CASE REPORT

B Y : B E L I N DA O R L I N E O. S .

Mentor : dr. Sumada, Sp. S and dr. Candra, Sp.S

PATIENT ID

Name : Mrs. DANR

DOB : 24 Dec 1961 (56 years old)

Gender : Female

Address : Br. Jadi Babakan Anyar Tabanan

Admission Date : September 16th, 2018

HISTORY TAKING

• The patient came to Wangaya Hospital in emergency room at 14th

September 2018 afternoon (approx. 2 pm) with chief complain of
decreased level of consciousness.
• One day before admission, her family said that she had malaise, fever, and
productive cough. She still can eat and drink but not as much as usual,
and have tendency to sleep, but easily to waken up.
• There was headache she complained one day before admission
• There is no nausea and vomiting
HISTORY OF PRESENT ILLNESS

• CHIEF COMPLAIN : Decreased level of consciousness

• RECENT MEDICAL STORY :
14/08/18 23/08/18 09/09/18 14/09/18 16/09/18
- Malaise and
drowsiness
- Hospitalized in Wangaya General - Intermittent - Decreased level
- Still can
Hospital with HCAP, dyspepsia, fever of
eat/drink but
pancytopenia ec aplastic anemia - Productive consciousness
not as much as
- Acid fast bacilli (-), Gene Xpert TB (-) cough - Hard to be
usual
- PITC (-) waken up
- Productive
- X-ray result : pneumonia cough (+)
- Discharge prognosis : dubius - Fever (+),
headache (+)
- Nausea (-),
vomiting (-)
HISTORY TAKING AND PAST ILNESS

• Past Medical History :

– She had been hospitalized a month ago in Wangaya General
Hospital because of lung infection, dyspepsia, and anemia
• Medication :
– This patient got cefixime, omeprazole, ondancetron, amlodipine,
ambroxol, and methylprednisolone when got discharged from
hospital
HABITS

• Smoking (-)
• Alcohol (-)
PHYSICAL EXAMINATION
• General Appearance : severely ill
• Level of Consciousness : comatose
• GCS : E2V2M4
• Blood Pressure : 110/70 mmHg
• Pulse : 120 bpm, regular
• Axillary Temperature : 38º C
• Respiratory Rate : 28 times/min, regular
• O2 Sat : 95% suppl. nasal cannula with O2 3lpm
 GENERAL STATUS
Head :
• Normocephalic

Neck :
• Swollen lymph node (-)

Eye :
• Pale conjunctiva (-/-), icteric sclera (-/-), palpebra swelling (-) , pupil reflex(+/+) isocor 3mm/3mm

ENT :
• Ear : discharge -/-
• Nose : discharge -/-, deviation (-)
• Oropharyngeal : not able to be evaluated
Lips :
• Cyanosis (-), dry lips (-)
GENERAL STATUS CON’T

Thorax :
• Inspection : symmetrycal
• Palpation : symmetrical
• Auscultation :
• Heart : S1S2 N regular murmur (-)
• Lungs : bronchovesicular/bronchovesicular, coarse
crackles +/+, Wheezing -/-
GENERAL STATUS CON’T
Abdomen :
• Inspection : distention (-), flat
• Auscultation : peristaltic (+) N
• Palpation : tenderness (-), liver 1 cm below costae, spleen not palpable, skin
turgor snaps rapidly back to normal position
• Percussion : tympanic
Ekstremities : warm, cyanosis (-), pale (-), CRT <2“

Vertebrae column : within normal limit

Inguinal : lymph node enlargement (-)

NEUROLOGICAL STATUS

• MENINGEAL SIGNS :
– Nuchal Rigidities :+
– Brudzinski I :+
– Brudzinski II : +/-
– Kernig : -/-

• CRANIAL NERVES : can not be evaluated

NEUROLOGICAL STATUS CON’T

• MOTORIC FUNCTION
– There is no lateralization

• SENSORIC FUNCTION
– Can not be evaluated
NEUROLOGICAL STATUS CON’T

• PHYSIOLOGIC REFLEXES
– Biceps : +2/+2
– Triceps : +2/+2
– Patellar : +2/+2
– Achilles : +2/+2
• PATHOLOGIC REFLEXES
– Babinski : +/- - Gordon : -/-
– Chaddock : +/- - Schaeffer : -/-
– Oppenheim : -/-
 LABORATORY FINDINGS
Tests Name Results Reference Range
Leucocyte 7.340 uL 4.000 – 10.000
Erythrocyte 4,19 x 106 uL 4,20 - 5,40 x 106
Haemoglobin 12,4 g/dL 12,0 – 16,0
Haematocryte 36,6 % 37,0 – 47,0 %
Thrombocyte 215.000 uL 150.000 – 400.000

Basophil 0,1% 0-1%

Eosinophil 0,0% 0-4%

Neutrophil 69,9% 50-70%
Lymphocyte 20,7% 20-40%
Monocyte 9,3% 2-8%
LABORATORY FINDINGS CON’T

Tests Name Results Reference Range

SGPT 72 U/L 0 – 42
SGOT 79 U/L 0 - 37

Sodium 136 mmol/L 136 - 145

Potassium 4,1 mmol/L 3,5 – 5,1
Chloride 100 mmol/L 97 - 111

Glucose 124 mg/dL 80 - 200

RESUME

Physical Neurological Laboratory

Anamnesis
Examination Status FIndings
• Decreased level • LOC : • Meningeal signs
of comatose (+) • Within normal
consciousness • GCS E2V2M4 • Pathologic limit
• Productive • Axilla reflexes (+)
cough temperature :
• Fever 38º C
• Lungs : coarse
crackles +/+
DIAGNOSIS

• Meningoencephalitis
• Pneumonia
THERAPY
• IVFD Normal Saline 20 dpm
• Oxygen suppl. Nasal cannula 3lpm
• Methylprednisolone 2 x 62,5 mg (IV)
• Esomeprazole 1 x 40 mg (IV)
• Citicoline 2 x 500 mg (IV)
• Ceftriaxone 2 x 2 g (IV)
• Cefotaxime 3 x 1 g (IV)
• Paracetamol 2 x 500 mg (PO)
• Monitoring general appearance, vital signs, respiratory distress signs
 FOLLOW UP
17/09/18 18/09/18
S : unconscious, productive cough, fever, dyspnea S : unconscious, productive cough, fever, dyspnea
O : comatose, GCS : E2M2V4 O : comatose, GCS : E2M2V4
BP : 130/90 mmHg BP : 140/80 mmHg
HR : 120 bpm HR : 105 bpm
RR : 28 times/min RR : 28 times/min
Temp : 38 Temp : 37,1
Lung : coarse crackles +/+ Lung : coarse crackles +/+
Meningeal signs (+) Meningeal signs (+)
Pathologic reflexes (+) Pathologic reflexes (+)

A : meningoencephalitis + pneumonia A : meningoencephalitis + pneumonia

P : IVFD Normal Saline 20 dpm P : IVFD Normal Saline 20 dpm
Oxygen suppl. Nasal cannula 3lpm Oxygen suppl. Nasal cannula 3lpm
Methylprednisolone 2 x 62,5 mg (IV) day-2 Methylprednisolone 2 x 62,5 mg (IV) day-3
Esomeprazole 1 x 40 mg (IV) Esomeprazole 1 x 40 mg (IV)
Citicoline 2 x 500 mg (IV) Citicoline 2 x 500 mg (IV)
Ceftriaxone 2 x 2 g (IV) day-2 Ceftriaxone 2 x 2 g (IV) day-3
Cefotaxime 3 x 1 g (IV) day-2 Cefotaxime 3 x 1 g (IV) day-3
Paracetamol 3 x 500 mg (PO) Paracetamol 3 x 500 mg (PO)
Monitoring general appearance, vital signs, respiratory distress signs Diet : milk suppl. Nasogastric tube 3 times a day
NGT and foley catheter insertion Monitoring general appearance, vital signs, respiratory distress signs
Preparing for Lumbal Punction tomorrow Lumbal Punction (postponed)
19/09/18 20/09/18
S : unconscious, productive cough, fever, dyspnea S : unconscious, productive cough, fever, dyspnea
O : comatose, GCS : E2M2V4 O : comatose, GCS : E2M2V4
BP : 140/90 mmHg BP : 160/90 mmHg
HR : 90 bpm HR : 88 bpm
RR : 26 times/min RR : 24 times/min
Temp : 37 Temp : 37
Lung : coarse crackles +/+ Lung : coarse crackles +/+
Meningeal signs (+) Meningeal signs (+)
Pathologic reflexes (+) Pathologic reflexes (+)

Lumbal puncture is done by the neurologist Blood glucose : 251 mg/dL

The LCS is clear, and it was drew about 10 ml for the sample, while
bood glucose was tested : 350 mg/dL

A : meningoencephalitis + pneumonia A : meningoencephalitis + pneumonia

P : IVFD Normal Saline 20 dpm P : IVFD Normal Saline 20 dpm
Oxygen suppl. Nasal cannula 3lpm Oxygen suppl. Nasal cannula 3lpm
Methylprednisolone 2 x 62,5 mg (IV) day-4 Methylprednisolone 1 x 62,5 mg (IV) day-5
Esomeprazole 1 x 40 mg (IV) Esomeprazole 1 x 40 mg (IV)
Citicoline 3 x 500 mg (IV) Citicoline 3 x 500 mg (IV)
Moxifloxacin 1 x 400 mg (IV) day-1 Moxifloxacin 1 x 400 mg (IV) day-2
Paracetamol 3 x 500 mg (PO) Paracetamol 3 x 500 mg (PO)
Diet : milk suppl. Nasogastric tube 3 times a day Diet : milk suppl. Nasogastric tube 3 times a day
Monitoring general appearance, vital signs, respiratory distress signs Monitoring general appearance, vital signs, respiratory distress signs
Monitoring blood glucose (tomorrow morning)
20/09/18 (9.00 pm)
S : unconscious, productive cough, fever, dyspnea
O : comatose, GCS : E1M1V1
BP : 140/90 mmHg
HR : 145 bpm
RR : 38 times/min
Temp : 38
Lung : coarse crackles +/+
Meningeal signs (+)
Pathologic reflexes (+)
APACHE SCORE : 20 (moderate)

A : meningoencephalitis + pneumonia
P : IVFD Normal Saline 20 dpm
Oxygen suppl. Nasal cannula 3lpm  NRM 8lpm
Methylprednisolone 2 x 62,5 mg (IV) day-3
Esomeprazole 1 x 40 mg (IV)
Citicoline 2 x 500 mg (IV)
Moxifloxacin 1 x 400 mg (IV) day-2
Paracetamol 3 x 500 mg (PO)  3 x 1 g (IV)
Diet : milk suppl. Nasogastric tube 3 times a day
Monitoring general appearance, vital signs, respiratory distress signs

Move to the high care unit

LUMBAL PUNCTURE RESULT
Tests Name Results Reference Range
Pandy’s Reaction Positive (+++) Negative
Nonne’s Reaction Positive (+++) Negative

Color Colorless (slightly cloudy)

Blood Negative

Monocyte 75%
Poly 25%
Erythrocyte 8
Shape normal
Cell 34 cell/uL 0–5

Glucose 98 (210 – 280) 60% - 80% from blood glucose

21/09/18 22/09/18
S : unconscious, productive cough, fever, dyspnea S : unconscious, productive cough, fever, dyspnea
O : comatose, GCS : E1M1V1 O : comatose, GCS : E2M2V4
BP : 160/95 mmHg BP : 160/90 mmHg
HR : 90 bpm HR : 88 bpm
RR : 26 times/min RR : 24 times/min
Temp : 37 Temp : 37
Lung : coarse crackles +/+ Lung : coarse crackles +/+
Meningeal signs (+) Meningeal signs (+)
Pathologic reflexes (+) Pathologic reflexes (+)
decubitus (+) Decubitus (+)
Blood glucose : 251 mg/dL
A : meningoencephalitis + pneumonia A: meningoencephalitis + pneumonia

P : IVFD Normal Saline 20 dpm P : IVFD Normal Saline 20 dpm

Oxygen suppl. NRM 8lpm Oxygen suppl. Nasal cannula 3lpm
Methylprednisolone 1 x 62,5 mg (IV) day-6 Methylprednisolone 1 x 62,5 mg (IV) day-7
Esomeprazole 1 x 40 mg (IV) Esomeprazole 1 x 40 mg (IV)
Citicoline 2 x 500 mg (IV) Citicoline 2 x 500 mg (IV)
Moxifloxacin 1 x 400 mg (IV) day-3 Moxifloxacin 1 x 400 mg (IV)  meropenem 3 x 1 g (IV)
Paracetamol 3 x 1 g (IV) Paracetamol 3 x 1 g (IV)
Diet : milk suppl. Nasogastric tube 3 times a day Diet : milk suppl. Nasogastric tube 3 times a day
Monitoring general appearance, vital signs, respiratory distress signs Monitoring general appearance, vital signs, respiratory distress signs
22/09/18 (4.15 pm)

The patient is apnea

5 cycle of CPR is done

Eyes : pupillary light reflexes -/-
Pupillary diameters are maximally dilated
ECG  flat
Patient is declared dead (4.45 pm)
LCS CULTURE (25/09/2018)

• Organism : no growth
• comment : no growth of any bacterias; could be caused by:
– Infection caused by fastidious bacterias (Heamophilus influenza,
M. TB) or
– virus
MENINGITIS
DEFINITION

• Meningitis is a clinical syndrome characterized by inflammation of

the meninges.
Meninges are layers
tissue that separate
the skull and the
brain
EPIDEMIOLOGY
• Although meningitis is a notifiable disease, the exact incidence rate
is unknown
• In 2010  430.000 deaths
• In 2013  303.000 deaths
• It can occur as a complication of other disease and about 50% an
opportunistic infection
• The risk is lower in older children, rises again in adulthood
• In adults, 66% all cases emerge without disability. The main
problems are deafness (14%) and cognitive impairment (10%)
ETIOLOGY

• Bacterial infections
• Viral infections
• Fungal infections
ROUTE OF ENTRY IN CNS

• Skull or back bone fractures (trauma)

• Medical procedures
• Along peripheral nerves
• Blood or lymphatic system
 Bacteria enters
blood stream/trauma
PAT H O P H YS I O L O G Y
Enters the mucosal
surface / cavity

Breakdown of
normal barriers

Proliferates in the
CSF

Inflammation of the
meninges

increase in ICP
BACTERIAL MENINGITIS

Known as septic meningitis

Spreads by : coughing or sneezing

Treatment available : antibiotics as per causative

organism
BACTERIAL MENINGITIS CON’T

30 – 80 % • Streptococcus pneumoniae

15 – 40 % • Neisseria meningitidis

2–7% • Haemophilus influenzae

TUBERCULAR MENINGITIS

Caused by Mycobacterium tuberculosis

infection begins in the lungs

Its progresses very slowly and the symptoms are vague

VIRAL MENINGITIS

Known as aseptic meningitis

More common than bacterial form, and usually less serious

Treatment : no specific treatment; most patients recover

completely on their own
VIRAL MENINGITIS CON’T

CAUSATIVE AGENTS :
• Enterovirus
• Adenovirus
• Arbovirus
• Measles virus
• Herpes simplex virus
• varicella
FUNGAL MENINGITIS

Much less common than the other two infections

Rare in healthy people

More likely in immunocompromised persons

caused by : cryptococcus, histoplasma, blastomyces, coccidiodes

CLINICAL MANIFESTATION
Data from van de Beek D, de Gans
J, Spanjaard L, Weisfelt M, Reitsma
JB, Vermeulen M. Clinical features
and prognostic factors in adults
with bacterial me ningitis. N Engl J
Med. 2004;351: 1849-1859
MENINGEAL SIGNS

Severe stiffness of the hamstrings

Severe neck stiffness causes a
causes inability to straighten the
patient’s hips and knees to flex
leg when the hip is flexed to 90
when the neck is flexed
degrees
ASSESSMENT AND DIAGNOSIS

• History taking
• Physical examination
• Imaging  CT scan and MRI
• Blood culture
• Lumbar puncture
CSF FINDING
TREATMENT
BACTERIAL MENINGITIS
VACCINATION AGAINST BACTERIAL
MENINGITIS

Data from US Centers for Disease Control and Prevention

(www.cdc.gov/vaccines)
• Bexsero:® Administer two doses (0, ≥1 month after first dose).
• Trumenba:® Administer two or three doses
– Administer two doses (0, 6 months after first dose) to healthy
adolescents who are not at increased risk for serogroup B
meningococcal disease.
– Administer three doses (0, 1 to 2 months after first dose, 6 months
after first dose) to adolescents who are at increased risk for
meningococcal disease (including during outbreaks of serogroup B
meningococcal disease).
TREATMENT FOR TUBERCULOUS
MENINGITIS
• Isoniazid, rifampicin, pyrazinamide, and streptomycin
• Second line drugs : aminoglycosides, fluoroquinolones
• Conventional therapy is given for 6 – 9 months
• In children BCG vaccine offers (approx. 64%) protective effect
VIRAL MENINGITIS
• Treatment is mostly supportive
• SEIZURE PROPHYLAXIS  lorazepam or phenytoin or barbiturates
• INCREASED ICP  mannitol 1 g/kg followed by 0,25 – 0,5 g/kg Q6H or/and
corticosteroids
• Rest is advised
• Antipyretic
• Antiemetics
• For suspected encephalitis, empiric acyclovir (10 mg/kg IV every 8 hours) coverage for
HSV should be continued until a negative CSF polymerase chain reaction is confirmed
or a second negative polymerase chain reaction in the setting of strong clinical
suspicion. If the polymerase chain reaction is positive, treatment is continued for 14 to
21 days. For arbovirus encephalitis, treatment is supportive
FUNGAL MENINGITIS

• amphotericin B (0.7-1 mg/kg/day IV) for at least 2 weeks

cryptococcus • Fluconazole is given for consolidation therapy (400 mg/day for 8
weeks)

Coccidioides • fluconazole (400 mg/day)

immitis
• amphotericin B (0.7 mg/kg/day)
candida • Flucytosine (25 mg/kg every 6 hours)
• Other medications and IV fluids will be used to treat symptoms
such as brain swelling, shock, and seizures
• Despite conflicting results from earlier studies of corticosteroids in
adults, the trial by deGans and van de Beck has persuasively
demonstrated a reduction in mortality and improved overall
outcome if dexamethasone 10 mg is given just before the first dose
of antibiotics and every 6 h for 4 days
COMPLICATIONS

• Impaired mental status

• Increased intracranial pressure and cerebral oedema
• Seizures
• Focal neurologic deficits (eg, cranial nerve palsy, hemiparesis)
• Cerebrovascular abnormalities
• Sensorineural hearing loss
• Intellectual impairment
PROGNOSIS

• Bacterial meningitis is usually fatal. Death rate can be as high as

90%. If the person survives, even with proper treatment, long-term
disabilities can result, including deafness, seizures, paralysis,
blindness, or loss of limbs.
• For a person with viral meningitis, full recovery can take place in
seven to 10 days.
ENCEPHALITIS
• Definition : inflammation of brain parenchyma
• Mostly caused by viruses
• Many patients with encephalitis also have evidence of associated
meningitis (meningoencephalitis) and, in some cases, involvement of
the spinal cord or nerve roots (encephalomyelitis,
encephalomyeloradiculitis
CLINICAL MANIFESTATIONS

Altered level
febrile of seizures
consciousness

Cranial nerve involuntary

weakness
deficits movements
CLINICAL MANIFESTATIONS CON’T

• Involvement of the hypothalamic-pituitary axis may result in

temperature dysregulation, diabetes insipidus, or the development
of the syndrome of inappropriate secretion of antidiuretic hormone
(SIADH).
ETIOLOGY

• Hundreds of viruses are capable of causing encephalitis, only limited are

identified → most commonly in immunocompetent adults are
herpesviruses (HSV, VZV, EBV)
• Epidemics of encephalitis are caused by arboviruses, which belong to
several different viral taxonomic groups
• Alphavirues (e.g. EEE virus, western equine encephalitis virus)
• Flaviviruses (e.g.WNV, St. Louis encephalitis virus, Japanese encephalitis
virus, Powassan virus)
• Bunyaviruses (e.g. California encephalitis virus serogroup, La Crosse virus)
LABORATORY FINDINGS
• Imaging : CT scan, MRI
• EEG
• LP; CSF examination :
– Contraindication : severely increased ICP
– Limphocytic pleocytosis
– Mildly elevated protein concentrations
– Normal glucose concentration
TREATMENT

• Supportive therapy
– Monitoring ICP
– Fluid restriction
– Avoidance of hypotonic solutions
– Suppression of fever
– Anticonvulsant regimens
TREATMENT CON’T

• Acyclovir for suspected HSV infection, should be starter empirically

in patients with suspected viral encephalitis
• Adult doses : 10 mg/kg IV every 8h (30 mg/kg per day total dose)
for 14 – 21 days