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Convulsion tbm + malaria 2  by kong
 

Convulsion tbm + malaria 2 by kong

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    Convulsion tbm + malaria 2  by kong Convulsion tbm + malaria 2 by kong Presentation Transcript

    • Tuberculous Meningitis
    •  Tuberculous meningitis is correctly characterized as a meningoencephalitis, as it affects not only meninges but also brain parenchym Is Myobacterium tuberculosis infection of the membranes and fluid surrounding the brain and spinal cord. most common in children aged 0 - 4years
    • In TBM, the signs and symptoms progress slowly overseveral weeks and can be divided into 3 stages. 1st stage: 1-2weeks, characterized by nonspecific symptoms such as fever, headache, irritability, drowsiness and malaise. 2nd stage: usually begins more abruptly. Most common features are lethargy, nuchal rigidity, seizures, Kernig (+), Brudzinski (+), hypertonia, vomiting, cranial nerve palsies and other focal neurologic signs. 3rd stage: is marked by coma, hemiplegia or paraplegia, hypertension, decerebrate posturing, deteriotation of vital signs and eventually death.
    • HOPI Character of fever Character of fits Neurological symptoms - Headache / Irritability /Drowsiness Bulging fontanelle (in infant) Associated /predisposing factors - Rashes (meningococcaemia) - Ear discharge - Head injury
    • Past H/O - Traveling to Malaria endemic area - Similar illness- H/O fever with fits - Hospitalization - Contact with any TB patient?Family History - Family H/O of febrile/afebrile convulsionImmunization history - eg. HiB vaccine, BCG vaccineMedication history - Current and previous
    •  Insidious onset Low-grade fever Headache Vomiting Subtle personality change
    •  The classic triad of diagnostic signs - nuchal rigidity - sudden high fever - altered mental status Poor feeding Vomiting Irritability Lethargy Seizures Reduce consciousness
    •  General condition - Vital signs: HR, Pulse, BP, Temperature - Anthropometry - Well /Ill - Alert and conscious? - Any head trauma? - Nutritional status Ear discharge? Petechiae, purpura rash Bulging Anterior Fontanelle
    •  Neurological examination - Abnormalities of posture - Abnormal movements - Tone - Power - Tendon reflexes - Eye movements - Breathing pattern - Loss of sphincter tone Meningeal sign - Neck stiffness - Kernig’s sign - Brudzinski’s sign
    •  Pyogenic meningitis Abscess Late syphilis Encephalitis
    •  Blood tests: FBC, erythrocyte sedimentation rate (ESR), blood sugar, U&E, coagulation, blood culture. Urine microscopy/culture if: age <18 months, complex seizure or no focus of infection found.
    •  Cerebrospinal fluid (CSF) - lymphocytosis : 100-1000/ml low glucose high protein Spiderweb clot is characteristic of TB meningitis The acid-fast bacilli may be seen on CSF smear or in early morning urine samples
    •  Also known as Pirquet test, or PPD test Positive in Mantoux Test. >10mm in duration at 72hours 2 units of purified protein derivative of tuberculin A positive result indicates TB exposure - 5 mm or more is positive in - An HIV-positive person - Persons with recent contacts with a TB patient - 10 mm or more is positive in - Recent arrivals (less than five years) from high- prevalence countries - Injection drug users - 15 mm or more is positive in - Persons with no known risk factors for TB
    •  Those who are immunologically compromised, especially those with HIV and low CD4 T cell counts, frequently show negative results from the PPD test. Steroid use, malnutrition and sarcoidosis can also lead to false-negative results, because the immune system needs to be functional to mount a response to the protein derivative injected under the skin.
    •  Chest X-ray - enlarged hilar lymph nodes - pleural effusion - Abnormal, sometimes miliary pattern CT and MRI - thickening of basal meninges - infarcts - cerebral oedema/hydrocephalus - tuberculomas
    •  General - Monitoring vital signs, conscious - Lowering temperature with antipyretics Initial therapy: Rifampicin, Isoniazid and Pyrazinamide plus one of (i) Streptomycin or (ii) Ethambutol
    •  Intensive phase (2 months) - daily Isoniazid, Rifampicin and Pyrazinamide - a 4th drug(either Ethambutol or Streptomycin) is added if initial drug resistance is present or the burden of organisms is high.
    •  Maintenance phase (7-10 months) - Isoniazid and Rifampicin for the remaining 7-10 months - given daily(perferred) or biweekly or thrice weekly*all intermittent dose regimens must be directly supervised.
    •  Corticosteroids - Indicated for children with TB meningitis - may be used in children with pleural effusion, pericardial effusion, severe miliary disease and endobronchial disease. - give steroids only when accompanied by appropriate antituberculous therapy dose : prednisolone 1-2mg/kg/day for 3-4weeks, then taper over 3-4weeks.
    •  Rifampicin : Hepatitis, orange discolouration of urine and tears, ‘flu- like’ syndrome with intermittent use Isoniazid : Hepatitis, neuropathy, pyridoxine deficit, agranulocytosis Ethambutol : Optic neuritis Pyrazinamide : Hepatitis, arthralgia
    •  Tuberculosis prevention and control efforts primarily rely on the vaccination of infants and the detection and appropriate treatment of active cases Vaccines - BCG Public health - WHO declared TB a "global health emergency" in 1993, and in 2006, the Stop TB Partnership developed a Global Plan to Stop Tuberculosis that aims to save 14 million lives between its launch and 2015
    • Prediction of prognosis of TBM is difficultbecause of the protracted course, diversityof underlying pathological mechanisms,variation of host immunity, and virulence ofM tuberculosis. Prognosis is relateddirectly to the clinical stage at diagnosis.
    • Cerebral Malaria
    •  the most common complication and cause of death in severe Plasmodium falciparum infection which is transmitted to humans by female Anopheles mosquitoes. is the leading cause of seizures and encephalopathy Its risk factors primarily include children <10 years of age; especially living in malaria-endemic areas.
    •  Changes in behaviour Impaired consciousness Jaundice Parasitaemia > 2% Continued vomiting Hyperpyrexia Oliguria Severe metabolic acidosis
    •  Cerebral malaria Pulmonary edema/ARDS Renal failure Haemoglobulinemia Shock Hypoglycaemia Severe anemia (Hb < 5g%)
    •  Sudden onset of convulsions Persistent high fever Severely impaired consciousness Headache Irritability Orthostatic hypotension Myalgia Red blood cell (RBC) sludging that leads to capillary blockage Hepatosplenomegaly Jaundice Retinal abnormalities
    •  Thick and thin blood films for malaria parasite Rapid malaria antigen detection test FBC, CRP, Clotting , ABG/lactate U&E, Glucose, Creatinine Blood culture CXR, ECG   CT followed by lumbar puncture
    •  Fluid requirements vary widely; careful fluid management is critical. Haemofilter early if renal failure. Ventilate early if pulmonary oedema. Consider exchange transfusion in very seriously ill patient if feasible. Monitor blood lactate and glucose : quinine may cause hypoglycaemia. Repeated U&E (and ABG if ARDS) Arrange repeated skilled microscopy to monitor the parasite counts.
    • There are two components of malaria prevention: Reduction of exposure to infected mosquitoes Chemoprophylaxis - necessary for all visitors to and residents of the tropics who have not lived there since infancy
    • 1. Paediatric Protocols 2nd edition2. Illustrated Textbook of Paediatrics 3rd edition, Lissauer Clayden3. Nelson Essentials of Paediatrics 5th edition4. Nelson Textbook of Paediatrics 19th edition5. Oxford handbook of clinical medicine 7th edition