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TUBERCULOUS MENINGITIS

TUBERCULOUS MENINGITIS. Dr Shreedhar Paudel April, 2009. TUBERCULOUS MENINGITIS……. Infection of meninges by Mycobacterrium Serious complication of childhood tuberculosis Common between 6 months to 24 months age May lead to serious disabling neurological sequale. TUBERCULOUS MENINGITIS…….

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TUBERCULOUS MENINGITIS

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  1. TUBERCULOUS MENINGITIS Dr ShreedharPaudel April, 2009

  2. TUBERCULOUS MENINGITIS…… • Infection of meninges by Mycobacterrium • Serious complication of childhood tuberculosis • Common between 6 months to 24 months age • May lead to serious disabling neurological sequale

  3. TUBERCULOUS MENINGITIS…… • PATHOGENESIS • Usually reaches the meninges through hematogenous route • May occur as a part of miliary tuberculosis

  4. TUBERCULOUS MENINGITIS…… • PATHOLOGY • The meningeal surface is covered with yellow grayish exudates and tubercles • The subarachnoid space and arachnoid villi are obliterated leading to poor absorption of CSF • The thick exudates may block the CSF pathway causing hydrocephalus • There might be thrombophlebitis and tuberculous encephalopathy

  5. Clinical Features • Prodromal stage ( stage of invasion) • Insidious onset with vauge symptoms • Fever, anorexia, disturbed sleep • Frequent vomiting, headache, photophobia • Stage of meningitis • Features of meningitis with focal neuroligical deficits • Stage of coma • Fever, loss of consciousness and altered respiratory pattern

  6. Diagnosis….. • LP and evaluation of CSF • Raised CSF pressure: 30-40 CM of water ( normal 3-4 CM of water) • CSF may be clear with formation of cobweb coagulum on standing ( like suspended pellicle ) • Protein: >40 mg/dl • Sugar: < 2/3rd of blood sugar level • Cell count: 100-400/μL, predomonance of lymphocytes • AFB stain and C/S

  7. Diagnosis….. • CT Head • May identify • Basal exudates • Inflammatory granuloma • Infarct lesions • Hydrocephalus • PCR for Mycobacterium • Other tests: Chest X- Ray, HIV ELISA

  8. TUBERCULOUS MENINGITIS • Differential Diagnosis • PURULENT MENINGITIS, • PARTIALLY TREATED MENINGITIS • ENCEPHALITIS, • TYPHOID ENCEPHALOPATHY, • BRAIN ABSCESS, • BRAIN TUMOR, • CHRONIC SUBDURAL HEMATOMA, • AMEBIC MENINGOENCEPHALITIS.

  9. TREATMENT OF TUBERCULOSIS MENINGITIS • Antitubercular treatment for 12 weeks • INITIAL PHASE-- 2 MTHS: HRZE • CONTINUATION PHASE--10 MTHS: HRE • DOSE OF DRUGS • ISONIAZID: 5mg/kg/day • RIFAMPICIN: 10mg/kg/day • ETHAMBUTOL: 15-20mg/kg/day • PYRAZINAMIDE: 30-40mg/kg/day

  10. TREATMENT OF TUBERCULOSIS MENINGITIS…… • STEROID THERAPY • DEXAMETHASONE IV- 1-2 WEEKS • ORAL PREDNISONE FOR 6 WEEKS • TAPER SLOWLY OVER 2 WEEKS • REDUCE THE INTENSITY OF CEREBRAL EDEMA • REDUCE THE DEVELOPMENT OF ARACHNOIDITIS • REDUCE FIBROSIS AND SPINAL BLOCK SUPPORTIVE AND SYMPTOMATIC THERAPY

  11. Prognosis • Depends on • Age of the patient • Stage of the disease at diagnosis • Adequacy of treatment • Presence of complications • Untreated cases die within 4-8 weeks • 20-25% mortality and 25% of survivors would have neurological deficits in stage 2 • 50% mortality and 100% neurological deficits among survivors in stage 3

  12. ENCEPHALITIS An inflammatory process of the central nervous system with dysfunction of the brain

  13. ENCEPHALITIS… • Encephalopathy is the cerebral dysfunction due to other causes than inflammatory response • Due to circulating toxins • Poisions • Abnormal metabolites • Intrinsic biochemical disorders

  14. ENCEPHALITIS… • ETIOLOGY • VIRAL: Measles, Mumps, Rubella, Enterovirus, HSV, CMV, EBV, Japanese B, WEST NILE, RABIES, DENGUE, HIV • OTHER: RICKETTSIA, • Cryptococcus • TOXOPLASMA, MALARIA • BACTERIAL: Mycobacterium, Salmonella, Shigella, Leptospirosis • REYE’S SYNDROME

  15. Clinical Features • ONSET: SUDDEN • SIGNS AND SYMPTOMS: FEVER, HEADACHE, VOMITING, ALTERED MENTAL STATUS, IRRITABILITY, APATHY , COMA • Typical features • Increased ICP Papilloedema Evidence of brain stem dysfunctions • Focal neurological deficits, • Respiratory/ Cardiac arrest due to Herniation of cerebellum

  16. Clinical Features … • DECEREBRATION, • DECORTICATION, • EXTRAPYRAMIDAL SYMPTOMS: JAPANEASE B • TEMPORAL OR FRONTAL LOBE FEATURES: HSV

  17. ENCEPHALITIS • DIAGNOSIS • HISTORY OF EXPOSURE • LP • CSF EVALUATION • PCR • SEROLOGICAL TESTS • TOXICOLOGICAL SCREENING • CT/ MRI

  18. MANAGEMENT OF ENCEPHALITIS • MANAGEMENT OF ABC • SYMPTOMATIC: ICT, FEVER, SHOCK, SEIZURES • SPECIFIC TREATMENT • HSV: ACYCLOVIR 30 MG/KG/DAY IN 3 DIVIDED DOSE FOR 10 DAYS • Focal neurological deficits, RBCs in CSF and focal involvement of temporal lobe on CT are important diagnostic clues for herpes simplex encephalitis

  19. REYE’S SYNDROME • Acute self limiting metabolic insult resulting in generalised mitochondrial dysfunction due to inhibition of fatty acid beta-oxidation. • Precipitated by use of aspirin in viral acute respiratory infections

  20. REYE’S SYNDROME • PATHOGENESIS • DYSFUNCTION OF LIVER, KIDNEY , CNS • GENERALISED MYOCARDIAL DYSFUNCTION • INHIBITION OF B-OXIDATION OF FATTY ACIDS • HYPERAMMONEMIA, NEUROHYPOGLYCAEMIA • COMMON AGE IS 2MTHS – 15 YEARS • RAPID PROGRESSION

  21. CLINICAL FEATURES • STAGE I - MILD CONFUSION, VOMITING, ANOREXIA • STAGE II – DELIRIUM, IRRITATION, DISORIENTATION • STAGE III – COMA • STAGE IV – APNEA, NON REACTING PUPIL, SHOCK

  22. DIAGNOSIS • HYPERAMMONEMIA, • ABNORMAL LFT, • INCREASED PROTHROMBIN TIME • GENERALISED SLOW WAVES IN EEG • HYPOGLYCEMIA • LIVER BIOPSY SHOWS FATTY CHANGES AND GLYCOGEN DEPLETION BUT NO NECROSIS

  23. TREATMENT • LOW PROTEIN DIET WITH ADEQUATE CALORY • TREATMENT OF HEPATIC FAILURE • TREATMENT OF RAISED ICT • TREATMENT OF HYPOGLYCAEMIA • SUPPLEMENTATION OF VITAMIN K , FFP • TREATMENT OF ACIDOSIS, HYPOXIA AND DYSELECTROLYTEMIA

  24. PROGNOSIS • POOR PROGNOSIS • 25-70% MORTALITY • SURVIVORS MAY HAVE NEUROLOGICAL SEQUALE

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