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
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
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
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 .
