TB Meningitis - CTeodorescu
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“V. Babeş” HospitalCraiova
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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.
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Introduction
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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.
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atient *. +.
History of present
illness
- years old female from an urban environment
$o history of trauma
Headachenot relievedbymedications
Cough
Chills
Simptomatology
Vomiting
Generalizedweakness
1 w e e k 3 w e e k s
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Anamnesis
Past medical history:
soriasis / in treatment for - years with anti#T$%α
$ot su0ering for diabetes, hepatitis
Family diseases:
no signi!cant family medical history nown
$o family history of the following1
2iabetes3ancer
TB
4epatitis
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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
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Anamnesis
Regular and acute medications:
;emicade 799 mg (Infiximabum)aracetamol ( !cetamino"hen)
Allergies:none nown
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Clinical examination
Awake, cooperative bt !i"clty
in speaking
#alli! $ace, icteric sclerae, moist bccal mcosa
%eck rigi!ity
H&&%'
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Clinical examination
Coarse rales
(eglate r)tym, H(* +bpm,B#* -/ mmHg
Symmetrical c)est expansion
C)est0ngs
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Clinical examination
So$t ab!omen, nten!erness
%o organomegaly
1ior!ano * , !arker rine emission
Ab!omen
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Clinical examination
2ll plses, no e!ema, no cyanosis
&ryt)emato*s3amos elementslocali4e! on skin o$ t)e large 5oints
o$ pper an! lowerlimbs&xtremities
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-st !iagnosis
AC6'& 2&B(70& S8%9(:;&AC6'& #%&6;:%7A <
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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.
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0aboratory !ata
C>(
micro point opacities
disseminated in both lung
!elds
#iliary $%&
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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 $,
J9A 5y)
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0aboratory !ata
#nemology examination
TB meningitis
iliary pulmonary TB form
9ermatologic examination
'atient with known with severe "soriasis intreatment with anti$* 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
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9iagnosis
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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
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9ierential !iagnosis
%ungal eningitis
+iral meningoencephalitisarameningeal Infection
6"henoid sinusitis/ brain abscess/ s"inal e"iduralabscess
$eoplastic eningitis / 5ymphoma
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'reatment
Dile !e tratamentme!icament
- ? @ / E + F -
--
-?
-@
-
-
-/
H7% cp -mg 777Gisoniazidum)
(72 cp -mg 77G pyrazinamidum)
#D; cp mg 77GrifampicinumI
&;B cp mg 77GethambutolomI
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'reatment
'reatment !aysme!icins
- ? @ / E + F -
--
-?
-@
-
-
-/
HHC J -mg 77 1/1h
* * * * * * * * * * * * * *
9examet)asone K 771 !" /day# h$%h1&
So!im C)lori!eJ ml 7
* * * * * *
1lco4a L Stamicin !5 777
:me4 tb 7
;anitol -L J ? mg77,
1 f at 1h
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'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
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&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**
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&voltion !ay @
S6BM&C'7V& :BM&C'7V& AS&SS;&%' #0A%
Hfebrile episode
$o headache6enerali'edweaness$ot vomiting
*table +*
3ooperative$o meningealsigns
TB meningitis 3ontinue
medications
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&voltion !ay -
Bioc)emistry 6lucoseconcentration
8-,= mg:dl ↓↓↓
Celllar cont
andy reaction
levatedprotein
78-mgA ↑
3hlorides C9 mgA
J=:mmc (799Alimfocite)
0mbar pnctre= Clear CS2
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&voltion
weeks later, on cltre o$ 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
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Complications o$ 'Bmeningitis
4ydrocephalus
3+H
3oma
otor de!cits
*ei'ures
Hbnormal behaviours
3entral $ervous *ystem Tuberculosis. www.uptodate.com
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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.
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N)y s)ol! we care<
*omeone gets sick from TB every fourseconds and someone !ies of TB e'ery
ten seconds (<4G, -99=)
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'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.
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'HA%O 8:6P