TB Meningitis - CTeodorescu

7/21/2019 TB Meningitis - CTeodorescu

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“V. Babeş” HospitalCraiova



Introduction

Tuberculosis (TB) remains one of the world’sdeadliest communicable diseases.

TB meningitis is one of the worst forms ofextrapulmonary tuberculosis whose evolution,untreated, is invariably fatal.

The clinical features of TB are the result ofbasilar meningeal !brosis and vascularin"ammation.



Introduction



Introduction

The use of antitumor necrosis factor#alpha

(T$%&) neutrali'ing antibody has also beenassociated with increased ris ofextrapulmonary TB including TB.

The mechanisms by which T$% is important ininitial and long#term control of tuberculosis arenot clear, and are liely to be numerous.



atient *. +.

History of present

illness

- years old female from an urban environment

$o history of trauma

Headachenot relievedbymedications

Cough

Chills

Simptomatology

Vomiting

Generalizedweakness

1 w e e k 3 w e e k s



Anamnesis

Past medical history:

soriasis / in treatment for - years with anti#T$%α

$ot su0ering for diabetes, hepatitis

Family diseases:

no signi!cant family medical history nown

$o family history of the following1

2iabetes3ancer

TB

4epatitis



Anamnesis

Social history:

5ives in a "at

ensioner

6ot 7 id (female) / 89 y.o.

$o tobacco, alcohol or drug use

2rins co0ee (7#-:day)

$o recent foreign travel

$o pets



Anamnesis

Regular and acute medications:

;emicade 799 mg (Infiximabum)aracetamol ( !cetamino"hen)

Allergies:none nown



Clinical examination

Awake, cooperative bt !i"clty

in speaking

#alli! $ace, icteric sclerae, moist bccal mcosa

%eck rigi!ity

H&&%'




Coarse rales

(eglate r)tym, H(* +bpm,B#* -/ mmHg

Symmetrical c)est expansion

C)est0ngs




So$t ab!omen, nten!erness

%o organomegaly

1ior!ano * , !arker rine emission

Ab!omen




2ll plses, no e!ema, no cyanosis

&ryt)emato*s3amos elementslocali4e! on skin o$ t)e large 5oints

o$ pper an! lowerlimbs&xtremities



-st !iagnosis

AC6'& 2&B(70& S8%9(:;&AC6'& #%&6;:%7A <



5aboratory data

$ormal <B3 (=,8>79?8u:5), an easierlymphopenia (7@A)

+ery accelerated *;(mm:7h C9mm:-h)6TDC@ E:5 F # hepatocytolisis6GTD=- E:5 F

Hlaline phosphatase/ 78 F

6amma 6T / 77F

6lucose / 7-C↑

6rinalysis= rare "at epithelial, rare <B3, raremicrobial "ora. acid p4 , density # 7989.



0aboratory !ata

C>(

micro point opacities

disseminated in both lung

!elds

#iliary $%&



0aboratory !ata

0mbar pnctre= Clear CS2

Bioc)emistry 6lucoseconcentration

7,7 mg:dl ↓

Celllar cont

andy reaction

levatedprotein

==mgA ↑

3hlorides C=9 mgA ↑

-:mmc

(79A $,

J9A 5y)



0aboratory !ata

#nemology examination

TB meningitis

iliary pulmonary TB form

9ermatologic examination

'atient with known with severe "soriasis intreatment with anti$* al"ha +or , years

(Infiximabum -..mg at , months)/ last "arenteraladministration at 0 11 ,.1, with the remission o+skin lesions accuse +rom 2- days headache andasthenia3

4ecommendations 5 infiximab discontinuation



9iagnosis



9iagnosis

-.'B ;&%7%17'7S

?.;707A(8 #60;:%A(8 'B 2:(;

@.9(61*7%96C&9 H&#A'7'7S

.:(A0 'H(6SH

.#S:(7AS7S 7% B7:0:17CA0 'H&(A#8



9ierential !iagnosis

%ungal eningitis

+iral meningoencephalitisarameningeal Infection

6"henoid sinusitis/ brain abscess/ s"inal e"iduralabscess

$eoplastic eningitis / 5ymphoma



'reatment

Dile !e tratamentme!icament

- ? @ / E + F -

--

-?

-@

-

-

-/

H7% cp -mg 777Gisoniazidum)

(72 cp -mg 77G pyrazinamidum)

#D; cp mg 77GrifampicinumI

&;B cp mg 77GethambutolomI



'reatment

'reatment !aysme!icins

- ? @ / E + F -

--

-?

-@

-

-

-/

HHC J -mg 77 1/1h

* * * * * * * * * * * * * *

9examet)asone K 771 !" /day# h$%h1&

So!im C)lori!eJ ml 7

* * * * * *

1lco4a L Stamicin !5 777

:me4 tb 7

;anitol -L J ? mg77,

1 f at 1h



'reatment

Dile !e tratamentme!icament

-E -+ -F ?

?-

?? ?@ ?

?

?/

?E

?+

?F

@

H7% cp -mg 777Gisoniazidum)

(72 cp -mg 77G pyrazinamidum)

#D; cp mg 77GrifampicinumI

&;B cp mg 77GethambutolomI

9examet)asone K 771 !" /zi# h$%h1& (aniti!ine cpr 77

B/ vitamin J 7

0iv ? cpr 77



&voltion !ay -

S6BM&C'7V& :BM&C'7V& AS&SS;&%' #0A%

%ebrile episode

(max 8K,@3)4eadache2iLculty inspeaing6enerali'edweaness

$ot vomiting

*table +*

3ooperative$o meningealsigns3;M # micropoint opacitiesdisseminated in

both lung!elds

TB meningitis $a correction

*tart annitol*tart T**



&voltion !ay @

S6BM&C'7V& :BM&C'7V& AS&SS;&%' #0A%

Hfebrile episode

$o headache6enerali'edweaness$ot vomiting

*table +*

3ooperative$o meningealsigns

TB meningitis 3ontinue

medications



&voltion !ay -

Bioc)emistry 6lucoseconcentration

8-,= mg:dl ↓↓↓

Celllar cont

andy reaction

levatedprotein

78-mgA ↑

3hlorides C9 mgA

J=:mmc (799Alimfocite)

0mbar pnctre= Clear CS2



&voltion

weeks later, on cltre o$ 0C( wasdevelo"ed #3 tuberculosis

S)e was !isc)arge! a$ter - mont) o$)ospitalisation wit) normal laboratory!ata an! no symptoms

She continuated anti%tuberculosis

treatment for 1 monthShe permanently discontinuedbiological therapy for psoriazis



Complications o$ 'Bmeningitis

4ydrocephalus

3+H

3oma

otor de!cits

*ei'ures

Hbnormal behaviours

3entral $ervous *ystem Tuberculosis. www.uptodate.com

http://www.uptodate.com/

http://www.uptodate.com/



Case #articlarity

The particularity of these case consist inthe atipical aspects#both1

clinical ( lac of fever, absence of meningealirritation) and

biological ( no biological in"ammatorysyndrome, a slightly modi!ed 3*%

biochemistry)of a tuberculous meningitis in a special

host, a patient on biologic therapy.



N)y s)ol! we care<

*omeone gets sick from TB every fourseconds and someone !ies of TB e'ery

ten seconds (<4G, -99=)



'ake )ome message

TB begins as a primary infection of the lungs

iliary tuberculosis (TB) is a potentially lethaldisease if not diagnosed and treated early

*tart HTT empirically when suspicion of TB

atient consiliation for medication:side e0ects

arly diagnosis and commencement of speci!ctherapy determines survival of the patient.



'HA%O 8:6P

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TB Meningitis - CTeodorescu