2. PARTICULARS
• 25 yr/F, married
• Rt handed
• Educated upto 5th std
• Works as daily wage worker in carton factory
• Resident of Jabalpur
• Informant Mother
• Reliability poor
3. HISTORY
• P/C: (04 months ago)
– Fever x 15 days duration
• Moderate grade
• Intermittent
• Associated with chills, no rigors
• No h/o evening rise of temperature/ night
sweats
4. HISTORY
– Headache x 05 days duration
• Insidious onset
• Moderate grade that has increased in
severity, affecting her daily chores
• Dull aching
• Begins over the forehead onwards and
spreads diffusely
• Associated with recurrent episodes of
projectile vomiting, irritability and
drowsiness
• Not associated with photophobia
5. HISTORY
– Diminution of vision x 04 months
• Insidious onset
• painless
• Describes as ‘blurring of vision’
• Gradually progressive
• Complete loss of vision both eyes x 03 wks
6. HISTORY
Associated h/o
– dribbling of saliva from Lt side of mouth
– difficulty in chewing, pushing bolus of food
into mouth
– slurring of speech with weak consonant
pronunciation since then
7. HISTORY
• No h/o loss of consciousness, neck pain,
seizures, abnormal behaviour, memory
disturbance
• No h/o abnormal sense of smell, loss of
sensation over face, gritty sensation in eyes,
facial deviation, hearing loss, tinnitus, vertigo,
nasal twang, regurgitation of food
• No h/o limb weakness, abnormal movement in
limbs
8. HISTORY
• No history s/o
– Sensory system involvement
– Cerebellar involvement
– Bowel & bladder involvement
• No h/o chest pain, palpitations, syncope
• No h/o cough, breathlessness, wheeze
• No h/o pain abdomen, constipation
• No h/o yellowish discoloration of eyes, urine
• No h/o recent travel, blood transfusions
9. HISTORY
• Managed initially as a c/o Enteric Fever with
empirical antibiotics for a period of 07 days
• Showed no response to treatment, though fever
subsided
• Headache persisted
10. HISTORY
• MRI Brain revealed
– Diffuse cerebral edema
– Effaced basal cisterns
– Abnormal signal intensity in b/l frontal region
s/o meningo-encephalitis
11. HISTORY
• CSF analysis revealed
S.No Parameter Values
1. Pressure 20 cms of water
2. Appearance clear
3. Proteins 190 mg/dl
4. Glucose 20 mg/dl (RBS-data NA)
5. Cytology Total cells – 150
Neutrophils – 6%
Lymphocytes – 94%
12. TREATMENT HISTORY
• Diagnosed as a c/o Tubercular Meningitis
• Started on ATT (HRZE) wef 16 Feb 16
• Suboptimal dose of Steroid
13. TREATMENT HISTORY
• H/o
– Nausea
– Vomiting x 01 wk
– Decrease appetite
• Detected to have Transaminitis
• Treatment modified to Levofloxacin,
Streptomycin and Ethambutal
20. EXAMINATION
– Pt is conscious, disoriented in time, place and
person
– Agitated and restless
– Ht: 160 cms, Wt: 45 kgs, BMI:18 kg/m2
– Thin built
– Temp: 100 F
– Pulse: 100/min
– BP: 138/100 mm Hg
– RR: 16/min
21. EXAMINATION
• Temporal wasting +
• No pallor, icterus, clubbing, cyanosis,
lymphadenopathy, raised JVP, pedal edema
• No stigmata of TB
• No neurocutaneous markers
22. SYSTEMIC EXAMINATION
• Neurologically, the pt. was drowsy, irritable and
not co-operative for detailed evaluation
– HMF could not be assessed
– Dysarthria +
– Kernigs sign +ve, Brudzinski sign +ve
23. SYSTEMIC EXAMINATION
• Cranial nerve
– II nerve: absent PL/PR, dilated pupil (b/l) (3
mm), sluggish reaction to light
– III, IV, VI nerve: Lt Lateral rectus palsy
– V nerve: intact sensations over face, absent
corneal and conjunctival reflex (b/l)
– VII nerve: Lt LMN palsy
– IX & X nerve: Gag reflex +
– XII nerve: Deviation of tongue to Lt +
24. SYSTEMIC EXAMINATION
• Motor system:
– Bulk normal
– Tone in all limbs: normal
– Power: Grade 4+ in all limbs
– Reflexes:
– Gait unsteady
– Patient was uncooperative for assessment of
cerebellar and sensory system examination
BICEPS SUPINATOR TRICEPS KNEE ANKLE PLANTAR
Rt ++ ++ ++ +++ +++ Extensor
Lt + + + +++ +++ Mute
25. SYSTEMIC EXAMINATION
• Ophthalmology examination:
– Clear fundal media
– Optic disc: normal in size, shape & margins
– Optic disc pallor noted
– Cup/Disc:: 0.5:1
– Optic atrophy (b/l) +
• Other Systems – No abnormality detected
26. INVESTIGATIONS (on admission)
Parameters Values
Hb 12.9 g%
TLC/mm3 6900
DLC P64 L25
Platelets 2.79 lac/mm3
ESR 88 mm fall in 01 hr
(Westergren’s)
S.Urea/Creatinine (mg/dl) 21/0.7
Na/K (mEq/L) 132/4
37. TREATMENT
• Continued on ATT (LSE regime) + Inj
Dexamethasone 20 mg iv
• Reintroduced INH as per American Thoracic
Society Guidelines
38. COURSE IN HOSPITAL
– Developed 01 episode of GTCS lasting 03-05 mins on
D3
– Inj Phenytoin Sodium 1000 mg iv loading dose given
followed by maintenance dose (6mg/kg)
– No recurrence of seizure thereafter
– AED Leviteracetam 1 g BD started
– Rt Medium Pressure VP shunt placed on D5 of
admission
39. POST OPERATIVELY
• Post-operatively, patient was conscious, oriented
and co-operative
• Continued on ATT and Inj Dexamethasone 20
mg iv daily
• Tolerated oral feeds
• Remained afebrile
40. POST OPERATIVELY
• No symptom of headache
• Persistence of symptoms in the form of
– mild dysarthria
– Difficulty in pushing food bolus into mouth
– Blindness
41. POST OPERATIVELY
• NCCT head revealed functional in-situ shunt
• Re-introduced ATT as per ATS protocol
• Developed asymptomatic Transaminitis
• Stopped INH & Rifampicin
• Restarted on Hepatic sparing ATT
44. PRESENT ISSUES
• Vision loss
• Unsteady gait continues (? Disuse atrophy)
• Deranged Liver enzymes
• Re-introduction of ATT
• Inability to make bolus of food
• Dependent on caretakers for daily chores
45. PLAN
• Continuation of ATT with gradual and slow re-
introduction of Rifampicin in low dose
• Tapering of steroids
• Physiotherapy
• Follow up
46. AIM
• Approach towards a case of Chronic Meningitis
and TBM
• ATT induced liver injury
• Re-introduction of ATT
47. ACKNOWLEDGEMENT
• Dept of Radiology and Radio-diagnosis
• Dept of Pathology
• Dept of Microbiology
• Dept of Anaesthesia & Critical Care Medicine
• Dept of Neurosurgery
• Dept of Ophthalmology
