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TB MENINGITIS CASE PRESENTATION
- 1.
- 2. Age 30yr Gender female Ip184693 Weight 67kg Height 162.5cm BMI 24 2
- 3. Chief complaint :a 30year old female admitted in hospital with chief complaint of severe headache, vomiting ,stroke. Past medical history : wedgner’s granuloma Surgical history: none Allergies: no known drug allergies 3
- 4. Medication reconciliation: Inj.Mannitol 100mlIV QID Inj. Optineuron 1 amp IV OD Inj.Dexamethasone 8mg IVTID Physical examination: Height: 162.5cms Weight:67kg BMI:24 Vitals: Pulse : 98/min B.P. : 120/80MmHg RR : 22/min Temp : 100º 4
- 5. Provisional Diagnosis : TBMENINGITIS with multiple tuberculoma 5
- 6. Labs: Parameter Normal Day Hb13-18mg/dl 12.2 TLC 4.5-11 15.3 sodium 136-145mmol/lt 134 Uric acid 2.2-6.0 8.8 platelets 1.5-4.5lac 2.98lac LDH 81-234 533 6 ANCA: positive CSF: ↓glucose,↑protein. MRI: ischemic infract (Rt.Thalamic region)
- 7. Pharmaceutical care plan Subjectiveevidences: •Headache •Vomitings •Left leg parasthesias Objective evidences: ANCA:positive CSF: ↓glucose,↑protein. MRI:mild lesions 7
- 8.
- 9. •Day:1 •c/o severe headache,vomitings, Stroke. •Past:fever treated for dengue in outside hospital. •Later admitted in yashodha with ↑headache and numbness in thumb. •Skin biopsy revealed neutrophilic leukocytosis and vasculitis and treated with omnacortil. •Later she was admitted to apollo and diagnosed with TB meningitis from the following reports. ANCA: positive CSF: ↓glucose,↑protein. Plan: Rifampicin sensitivity •Inj.pantoprazole 40mg IV OD •T.Pyrazinamide 750mg PO BD •T.Pyridoxine 40mg PO OD •T.Ethambutol 1g PO OD •Inj.Enoxaparin 40mg SC OD •T.Aspirin 150mg PO OD •T.Isoniazid 300mg PO OD •T.Tayo 60k PO once a week •Inj.Levofloxacin 750mg IV OD •T.Flunarazine 10mg PO HS •Syp.Lactulose 15ml RT HS •Inj.Streptomycin 750mg IM OD •Inj.Tramadol 50mg IV BD •Naproxin 500mg PO BD •Inj.ondansetron 4mg IV BD •T.Dexamethasone 8mg POTID after food •Inj.leviteracetam 500mg IV BD
- 10. Day:2 •Re evaluation ofvasculitis •MRI: leision, acute ischemic brain infarct. •Rifampicin is resistent Day :3 •Pallor and presented with joint pains in fingers and knees •hallucinations •CBC and uric acid tests were done •Hb:8g/gl •Uric acid -8.8 •Transfused 1 pint of PRBC •T.Febuxostat 80mg PO OD •T.Alprazolam 0.25mg PO HS •Stop pyrazinamide •CST •T.Acetazolamide 250mg POTID •Naturiax fibre powder 1 tsp •CST
- 11. Day:4 •Melena was seen dropin hb-?UGI bleed •Plan:DVT Stockings •PhysiotherapyTID •Head ache mild Day:5 Patient stable No headache Plan to discharege with ATT Stop acetazolamide Tramadol Naproxin CST CST
- 12. Sno Drug DoseRout e Frequenc y Indication Start date Stop date 1 Inj.pantoprazole 40mg IV OD Ulcer Px 1 2 T.Pyrazinamide 750mg PO BD ATT 1 3 3 T.Pyridoxine 40mg PO OD Vit supp 1 4 T.Ethambutol 1g PO OD ATT 1 5 Inj.Enoxaparin 40mg SC OD DVT Px 1 6 T.Aspirin 150mg PO OD Stroke 1 7 T.Isoniazid 300mg PO OD ATT 1 8 T.Tayo 60k 1tab PO Once a week Vit D 1 12 DRUG CHART:
- 13. Sno Drug DoseRout e Frequenc y Indication Start date Stop date 9 Inj.Levofloxacin 750mg IV OD ATT 1 10 T.Flunarazine 10mg PO HS Head ache 1 11 Syp.Lactulose 15ml RT HS Constipation 12 Inj.Streptomycin 750mg IM OD ATT 1 13 Inj.Tramadol 50mg IV BD Head ache 1 14 Inj.ondansetron 4mg IV BD Vomitings 1 15 T.Dexamethasone 8mg PO TID vasculitis 1 16 T.Acetazolamide 250mg PO TID headache 2 17 Naturiax fibre 1 tsp PO BD Protein supp 2 13 DRUG CHART:
- 14. Sno Drug DoseRout e Freque ncy Indication Start dose Stop dose 18 T.Febuxostat 80mg PO OD Uric acid 3 19 T.Alprazolam 0.25mg PO HS hallucinatio ns 3 20 Naproxin 500mg PO BD headache 1 21 Leviteracetam 500mg IV BD Seizure Px 1 DRUG CHART
- 15. Assessment: •A 30year oldfemale admitted in hospital with chief complaint of severe headache associated with vomitings and high grade fever (T max-104˚) at night times. •previously she was admitted in yashodha with severe headache, stroke, numbness of thumb, skin biopsy revealed neutrophilic leukocytosis , vasculitis, and was on omnacortil. •later she was admitted in apollo and diagnosed with TB Meningitis •On day3 she complained with pain in the fingers joints and knees. uric acid test was done and revealed ,high uric acid levels(8.8)and stopped pyrazinamide. •On day 4 she was pallor and experienced with melena .CBC revelaed drop in Hb. They Suspected UGI? bleed and stooped pain killers. Acetazolamide was stopped due to melena 15
- 16. TB Meningitis: •T.Pyrazinamide 750mgPO BD •T.Pyridoxine 40mg PO OD •T.Ethambutol 1g PO OD •T.Isoniazid 300mg PO OD •Inj.Levofloxacin 750mg IV OD •Inj.Streptomycin 750mg IM OD Head ache: •T.Flunarazine 10mg PO HS •Inj.Tramadol 50mg iv bd •T.Acetazolamide 250mg POTID •Naproxin 500mg PO BD
- 17. Supportive care: •Inj.Pantoprazole 40mgIV OD ulcer prophylaxis •T.Aspirin 150mg PO OD for stroke •T.Tayo 60k PO once a week for vit-D •Naturiax fibre powder 1 tsp for protein •T.Alprazolam 0.25mg PO HS for hallucinations •Inj.leviteracetam 500mg IV BD for seizure prophylaxis Hyperurecemia : T.Febuxostat 80mg PO OD
- 18. Plan: 18 Recommendations: • Pyrazinamide isrecommended along with febuxostat as the uric acid levels decreased to low level if used alone. •As there is no effective treatment forTB Meningitis pyrazinamide can be given along with febuxostat with close uric acid monitiring.
- 19. Disease monitoring parameters: TBMeningitis: •Hyponatremia •Stroke •Exacerbation of chronic diseases •Hypoxemia •CBC Stroke: •Bloodpressure •CBC
- 20. Drug monitoring parameters: Pantoprazole:weight changes, mild diarrhea, gas, stomachpain Pyrazinamide: gout, anorexia, sideroblastic anemia, utricaria, porphyria Ethambutol : headache, loss of appetite, worsening gout Enoxaparin: bleeding gums, hemoptysis, nose bleed, red or brown urine Aspirin : vertigo, itchy rash, worsening of asthama, tinitis Isoniazid: yellow skin, dark urine, numbness, seizers,confusion Tayo 60k : loss of appetite, bone or muscle pain Levofloxacin : constipation, dizziness, abdominal pain, abdominalgas Flunarazine : weight gain, extra pyramidal effects, depression Lactulose : diarrhea, bloating gas, stomach pain Streptomycin: parasthesia of face, utricaria, esinophilia Tramadol : convulsions, itching, flushing Ondansetron: lightheadedness, blurred vision, muscle spasms Dexamethasone : swelling, weight gain, insomnia, mood changes Acetazolamide : melena, frequent urination Leviteracetam: hallucinations, weakness,irregular heart beats 20
- 21. Patient counseling: •We haveto support the patient that none of theTB medications are harmful and does not cause any intestinal obstruction. •Psycologically support the patient that stroke can be managed with physiotherapy and supportive care •Alprazolam which is prescribed for hallucinations should not be taken regularly . •The duration of treatment for tb meningitis is for 9 months,and the medications are to be take regularly without any failure. •Wash your hands properly •Maintain good hygeine •Lots of water and vegetables with unrefined sea salt •Physiotherapy 21
- 22. DISCHARGE MEDICATIONS: •T.Pyrazinamide 750mgPO BD for 9 months •T.Pyridoxine 40mg PO OD for 9 months •T.Ethambutol 1g PO OD for 9 months •T.Isoniazid 300mg PO OD should be taken on empty stomach •Inj.Levofloxacin 750mg IV OD for 9 months •Inj.Streptomycin 750mg IM OD for 9 months T.Febuxostat 80mg PO OD for 15 days •T.Pantoprazole 40mg IV OD ulcer prophylaxis for 3 days •T.Aspirin 150mg PO OD for stroke at night time every day •T.Tayo 60k PO once a week for vit-D •Naturiax fibre powder 1 tsp for protein suppliment X 10days •T.leviteracetam 500mg IV OD for seizure prophylaxis
Editor's Notes
- #7 transfusion-associated circulatory overload, determining the therapeutic utility of pre-transfusion loop diuresis is an urgent need.