Professional Documents
Culture Documents
No
Question Anwser
.
-History Taking :
We found altered consciousness, low grade fever 2 weeks, decrease appetite
-physical and neurogical examination
Buldging large fontanel
Right N VI palsy, increase physiologic reflex increase, clonus is positive
-support examination
We found from Head CT Scan : meningeal enhancement, infraction in basal ganglia, hydrocephalus
CSF analysis :
Color, appearance is colorness, clear, Nonne pandy is positive, count cell is 154, with dominan
mononuclear cell, glucose CSF and plasma ratio is less than 0.5%
Base on history taking, physical neurogival examination and support examination, we combine with
1. Dasar diagnosis marais score (or TBM score) is 14 so we diagnosed patient with meningitis tuberculous grade 2
but a negative Xpert result does not rule out tuberculosis disease, therefore clinicians should still consider
initiation of tuberculosis treatment in children with history and clinical features suggestive of tuberculosis
disease despite a negative Xpert result.
sensitivity and specificity Xpert and microscopy in CSF of TBM patient?
Based on literature, in children with TBM, positive result of MTB microbiology from CSF was low, only
….%
Because of that literature, and less sensitive and specific from CSF microbiology, so for diagnostic
approach we used clinical sign and symptom, CSF analysis and also neuroimaging approach, and we have
some diagnostic criteria to establish TBM diagnosis in children such as Marais score.
Basal meningeal enhancement75%
Infarcts8%–44%
Communicating hydrocephalus80%
Neuroimaging finding
4. Tuberculomas8%–31%
in TBM
MRI has a higher sensitivity than a CT scan. A CT scan may itself be normal initially in almost 30% of
the cases. Hence, a normal neuroimaging initially does not rule out the possibility of TBM
The recommended daily doses of ATT include H 10 (7-15) mg/kg, R 15 (10-20) mg/kg, Z 35 (30-40)
mg/kg and E 20 (15-25) mg/kg therapy TBM 2months RHZE with 10 months of RH regimen
5. Treatment TBM
H has good CSF penetration and can achieve CSF levels over 30 times the minimum inhibitory
concentration (MIC) of Mtb rapidly and use prednisone 2mg/kgbb for 4weeks,
Side effect
6. AntiTuberculousTerap
i
From Walgreen TBC and incubation period for TBC infection. Hematogenous can occur in 3months after
primary infection of TBC, so we can conclude this patients has hematogenous phase of TB infections
around in 3months since first of symptom occur.
A thick gelatinous exudate containing erythrocytes, neutrophils, macrophages and lymphocytes is formed
around the brain stem, sylvian fissures and basal cisterns, causing obstruction to the flow of CSF from the
cerebral aqueduct or fourth ventricle. Absorption of CSF is also interfered leading to raised intracranial
pressure (ICP) and hydrocephalus. The basal exudates may lead to periarteritis of the cerebral arteries
Mekanisme TTIK,
10. leading to infarction of the caudate nucleus and internal capsule. There may be oedema of the brain,
hydrocephalus
perivascular infiltration and inflammation of the blood vessel walls leading to narrowing or occlusion by
thrombi resulting in infarcts in the distribution of the medial striate and thalamic perforating arteries
Different Diagnosis
16
Anemia
18. Criteria General GENERAL CONDITION CRITERIA (Keadaan Umum) OF THE PATIENT.
Condition of patient A.Fully alert, consist of :
-Conscious/ compos Mentis
-Vital signs/ stable
-Fulfill independent needs
B.Moderatelly ill. Have at least 3 (three) points below:Consists of:
-Conscious to Apathy
-Vital signs stable
-Requires medical procedure & injury/wounds at least 3x/day
-Requires observation
-Fulfillment of needs assisted
C. Severely ill. Have at least 2 (two) points below Consists of:
-Full awareness to somnolence
-Vital signs are unstable
-Using vital organ aids (such as ventilator)
-Requires intensive care
-Requires close observation
-Fulfillment of needs assisted entirely
Vasogenic cerebral edema, the most common form, results from the disruption of the blood-brain-
19. Edema Cerebrii barrier. With the disrupted blood-brain-barrier ions and proteins flow more freely into the extravascular
space which causes osmotic draw of fluid into the brain interstitium. For example, vascular endothelial
growth factor (VEGF), glutamate, and leukotrienes produced locally increase the permeability of vessels
around tumors.[4] These factors and a lack of tight endothelial cell junctions in the vessels around the
tumors cause this increased permeability, which allows for an influx of proteinaceous solute and fluid into
the brain parenchyma, particularly in the white matter.[5] Peritumor edema, for example, leads to 65% of
patients developing cognitive impairment resulting from displacement and damage to white matter tracts.
[6]
Cellular or cytotoxic edema often results within minutes of the insult/injury and affects glial, neuronal,
and endothelial cells within the brain. In cytotoxic edema, the cells lack hemostatic mechanisms, and
primarily sodium enters the cell freely, with the failure of the export mechanism. Anions then follow,
attempting to return neutrality to the cell, resulting in intracellular edema as the cells swell with increased
water following the ions into the intracellular compartment.[7] Traumatic brain injury and stroke cause
this form of edema.
Interstitial cerebral edema results from the outflow of cerebrospinal fluid from the intraventricular space
to the interstitial areas of the brain. Patients with hydrocephalus or meningitis are examples of
those affected by this etiology. The increased pressure, against the cerebrospinal fluid (CSF) and brain,
drives fluid into the brain parenchyma. The fluid accumulates in the extracellular space of mostly the
white matter causing the cerebral edema.
Symptoms appear as the intracranial pressure (ICP) rises above 20 cm H2O in most patients. Treatment
for cerebral edema targets the underlying cause and any life-threatening complications. Treatments
include hyperventilation, osmotherapy, diuretics, corticosteroids, and surgical decompression .
Why choice mannitol Because mannitol can improve and increase cerebral perfusion pressure in patients with cerebral edema,
20. in the patient, didn’t patients also tend to have high sodium levels and Hyperosmolar saline is chosen in patients with
choice HS hypovolume and hyponatremia.
Head up or Head up 15-30 : cerebral perfusin pressure increase, and promote cerebral venous drainage
21. Oxygen Oxygen suplementation : for ensure saturation oxygen of more than 90% and prevent hypoxia in patient
suplementation with cerebral edama
1. Hernia Subfalcine
2. Hernia Tentorial Lateral or uncal
22. Herniasi Otak
3. Hernia Tentorial Central or axial
4.Tonsiller