TB MENINGITIS CASE PRESENTATION

TB MENINGITIS

AYESHA FAREEDPHARM D.

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Age 30yr Gender female Ip 184693 Weight 67kg Height 162.5cmBMI 24

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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

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Medication reconciliation:Inj.Mannitol 100ml IV QIDInj. Optineuron 1 amp IV ODInj.Dexamethasone 8mg IV TID

Physical examination:Height: 162.5cmsWeight:67kgBMI:24 Vitals:Pulse : 98/min B.P. : 120/80MmHg RR : 22/minTemp : 100º

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Provisional Diagnosis : TB MENINGITIS with multiple tuberculoma

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Labs:

Parameter Normal Day

Hb 13-18mg/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

ANCA: positiveCSF: ↓glucose,↑protein. MRI: ischemic infract (Rt.Thalamic region)

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Pharmaceutical care plan

Subjective evidences:•Headache•Vomitings•Left leg parasthesias

Objective evidences:ANCA:positiveCSF: ↓glucose,↑protein. MRI:mild lesions

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Final diagnosis: TB MENINGITIS

•Day:1•c/o severe headache, vomitings,Stroke.•Past:fever treated for denguein 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: positiveCSF: ↓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 PO TID after food•Inj.leviteracetam 500mg IV BD

Day:2•Re evaluation of vasculitis•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 PO TID•Naturiax fibre powder 1 tsp•CST

Day:4•Melena was seendrop in hb-?UGI bleed•Plan:DVT Stockings•Physiotherapy TID•Head ache mild

Day:5Patient stableNo headachePlan to discharege with ATT

Stop acetazolamideTramadol NaproxinCST

CST

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Sno

Drug Dose Route

Frequency

Indication Start date

Stop date

1Inj.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

DRUG CHART:

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Sno

Drug Dose Route

Frequency

Indication Start date

Stop date

9Inj.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

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DRUG CHART:

Sno Drug Dose Route

Frequency

Indication

Start dose

Stop dose

18 T.Febuxostat

80mg PO OD Uric acid 3

19 T.Alprazolam

0.25mg

PO HS hallucinations

3

20 Naproxin 500mg

PO BD headache 1

21 Leviteracetam

500mg

IV BD Seizure Px 1

DRUG CHART

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Assessment:•A 30year old female 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

TB Meningitis:•T.Pyrazinamide 750mg PO 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 PO TID•Naproxin 500mg PO BD

Supportive care:•Inj.Pantoprazole 40mg IV 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

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Plan:Recommendations:• Pyrazinamide is recommended along with febuxostat as the uric acid levels decreased to low level if used alone.•As there is no effective treatment for TB Meningitis pyrazinamide can be given along with febuxostat with close uric acid monitiring.

Disease monitoring parameters:TB Meningitis: •Hyponatremia•Stroke•Exacerbation of chronic diseases•Hypoxemia•CBC

Stroke:•Bloodpressure•CBC

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Drug monitoring parameters:Pantoprazole: weight changes, mild diarrhea, gas, stomachpainPyrazinamide: gout, anorexia, sideroblastic anemia, utricaria, porphyriaEthambutol : headache, loss of appetite, worsening goutEnoxaparin: bleeding gums, hemoptysis, nose bleed, red or brown urine Aspirin : vertigo, itchy rash, worsening of asthama, tinitisIsoniazid: yellow skin, dark urine, numbness, seizers,confusionTayo 60k : loss of appetite, bone or muscle painLevofloxacin : constipation, dizziness, abdominal pain, abdominalgasFlunarazine : weight gain, extra pyramidal effects, depressionLactulose : diarrhea, bloating gas, stomach painStreptomycin: parasthesia of face, utricaria, esinophilia Tramadol : convulsions, itching, flushingOndansetron: lightheadedness, blurred vision, muscle spasmsDexamethasone : swelling, weight gain, insomnia, mood changesAcetazolamide : melena, frequent urinationLeviteracetam: hallucinations, weakness,irregular heart beats

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Patient counseling:

•We have to support the patient that none of the TB 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

DISCHARGE MEDICATIONS:

•T.Pyrazinamide 750mg PO 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 monthsT.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

Thank you