case 47 : 45M TB Meningitis

Tb meningitis

July 12, 2021

thanks Dr. Keerthi (intern)

 A 45 yr old male  chronic alcoholic since 20 yrs carpenter by occupation was brought to causality with 

CHIEF COMPLAINTS 

•difficulty in walking&decreased appetite since 15 days

•constipation since 5 days

•fever and pedal edema since 3 days

•vomiting since 2 days

HISTORY OF PRESENT ILLNESS

•patient was apparently asymptomatic 6 months back then  he had b/l pedal edema  and for which he taken herbal medicine for 15 days and the edema relieved then they went to hospital in chityala and he was  diagnosed with hypothyroidism and taking T.thyronorm 25mcg since then.

•1.5 month back he had history of fever,dry cough&weight loss from then

•20days  back he had tingling&numbness in b/l lower limbs till ankle and got admitted in our hospital and diagnosed as peripheral neuropathy and given symptomatic treatment and discharged after four days then from the next day patient had difficulty in walking and decreased appetite since then

•H/o constipation since 5 days.

•Fever - low grade , intermittent , releived with treatment since 3 days.

•B/l pedal edema - pitting , extending upto knees since 3 days.

•Vomiting - non bilious , non projectile , associated with food particles since 2 days.

•Altered sensorium since 1 day.


HISTORY OF PAST ILLNESS 

•Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD/TB


TREATMENT HISTORY 

He was on T.Thyronorm 25mcg for hypothyroidism 


PERSONAL HISTORY 

•HE is chronic alcoholic since 20 yrs


FAMILY HISTORY 

•No familiar history 


GENERAL EXAMINATION 

•patient was in altered sensorium 

•moderately built and moderately nourished

•icterus and pallor

•b/l pedal edema

•no lymphaedenopathy 


O/E

pt was in altered sensorium 

not oriented to T/P/P

GCS:-E2V2M4


VITALS

PR:86 BPM

BP:90/50 mmhg

Spo2:-98% on RA


CVS:S1 S2 + ,no murmurs

RS:BSE+,NVBS

P/A:Soft,NT

CNS 

NECK STIFFNESS+ 

                                 RIGHT                  LEFT 

  Tone  - UL               N                            N 

               LL              Hypo                   Hypo 

Power  - UL             1/5                        3/5 

               LL              0/5                       0/5 

Reflexes   Biceps     ++                        + 

                 Triceps      ++                        + 

                 Supinator   ++                       +

                 Knee          +                          +

                 Ankle          -                           -

                 Plantar    Withdrawl        

                            

PROVISIONAL DIAGNOSIS: 

TB MENINGITIS

CVA (embolic infarct in B/l cerebral hemispheres )

HYPOTHYROIDISM

HYPONATREMIA (secondary to SIADH )

CORONARY ARTERY DISEASE WITH HFiEF (42%) 

INVESTIGATIONS :

CBP

CUE 

APTT,PT

TROPONIN I

RBS

SR.ELECTROLYTES

ABG

BLOOD UREA 

SR.CREATININE 

LFT 





CHEST RADIOGRAPHY





MRI


●CSF analysis 


ECG  



Treatment :

 1)Inj CEFTRIAXON 2gm × IV ×BD

2)Inj DEXMETHASONE 8mg×IV × BD

3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)TAB PCM 650mg / sos

ON 13/07/2021 : 

On examination 

    E2V1M4 

    Afebrile 

PR : 92bpm 

RR  22cpm

BP  120/90 mmhg 

Spo2:91%on room air 

CVS : s1s2 heard 

RS   : NVBS + 

        Rgt side wheeze in MA,IMA, IAA 

PA  :SOFT 

CNS :             RIGHT                  LEFT 

  Tone  - UL               N                            N 

               LL              Hypo                   Hypo 

Power  - UL             1/5                        3/5 

               LL              0/5                       0/5 

Reflexes   Biceps     ++                        + 

                 Triceps      ++                        + 

                 Supinator   ++                       +

                 Knee          +                          +

                 Ankle          -                           -

                 Plantar    Withdrawl       

Investigtions :       

LIVER FUNCTION TEST 
TB: 2.13 
DB:  1.24 
SGOT: 80
SGPT:16 
ALP: 164 
Tp: 4.7
Albumin : 2.4 
A/ G : 1.01 

CSF ANALYSIS 
     



BACTERIAL CULTURE AND SENSITIVITY REPORT



CSF CYTOLOGY 




C REACTIVE PROTEIN

      CRP: negative 
2D ECHO


ABG 
Ph : 7.51
Pco2 : 34.1 
Po2: 98.3
Hco3: 27 

CSF ADA : 14 IU/L 

 HEMOGRAM : 
          HB : 9.9 
          TLC :11000
               N: 95 
               L:02
          Platelets: 2.14 
         Microcytic hypochromic anemia with neutrophilic leucocytes 

RADIOLOGY
       


       
       

Treatment : 

1)Inj CEFTRIAXON 2gm × IV ×BD

2)Inj DEXMETHASONE 8mg×IV × BD

3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day
                                         100mg-1/day
9)TAB ASPIRIN 150mg × RT×OD
10)TAB ATORVAS 40 mg ×RT ×OD

On 14/07/2021 : 
On examination 

    E2V1M4 

    Afebrile 

PR : 88bpm 

RR  24cpm

BP  120/90 mmhg 

Spo2:91%on room air 

CVS : s1s2 heard 

RS   : NVBS + 

        Rgt side wheeze in MA,IMA, IAA 

PA  :SOFT 

CNS :                        RIGHT                  LEFT 

  Tone  - UL               N                            N 

               LL              Hypo                   Hypo 

Power  - UL             1/5                        3/5 

               LL              0/5                       0/5 

Reflexes   Biceps     ++                        + 

                 Triceps      ++                        + 

                 Supinator   ++                       +

                 Knee          +                          +

                 Ankle          -                           -

                 Plantar    Withdrawl        

 Investigations : 

 Hemogram : 

        Hb : 9.6 

        TLC :11,500

         Platelets : 1.84 

         Normocytic normochromic anemia with neutrophilic leucocytosis 

RFT:

   Sr creatitine : 0.5 

   Sr urea : 33

    Na+:121 

    K+ : 3.8

    Cl-84 

ABG 

     Ph : 7.5 

     Pco2: 27

     Hco3 : 21.3 


Treatment : 

1)Inj CEFTRIAXON 2gm × IV ×BD

2)Inj DEXMETHASONE 8mg×IV × BD
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day              100mg-1/day

  9)RT feeds- 100 ml milk with 3-4 scoops protein powder 4th hourly
100 ml free water 2hrly
10) tab Aspirin 150 mg RT /OD
11)tab Atorvas 40 mg RT /OD
13)  Oral suction 2 hrly
14) Position change 2 hrly
15) Tab Thyronorm 25mcg RT /OD
16) Nebulization with Budesonide/Ipratropium/6th hrly
17)Tab Benadon plus 40 mg RT /OD

ON 15/07/2021 : 

On examination 

    E4V4M4 

    Afebrile 

PR : 120bpm 

RR  24cpm

BP  110/90 mmhg 

Spo2:90%on room air 

        95% on 4 lit o2 

CVS : s1s2 heard 

RS   : NVBS + 

        Rgt side wheeze in MA,IMA, IAA 

PA  :SOFT 

CNS                         RIGHT                  LEFT 

  Tone  - UL               N                            N 

               LL              Hypo                   Hypo 

Power  - UL             1/5                        3/5 

               LL              0/5                       0/5 

Reflexes   Biceps     ++                        + 

                 Triceps      ++                        + 

                 Supinator   ++                       +

                 Knee          +                          +

                 Ankle          -                           -

                 Plantar    Withdrawl 

Investigations ,: 


Serum electrolytes 

          Na+121 

          K+. 4.1

          Cl- 82 


Treatment : 


1)Inj CEFTRIAXON 2gm × IV ×BD
2)Inj DEXMETHASONE 8mg×IV × BD
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day              100mg-1/day

  9)RT feeds- 100 ml milk with 3-4 scoops protein powder 4th hourly
100 ml free water 2hrly
10) tab Aspirin 150 mg RT /OD
11)tab Atorvas 40 mg RT /OD
13)  Oral suction 2 hrly
14) Position change 2 hrly
15) Tab Thyronorm 25mcg RT /OD
16) Nebulization with Budesonide/Ipratropium/6th hrly
17)Tab Benadon plus 40 mg RT /OD

On 16/07/2021 
 On examination 
   E1V1M1
   Afebrile 
PR : 114bpm 
RR  24cpm
BP  80/60mmhg 
Spo2:88%on room air  
          96%on 4 lit o2 
CVS : s1s2 heard
RS   : NVBS + 
          Rgt side wheeze in MA,IMA, IAA 
PA  :SOFT 
CNS                         RIGHT                  LEFT 

  Tone  - UL               N                            N 

               LL              Hypo                   Hypo 

Power  - UL             1/5                        3/5 

               LL              0/5                       0/5 

Reflexes   Biceps     ++                        + 

                 Triceps      ++                        + 

                 Supinator   ++                       +

                 Knee          +                          +

                 Ankle          -                           -

                 Plantar    Withdrawl 

Investigations :


    Na + :128

     K+:4.1

    Cl-: 91 


ABG 

    Ph : 7.48

    Pco2: 28.9

    Po2 : 78.2

    Hco3:21.5 

 



ECG 

     




Treatment : 


1)Inj CEFTRIAXON 2gm × IV ×BD
2)Inj DEXMETHASONE 8mg×IV × BD
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day              100mg-1/day

  9)RT feeds- 100 ml milk with 3-4 scoops protein powder 4th hourly
100 ml free water 2hrly
10) tab Aspirin 150 mg RT /OD
11)tab Atorvas 40 mg RT /OD
13)  Oral suction 2 hrly
14) Position change 2 hrly
15) Tab Thyronorm 25mcg RT /OD
16) Nebulization with Budesonide/Ipratropium/6th hrly
17)Tab Benadon plus 40 mg RT /OD

On 17/07/2021 

On examination 
   E1V1M1
   Afebrile 
PR : 100bpm 
RR  24cpm
BP  110/80mmhg @12 ml/hr NOR ADRENALINE 
      Spo2: 85%on room air  
                94%on 4 lit o2 
CVS : s1s2 heard
RS   : NVBS + 
         Decreased air entry in right side 
PA  :SOFT 
CNS                         RIGHT                  LEFT 

  Tone  - UL               N                            N 

               LL              Hypo                   Hypo 

Power  - UL             1/5                        3/5 

               LL              0/5                       0/5 

Reflexes   Biceps     ++                        + 

                 Triceps      ++                        + 

                 Supinator   ++                       +

                 Knee          +                          +

                 Ankle          -                           -

                 Plantar    Withdrawl 

Investigations :


Hb : 10.7

TLC: 24,300

    N:95% 

    L:2%

    E:2%

    M:1%

PLT: 1.73 

Electrolytes :

    Na+ : 126

    K+:    4.5 

    Cl- :  94 

LFT:

    TB: 3.79

     DB: 2.63

     SGOT: 312 

     SGPT :121 

      ALP : 248 

     TP : 4.6 

     ALBUMIN : 2.2 

     A/G : 0.96 

     



Treatment : 


1)Inj CEFTRIAXON 2gm × IV ×BD
2)Inj DEXMETHASONE 8mg×IV × BD
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day              100mg-1/day

  9)RT feeds- 100 ml milk with 3-4 scoops protein powder 4th hourly
100 ml free water 2hrly
10) tab Aspirin 150 mg RT /OD
11)tab Atorvas 40 mg RT /OD
13)  Oral suction 2 hrly
14) Position change 2 hrly
15) Tab Thyronorm 25mcg RT /OD
16) Nebulization with Budesonide/Ipratropium/6th hrly
17)Tab Benadon plus 40 mg RT /OD

DEATH SUMMARY : 

This is a case of 45 year old male with TB MENINGOENCEPHALITIS  with POTTS SPINE  with raised intracranial pressure with CVA ( embolic infarct in B/L cerebral hemisphere ) with hypothyroidism with hyponatremia with CAD .The pt was admitted on 10/07/2021 at 10:30 pm ,the next day,the pt underwent lumbar puncture ,and ATT was started on 12/07/2021 .the pt was treated with IV antibiotics for sepsis and 3%Nacl for hyponatremia and RT feeds were given for feeding and nutrition . The pt GCS was deteriorating day by day and on 17/07/2021    at 6 pm elective intubation was done and 6:30 pm ,the pt was found to have absent central and peripheral pulses with 0%saturation .the pt was intubated and CPR  started .inspite of all resusitative efforts ,pt couldn’t be revived and declared dead at 17/07/2021 at 7:26pm 

Immediate cause : SUDDEN CARDIOPULMONARY ARREST WITH REFRACTORY HYPTENSION 

Antecedent cause : TB MENINGOENCEPHALITIS WITH POTTS SPINE WITH RAISED ICP 


 

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