Recently, the incidence of pulmonary and extrapulmonary tuberculosis has been increasing due to the dilution of tuberculosis control and the emergence of refractory tuberculosis. Tuberculous meningitis in extrapulmonary tuberculosis is characterized by non-seasonality, history of tuberculosis or exposure, slow onset, long duration, predominantly meningeal irritation, mild impaired consciousness, and either high or low fever. Cerebrospinal fluid chloride and sugar are reduced, protein is significantly increased, leukocytosis, mainly lymphocytes, cerebrospinal fluid film smear and culture can detect Mycobacterium tuberculosis, positive nodulin test, X-ray chest film can sometimes find tuberculosis lesions. “Fever and coma” can be one of the symptoms of many diseases (such as infection by other intracranial pathogens, encephalopathy of systemic diseases, etc.). Therefore, a clear diagnosis is essential at this time. Lumbar cerebrospinal fluid examination, cranial CT scan and other relevant biochemical routine tests can be performed at the Department of Neurology of the local hospital at the county level or above. Once the diagnosis of tuberculous meningitis is confirmed treatment.
(a) General treatment should be hospitalized
Bed rest, supply nutritious food with high vitamins (A, D, C) and high protein, nasal feeding for coma, try feeding if you can swallow. The room should be regularly ventilated and disinfected, and the air in the room should be fresh and well-lit. Pay attention to eye, nose and mouth care, turning, and prevent the occurrence of hemorrhoids and pulmonary stasis.
(B) anti-tuberculosis treatment anti-tuberculosis drugs should be chosen with high penetration
The bactericidal agent with high cerebrospinal fluid concentration should be observed during treatment, and the combination of drugs with the same toxic side effects should be avoided as far as possible. At present, the commonly used combination program is as follows
(1) Isoniazid, streptomycin and ethambutol or p-aminosalicylic acid;
②Isoniazid, rifampicin and streptomycin;
(3) Isoniazid, rifampicin and ethambutol. (The specific usage, dosage and treatment course are in the hands of the specialist).
(c) Application of adrenocorticosteroids adrenocorticosteroids can inhibit inflammatory response
It can reduce endarteritis, thereby rapidly reducing symptoms of poisoning and meningeal irritation; it can lower brain pressure, reduce cerebral edema and prevent obstruction of the spinal canal. It is an effective adjunctive therapy to anti-tuberculosis drugs. Generally early application is more effective. Prednisone can be used 1~2mg/kg per day orally for 6~12 weeks, and the drug can be gradually reduced and stopped 4~6 weeks after the condition improves. Or use dexamethasone 0,25-1mg/kg per day in tranquilization. In the acute stage, hydrocodisone can be used 5-10mg/kg per day for 3-5 days and then changed to prednisone orally.
(IV) Symptomatic treatment
1. Increased cerebral pressure
(1) 20% mannitol 5-10ml/kg rapid intravenous injection, once every 4-6 hours if necessary, 50% glucose 2-4ml/kg sedation, alternating with mannitol.
(2) Acetazolamide 20-40mg/kg daily in 2-3 doses for 3 days and stop for 4 days.
(3) If necessary, ventricular puncture drainage, not more than 200ml per day for 2-3 weeks.
2.High fever and convulsions are treated according to the latter chapter.
(3) Due to vomiting, insufficient intake, cerebral hyponatremia should be supplemented with the required water and sodium.
(E) Intrathecal medication and other treatments
In conclusion, the prognosis of tuberculous meningitis has greatly improved in recent years due to the improvement of diagnostic methods and the development and continuous improvement of chemotherapy protocols. Early and reasonable treatment can lead to complete cure.
The criteria for its cure are.
① Clinical symptoms and signs completely disappear, and there are no sequelae.
② Normal cerebrospinal examination.
(3) No recurrence after two years of follow-up observation after the course of treatment. If the diagnosis is not timely, the treatment is not reasonable, or the child is too young or the lesion is too serious, there is still a high mortality rate (15-36%). In the course of treatment follow-up, recurrence cases are found, and the prognosis can still be improved with reasonable treatment.