V.

Babe Hospital
Craiova

Introduction
Tuberculosis (TB) remains one of the worlds
deadliest communicable diseases.
TB meningitis is one of the worst forms of
extrapulmonary tuberculosis whose evolution,
untreated, is invariably fatal.
The clinical features of TBM are the result of
basilar meningeal fibrosis and vascular
inflammation.

Introduction

Introduction
The use of antitumor necrosis factor-alpha
(TNF) neutralizing antibody has also been
associated with increased risk of
extrapulmonary TB including TBM.
The mechanisms by which TNF is important in
initial and long-term control of tuberculosis are
not clear, and are likely to be numerous.

Patient S. V.
History of present
illness
Headache
not relieved
by
medications
Cough

Simptomatolo
gy

ks
e
we

we
ek

Vomiting
Generalized
weakness

Chills
52 years old female from an urban environment;
No history of trauma

Anamnesis
Past medical history:
Psoriasis in treatment for 2 years with anti-TNF;
Not suffering for diabetes, hepatitis
Family diseases:
no significant family medical history known
No family history of the following:
Diabetes
Cancer
TB
Hepatitis

Anamnesis
Social history:
Lives in a flat;
Pensioner;
Got 1 kid (female) 30 y.o.;
No tobacco, alcohol or drug use;
Drinks coffee (1-2/day);
No recent foreign travel;
No pets

Anamnesis
Regular and acute medications:
Remicade 100 mg (Infliximabum);
Paracetamol (Acetaminophen)

Allergies:
none known

Clinical examination
HEENT
Awake, cooperative but difficulty
in speaking

Pallid face, icteric sclerae, moist

buccal mucosa

Neck rigidity

Clinical examination

Coarse rales

Regulate rhtym, HR- 80bpm,

BP- 100/60 mmHg

Symmetrical chest expansion

Chest/
Lungs

Clinical examination

Soft abdomen, untenderness

No organomegaly

Giordano - , darker urine emission

Abdomen

Clinical examination

Full pulses, no edema, no cyanosis

Erythemato-squamous elements
localized on skin of the large joints
of upper and lowerlimbs

Extremitie
s

1 diagnosis
st

ACUTE FEBRILE SYNDROME

ACUTE PNEUMONIA ?

Laboratory data
Normal WBC (6,3*10^3u/L), an easier
lymphopenia (14%);
Very accelerated ESR(55mm/1h; 70mm/2h);
GPT=74 U/L - hepatocytolisis;GOT=62 U/L ;
Alkaline phosphatase 135 ;
Gamma GT 115;
Glucose 127;
Urinalysis rare flat epithelial, rare WBC, rare
microbial flora. acid pH , density - 1030.

Laboratory data

CXR
micro point opacities

disseminated in both lung

fields
Miliary TB?

Laboratory data
Lumbar puncture Clear CSF

Biochemistry

Cellular count

Glucose
concentration

15,1 mg/dl

Pandy reaction

+++

Elevated
protein

66mg%

Chlorides

760 mg%

255/mmc
(10% PMN,
90% Ly)

Laboratory data
Pneumology examination
TB meningitis
Miliary pulmonary TB form
Dermatologic examination
Patient with known with severe psoriasis in
treatment with anti-TNF alpha for 2 years
(Infliximabum 400mg at 2 months), last parenteral
administration at 9 11 2012 with the remission of
skin lesions accuse from 3-4 days headache and
asthenia.
Recommendations : infliximab discontinuation

Diagnosis

Diagnosis

1.TB MENINGITIS
2.MILIARY PULMONARY TB FORM
3.DRUG-INDUCED HEPATITIS
4.ORAL THRUSH
5.PSORIASIS IN BIOLOGICAL THERAPY

Differential diagnosis

Fungal Meningitis
Viral meningoencephalitis
Parameningeal Infection
Sphenoid sinusitis, brain abscess, spinal epidural
abscess

Neoplastic Meningitis Lymphoma

Treatment
Zile de tratament/
medicament

1
0

1
1

1
2

1
3

1
4

1
5

1
6

HIN cp 100mg III

(isoniazidum)

+ + + + + +

+ + + + + + + + + +

RIF cp 150mg II
(pyrazinamidum)

+ + + + + +

+ + + + + + + + + +

PZM cp 500 mg II
(rifampicinum)

+ + + + + +

+ + + + + + + + + +

EMB cp 400mg II
(ethambutolom)

+ + + + + +

+ + + + + + + + + +

Treatment
Treatment days/
medicins

1
0

1
1

1
2

1
3

1
4

1
5

1
6

HHC fl 100mg II 1/12

h

+ + -

Dexamethasone fi II
1 fi* 2/day, h8-h16

+ + + + + +

+ + + + + + + + + +

Sodium Chloride
fl 500 ml I

+ + + + + +

+ + + +

Glucoza 5%

+ + + + + +

+ + + + + + + + + +

Stamicin dj III

+ + + + + +

+ + + + + + + + + +

Omez tb I

+ + + + + +

+ + + + + + + + + +

Manitol 15% fl 250 mg + + + + + +

II,
1 f at 12h

+ + + + + + + + + +

Treatment
Zile de tratament/
medicament

17

18

19

22

23

2
4

HIN cp 100mg III

(isoniazidum)

+ + + +

+ + + + + + +

RIF cp 150mg II
(pyrazinamidum)

+ + + +

+ + + + + + +

PZM cp 500 mg II
(rifampicinum)

+ + + +

+ + + + + + +

EMB cp 400mg II
(ethambutolom)

+ + + +

+ + + + + + +

Dexamethasone fi II
1 fi* 2/zi, h8-h16

+ + + +

+ + + + + + +

Ranitidine cpr II

+ + + +

+ + + + + + +

B6 vitamin fl I

+ + + +

+ + + + + + +

Liv 52 cpr II

+ + + +

+ + + + + + +

2
0

2
1

2
5

2
6

2
7

2
8

2
9

3
0

Evolution day 1
SUBJECTIVE

OBJECTIVE

ASESSMENT

PLAN

Febrile episode
(max 38,4C)
Headache
Difficulty in
speaking
Generalized
weakness
Not vomiting

Stable VS
Cooperative
No meningeal
signs
CRX - micro
point opacities
disseminated in
both lung
fields

TB meningitis

Na correction
Start Mannitol
Start TSS

Evolution day 3
SUBJECTIVE

OBJECTIVE

ASESSMENT

PLAN

Afebrile episode
No headache
Generalized
weakness
Not vomiting

Stable VS
Cooperative
No meningeal
signs

TB meningitis

Continue
medications

Evolution day 10
Lumbar puncture Clear CSF
Biochemistry

Cellular count

Glucose
concentration

32,6 mg/dl

Pandy reaction

+++

Elevated
protein

132mg%

Chlorides

750 mg%

96/mmc (100%
limfocite)

Evolution
4 weeks later, on culture of LCR was
developed M. tuberculosis
She was discharged after 1 month of
hospitalisation with normal laboratory
data and no symptoms
She continuated anti-tuberculosis
treatment for 12 month
She permanently discontinued
biological therapy for psoriazis

Complications of TB
meningitis
Hydrocephalus
CVA
Coma
Motor deficits
Seizures
Abnormal behaviours

Central Nervous System Tuberculosis. www.uptodate.com

Case Particularity
The particularity of these case consist in
the atipical aspects-both:
clinical ( lack of fever, absence of meningeal
irritation) and
biological ( no biological inflammatory
syndrome, a slightly modified CSF
biochemistry)

of a tuberculous meningitis in a special

host, a patient on biologic therapy.

Why should we care?

Someone gets sick from TB every four
seconds and someone dies of TB every
ten seconds (WHO, 2006)

Take home message

TBM begins as a primary infection of the lungs
Miliary tuberculosis (TB) is a potentially lethal
disease if not diagnosed and treated early
Start ATT empirically when suspicion of TB;
Patient consiliation for medication/side effects
Early diagnosis and commencement of specific
therapy determines survival of the patient.

THANK YOU!