be taken for two monthsFollowed by these medications again;

• Isoniazid• Rifam picin*These two medications alone will be taken by patients for another 10 months

*Medical treatment may vary according to the response of the individual patient. Drug resistant TB meningitis may require long schedules of medical treatment with a variety of alternative antibiotics.

Physiotherapy management

Assessment Subjective assessment General information PC HoPC• pain assessment, using VAS and Body chart PMH DH SH FH Premobid status Patient’s expectation

Cont..

Objective Assessment Observation• General Posture attachments Physical appearance Patient’s physique• Local Bony deformity Skin texture and color Pressure sores• Palpation Temperature

• Examination ROM Measure muscle bulk• Special test Cranial nerve test• Function Activity ADL’s

Problem list

Short term goal• Pain• High temperature• Respiratory dysfunction• Joint pain• Joint stiffness• spasticity• Impaired posture

Long term goal• Muscle atrophy• Contractures• Balance and coordination Rehabilitation • Gait • ADL’s

Treatment; Short term goal Problem Treatment Frequency Duration

Breathing dysfunction

Joint pain

Breathing exercise

ROM & Massage

Am + PM2 sets, 5 reps

Am + PM3 sets, 5 reps

Day 1-wk3 & continue

Day 1- Wk 3 & continue

High temp cryotherapy 3 sets, 5 reps Day 1- Wk1

Joint stiffness ROM/ PNF 3 sets, 5 reps Am + PM

Day 1- wk3

arching back and neck retraction

spasticity

Positioning & ROM (Passive)

-rhythmic rotation

Every two hourly

Am + PM2 sets, 5 reps

Day 1- wk3 & cont.

Day 1-wk3

Muscle atrophy Isometric resistance exercise

3 sets, 5 reps Am + PM

Day 1-wk 3

Treatment; Long term Goal Problem Treatment Frequency Duration Muscle atrophy Strengthening

Exercise, Approximation

4 sets, 5reps wk3- wk. 6

Balance & coordination

Balance training

2 sets, 5 reps

wk3-wk 6

ADL’s -Stairs climbing, 3 sets,5 reps wk6-wk 10 avoiding obstacles

Gait -gait training Am+ PM wk6-wk 10 3 sets,4 reps

Prognosis

• The out look of the treatment will depend on the severity of the patient’s symptoms and how fast you attend to treatment

• Getting an early diagnosis can also enable the doctor to provide treatment quickly and accurately.

• If treatment is received before complications develop, the outlook will be

good.

Prevention

• Children should be vaccinated with BCG in order to be protected• Avoid talking to TB meningitis patient face to face• BCG vaccine used to be offered to all children at secondary school, ages

between 13-17• The current programme of vaccination targets babies, children and older

people who are most likely to catch the disease.• The vaccine is also recommended for healthcare workers who may be

exposed to TB.

Complication

• seizures• hearing loss• increased pressure in the brain (intracranial pressure)• brain damage• stroke• Blindness• death

Summary

• Tuberculosis Meningitis also known as TB Meningitis is an inflammatory disease of the leptomeninges, the tissue surrounding the brain and spinal cord.

• Mycobacterium Tuberculosis bacilli enter the host by droplet inhalation.• Special diagnosis technique include, meninges biopsy and lumber puncture• Management can be both by taking medication and physiotherapy

treatment.• TB infection usually begins in the lungs and in about 1 – 2% of cases the

infection can progress to TB meningitis.• TB meningitis usually develops slowly• TB meningitis is a life-threatening infectious disease

References

Medical Treatments of TBM. Retrieved from http://www.dsprud.com/tuberculous-meningitis-2.html

Preventive measures against TBM. Retrieved from https://www.meningitisnow.org/meningitis-explained/what-meningitis/types-and-causes/tb-meningitis/

Stages of TBM. Retrieved from http://emedicine.medscape.com/article/1166190-overview

Symptoms of TBM. Retrieved from https://medlineplus.gov/ency/article/000650.htm TB meningitis (n.d). Meningitis Research foundation. Retrieved from September 2,

2016, from http://www.meningitis.org/disease-info/types-causes/tb-

Any Question