CASE PRESENTATION

Doreen Tadala Banda

MBBS V
Demographics
Initials: L.M
Age: 30 years old
Sex: Male
Residence: Ndirande
Date admitted: 21/02/24
Clerked on: 21/02/24
Referral: Elley private clinic
Source of history: Patient, guardian and health passport book
Background
• PLWHIV Diagnosed in 2022 on 13A and cotrimoxazole
preventive therapy with poor drug compliance (last viral load
done on 29th April 2023, VL=267 copies/mL with adherence of
77%). Last recorded clinical visit 8Dec 2023

• Presented to a private clinic on 14/02/24 with complaints of

non-productive cough for 3 days and pleuritic chest pain.
Treated with amoxicillin 1g bd PO 5/7. Did not finish medication
after not seeing improvement 3 days on treatment.
Presenting Complaint
• Malaise 2/7
• Confusion 1/7
History of presenting complaint
• Had been unwell for a day with feeling of malaise which was
followed by an episode of vomiting once a night prior to
presentation, about a handful, only foodstuff and non bloody
• On the morning of presentation he started complaining of
headache;
• Dull headache, gradual onset, progressive
• Severity/exacerbating/relieving factors couldn’t be assessed.
• Associated photophobia and fever but no neck stiffness, no
seizures, no LOC, no focal neurological signs.
History of presenting complaint
• He took a nap around 1pm and was noted to be
confused upon waking up 2hours later;
• Giving inappropriate responses and exhibiting unusual
behavior. Weight loss- reported reduced food intake due
to increased food cost
• No other GIT symptoms
• +ve weight loss but no drenching night sweats
• No history of trauma
History of presenting complaint
• Presented to Elley private clinic at 5pm, MRDT was
negative then he was referred to QECH for further
management
• No treatment was given at the private clinic
Drug and allergy history
• 13A (TDF/3TC/DTG)
• Cotrimoxazole 960mg od

• No known allergies
Past medical history
• As in the background
• No history of psychiatric illness
• No history of Diabetes mellitus, hypertension, asthma
or epilepsy
• No previous Tuberculosis diagnosis
Surgical history
• No previous surgeries
Social history
• Not married but has two kids who live with their maternal grandmother
• Lives alone most times, sometimes with parents
• Works as a builder
• Can only afford one meal a day, mostly nsima with vegetables
• Highest level of education is standard 4
• No known TB contacts
• Does not smoke or use illicit drugs
• Started taking alcohol in 2015, mostly kachasu, sometimes magagada
• Drinks every time he has money, becomes heavily drunk
• CAGE not assessed
• Last drank 2 weeks ago
Family history
• No history of Diabetes mellitus, hypertension, asthma
or epilepsy
• No history of psychiatric illness
Review of other systems
Respiratory system
• Cough
• Almost 2 weeks
• Non productive
• Associated pleuritic chest pain but no shortness of breath
Review of other systems
• Cardiovascular: no palpitations,
no dyspnea or orthopnea, no
paroxysmal nocturnal dyspnea
• Endocrine: No exophthalmos, no
neck swelling, no heat or cold
intolerance, no increased or
decreased sweating, no horse
voice, no thirst
• Haematology: No prolonged
bleeding after injury, bruising
easily, Gum/Nose bleeding
• Genitourinary: No frequency or
urgency, no incontinence,
normal urine color, no genital
ulcers or swelling
• Dermatology: No rash
General examination
• Reduced GCS of 14/15 • No oral Kaposi sarcoma lesions
• V4 (confused) E4, M6
• No lymphadenopathy
• Well nourished
• Normal BMI of 19.6kg/m2
• Warm extremities CRT<2s
• No pallor • Pulses strong, good volume
• No jaundice • No gibbous
• No cyanosis
• No oedema
• No petechiae
• No oral thrush
Vital signs
On admission(time of clerking)
Parameter Reading Comment
Respiratory rate 16bpm Normal
Pulse rate 62bpm Normal
Oxygen saturation 96% on room air Normal
Blood pressure 119/86 mmHg Normal
Temperature 36.2° C Normal
Neurological examination

No neck stiffness
Brudzinski’s sign and kernig’s sign negative
 Cranial nerve examination
Cranial nerve Findings
1 Not assessed
2 Pupils round, symmetrical, equal and reacting to light
Direct and consensual reflexes present
Acute vision
Visual field not assessed, fundoscopy not done

3, 4 and 6 Normal eye movements, no lid ptosis

5 Reacts to stimulus and able to chew
7 No facial asymmetry
Smiling
8 Did not assess but patient was able to hear
10 and 9 Able to speak and drink
11 Shrugs shoulders to pain, able to turn head
12 Normal tongue movements
Upper and lower limb examination
Lower limbs Upper limbs

Inspection Normal positioning, no tremors, No tremors, fasciculation or

fasciculation or asymmetry asymmetry
Tone Normal Normal

Power 5/5 5/5

Reflexes Normal Normal

Sensation Crude touch and pain sensations Crude touch and pain sensation
present present

Coordination Could not assess Could not assess

Gait Could walk unaided N/A

Respiratory examination
• Normal shape, no scarification
• Equal chest expansion, no tracheal deviation
• Resonant percussion notes
• Vesicular breath sounds, no crackles
Cardiovascular examination
• No hyperactive precordium, no scarification
• Apex beat at 5th intercostal space, midclavicular line
on the left
• No heaves or thrills
• Normal heart sounds S1+S2+0
Gastrointestinal examination
• Flat no obvious masses
• Non tender
• No hepatosplenomegaly
• No palpable masses
• No shifting dullness
• No renal angle tenderness
• Normal bowel sounds
Summary
• L.M, 30 year old male PLWHIV on 13A and
cotrimoxazole with poor compliance who presented
with 1 day history of confusion and 2 day history of
malaise with a background of two weeks non
productive cough. On examination he was confused
with GCS of 14/15, no meningitic features with the
rest of the examination nonremarkable
Problem list
Subjective Objective
1. Confusion 1. Low GCS
2. Cough
2. Poor compliance to ART
3. Headache
4. photophobia
5. Pleuritic chest pain
6. Vomiting
7. Fever
8. Malaise
9. PLWHIV
Differential diagnosis
1. Meningitis
• Bacterial (Streptococcus Pneumoniae , Salmonella spp, Neisseria Meningitidis, Hemophilus
influenzae)
• TB Meningitis
• Cryptococcal meningitis
2. Advanced HIV disease
• Disseminated TB
• Cryptococcemia
• Pneumocystis Jirovecii
3. Severe community acquired pneumonia
• Streptococcus pneumoniae
• Hemophilus influenza
• Atypical causes: Mycopasma pneumonia, staphylococcus aureus
• Rule out hypoglycemia
Investigations
• CSF analysis: microscopy, gram • Blood culture
stain, CrAg, India ink, Xpert • CD4 count
MTB/RIF
• Urine LAM
• Random blood glucose
• Chest x-ray
• Serum CrAg
• FASH
• Urea electrolytes and creatinine
• Liver function tests
Results
1. Random blood glucose: 114mg/dL
2. CD4 count: 37 C/μL
3. Urine LAM: Negative
4. Serum CrAG: Negative
Results
4.Renal function tests
• Urea: 15.1mg/dL
• Creatinine 0.87mg/dL
Full blood count
MEASURE RESULT NORMAL RANGE UNITS
WBC 4.06 3.39-8.86 *10^3 microliters
HB 11.8 11.1-14.7 g/dL
MCV 86.6 71-95 femtoliters
RDW-SD 50.4 38-50
PLT 373 150-450 *10^3 microliters
RBC 4.33 3.91-5.31
NEU 2.99 1.5-5
LYMPH 0.44 1.05-2.55
MONO 0.61 0.22-0.63
PDW 8.9 9.7-15.1 femtoliters
Liver function tests
Measure Result Range
AST 29.68U/L 0-50
ALT 7.6U/L 0-37
ALP 81.3 U/L 30-126
GGT 25.23 U/L 0-40
Albumin 4.0 mg/dL 3.5-5.5
Total protein 8.3 mg/dL 6-8
Direct bilirubin 0.18 mg/dL 0-1.4
Total bilirubin 0.38 mg/dL 0-1.4
CSF ANALYSIS
MEASURE RESULT NORMAL
On sample collection clear, subjective high
opening pressure
White cell count 93 (0-5) 10∧6/L
Polymorphs 26 (0-100)%
Lymphocytes 74 (0-100)%
Red blood cells 3
CSF glucose 1.6 (2.22-3.88) mmol/L
Protein 1.86 (0.15-0.4)g/L
Cryptococcal antigen Negative
India ink Negative
Xpert MTB/RIF NOT DONE
Chest x-ray
Management
Initial management
• Ceftriaxone 2g IV BD
• Paracetamol 1g po QID
• Admit to ward 3B
In the ward
• TB meningitis:
• 2months RHZE then 7 months RH
• Prednisolone 60mg PO od 1 month, taper off 25% over 4 weeks
• Pyridoxine 25mg po OD
• Presumptive bacterial meningitis
• Ceftriaxone 2g IV BD
• ART re-initiation and adherence counselling
• Advice to family
• Any household member who is coughing should be screened for TB
• Screen all contacts under 5 years of age
Update 25/02/2024
• Vital signs
• Respiratory rate: 24bpm
• Oxygen saturation: 93% on room air
• Heart rate: 103 bpm
• Blood pressure: 141/94 mmHg
• Temperature: 37.8°C
• Patient had deteriorated to GCS of 11/15
• E=4,V=2,M=5
• Patient not eating, plan for nasogastric tube
Learning point:
Learning point: The use of steroids in
treatment of TBM in PLWHIV
• Corticosteroids reduce inflammation by inhibiting the
synthesis of inflammatory cytokines and stabilizing the
blood-brain barrier
• The mortality and morbidity observed in TBM are due to
an inflammatory process set off by the M. tuberculosis in
the CNS and resultant dysregulated host immune
response
• Mortality from TBM is up to 70% among PLWHIV and up
to 40% in people without HIV
Learning point: The use of steroids in
treatment of TBM in PLWHIV
• Adjunctive corticosteroids have been shown to reduce death by
~40% but not disability in TBM overall
• The survival benefit of glucocorticoids in HIV-TBM co-infection,
however, is less certain
• However, (pending further studies), there is possibility of a small
reduction in mortality that has not been excluded by previous
RCT with no significant added side effects which justifies the use
of corticosteroids for patients with TBM and HIV infection given
the long term mortality and long-term disability associated with
this condition
Learning point: The use of steroids in
treatment of TBM in PLWHIV
• The incidence of IRIS during the first 6 months is the
same between patients treated with adjuvant
glucorticosteroids and those not treated with
adjuvant glucorticosteroids
• WHO recommends 6-8 weeks of adjuvant
glucocorticoid therapy for patients with TBM
suspected or confirmed in patients with and without
HIV infection
References
1. Sarah Kimuda, Derrick Kasozi, Suzan Namombwe,
Jane Gakuru, Timothy Mugabi, Enock Kagimu et al
(2023) Advancing Diagnosis and Treatment in
People Living with HIV and Tuberculosis Meningitis.
Current HIV/AIDS Reports (2023) 20:379–393.
https://doi.org/10.1007/s11904-023-00678-6
2. https://www.uptodate.com/contents/central-nervo
us-system-tuberculosis-treatment-and-prognosis
(Accessed on 25/02/2024
THANK YOU