Mr. J.A., a 64-year-old man, presented with progressive disorientation, fever, headaches, and neck stiffness. Examination found nuchal rigidity and a positive Brudzinski sign. His CSF was turbid with elevated proteins, low glucose, and high white blood cells. This suggested a diagnosis of tuberculous meningitis. Treatment began with daily isoniazid, rifampin, pyrazinamide, and ethambutol for two months, followed by isoniazid and rifampin for 7-10 more months. Dexamethasone was also prescribed for 6-8 weeks to reduce intracranial pressure and sequelae. The goals

1. Case presentation
onTreatment Extra
pulmonary and
Tuberculosis Meningitis
From medical ward

2. Presentation outline
•Case Identification
•Subjective finding
•Objective finding
•Assessment
•Treatment
•Care plan

3. Case identification
• Name: Mr J.A
• Age: 64
• Sex: M
• Address :from Oromiya , JARSOO
• Date of admission 21/4/11
• Ward : Medical –TB ward
• Bed number :90
• Card number :337484

4. Anthropometric measurement
• Age :64
• Weight :82 kg
• Height : 1.68 m
• BMI : 21.03

5. Subjective finding
• J.A is a 64-year-old, 82-kg man who is brought to the emergency
department after a 4-day period during which he became progressively
disoriented, febrile to 40.5◦C, and obtunded. He also had severe headaches
during this time.
• Physical examination revealed moderate nuchal rigidity and a positive
Brudzinski sign (neck resistant to flexion).
• An initial diagnosis of possible meningitis was made, and a lumbar
puncture ordered.
• The cerebrospinal fluid (CSF) appeared turbid, and laboratory analysis
revealed an elevated protein concentration of 200 mg/dL,a decreased
glucose concentration of 30 mg/dL, and a white blood cell count of 500/μL
(85% lymphocytes).
• A Gram stain of the spinal fluid and a sputum smear for AFB were
negative; other laboratory tests were within normal limits.
• A diagnosis of tuberculous meningitis was presumed. Discuss the
presentation and prognosis of tuberculous meningitis.

6. • Medication history : He has not treated
• Past medication history : no
.FH: He has no family history of DM , HTN cardiac or renal disease .
Social : had a history of cigarette smoking before he was first
diagnosed for TB but he denies to smoking after then.

7. Objective finding
GA : acute sick looking
HEENT : pink conjunctivitis
Chest : there is decreased air entry on right side of posterior lower 1/3
of chest .
CVS : S1 and S2 well heard no gallop and murmur
ABD : flat moves with respiration , there is tenderness on epigastric
area , no ascitis .

8. • MS : has tenderness on the back
 No deformity
• ISH : no rash
• CNS : COTPP

9. Objective finding
• Laboratory findings
• The cerebrospinal fluid (CSF) appeared turbid
• an elevated protein concentration of 200 mg/dL
• a decreased glucose concentration of 30 mg/dL,
• a white blood cell count of 500/μL (85% lymphocytes).
• Gram stain of the spinal fluid and a sputum smear for AFB were negative;
• ; other laboratory tests were within normal limits.
• Nucleic acid amplification tests and interferon-γrelease assays may aid in
the diagnosis of tuberculosis

10. Assessment
• irreversible brain damage or death
.Complications
. Cryptococcal Meningitis
. HSV encephalitis

11. Treatment
• Treatment should be initiated in J.A with daily administration of
isoniazid 300 mg, rifampin 600 mg, pyrazinamide 2,000 mg,
• and ethambutol 1,600 mg for the first 2 months.
• After this initial phase of treatment, J.A should receive daily isoniazid
and rifampin for an additional 7 to 10 months, although the optimal
duration of therapy is unknown.
• In addition, because J.A is older, pyridoxine 10 to 50 mg/day should
be given to prevent the occurrence of peripheral neuropathy from
isoniazid. It also
• should be remembered that rifampin may impart a red to orange
color to the CSF.

12. • Isoniazid readily penetrates into the CSF, with CSF concentrations
reaching up to 100% of those in the serum.
• Rifampin is often included in tuberculous meningitis regimens and
may be associated with reduced morbidity and mortality; however,
even with inflammation, CSF concentrations of rifampin are only 6%
to 30% of those found in the serum.
• Ethambutol should be used in the highest dosage to achieve
bactericidal concentrations in the CSF because its CSF concentrations
are only 10% to 54% of those in the serum. Streptomycin penetrates
into the CSF poorly even with inflamed meninges.

13. CORTICOSTEROIDS
• Corticosteroids in moderate to severe tuberculous meningitis
• appear to reduce sequelae and prolong survival.
• The mechanism for this benefit is likely owing to reduction of
intracranial pressure.
• Dexamethasone 8 to 12 mg/day (or prednisone equivalent) for 6 to 8
weeks should be used and then tapered slowly after symptoms
subside.

14. DTP
• Mr J.A has Treated with PTB , EPTB and TB Meningitis so the
recommended regimen according to the updated NATIONAL
GUIDELINES FOR TB, DR-TB AND LEPROSY IN ETHIOPIA is

15. Care plan
• Monitor Vital signs
• Monitor for side effects of the medications
To do LFT , TSH , RFT , LP ,CSF and audiometric test
• Patient education ( adherence counseling and nutritional diet )
• Follow the dose of the medications
• Do Culture and DST test

16. Goal of therapy
• To cure the TB patient and restore quality of life and productivity
• To prevent recurrence of the disease
• To decrease transmission of the disease
• To avoid toxic medicine effects,
• To Improve the clinical condition of patients and to manage
complications.

17. Intervention
• the patients should be treated according to updated new regimen .
• contacted the doctor and communicate based on evidence .