30yrs old female admitted with C/o fever with chills and headache since two months and altered sensorium of one day duration with difficulty in breathing.clinically obtunded,cold clammy. significant findings are CNS - Drowsy,Pupils - B/l 5mm SRTL,GCS - E3V1M6,Kernigs and brudzinski signs positive,B/l Plantar flexor.Power - 3/5 in all four limbs.Vitals stable.CT,MRI brain and CSF report enclosed.

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TBM c obstructive Hydrocephalus. Management:Inj Mannitol,IV drip,Inj Phenytoin,ATT Inj Streptomycin Rifampicin, Pyrazinamide Ethumbutol,Inj Methylprednisolone,PPI,Inj MVI,Moist O2, Nebulization,Inj Pipercilin Tazobactum, Ryles feeding if necessary.Monitor PRT & Vitals,LFT,RFT,CPK,LDH,Na+,K+,Hco3-,ECG.Refer to Neurosurgeon for opinion & management for Shunt & accordingly

Thanks Dr Prashant Vedwan
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History of Fever since 1 month with development of Altered Sensorium and presence of Hydrocephalus on MRI CSF picture of increased protein s/o Chronic Etiology like TBM.... But also rule out Chronic meningitis...

Radiological picture is suggestive of communicating hydrocephalus. CSF lymphocytic pleocytosis with elevated protein. Most probablt Neuro tuberculosis presented with chronic meningitis Start ATT with steroids.

Young female, Clinical presentation is suggestive of chronic meningitis( > 2 months )Alteration in sensorium indicate associated encephalone involvement/ associated metabolic dysfunction. CSF poly morphonuclear leukocytosis with elevated protein and normal sugar. Ct brain sulci and gyri not seen. MRI shows acute hydrocephalus. I AM UNABLE TO SEE THE CONTRST MRI TO LOOK FOR MENINGEAL ENHANCEMENT WHICH IS VERY IMPORTANT INTHIS CASE. Clinical ,csf plus radiology suggestive of chronic meningitis with normal CSF sugar. Needs CsF exam for TB,HIV,cryptococcus. LOW Hb increase ESR ,deranged LFT all in favour of TB and in other conditions also. Emperically start ATT with prednisolone and simultaneously exlude other conditions including vasculitis.

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It's a TBM ...MRI S/o hydrocephalus also ...kindly do fundus examination ...if papilloedema...then plan for ventriculostomy..for omaya reservoir placement ...as csf protein is raised shunt is not an option rt now ...regular tap from omaya to be done .once csf values are appropriate then plan for shunt if hydrocephalus persist .. regularly csf tap and ATT .. STEROID .. IMPROVE THE CONDITION AND SHUNT NOT TO BE needed ...

Thank u sir.
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Tuberculosis meningitis Management as suggested by Dr.Padam Chand

Thanks ! Dr.Prashant Vedwan
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However the protocol starts with Broad spectrum Antibiotics including Vancomycin plus ATT including Steroid

It's TBM. as pt is altered and Periventricular lucencies are present, pt needs urgent CSF diversion. Young female, consider for endoscopic third ventriculostomy. Also start with ATT and most importantly steroids.

TBM Anti Koch’s Corticosteroids can be added

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