CASE REPORT

MENINGITIS TUBERCULOSIS
SENIOR CLINICAL CLERKSHIP

By :
Frida E A Wulandari

04124708008

Nahtadia Laksitasari 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
Age
Sex
Occupation
Admitted

: Mr. Muhammad Guntur

: 22 years old
: Male
: Jobless
: 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
Nutrition
Temperature
Pulse
Respiratory rate
Blood pressure

: E3M5V3
: Sufficient
: 36.7 oC
: 80 beats/min
: 20 times/min
: 100/70 mmHg

Heart
Lungs
Liver
Spleen
Extremities
Genital

Psychiatric state
Attitude
Attention

: Cooperative
: Normal

Facial Expression
: Natural
Psychological contact : Natural

: Brachicephaly
: Normal
: Yes
: No
: No

Deformity
Fracture
Fracture pain
Vessel
Pulsation

: No
: No
: No
: No widening
: No disorder

: Straight

Deformity

: No

Neurological state
Head
Shape
Size
Symetric
Hematome
Tumor
Neck
Position

: No abnormality
: No abnormality
: No abnormality
: No abnormality
: See neurological state
: No abnormality

Torticolis
: No
Nape of neck stiffness : No
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

Tumor
Vessels

: No
: No widening

Right
No disorder
No
No
No

Left
No disorder
No
No
No

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

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

No
No

No
No

No
No
No

No
No
No

Right
No
No
No

Left
No
No
No

No
No
No
No
No abnormality

No
No
No
No
No abnormality

Round
3mm
Isochor
No

Round
3mm
Isochor
No

Positive
Positive
Positive
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

Right
No disorder
No
Yes

Left
No disorder
No
Yes

Normal
Normal
Normal

Normal
Normal
Normal

Right
Simetric
Normal
Normal
Normal

Left
Simetric
Normal
Normal
Normal

No disorder
No disorder

No disorder
No disorder

No disorder

No disorder

No disorder
No disorder
No disorder

No disorder
No disorder
No disorder

Right
No disorder
No disorder
Normal
Normal

Left
No disorder
No disorder
Normal
Normal

No
No

No
No

Right
No disorder
No disorder
No
No
Normal

Left
No disorder
No disorder
No
No
Normal

No disorder
No disorder
No disorder
No disorder

No disorder
No disorder
No disorder
No disorder

 Caroticus sinus
Sensory
1/3 posterior tounge

No disorder

No disorder

N.XI: Accessorius Nerve

Shoulder Raising
Head Twisting

Right
No disorder
No disorder

Left
No disorder
No disorder

N.XII: Hypoglossus Nerve

Tounge Showing
Fasciculation
Papil Athrophy
Dysarthria

Right
No deviation
No
No
No

Left
No deviation
No
No
No

Right
Lateralisation (-)
Lateralisation (-)
decrease

Left
Lateralisation (-)
Lateralisation (-)
decrease

Right
Lateralisation (-)
Lateralisation (-)
decrease

Left
Lateralisation (-)
Lateralisation (-)
decrease

negative
negative

negative
negative

Decrease
Decrease

Decrease
Decrease

Positive
Positive
Negative
Negative
Negative
Negative
Negative

Positive
Positive
Negative
Negative
Negative
Negative
Negative

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
KPR
APR
Pathological reflex
Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer
Rossolimo

 Mendel Bechterew
Abdominal skin reflex
Upper
Middle
Lower
Tropik
SENSORY
Can not be assessed
PICTURE

Negative
Negative
Negative
Negative

Negative
Negative
Negative
Negative

VERTEBRAL COLUMN
Kyphosis
Lordosis
Gibbus
Deformity

: Yes
: No
: No
: No

Tumor
Meningocele
Hematome
Tenderness

: No
: No
: No
: No

SYMPTOMS OF MENINGEAL IRRITATION

Nape of neck stiffness
Kerniq
Lasseque
Brudzinsky
Neck
Cheek
Symphisis
Leg I
Leg II
GAIT AND BALANCE
Gait
Ataxia
: Can not be assesed
Hemiplegic
: Can not be assesed
Scissor
: Can not be assesed
Propulsion
: Can not be assesed
Histeric
: Can not be assesed
Limping
: Can not be assesed
Steppage
: Can not be assesed
Astasia-Abasia
: Can not be assesed

Left
Yes
Yes
No

No
No
No
No
No

No
No
No
No
No

Balance and Coordination

Romberg
: Can not be assessed
Dysmetri
: Can not be assessed
finger finger : Can not be assessed
finger nose
: Can not be assessed
heel - heel
: Can not be assessed
Reboundphenomenon : Can not be assessed
Dysdiadochokinesis : Can not be assessed
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

Right
Yes
Yes
No

Alexia
Nominal aphasia

: No
: No

LABORATORY FINDINGS
BLOOD (20 August 2014)
Hb
: 13.0 gr/dl
Erythrocyte
: 4.31 mil/mm3
Hematocrit
: 35 vol%
Leucocyte
: 8900/mm3
LED
: 35 mm/hour
Thrombocyte
: 288000/mm3
Diff Count
: 0/0/0/84/10/6
Total cholesterol
: 225 mg/dl
Ureum
: 17 mg/dl
Creatinin
: 0.93 mg/dl
Na
: 136 mmol/l
K
: 5.6 mmol/l

(12-16)
(4.0-5.0)
(37-43 vol%)
(5000-10000)
(<38)
(200.000-500.000)
(0-1/1-3/2-6/50-70/20-40/2-8)
(<200)
(15-39)
(0,6-1,0)
(135-155)
(3,5-5,5)

URINE
: Not Performed
CEREBRO SPINAL FLUID : Patients family refused to perform the lumbal punctie
SPECIFIC EXAMINATION
Cranium X- Ray
Chest X- Ray (June 14th 2014)
Lung tuberculosis suspected
Head CT-Scan (June 13rd 2014)
old infarction at left interne capsule

: Not performed
: minimal infiltration at upper-middle lung,
: mild ventriculomegaly with edema and an

RESUME
IDENTIFICATION
Name
Age
Sex
Occupation
Admitted

: Mr. Muhammad Guntur

: 22 years old
: Male
: Jobless
: 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 oC
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

Movement

Lateralisation (-)

Power

Lateralisation (-)

Left trunk

Right arm

Left arm

+BC

+BC

Tonus
Klonus
Physiological ref
Pathological ref

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
Erythrocyte
: 4.31 mil/mm3

(12-16)
(4.0-5.0)

Hematocrit
Leucocyte
LED
Thrombocyte
Diff Count
Total cholesterol
Ureum
Creatinin
Na
K

:
:
:
:
:
:
:
:
:
:

35 vol%
8900/mm3
35 mm/hour
288000/mm3
0/0/0/84/10/6
225 mg/dl
17 mg/dl
0.93 mg/dl
136 mmol/l
5.6 mmol/l

(37-43 vol%)
(5000-10000)
(<38)
(200.000-500.000)
(0-1/1-3/2-6/50-70/20-40/2-8)
(<200)
(15-39)
(0,6-1,0)
(135-155)
(3,5-5,5)

URINE
: Not Performed
CEREBRO SPINAL FLUID : Patients family refused to perform the lumbal punctie
SPECIFIC EXAMINATION
Cranium X- Ray
Chest X- Ray (June 14th 2014)
Lung tuberculosis suspected
Head CT-Scan (June 13rd 2014)
old infarction at left interne capsule
DIAGNOSIS
Clinical diagnosis

: Not performed
: minimal infiltration at upper-middle lung,
: mild ventriculomegaly with edema and an

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
Quo ad functionam

: Dubia ad bonam
: 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

1)
2)
3)
4)

Meningoencephalitis
Decreasing level of consciousness
Headache
Convulsion
Nape stiffness

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

meningoencephalitis.