3. Tuberculous Meningitis

4.  Tuberculous meningitis is correctly
characterized as a meningoencephalitis,
as it affects not only meninges but also
brain parenchym
 Is Myobacterium tuberculosis infection
of the membranes and fluid surrounding
the brain and spinal cord.
 most common in children aged 0 - 4years

5. In TBM, the signs and symptoms progress slowly over
several weeks and can be divided into 3 stages.
 1st stage: 1-2weeks, characterized by nonspecific
symptoms such as fever, headache, irritability,
drowsiness and malaise.
 2nd stage: usually begins more abruptly. Most
common features are lethargy, nuchal rigidity,
seizures, Kernig (+), Brudzinski (+), hypertonia,
vomiting, cranial nerve palsies and other focal
neurologic signs.
 3rd stage: is marked by coma, hemiplegia or
paraplegia, hypertension, decerebrate posturing,
deteriotation of vital signs and eventually death.

6. HOPI
 Character of fever
 Character of fits
 Neurological symptoms
- Headache / Irritability /Drowsiness
 Bulging fontanelle (in infant)
 Associated /predisposing factors
- Rashes (meningococcaemia)
- Ear discharge
- Head injury

7. Past H/O
- Traveling to Malaria endemic area
- Similar illness- H/O fever with fits
- Hospitalization
- Contact with any TB patient?
Family History
- Family H/O of febrile/afebrile
convulsion
Immunization history
- eg. HiB vaccine, BCG vaccine
Medication history
- Current and previous

8.  Insidious onset
 Low-grade fever
 Headache
 Vomiting
 Subtle personality change

9.  The classic triad of diagnostic signs
- nuchal rigidity
- sudden high fever
- altered mental status
 Poor feeding
 Vomiting
 Irritability
 Lethargy
 Seizures
 Reduce consciousness

10.  General condition
- Vital signs: HR, Pulse, BP, Temperature
- Anthropometry
- Well /Ill
- Alert and conscious?
- Any head trauma?
- Nutritional status
 Ear discharge?
 Petechiae, purpura rash
 Bulging Anterior Fontanelle

11.  Neurological examination
- Abnormalities of posture
- Abnormal movements
- Tone
- Power
- Tendon reflexes
- Eye movements
- Breathing pattern
- Loss of sphincter tone
 Meningeal sign
- Neck stiffness
- Kernig’s sign
- Brudzinski’s sign

12.  Pyogenic meningitis
 Abscess
 Late syphilis
 Encephalitis

14.  Blood tests: FBC, erythrocyte
sedimentation rate (ESR), blood sugar,
U&E, coagulation, blood culture.
 Urine microscopy/culture if: age <18
months, complex seizure or no focus of
infection found.

15.  Cerebrospinal fluid (CSF)
- lymphocytosis : 100-1000/ml
 low glucose
 high protein
 Spiderweb clot is characteristic of TB
meningitis
 The acid-fast bacilli may be seen on CSF
smear or in early morning urine samples

16.  Also known as Pirquet test, or PPD test
 Positive in Mantoux Test.
 >10mm in duration at 72hours
 2 units of purified protein derivative of tuberculin
 A positive result indicates TB exposure
- 5 mm or more is positive in
- An HIV-positive person
- Persons with recent contacts with a TB patient
- 10 mm or more is positive in
- Recent arrivals (less than five years) from high-
prevalence countries
- Injection drug users
- 15 mm or more is positive in
- Persons with no known risk factors for TB

17.  Those who are immunologically
compromised, especially those with HIV
and low CD4 T cell counts, frequently
show negative results from the PPD test.
 Steroid use, malnutrition and sarcoidosis
can also lead to false-negative results,
because the immune system needs to be
functional to mount a response to the
protein derivative injected under the
skin.

18.  Chest X-ray
- enlarged hilar lymph nodes
- pleural effusion
- Abnormal, sometimes miliary pattern
 CT and MRI
- thickening of basal meninges
- infarcts
- cerebral oedema/hydrocephalus
- tuberculomas

19.  General
- Monitoring vital signs, conscious
- Lowering temperature with antipyretics
 Initial therapy:
Rifampicin, Isoniazid and Pyrazinamide
plus one of (i) Streptomycin or
(ii) Ethambutol

20.  Intensive phase (2 months)
- daily Isoniazid, Rifampicin and
Pyrazinamide
- a 4th drug(either Ethambutol or
Streptomycin) is added if initial drug
resistance is present or the burden of
organisms is high.

21.  Maintenance phase (7-10 months)
- Isoniazid and Rifampicin for the
remaining 7-10 months
- given daily(perferred) or biweekly or
thrice weekly
*all intermittent dose regimens must be
directly supervised.

23.  Corticosteroids
- Indicated for children with TB
meningitis
- may be used in children with pleural
effusion, pericardial effusion, severe
miliary disease and endobronchial
disease.
- give steroids only when accompanied
by appropriate antituberculous therapy
dose : prednisolone 1-2mg/kg/day for
3-4weeks, then taper over 3-4weeks.

24.  Rifampicin : Hepatitis, orange
discolouration of urine and tears, ‘flu-
like’ syndrome with intermittent use
 Isoniazid : Hepatitis, neuropathy,
pyridoxine deficit, agranulocytosis
 Ethambutol : Optic neuritis
 Pyrazinamide : Hepatitis, arthralgia

25.  Tuberculosis prevention and control efforts primarily
rely on the vaccination of infants and the detection
and appropriate treatment of active cases
 Vaccines
- BCG
 Public health
- WHO declared TB a "global health emergency" in
1993, and in 2006, the Stop TB Partnership
developed a Global Plan to Stop Tuberculosis that
aims to save 14 million lives between its launch and
2015

26. Prediction of prognosis of TBM is difficult
because of the protracted course,
diversity
of underlying pathological mechanisms,
variation of host immunity, and virulence of
M tuberculosis. Prognosis is related
directly to the clinical stage at diagnosis.

27. Cerebral Malaria

28.  the most common complication and cause
of death in severe Plasmodium falciparum
infection which is transmitted to humans by
female Anopheles mosquitoes.
 is the leading cause of seizures and
encephalopathy
 Its risk factors primarily include children
<10 years of age; especially living in
malaria-endemic areas.

29.  Changes in behaviour
 Impaired consciousness
 Jaundice
 Parasitaemia > 2%
 Continued vomiting
 Hyperpyrexia
 Oliguria
 Severe metabolic acidosis

30.  Cerebral malaria
 Pulmonary edema/ARDS
 Renal failure
 Haemoglobulinemia
 Shock
 Hypoglycaemia
 Severe anemia (Hb < 5g%)

31.  Sudden onset of convulsions
 Persistent high fever
 Severely impaired consciousness
 Headache
 Irritability
 Orthostatic hypotension
 Myalgia
 Red blood cell (RBC) sludging that leads to
capillary blockage
 Hepatosplenomegaly
 Jaundice
 Retinal abnormalities

32.  Thick and thin blood films for malaria
parasite
 Rapid malaria antigen detection test
 FBC, CRP, Clotting , ABG/lactate
 U&E, Glucose, Creatinine
 Blood culture
 CXR, ECG
 CT followed by lumbar puncture

34.  Fluid requirements vary widely; careful
fluid management is critical. Haemofilter
early if renal failure. Ventilate early if
pulmonary oedema.
 Consider exchange transfusion in very
seriously ill patient if feasible.
 Monitor blood lactate and glucose :
quinine may cause hypoglycaemia.
 Repeated U&E (and ABG if ARDS)
 Arrange repeated skilled microscopy to
monitor the parasite counts.

35. There are two components of malaria prevention:
 Reduction of exposure to infected
mosquitoes
 Chemoprophylaxis
- necessary for all visitors to and residents
of the tropics who have not lived there
since infancy

36. 1. Paediatric Protocols 2nd edition
2. Illustrated Textbook of Paediatrics 3rd
edition, Lissauer Clayden
3. Nelson Essentials of Paediatrics 5th
edition
4. Nelson Textbook of Paediatrics 19th
edition
5. Oxford handbook of clinical medicine 7th
edition