TB meningitis: A case report
Monika C1*, Parimala2
1Staff Nurse, Kauvery Hospital, Chennai, Tamilnadu, India.
2Clinical Instructor, Kauvery Hospital, Chennai, Tamilnadu, India.
Correspondence : 9790861662; E-mail: nursingdirector.kch@kauveryhospital.com
TB meningitis: A case report
Background
Tuberculosis (TB) is one of the most prevalent infectious diseases of human beings and contributes considerably to illness and death around the world. The causative organism is Mycobacterium tuberculosis. The disease is spread by inhaling tiny droplets that contain the bacteria, from the coughs or sneezes of an infected person. TB primarily affects the lungs but it may infect any part of the body including the meninges, kidneys, bones and lymph nodes.
Tuberculous meningitis (TBM) manifests as extra-pulmonary tuberculosis and is caused by the seeding of the meninges with M. tuberculosis, where it forms Rich foci which are caseating subpial or subependymal foci of tuberculous infection in the cortex of the brain. Such a tuberculous focus can discharge its contents into the subarachnoid space or into the ventricular system resulting in tuberculous meningitis. They cause an intense inflammatory response that leads to the symptoms of meningitis.
Case Presentation
An 18-year female was admitted to Kauvery hospital with complaints of high-grade and intermittent fever for 12 days, vomiting for 5 days, headache, generalized fatigue and neck pain. Basic investigations were done that showed an elevated WBC count, and she was started on antibiotics. On the 3rd day of hospitalization, she had disorientation, fatigue and severe neck pain. A lumbar puncture was done and cerebrospinal fluid (CSF) was sent for analysis. It showed elevated protein and WBC count in the CSF fluid. The patient was placed also on anti-viral and osmotic diuretic medications. CSF GeneXpert detected M. tuberculosis. Hence, the patient was diagnosed with TB meningitis. She was started on anti-tuberculosis treatment (ATT), and the patient’s condition was clinically improved. At the time of discharge, patient was conscious, oriented and hemodynamically stable.
On clinical assessment
| Temperature | Pulse | Respiration | Blood pressure | SPO2 |
| T- 99.8 F | 68/min | 18/min | 120/80mmHg | 98% |
On physical examination, the patient was conscious & oriented. She looks dull and is irritable behaviour.
Investigation Reports
| Date | Investigation | Report |
| 04/01/2023 | CBC | HB:12.7 g/dl |
| WBC:12200 cells/cumm | ||
| Platelet count: 594000 cells/cumm | ||
| ESR: 30 | ||
| RFT and electrolytes | Urea: 17.7 mg/dL | |
| Creatinine: 0.56 mg/dL | ||
| Sodium: 129 mmol/L | ||
| Potassium: 4.02 mmol/L | ||
| Chloride: 91.6 mmol/L | ||
| Bicarbonate: 21.4 mmol/L | ||
| LFT | All parameters in normal range | |
| Blood and urine culture | No growth | |
| 06/01/2023 | CSF analysis | Volume – 3 ml |
| Appearance – Slightly turbid | ||
| Glucose – 33 mg/dl | ||
| CSF Protein – 134.5 mg/dl | ||
| Total WBC -320 Cells/cumm | ||
| Neutrophils – 10% | ||
| Lymphocytes – 90% | ||
| CSF: Gram stain | Occasional cells and inflammatory cells seen | |
| CSF: GeneXpert | M. tuberculosis detected | |
| Immunoassay-ANA | 8.5 U/L |
Management
The patient was initially treated with antibiotics, antipyretics and other supportive management. After a diagnosis of TB meningitis patient received anti-tuberculosis treatment (ATT), vitamin supplements and other supportive management.
Drug Chart
| Empirical treatment | ||
| S.No | Drug name | Dose/Frequency |
| 1 | Inj. Xone | 2 g/OD |
| 2 | Inj. Pan | 40 mg/OD |
| 3 | Inj. Para | 1 g/SOS |
| 4 | Inj. Acyclovir | 500 mg/TDS |
| 5 | Inj. Mannitol | 100 ml/BD |
| Definitive treatment | ||
| 1 | Tab. R Cinex | 600 mg/OD |
| 2 | Tab. Combutol | 1000 mg/HS |
| 3 | Tab. Pyrazinamide | 1500 mg/OD |
| 4 | Vit B 6 (Benadon) | 40 mg/OD |
| 5 | Tab. Wysolone | 20 mg/BD |
Nursing Care
- Assisted the patient with activities of daily living
- Provided the patient with high protein intake and hydration
- Advised the patient to take medications regularly
- Educated about personal care and hygienic measures
- Explained about ATT medications and side effects.
Discussion
Patients with TBM develop typical clinical features like headache, fever, and stiff neck, although meningeal signs may be absent in the early stages. The duration of illness can range from several days to months.
GeneXpert MTB is an advanced and automated rapid nucleic acid amplification test for MTB endorsed by the WHO.
WHO guidelines recommend a first-line regimen of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol followed by 10 months of isoniazid and rifampicin; they offer a good clinical outcome for patients with TB Meningitis.
Conclusion
Tuberculosis remains one of the most challenging causes of meningitis, posing challenges in diagnosis because of the difficulties in rapidly identifying MTB in CSF samples. Early diagnosis of tuberculous meningitis, effective anti-tuberculosis and adjunctive corticosteroid therapy are crucial for treating and favourable outcomes of tuberculous meningitis.
References
- Slane VH, et al. Tuberculous Meningitis. [Updated 2022 Nov 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541015/
- Chin JH. Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract. 2014;4(3):199-205.
- Wang MG, et al. Treatment outcomes of tuberculous meningitis in adults: a systematic review and meta-analysis. BMC Pulm Med. 2019;19:200.
Ms. Monika,
Staff Nurse
Ms. Parimala
Clinical Instructor