MENINGITIS TB

MENINGITIS TB

Pathophysiology

• The primary focus elsewhere. 
• In the early stages a small tubercles found in the brain and meninges. 
• Neurological Complications preceded by tubercles and hypersensitivity reactions to TB antigens in the sub arachnoid space à produce thick exudates in basal cysterna and will include cranial nerves and blood vessels in the circulus willis 
• Barriers to the flow of liquor that will cause obstructive hydrocephalus 
• Inhibits the absorption of CSF so that it can also occur comunicating hirocephalus 
• Infarction occurs when going ok:

         a. vasculitis

         b. direct invasion of bacteria in the blood vessels,

         c. compresi blood vessels due to arachnoiditis

Clinical Picture

Symptoms	Sign
Prodromal Anorexia Weight Loss Cougt Night Sweat CNS Headache Meningismus Altered Level of conciousnes	Adenopathy Adventitious Sound on Auscultation of lungs Choroidal tuberkel Fever (highest in the late aftenoon) Nuchal rigidity Papiledema Fokal Neurological Sign Positive tuberkulin test

Diagnosis

Diagnosa

1. Tuberkulin test
2. Chest X-Ray

• hillar adenopathy
• upper lobe nodular infiltrat
• milliary pattern

    3. CT Scan and MRI

• Hydrocephalus
• Basilar meningeal enhancement post contras
• Cerebral infarktion

      4. CSF Examination

• Lymphocytic pleocytosis
• Hypoglycorrhacia
• Acid fast smear and culture

5. eye Examination for choroidal tuberkles
6. Sputum and urine smear and kulture for acid-fast bacilli

LP examination on TB Meningitis
1. increase in initial pressure
2. cells increased between 10-500 tu MN
3. increased protein 100-500 mg / dl
4. decrease in glucose
5. positive cultures in 75% of cases 3-6 weeks
6. decline in chloride
7. tuberkulostearic positive assay
8. bromine ratio of serum / CSF low

Therapy
In adults;
- INH 5 mg / kg / day, max 300 mg / day
- Rifampicyn 10 mg / kg / day, max 600 mg / day
- Pyrazinamide 15-30 mg / kg / day, max 2 g / day
- On this therapy can be given pyridoksine 50 mg / day.
- In the case of resistance can be given ethambutol 15-20 mg / kg / day

In adults with HIV;
- INH 10-15 mg / kg / day
- Rifampicyn 10-15 mg / kg / day
- Ethambutol 25 mg / kg / day or pyrazinamide 20-30 mg / kg / day and streptomycyn, rifabutin, clofazimine
This therapy is continued for at least 6-9 months and at least 6 months or until a negative culture

American Academy Of Pediatric Recommendations;
- INH 10-15 mg / kg / day, max 300mg
- Rifampicyn 10-20 mg / kg / day, max 600mg
- Pyrazinamide 20-40 mg / kg / day, max 2 g
- Streptomicyn 20-40 mg / kg / day
- Over the past 2 months, followed by INH and rifampicyn day once or 2 times a week for 10 months.

Dexamethasone dose 0.3-0.5 mg / kg / day in the early weeks of therapy followed by prednisone 2 mg / kg / day, tappering for 3-4 weeks.
Indications dexamethasone usage;
1. decline in consciousness
2. Papilledema
3. Focal neurological deficits
4. Opening CSF> 300 mmH2O.

Drug	Side Effects
INH Rifampicyn Ethambutol Pyrazinamide Streptomycin	Hepatotoxic Neuropathy perifer Phenitoin toxicity Hepatotoxic Interstitial nephritis Optic Neuropathy Hepatotoxic Arthralgia with hiperuricemia Vestibular toxicity

Prognosis
When patients present with consciousness down, then the 50-70% mortality. Another thing that affects prognosis;
1. age (the highest mortality when very young or very old)
2. malnutrition
3. miliary tuberculosis
4. patients who worsen underlying illnesses such as alcoholism
5. hydrocephalus
6. cerebrovascular complications
7. low glucose concentration
8. increase in protein concentration
9. prognosis in patients with HIV is determined by CD4 cell count
    at the time he was sick