2. TUBERCULAR MENINGITIS
• PRESENTING COMPLAIN:
• 20 YEAR MALE, BIKASH RAI
• FROM JHAPA
• PRESENTED TO ER WITH COMPLAIN
• FEVER FOR 2 WEEKS
• HEADEACHE FOR 2 WEEKS
• ALTERED SENSORIUM FOR 5 DAYS
• SOB FOR 3 DAYS
• ASSOCITED WITH VOMITING ,ABNORMAL BEHAVIOUR AND WEIGHT LOSS.
• BOWEL AND BLADDER HABBIT NORMAL.
3. • PERSONAL HISTORY:NON ALCOHOLIC, NON SMOKER
• PAST HISTORY: NO SIMILAR ILLNESS IN THE PAST, NO HO PTB, HTN,
DM etc.
• FAMILY HISTORY: NO SIMILAR ILLNESS IN THE FAMILY, NO HO PTB IN
THE FAMILY.
4. HOPI:
• PATIENT WAS APPARENTLY WELL 2 WEEKS AGO THEN HE DEVELOPS HIGH GRADE
FEVER MAX RECORDED TEMPREATURE OF 101 F WITHOUT CHILLS AND RIGORS ,
SKIN RASHES OR JOINT PAIN. ALONG WITH FEVER THERE WAS HO OF HEADACHE
FOR SAME DURATION. HE ALSO HAD HO ALTERED SENSORIUM FOR LAST 5 DAYS
WHICH WAS SUDDEN IN ONSET A/W VOILENT BEHAVIOUR AND NOT OBEYING
COMMANDS.HOWEVER, THERE WAS NO HO ABNORMAL BODY MOVEMENTS OR
ANY DRUG INTOXICATION. THERE IS ALSO HO VOMITING FOR LAST 3DAYS WHICH
WAS PROJECTILE MULTIPLE EPISODES CONTANING FOOD PARTICLES.THERE WAS
NO HO OF CHEST PAIN, ABDOMINAL DISCOMFORT DIARRHOEA ETC.
7. • CNS EXAM:
• HMF: CONFUSED, NOT ORIENTED TO TIME, PERSON AND
PLACE, VOILENT BEHAVIOR
• NECK RIGIDITY: PRESENT
• SENSORY: COULD NOT BE ASSESSED.
• MOTOR: 3/5 IN BOTH UL AND LL BL
• CRANIAL NERVES: LATERAL RECTUS PALSY(6TH NERVE), DIPLOPIA
+, FACIAL NERVE AND PUPILLARY REFLEX WAS INTACT.
8. • RESPIRATORY EXAM:USE OF ACCESSORY MUSCLE AND CREPITATIONS
WAS PRESENT AT BL INFRAMAMMARY AND INFRA AUXILLARY AREA.
• CVS EXAM: APEX AT 5TH ICS AT MCL, S1S2 NO ADDED SOUNDS PRESENT.
9. HEMATOLOGICAL BIOCHEMISTRY OTHERS
CBC:
HB:14.4
TLC:4640
DLC: N72,L19
PLATELET:417000
HIV/HCV/HBSAG: NEGATIVE
PT/INR: 16/1.07
GRBS:115
Na/K: 132/4.3
UREA/CR: 64/0.93
LFT:
TOTAL PROTEIN :7.9
ALBUMIN:3.8
TB:0.33
CONJ: 0.05
AST/ALT:134/5
URINE RE:
SUGAR: NEG
PROTEIN:2+
RBC: NOT SEEN
WBC:0-2
EPITHELIAL CELLS :1-3
OPTIMAL : NEGATIVE
PS FOR MALARIAL PARASITE: NEGATIVE
CSF ANALYSIS:
GLUCOSE: 27
PROTEIN:109
TLC:10
NON-GRANULOCYTE:70
GRANULOCYTE:30
NCCT HEAD: NORMAL SCAN.
10. FINAL DIAGNOSIS:
• ACUTE HYPOACTIVE DELIRIUM
• ETIOLOGY: TUBERCULAR MENGITITS
• WITH BL LATERAL RECTUS PALSY
• WITH OPTIC NEURITIS
• WITH ASPIRATION PNEMONIA
11. COURSE OF ILLNESS IN THE IPD
• AT ER PATIENT WAS MANAGED WITH CEFTRIAXONE, DEXONA,
CLINDAMYCIN(ASPIRATION) AND SYMPTOMATICS. HIS BP WAS
ELEVATED, TACHYCARDIC AND DYSNEIC SPO2 WAS 89 % IN RA.
BIOCHEMICAL AND HEMATOLIGAL REPORTS WAS WNL AND LP
ANALYSIS WAS NIL AND NCCT WAS NORMAL.
• HE WAS SHIFTED TO WARD AND 2ND LP WAS DONE WHICH SHOWS
RAISED PROTEIN AND LOW GLUCOSE WITH LYMPHOCYTOSIS, GENE
XPERT WAS NEGATIVE, ADA COULD NOT BE ANALYSED. SPUTUM AFB
WAS NEGATIVE. C/S SHOWS PRESENCE OF STAPHYLOCCOCUS AND
PSEUDOMONAS GROWTH. HE WAS THEN STARTED ON ATT WITH
AMIKACIN AND LEVOFLOXACIN.ON NEXT DAY PATIENT STARTED
IMPROVING AND VITALS WAS STABLE WITH TWO SPIKES OF FEVER
WHICH SUBSIDES ON 3RD DAY.
12. CONT..
• LATER ON 3RD DAY PATIENT HAD COMPLAIN OF BLURRING OF VISION
OF RIGHT EYE, OPTHALMO CONSULTAION WAS DONE.HE WAS
DIAGNOSED WITH OPTIC NEURITIS FOR WHICH HE WAS PRESCRIBED
INJ METHYLPREDNISOLONE 250MG QID FOR 3DAYS.
• ON 6TH DAY HIS VISION STARDED IMPROVING, NG WAS REMOVED
AND ALLOWED ON ORAL DIET.
• ON DAY 8TH HE WAS SYMPTOMATICALLY BETTER AND WAS
DISCHARED WITH ATT AND PREDNISOLONE.
• ON FOLLOW UP AFTER 7DAYS HE WAS IN GOOD HEALTH WITH
NORMAL ROUTINE LAB REPORTS.
