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Tuberculous Meningitis, Vasculitis, and Pericarditis presented by deep coma.

ABSTRACT: A 32 years old male patient presented to the emergency room with complete loss of consciousness since three hours. This was after two weeks of night fever, sweating and considerable loss of weight with self-treatment by antipyretic drugs. In the last two days, the patient develops confusion and altered behavior. Clinical examination revealed high-grade fever and coma. CXR revealed mild cardiomegaly. Treatment started with intravenous fluids, antipyretics, and antibiotics. On the next day , Echocardiography revealed mild Mitral regurgitation (MR), mild pericardial effusion with thickening of the pericardial membrane that suggested pericarditis. ESR was significantly elevated (57 mm/hour). After three days of treatment without improvement, Tuberculosis (TB) proposed and laboratory investigations implemented. Brain MRI T1 weighted images with Gadolinium injection revealed basal meningeal enhancement with multiple tiny cerebral granulomas.FLAIR-weighted images revealed multiple small high signal intensity foci in bilateral temporal lobes and the basal ganglia strongly suggesting vasculitis and ischemic lesions. CSF sample and culture was done, and anti-tuberculous drugs started with IV fluids, corticosteroids, and other supportive drugs. The results of CSF culture confirmed the diagnosis of Tuberculous meningitis. After two months of continuous anti-tuberculous treatment, the patient seemed to regain consciousness. The patient continued Rifampicin tab 700 mg, Isoniazid tab 350 mg, Ethambutol tab 400 mg, Pyridoxine tab 80 mg, Aspirin tab 100 mg and other supportive drugs for six months. The patient regained full health without any mental or motor disabilities.

SUBMITTER: Alshoabi SA

PROVIDER: S-EPMC6290220 | biostudies-other | 2018 Nov-Dec

REPOSITORIES: biostudies-other

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Tuberculous Meningitis, Vasculitis, and Pericarditis presented by deep coma.

Alshoabi Sultan Abdulwadoud SA

Pakistan journal of medical sciences 20181101 6

A 32 years old male patient presented to the emergency room with complete loss of consciousness since three hours. This was after two weeks of night fever, sweating and considerable loss of weight with self-treatment by antipyretic drugs. In the last two days, the patient develops confusion and altered behavior. Clinical examination revealed high-grade fever and coma. CXR revealed mild cardiomegaly. Treatment started with intravenous fluids, antipyretics, and antibiotics. <b><i>On the next day</ ...[more]

PMID: 30559826

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Project description:BackgroundTuberculous meningitis is a serious form of tuberculosis (TB) that affects the meninges that cover a person's brain and spinal cord. It is associated with high death rates and with disability in people who survive. Corticosteroids have been used as an adjunct to antituberculous drugs to treat people with tuberculous meningitis, but their role has been controversial.ObjectivesTo evaluate the effects of corticosteroids as an adjunct to antituberculous treatment on death and severe disability in people with tuberculous meningitis.Search methodsWe searched the Cochrane Infectious Diseases Group Specialized Register up to the 18 March 2016; CENTRAL; MEDLINE; EMBASE; LILACS; and Current Controlled Trials. We also contacted researchers and organizations working in the field, and checked reference lists.Selection criteriaRandomized controlled trials that compared corticosteroid plus antituberculous treatment with antituberculous treatment alone in people with clinically diagnosed tuberculous meningitis and included death or disability as outcome measures.Data collection and analysisWe independently assessed search results and methodological quality, and extracted data from the included trials. We analysed the data using risk ratios (RR) with 95% confidence intervals (CIs) and used a fixed-effect model. We performed an intention-to-treat analysis, where we included all participants randomized to treatment in the denominator. This analysis assumes that all participants who were lost to follow-up have good outcomes. We carried out a sensitivity analysis to explore the impact of the missing data.Main resultsNine trials that included 1337 participants (with 469 deaths) met the inclusion criteria.At follow-up from three to 18 months, steroids reduce deaths by almost one quarter (RR 0.75, 95% CI 0.65 to 0.87; nine trials, 1337 participants, high quality evidence). Disabling neurological deficit is not common in survivors, and steroids may have little or no effect on this outcome (RR 0.92, 95% CI 0.71 to 1.20; eight trials, 1314 participants, low quality evidence). There was no difference between groups in the incidence of adverse events, which included gastrointestinal bleeding, invasive bacterial infections, hyperglycaemia, and liver dysfunction.One trial followed up participants for five years. The effect on death was no longer apparent at this time-point (RR 0.93, 95% CI 0.78 to 1.12; one trial, 545 participants, moderate quality evidence); and there was no difference in disabling neurological deficit detected (RR 0.91, 95% CI 0.49 to 1.69; one trial, 545 participants, low quality evidence).One trial included human immunodeficiency virus (HIV)-positive people. The stratified analysis by HIV status in this trial showed no heterogeneity, with point estimates for death (RR 0.90, 95% CI 0.67 to 1.20; one trial, 98 participants) and disability (RR 1.23, 95% CI 0.08 to 19.07; one trial, 98 participants) similar to HIV-negative participants in the same trial.Authors' conclusionsCorticosteroids reduce mortality from tuberculous meningitis, at least in the short term.Corticosteroids may have no effect on the number of people who survive tuberculous meningitis with disabling neurological deficit, but this outcome is less common than death, and the CI for the relative effect includes possible harm. However, this small possible harm is unlikely to be quantitatively important when compared to the reduction in mortality.The number of HIV-positive people included in the review is small, so we are not sure if the benefits in terms of reduced mortality are preserved in this group of patients.

Project description:BACKGROUND:Tuberculous pericarditis is associated with high morbidity and mortality even if antituberculosis therapy is administered. We evaluated the effects of adjunctive glucocorticoid therapy and Mycobacterium indicus pranii immunotherapy in patients with tuberculous pericarditis. METHODS:Using a 2-by-2 factorial design, we randomly assigned 1400 adults with definite or probable tuberculous pericarditis to either prednisolone or placebo for 6 weeks and to either M. indicus pranii or placebo, administered in five injections over the course of 3 months. Two thirds of the participants had concomitant human immunodeficiency virus (HIV) infection. The primary efficacy outcome was a composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. RESULTS:There was no significant difference in the primary outcome between patients who received prednisolone and those who received placebo (23.8% and 24.5%, respectively; hazard ratio, 0.95; 95% confidence interval [CI], 0.77 to 1.18; P=0.66) or between those who received M. indicus pranii immunotherapy and those who received placebo (25.0% and 24.3%, respectively; hazard ratio, 1.03; 95% CI, 0.82 to 1.29; P=0.81). Prednisolone therapy, as compared with placebo, was associated with significant reductions in the incidence of constrictive pericarditis (4.4% vs. 7.8%; hazard ratio, 0.56; 95% CI, 0.36 to 0.87; P=0.009) and hospitalization (20.7% vs. 25.2%; hazard ratio, 0.79; 95% CI, 0.63 to 0.99; P=0.04). Both prednisolone and M. indicus pranii, each as compared with placebo, were associated with a significant increase in the incidence of cancer (1.8% vs. 0.6%; hazard ratio, 3.27; 95% CI, 1.07 to 10.03; P=0.03, and 1.8% vs. 0.5%; hazard ratio, 3.69; 95% CI, 1.03 to 13.24; P=0.03, respectively), owing mainly to an increase in HIV-associated cancer. CONCLUSIONS:In patients with tuberculous pericarditis, neither prednisolone nor M. indicus pranii had a significant effect on the composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. (Funded by the Canadian Institutes of Health Research and others; IMPI ClinicalTrials.gov number, NCT00810849.).

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Tuberculous Meningitis, Vasculitis, and Pericarditis presented by deep coma.

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Tuberculous Meningitis, Vasculitis, and Pericarditis presented by deep coma.

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