CASE REPORT

MENINGITIS TUBERCULOSIS

SENIOR CLINICAL CLERKSHIP








By :
Frida E A Wulandari 04124708008
Nahtadia L Pohan 04101401056

Advisor : Dr. H. A. Rachman Toyo, Sp.S(K)



DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
MOHAMMAD HOESIN GENERAL HOSPITAL
PALEMBANG
2014



ENDORSEMENT PAGE

Case Report

MENINGITIS TUBERCULOSIS

Presented by:

Frida E A Wulandari 04124708008
Nahtadia L Pohan 04101401056



Has been accepted as one of requirements in undergoing senior clinical clerkship period of
August 4th September 8th in Department of Neurology Faculty of Medicine Sriwijaya
University Mohammad Hoesin General Hospital Palembang.


Palembang, November 2014

Advisor


Dr. H. A. Rachman Toyo, Sp.S(K)













NEUROLOGY MEDICAL REPORT


IDENTIFICATION

Name : Mr. Muhammad Guntur
Age : 22 years old
Sex : Male
Occupation : Jobless
Admitted : August 20th 2014 10:25


ANAMNESIS

Patient was admitted to decreasing level of consciousness

2 days before admission patient was having a difficulty to communicate with his
family, he was just lying on bed, and sometimes freaked out and blabbering. The history of
headache (+), high fever (+).
Patient was once diagnosed with meningitis TB approximately 2 months ago, with
chief complaint headache (+), convulsion (+), and decreasing level of consciousness. Patient
was treated with MDT-TB category 1, and it only lasted for 2 days.
This is the second time, patient presents these symptoms.

PHYSICAL EXAMINATION

PRESENT STATE
Internal State

Conciousness : E
3
M
5
V3
Nutrition : Sufficient
Temperature : 36.7
o
C
Pulse : 80 beats/min
Respiratory rate : 20 times/min
Blood pressure : 100/70 mmHg


Psychiatric state
Attitude : Cooperative
Attention : Normal

Neurological state
Head
Shape : Brachicephaly
Size : Normal
Symetric : Yes
Hematome : No
Tumor : No
Neck
Position : Straight


Heart : No abnormality
Lungs : No abnormality
Liver : No abnormality
Spleen : No abnormality
Extremities : See neurological state
Genital : No abnormality



Facial Expression : Natural
Psychological contact : Natural



Deformity : No
Fracture : No
Fracture pain : No
Vessel : No widening
Pulsation : No disorder

Deformity : No
Torticolis : No
Nape of neck stiffness : No
Tumor : No
Vessels : No widening


CRANIAL NERVES
N.I: Olfaktorius nerve
Smelling
Anosmia
Hyposmia
Parosmia

N.II: Opticus nerve
Visual acuity
Campus visi





Anopsia
Hemianopsia
Oculi fundus
Edema papil
Atrophy papil
Retina bleeding

N.III: Occulomotorius,
N.IV: Trochlearis, and
N.VI: Abducens nerves
Diplopia
Eyes gap
Ptosis
Eyes position
Strabismus
Exophtalmus
Enophtalmus
Deviation conjugae
Eyes movement
Pupil
Shape
Size
Isochor/anisochor
Midriasis/miosis
Light reflex
direct
consensuil
accommodation
Argyl Robertson



Right
No disorder
No
No
No

Right
6/6 PH (-)
V.O.D





No
No

No
No
No



Right
No
No
No

No
No
No
No
No abnormality

Round
3mm
Isochor
No

Positive
Positive
Positive
No



Left
No disorder
No
No
No

Left
6/6 PH (-)
V.O.S





No
No

No
No
No



Left
No
No
No

No
No
No
No
No abnormality

Round
3mm
Isochor
No

Positive
Positive
Positive
No


N.V: Trigeminus nerve
Motoric
Biting
Trismus
Corneal reflex
Sensory
Forehead
Cheek
Chin

N.VII: Facialis nerve
Motoric
Frowning
Eyes closing
Giggling
Nasolabial fold
Facial shape
rest
Speaking/whistling
Sensory
2/3 anterior tounge

Autonomy
Salivation
Lacrimation
Chvosteks sign

N.VIII: Statoacusticus nerve
Cochlearis nerve
Whispering
Hour ticking
Weber test
Rinne test
Vestibularis nerve
Nystagmus
Vertigo

N.IX: Glossopharingeus, and
N.X: Vagus nerves
Pharyngeal arch
Uvula
Swallowing disorder
Hoarsing/nasalising
Heart beat
Reflex
Vomiting
Coughing
Occulocardiac
Caroticus sinus
Sensory

Right
No disorder
No
Yes

Normal
Normal
Normal


Right
Simetric
Normal
Normal
Normal

No disorder
No disorder

No disorder


No disorder
No disorder
No disorder


Right
No disorder
No disorder
Normal
Normal

No
No


Right
No disorder
No disorder
No
No
Normal

No disorder
No disorder
No disorder
No disorder


Left
No disorder
No
Yes

Normal
Normal
Normal


Left
Simetric
Normal
Normal
Normal

No disorder
No disorder

No disorder


No disorder
No disorder
No disorder


Left
No disorder
No disorder
Normal
Normal

No
No


Left
No disorder
No disorder
No
No
Normal

No disorder
No disorder
No disorder
No disorder

1/3 posterior tounge No disorder No disorder

N.XI: Accessorius Nerve
Shoulder Raising
Head Twisting

N.XII: Hypoglossus Nerve
Tounge Showing
Fasciculation
Papil Athrophy
Dysarthria


MOTORIC
Arms
Motion
Power
Tones
Physiological Reflex
Biceps
Triceps
Radius
Ulna
Pathological Reflex
Hoffman Tromner
Leri
Meyer
Trofik

LEG
Motion
Power
Tones
Clonus
Thigh
Foot
Physiological reflex
K P R
A P R
Pathological reflex
Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer
Rossolimo
Mendel Bechterew
Abdominal skin reflex
Upper
Middle
Right
No disorder
No disorder

Right
No deviation
No
No
No



Right
Lateralisation (-)
Lateralisation (-)
decrease






-
-
-
-

Right
Lateralisation (-)
Lateralisation (-)
decrease

negative
negative

Decrease
Decrease

Positive
Positive
Negative
Negative
Negative
Negative
Negative

Negative
Negative
Left
No disorder
No disorder

Left
No deviation
No
No
No



Left
Lateralisation (-)
Lateralisation (-)
decrease






-
-
-
-

Left
Lateralisation (-)
Lateralisation (-)
decrease

negative
negative

Decrease
Decrease

Positive
Positive
Negative
Negative
Negative
Negative
Negative

Negative
Negative
Lower
Tropik
Negative
Negative

Negative
Negative


SENSORY
Can not be assessed
PICTURE









VERTEBRAL COLUMN

Kyphosis : Yes Tumor : No
Lordosis : No Meningocele : No
Gibbus : No Hematome : No
Deformity : No Tenderness : No

SYMPTOMS OF MENINGEAL IRRITATION

Nape of neck stiffness
Kerniq
Lasseque
Brudzinsky
Neck
Cheek
Symphisis
Leg I
Leg II
Right
Yes
Yes
No

No
No
No
No
No
Left
Yes
Yes
No

No
No
No
No
No


GAIT AND BALANCE
Gait Balance and Coordination
Ataxia : Can not be assesed Romberg : Can not be assessed
Hemiplegic : Can not be assesed Dysmetri : Can not be assessed
Scissor : Can not be assesed finger finger : Can not be assessed
Propulsion : Can not be assesed finger nose : Can not be assessed
Histeric : Can not be assesed heel - heel : Can not be assessed
Limping : Can not be assesed Reboundphenomenon : Can not be assessed
Steppage : Can not be assesed Dysdiadochokinesis : Can not be assessed
Astasia-Abasia : Can not be assesed Trunk Ataxia : Can not be assessed
Limb Ataxia : Can not be assessed

ABNORMAL MOVEMENTS
Tremor : No
Chorea : No
Athetosis : No
Ballismus : No
Dystoni : No
Myoclonus : No

VEGETATIVE FUNCTION
Micturition : Catheterized
Defecation : No abnormality

LIMBIC FUNCTION
Motoric aphasia : No
Sensoric aphasia : No
Apraksia : No
Agraphia : No
Alexia : No
Nominal aphasia : No



LABORATORY FINDINGS
BLOOD (20 August 2014)
Hb : 13.0 gr/dl (12-16)
Erythrocyte : 4.31 mil/mm
3
(4.0-5.0)
Hematocrit : 35 vol% (37-43 vol%)
Leucocyte : 8900/mm
3
(5000-10000)
LED : 35 mm/hour (<38)
Thrombocyte : 288000/mm
3
(200.000-500.000)
Diff Count : 0/0/0/84/10/6 (0-1/1-3/2-6/50-70/20-40/2-8)
Total cholesterol : 225 mg/dl (<200)
Ureum : 17 mg/dl (15-39)
Creatinin : 0.93 mg/dl (0,6-1,0)
Na : 136 mmol/l (135-155)
K : 5.6 mmol/l (3,5-5,5)

URINE : Not Performed
CEREBRO SPINAL FLUID : Patients family refused to perform the lumbal punctie

SPECIFIC EXAMINATION
Cranium X- Ray : Not performed
Chest X- Ray (June 14th 2014) : minimal infiltration at upper-middle lung,
Lung tuberculosis suspected
Head CT-Scan (June 13rd 2014) : mild ventriculomegaly with edema and an
old infarction at left interne capsule


RESUME

IDENTIFICATION

Name : Mr. Muhammad Guntur
Age : 22 years old
Sex : Male
Occupation : Jobless
Admitted : August 20th 2014 10:25

ANAMNESIS

Patient was admitted to decreasing level of consciousness

2 days before admission patient was having a difficulty to communicate with his
family, he was just lying on bed, and sometimes freaked out and blabbering. The history of
headache (+), high fever (+).
Patient was once diagnosed with meningitis TB approximately 2 months ago, with
chief complaint headache (+), convulsion (+), and decreasing level of consciousness. Patient
was treated with MDT-TB category 1, and it only lasted for 2 days.
This is the second time, patient presents these symptoms.


PHYSICAL EXAMINATION
Conciousness (GCS score) : GCS 11 (E3M5V3)
Temperature : 36.7
o
C
Pulse : 80 beats/min
Respiratory rate : 20 times/min
Blood pressure : 100/70 mmHg

Neurological examination:
N III : round pupil, isokor, Light reflex +/+, diameter 3 mm
N VII : symmetrical plica nasolabialis
N XII : no tongue deviation

Motoric function Right trunk Left trunk Right arm Left arm
Movement Lateralisation (-)
Power Lateralisation (-)
Tonus
Klonus - -
Physiological ref
Pathological ref - - +BC +BC

Sensory function : can not be assesed yet
Limbic function : no disorders
Vegetative function : catheterized
Meningeal signs : nape stiffness (+)
Abnormal movements : -
Gait dan balance : can not be assessed yet



LABORATORY FINDINGS
BLOOD (20 August 2014)
Hb : 13.0 gr/dl (12-16)
Erythrocyte : 4.31 mil/mm
3
(4.0-5.0)
Hematocrit : 35 vol% (37-43 vol%)
Leucocyte : 8900/mm
3
(5000-10000)
LED : 35 mm/hour (<38)
Thrombocyte : 288000/mm
3
(200.000-500.000)
Diff Count : 0/0/0/84/10/6 (0-1/1-3/2-6/50-70/20-40/2-8)
Total cholesterol : 225 mg/dl (<200)
Ureum : 17 mg/dl (15-39)
Creatinin : 0.93 mg/dl (0,6-1,0)
Na : 136 mmol/l (135-155)
K : 5.6 mmol/l (3,5-5,5)

URINE : Not Performed
CEREBRO SPINAL FLUID : Patients family refused to perform the lumbal punctie

SPECIFIC EXAMINATION
Cranium X- Ray : Not performed
Chest X- Ray (June 14th 2014) : minimal infiltration at upper-middle lung,
Lung tuberculosis suspected
Head CT-Scan (June 13rd 2014) : mild ventriculomegaly with edema and an
old infarction at left interne capsule

DIAGNOSIS
Clinical diagnosis :
Decreasing level of consciousness
Nape stiffness
Organic Mental Disorder
Topical diagnosis : meningen, encephalon
Ethiology diagnosis : meningoencephalitis TB

MANAGEMENT
Non-pharmacology : diet 1650 kkal


Pharmacology :
IVFL NaCL gtt XX/menit
Rifampisin tab 600 mg 1 x 1
Isoniazid tab 400 mg 1 x 1
Pirazinamid tab 500 mg 2 x 1
Dexamethasone ampoule 4x1
OMZ vial 40 mg 1x1
Haloperidol 3 mg 2x1.5 mg
Risperidone 4 mg 2x2 mg

Planning :
Lumbal punctie
Head CT Scan with contrast

PROGNOSIS
Quo ad vitam : Dubia ad bonam
Quo ad functionam : Dubia ad malam


CASE ANALYZE

Differential diagnosis of etiology
Meningitis
1) Decreasing level of consciousness
2) Nape stiffness
3) Headache

Encephalitis
1) Decreasing level of consciousness
2) Convulsion
3) Headache

Meningoencephalitis
1) Decreasing level of consciousness
2) Headache
3) Convulsion
4) Nape stiffness

In conclusion, the etiology of this patients decreasing level of consciousness is
meningoencephalitis.