CASE REPORT

TUBERCULOUS MENINGITIS

Supervisor: dr. Ridwan M Daulay, Sp.A(K) Presentator: Lee Wei Lun 080100419
PEDIATRICS DEPARTMENT FACULTY OF MEDICINE UNIVERSITY OF NORTH SUMATERA HAJI ADAM MALIK GENERAL HOSPITAL CENTER

MEDAN 2013

Definition, Etiology and Risk Factors of meningitis

Definition
Etiology
The disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges

Bacterial, Viral, Noninfectious

Fungal,

Parasitic,

Risk Factor

- Immunodeficiency associated with young age, aging, malnutrition etc - Immunosuppressed individuals - Defect complemen system (C5-C8) in Eskimos. - Congenital or acquired CSF leakage (may be due to trauma)

Tuberculous Meningitis
Infection of the meninges by Mycobacterium tuberculosis.

Pathogenesis

Pathophysiology
Bacterial seeding Increased pearmeab ility BBB
Inflammation of spinal nerves and roots
Inflammation of cranial nerves

Cerebral edema
Meningea l signs
Cranial neurophatie s

Presence of toxic mediator s

Diagnosis
Nonspecific symptoms:
Fever, Irritability, Drowsiness, and Malaise

Confusion, meningeal signs, seizures

Coma, Hemiparesis, Nerves palsies

Lumbal Puncture

Blood Culture

Radiology

PCR
Lumbal Puncture

CSF culture
CSF Staining CSF Analysis
Lymphocytic-predominant pleiocytosis Elevated protein levels 100-500mg/dL Low glucose <45mg/dL

Brain CT-Scan
Radiology Hydrocephalus Tuberculomas Infarctions

Chest X-ray
Suggesting active or previous pulmonary tuberculosis

10% have milliary disease

Management

Glucocorticoid

Antibioti c

Evidence that inflammatory cytokines Adjunctive therapy was reduced audiologic and neurologic sequelae

Antituberculous drugs
INH ( 10 mg/kg BB/day) Rifampicin (10-20 mg/kgBB/day) Pyrazinamide (15-30 mg/ kgBB /day Ethambutol (15-25 mg/ kgBB/day) Streptomycin (20-40 mg/ kgBB/day)

CASE REPORT

Name Age Sex MR Address

: PF : 1 year 10 months : Female : 54.33.98 : Desa Batu Lapan, Deli Serdang Date of Admission : January 06th 2013

CHIEF COMPLAINT: Altered level of consciousness HISTORY: It started 2 days ago and was preceded by an episode of seizure. The seizure was generalized, with stiffening and rigidity of all four extremities and the patients eyeballs appeared to be rolled upwards. The seizure only occurred once with duration of 1 hour and the patient was unconscious since then. The patient does not have any history of seizure before this. Fever(+) for the past 1 week with fluctuating body temperature, body temperature tends to decrease with consumption of antipyretic drugs. Cough(+) for the past 1 week, unproductive. History of coming into contact with any person with chronic coughs was not found. 2 days ago, before the seizure occurred, the patient experienced 2 episodes of vomit. Contents of the vomits are the foods and drinks ingested. Previous traumatic event was not found.

Pregnancy history : 2nd child of the family, history of sickness during pregnancy (-), diabetes (-), hypertension (-), consumption of medications (-), consumption of herbal drinks (-). Delivering history : Born at home with the help of a midwife, aterm, cried immediately, birth weight: 3000gram and body length: 50cm. bluish appearance (-), seizures (-) .

History of Growth &Development: Sitting : 8 month Walking : 1 year Currently patient can mention certain words like: mama, bapak, kakek and nenek
History of Feeding: Birth 5 mo : Breast milk only 5 mo 1 yr : Breast milk + conventional milk + porridge 1 year present : conventional milk + soft rice History of Immunization: Unclear

History of previous illness: Patient was initially treated in Kabupaten A. Tamiang General Hospital for two days with the diagnosis: Encephalitis with bronchopneumonia.

History of previous medications: Injection of Metamizole Sodium, Ampicillin, Gentamycin and Phenytoin

Age: 1 years 10 months, girl Body weight (BW): 9 kg, Body length: 81 cm, Body weight in 50th percentile according to age: 11.8 kg Body length in 50th percentile according to age: 84.0 cm Body weight in 50th percentile according to body length: 11.1 kg BW/BL : 9/11.1 9/11.8 81/84 x 100% x 100% x 100% = 81.08% = 76.27% = 96.42%

BW/age : BL /age :

Presence Status: Sensorium: GCS 9 (E3V2M4) BP = 90/60 mmHg HR = 120 x/i RR = 26 x/i, T = 38.5C Body weight (BW) : 9.0 kg Body length (BL) : 81 cm Head Circumference (HC): 43 cm Anemic (-), icteric (-), dyspnea (-) cyanotic (-), edema (-).

Physical Examination
Head Eyes: light reflex (+/+), isochoric pupil 3 mm, pale conjuctiva palpebra inferior, icteric sclera (-/-) Nose / Ears / Mouth : within normal limits

Neck Thorax

lymph node enlargement (-), stiff neck (-) symmetric fusiform, retraction (-) HR: 120 bpm, regular, murmur (-), RR: 26 x/i, reguler, ronchi (-/-) soepel, normoperistaltic; liver, spleen: not palpable pulse 120 bpm, regular, adequate pressure/volume warm axilla, capillary refill time <3s Physiologic reflexes : APR (+), KPR (+) Pathologic reflexes : Babinsky (+/+), Chaddock (+/+), Gordon (+/+), Oppenheim (+/+) Spasticity of right leg (+) female, normal

Abdomen Extremities

Genitalia

Laboratory Findings:

Test Hb RBC WBC Hematocrite PLT MCV MCH MCHC RDW MPV PCT PDW

Complete Blood Count

Result 9.20 4.26 13.10 30.70 487 72.10 21.60 30.00 16.60 8.30 0.41 8.8 Normal Value 11.3 14.1 4.40 4.48 6.0 17.5 37 41 217 - 497 81 95 25 29 29 31 11.6 14.8 7.2 10 Unit g% 106/mm3 103/mm3 % 103/mm3 fL Pg g% % fL % fL

Test Neutrophil Lymphocyte Monocyte

Result 70.20 21.00 8.50

Normal Value 37 48 20 40 28

Unit % % %

Eosinophil
Basophil Neutrophil absolute Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute

0.10
0.200 9.20 2.75 1.12 0.01 0.02

16
01 1.9 5.4 3.7 10.7 0.2 0.6 0.20 0.50 0 0.1

%
% 103/L 103/L 103/L 103/L 103/L

Carbohydrate metabolism Blood glucose level (ad random) 59.50 < 200 mg/dL

Renal Ureum Creatinine Electrolytes Sodium (Na) Pottasium (K) Chloride (Cl) 140 4.0 106 135-155 3.6-5.5 96-106 mEq/L mEq/L mEq/L 10.90 0.20 < 50 0,24 0.41 mg/dL mg/dl

Analysis of Cerebrospinal Fluid

Result Normal Value Unit

Test

Colour LDH Total Protein Leucocyte Count Erytrocyte Count Glucose pH MN Cells PMN Cells

Clear 223 56 0.098 0 24 8.0 52 58

Clear <200 <45 <32 U/L mg/dL 103/L 106/L 40 76 78 % % mg/dL

Radiology (Chest X-ray)

[6/1/2013]

Differential Diagnosis: Encephalitis Meningoencephalitis Meningitis

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i (micro) - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV - Inj. Ampicillin 450 mg/6 hours/IV - Paracetamol 3x100 mg
Diagnostic Planning: Consult Neurology Division Head CT-Scan Mantoux test done on left volar, read on 9th January Blood culture

January 7th 2013

Decreased level of consciousness (+), fever(+)

Thorax: symmetric fusiform, retraction (-), HR: 110 bpm, regular, murmur (-) Sens: GCS 9 (E3V2M4), T= 38.3C RR: 24 x/i, reguler, ronchi (-/-) Head: Abdomen: soepel, normoperistaltic; liver, spleen, and Eyes: light reflex (+/+), isochoric pupil 3 mm, pale renal are not palpable conjuctiva palpebra inferior, icteric sclera (-/-) Extremities: pulse 110 bpm, regular, adequate Nose: nasal canule (+) pressure/volume, warm acral, capillary refill time <3 Ears / Mouth : within normal limits Physiologic reflexes : APR (+), KPR (+) Neck : lymph node enlargement (-), stiff neck (-) Pathologic reflexes : Babinsky (+/+), Chaddock (+/+), Gordon (+/+), Oppenheim (+/+) DD: 1. Encephalitis 2. Meningoencephalitis 3. Meningitis

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i (micro) - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV (H1) - Inj. Ampicillin 450 mg/6 hours/IV (H1) - Inj. Dexamethasone 9mg/6hours/IV - Paracetamol 3x100 mg

Pediatric Neurologist Consultation: Working Diagnosis: Encephalitis Treatment: IVFD NaCl 3%/12 hours done in 2 hours time Liver Function Test AST/SGOT: 45U/L (N: <32) ALT/SGPT: 17 U/L (N: <31) Ferritin: results pending Iron (Fe): 25 mg/dL (N: 61 157) TIBC: 153 mcg/dL (N: 112 346)

January 8th 2013

Decreased level of consciousness (+), fever(+)

Thorax: symmetric fusiform, retraction (-), HR: 106 bpm, regular, murmur (-) Sens: GCS 9 (E3V2M4), T= 38.6C RR: 30 x/i, reguler, ronchi (-/-) Head: Abdomen: soepel, normoperistaltic; liver, spleen, and Eyes: light reflex (+/+), isochoric pupil 2 mm, pale renal are not palpable conjuctiva palpebra inferior, icteric sclera (-/-) Extremities: pulse 106 bpm, regular, adequate Nose: nasal canule (+) pressure/volume, warm acral, capillary refill time <3 Ears / Mouth : within normal limits Physiologic reflexes : APR (+), KPR (+) Neck : lymph node enlargement (-), stiff neck (-) Pathologic reflexes : Babinsky (+/+), Chaddock (+/+), Gordon (+/+), Oppenheim (+/+) DD: 1. Encephalitis 2. Meningoencephalitis 3. Meningitis

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i micro - IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV (H2) - Inj. Ampicillin 450 mg/6 hours/IV (H2) - Inj. Dexamethasone 9mg/6hours/IV - Paracetamol 3x100 mg Gastric Aspiration was done and samples taken for microbiology and acid-fast test. Results from blood culture Staphylococcus saprophyticus using Bactec:

Balance: I: 850cc; O:670cc = 180cc Urine Dipstick: Leu Nit Uro Prot pH Blo Sg Ket Bil Glu - - 0.2 5.0 - 1.005 - - -

January 9th 2013

Decreased level of consciousness (+), fever(+)

Thorax: symmetric fusiform, retraction (-), HR: 106 bpm, regular, murmur (-) Sens: GCS 9 (E3V2M4), T= 38.5C RR: 28 x/i, reguler, ronchi (-/-) Head: Abdomen: soepel, normoperistaltic; liver, spleen, and Eyes: light reflex (+/+), isochoric pupil 2 mm, pale renal are not palpable conjuctiva palpebra inferior, icteric sclera (-/-) Extremities: pulse 106 bpm, regular, adequate Nose: nasal canule (+) pressure/volume, warm acral, capillary refill time <3 Ears / Mouth : within normal limits Physiologic reflexes : APR (+), KPR (+) Neck : lymph node enlargement (-), stiff neck (-) Pathologic reflexes : Babinsky (+/+), Chaddock (+/+), Gordon (+/+), Oppenheim (+/+) DD: 1. Encephalitis 2. Meningoencephalitis 3. Meningitis + Suspect Sepsis

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i micro - IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV (H3) - Inj. Ampicillin 450 mg/6 hours/IV (H3) - Inj. Dexamethasone 9mg/6hours/IV - Paracetamol 3x100 mg

Results of Mantoux Test: negative

Results from microbiology on gastric aspirates: Epithelial: 0-1/lpb Leucocytes: 0-1/lpb BTA: negative Fungal: negative Gastric Aspiration was repeated. Immunoserology Qualitative CRP: positive Procalcitonin: 1.24ng/mL (N:<0.05)

January 10th 2013

Decreased level of consciousness (+), fever(+)

Thorax: symmetric fusiform, retraction (-), HR: 108 bpm, regular, murmur (-) Sens: GCS 9 (E3V2M4), T= 37.9C RR: 26 x/i, reguler, ronchi (-/-) Head: Abdomen: soepel, normoperistaltic; liver, spleen, and Eyes: light reflex (+/+), isochoric pupil 2 mm, pale renal are not palpable conjuctiva palpebra inferior, icteric sclera (-/-) Extremities: pulse 108 bpm, regular, adequate Nose: nasal canule (+) pressure/volume, warm acral, capillary refill time <3 Ears / Mouth : within normal limits Physiologic reflexes : APR (+), KPR (+) Neck : lymph node enlargement (-), stiff neck (-) Pathologic reflexes : Babinsky (+/+), Chaddock (+/+), Gordon (+/+), Oppenheim (+/+) DD: Tuberculous Meningitis + suspect sepsis

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i micro - IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV (H4) - Inj. Ampicillin 450 mg/6 hours/IV (H4) - INH 1 x 90mg (H1) - Rifampin 1 x 90mg (H1) - Pyrazinamid 1 x 180mg (H1) - Ethambutol 1 x 135mg (H1) - Prednisone 3 x 3mg (H1) - Paracetamol 3x100 mg

Results from microbiology on gastric aspirates: Epithelial: 0-1/lpb Leucocytes: 5 - 10/lpb BTA: positive 1 (+) Fungal: negative
Results from Brain CT Scan: Right Frontal periventricular infarct+ communicating hydrocephalus

Results from Brain CT Scan: Right Frontal periventricular infarct+ communicating hydrocephalus

January 11th 2013

Decreased level of consciousness (+), fever(+)

Thorax: symmetric fusiform, retraction (-), HR: 102 bpm, regular, murmur (-) Sens: GCS 9 (E3V2M4), T= 38C RR: 26 x/i, reguler, ronchi (-/-) Head: Abdomen: soepel, normoperistaltic; liver, spleen, and Eyes: light reflex (+/+), isochoric pupil 2 mm, pale renal are not palpable conjuctiva palpebra inferior, icteric sclera (-/-) Extremities: pulse 102 bpm, regular, adequate Nose: nasal canule (+) pressure/volume, warm acral, capillary refill time <3 Ears / Mouth : within normal limits Physiologic reflexes : APR (+), KPR (+) Neck : lymph node enlargement (-), stiff neck (-) Pathologic reflexes : Babinsky (+/+), Chaddock (+/+), Gordon (+/+), Oppenheim (+/+) DD: Tuberculous Meningitis + suspect sepsis

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i micro - IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV (H5) - Inj. Ampicillin 450 mg/6 hours/IV (H5) - INH 1 x 90mg (H2) - Rifampin 1 x 90mg (H2) - Pyrazinamid 1 x 180mg (H2) - Ethambutol 1 x 135mg (H2) - Prednisone 3 x 3mg (H2) - Paracetamol 3x100 mg

Balance: I: 900cc; O:680cc = 220cc Urine Dipstick: Leu Nit Uro Prot pH Blo Sg Ket Bil Glu - - 0.2 5.0 + 1.015 - - -

January 12th 2013

Decreased level of consciousness (+), fever(+), breathlessness (+), gasping (+) with risk of respiratory failure
Thorax: symmetric fusiform, epigastrium retraction(+), HR: 160 bpm, regular, murmur (-) Sens: GCS 5 (E1V2M2), T= 38.4C BP: 60/20 mmHg RR: 44 x/i, reguler, ronchi (-/-) Head: Abdomen: soepel, normoperistaltic; liver, spleen, and Eyes: light reflex (+/+), mydriasis (+), pale conjuctiva renal are not palpable palpebra inferior (+/+) Extremities: pulse 160 bpm, regular, adequate Nose: nasal canule (+) pressure/volume, warm acral, capillary refill time <3 Ears / Mouth : gasping (+) Physiologic reflexes : APR (+), KPR (+) Neck : lymph node enlargement (-), stiff neck (-) Pathologic reflexes : Babinsky (+/+), Chaddock (+/+), Gordon (+/+), Oppenheim (+/+) DD: Tuberculous Meningitis + suspect sepsis + Anemia ec DD/ Iron deficiency Chronic disease

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i micro - IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV (H6) - Inj. Ampicillin 450 mg/6 hours/IV (H6) - INH 1 x 90mg (H3) - Rifampin 1 x 90mg (H3) - Pyrazinamid 1 x 180mg (H3) - Ethambutol 1 x 135mg (H3) - Prednisone 3 x 3mg (H3) - Paracetamol 3x100 mg

Results from complete blood test: Haemoglobin: 9.70% RBC: 4.40 x 106/mm3 MCV: 66.80 fL MCH:22.00 pg Leucocyte: 29.40 x 103/mm3 Thrombocyte: 42 x 103/mm3 Hypochromic microcytic anemia + leucocytosis + thrombocytopenia Patients condition worsen, transferred to HCU Respiratory distressed were seen with RR 10x/i. intubation was done on patient and ETT was inserted. VTP 30/minute with oxygen 10L/i.

[12/1/2013]
Blood Gas Analysis pH 7.4 7.35 7.45

pCO2 pO2 Bicarbonate Total CO2 Base Excess (BE)

22 265 13.6 14.3 -11.2

38 42 85 100 22-26 19 25 (-2) (+2)

mmHg mmHg mmol/L mmol/L mmol/L

SaO2
Electrolytes Calcium (Ca) Sodium (Na)

100

95 100

6.0 120

8.4 10.4 135-155

mg/dL mEq/L

Potassium (K)
Chloride (Cl)

2.5
97

3.6-5.5
96-106

mEq/L
mEq/L

January 13th 2013

Decreased level of consciousness (+), fever(+)

Sens: GCS 4 (E1V1M2), T= 38C BP: 80/40 mmHg Head: Eyes: light reflex (+/+), mydriasis (+), pale conjuctiva palpebra inferior (+/+) Nose: NGT (+) Ears / Mouth : ETT (+) Neck : lymph node enlargement (-), stiff neck (-) Thorax: symmetric fusiform, epigastrium retraction(-), HR: 168 bpm, regular, murmur (-) RR: 30 VTP/i, reguler, ronchi (-/-) Abdomen: soepel, normoperistaltic; liver, spleen, and renal are not palpable Extremities: pulse 168 bpm, regular, inadequate pressure/volume, cold acral, capillary refill time >3

DD: Tuberculous Meningitis + suspect sepsis + Anemia ec DD/ Iron deficiency Chronic disease

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i micro - IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV (H7) - Inj. Ampicillin 450 mg/6 hours/IV (H7) - INH 1 x 90mg (H4) - Rifampin 1 x 90mg (H4) - Pyrazinamid 1 x 180mg (H4) - Ethambutol 1 x 135mg (H4) - Prednisone 3 x 3mg (H4) - Paracetamol 3x100 mg

Correction of hypocalcemia: with 4.5cc calcium gloconate in 4.5cc NaCl 0.9% in 15 minutes Correction of hypokalemia: with 4.5 mEq in 24cc D5% in 1 hour Correction of hyponatremia: with 210cc Nacl 0.9% D5% in 4 hours and followed by 13cc/hour for the next 20 hours. Patient was consulted to anaesthesia department for the insertion of CVC line. CVC line inserted at left thorax.

January 14th 2013

Decreased level of consciousness (+), fever(+)

Thorax: symmetric fusiform, epigastrium retraction(-), CVC line (+), HR: 148 bpm, regular, murmur (-) Sens: GCS 4 (E1V1M2), T= 38.5C BP: 80/40 mmHg RR: 30 VTP/i, reguler, ronchi (-/-) Head: Abdomen: soepel, normoperistaltic; liver, spleen, and Eyes: light reflex (+/+), mydriasis (+), pale conjuctiva renal are not palpable palpebra inferior (+/+) Extremities: pulse 148 bpm, regular, inadequate Nose: NGT (+) pressure/volume, cold acral, capillary refill time >3 Ears / Mouth : ETT (+) Physiologic reflexes : APR (+), KPR (+) Neck : lymph node enlargement (-), stiff neck (-) Pathologic reflexes : Babinsky (-/-), Chaddock (-/-), Gordon (-/-), Oppenheim (-/-) DD: Tuberculous Meningitis + suspect sepsis + Anemia ec DD/ Iron deficiency Chronic disease

Management: - Bed rest with 30 head elevation - O2 1 liter/minute via nasal canule - IVFD D5% NaCl 0,45% 19 gtt/i micro - IVFD NaCl 3% 90cc 45 gtt/i micro/ 12 hours - Diet SV 900 kcal with 18g protein - Inj. Phenytoin 25mg/12hours in 5cc D5% in 20 minutes - Inj. Ceftriaxone 450 mg/12 hours/IV (H8) - Inj. Ampicillin 450 mg/6 hours/IV (H8) - INH 1 x 90mg (H5) - Rifampin 1 x 90mg (H5) - Pyrazinamid 1 x 180mg (H5) - Ethambutol 1 x 135mg (H5) - Prednisone 3 x 3mg (H5) - Paracetamol 3x100 mg

Urine catheter was inserted Balance: I: 500cc; O:360cc = 140cc Urine Dipstick: Leu Nit Uro Prot pH Blo Sg Ket Bil Glu - - 0.2 ++++ 5.0 ++ 1.025 ++ - -

January 14th 2013

At 0945 hours patient fell into apnoea with a GCS score of 3 delayed light reflexes, dilated pupil right = left 6 mm pulse and blood pressure were unmeasurable temperature fell to 35,10C dirty red fluid was seen in the NGT and urine was stained red. A : Respiratory failure + Shock Septic + Tuberculous Meningitis + Anemia P: - VTP 30x/minute with oxygen of 10/L was administered continuously but oxygen saturation was failed to be measured using pulse oxymetry. - Fluid challenge with IVFD NaCl 0.9% 10cc/kg/hour (90cc/hour) at 30 gtt/minute from 0945 to 1045 hours. Patients last recorded blood pressure was 60/20 mmHg during re-evaluation at 1015 hours. - Blood glucose level was 50mg/dL and 2cc/kg Dextrose 10% (20cc) was given as bolus. - Adrenaline of 0.1cc.kg (10cc) was injected intravenously followed by dobutamine 0,5cc/hour. Patients failed to response to the emergency intervention given and remained in shock. At 1100 hours patient was declared decease based on maximal dilation of pupil.

DISCUSSION
THEORY
In tuberculous meningitis, a prodromal phase of low-grade fever, malaise, headache, dizziness and vomiting may persist for a few weeks, after which patients can then develop more severe headache, altered mental status, stroke, hydrocephalus, and cranial neuropathies. Seizures occurs in about 50% of child tuberculous meningitis.

CASE PF, was admitted with the chief complain of altered mental status. Symptoms that preceded the decrease of consciousness includes fever, vomiting and an episode of seizure.

DISCUSSION
THEORY
Characteristic CSF findings of tuberculous meningitis include: (i) Clear fluid (ii) Lymphocytic-predominant pleiocytosis. Total white cell counts are usually between 100 and 500 cells/L. MN>PMN (iii) Elevated protein levels, typically between 100 and 500 mg/dL, (iv) Low glucose, usually less than 45mg/dL or CSF: plasma ratio <50%

CASE
CSF analysis shows a clear colored fluid, slight increase in proteins level: 56mg/dL and decrease level of CSF glucose: 24mg/dL. Pleiocytosis was not found. MN 52%, PMN 58%. Atypical CSF findings are well described, particularly in immune-suppressed patients, and the CSF can be acellular or contain a predominance of neutrophils .

DISCUSSION
THEORY Gastric aspirates and bone marrow aspirates may assist in detecting extra-neural tuberculosis in children

CASE Gastric aspiration was done twice. On the second time, results shows that acid-fast bacilli was found to be positive 1 (+1) on smear.

DISCUSSION
THEORY
The commonest cerebral CT features of tuberculous meningitis are hydrocephalus and basal contrast enhancing exudates. Both features are more common in children (80%). Infarctions as a result of ongoing vasculitis or tuberculoma are found in approximately 20% of patients.

CASE results of CT-scan from the radiologist: Right frontal periventricular infarct with communicating hydrocephalus possibly due to meningitis

PF, 1 year 10 months, female who first entered with the diagnosis of encephalitis was diagnosed with tuberculous meningitis with sepsis. The diagnosis was established based on history taking, clinical manifestations, laboratory and radiological findings. Patient was treated for 9 days.

The condition of the patient worsen after 2 days into antituberculosis drugs and finally pass away on the 5th day of antituberculosis therapy due to respiratory failure.

Thank you