DefinePK

Research Objective

To present a case of a pediatric patient with tuberculous meningitis (TBM) who exhibited cerebral salt wasting (CSW) and to highlight the diagnostic challenges and management of hyponatremia in such cases.

Methodology

Case report detailing a 10-year-old female patient presenting with symptoms of TBM. Diagnostic workup included laboratory tests (serum electrolytes, osmolality, urine osmolality, urine sodium, uric acid), CT scan of the brain, and CSF analysis. GeneXpert was used for TB detection and resistance profiling. The patient's response to different management strategies was observed.

Methodology Flowchart

                        graph TD
    A["Patient Presentation: Fever, Headache, Vomiting"] --> B["Laboratory Workup"];
    B --> C["Low Serum Sodium, Low Serum Osmolality"];
    B --> D["CSF Analysis: Increased Protein, Lymphocytes"];
    B --> E["GeneXpert: Rifampicin-Resistant TB"];
    C --> F["Rule out SIADH: Fluid Restriction"];
    F -- Unresponsive --> G["Diagnosis: TBM with Cerebral Salt Wasting"];
    G --> H["Treatment: ATT, Hypertonic Saline, Fludrocortisone"];
    H --> I["Monitoring and Improvement"];
    I --> J["Discharge"];                    

Discussion

Hyponatremia in TBM can result from various factors, including SIADH and CSW, which require distinct management approaches. Differentiating between SIADH and CSW is crucial, as treatment for one can exacerbate the other. CSW is characterized by hypovolemia, hyponatremia, and inappropriately increased urine sodium and osmolality. The case highlights the importance of considering CSW in TBM patients with hyponatremia, especially when fluid restriction is ineffective. Fludrocortisone is a key treatment for CSW.

Key Findings

The patient presented with fever, headache, and vomiting, along with hyponatremia (serum sodium 128 mEq/l) and low serum osmolality. CSF analysis showed increased protein and lymphocytes. GeneXpert detected rifampicin-resistant Mycobacterium tuberculosis. Despite initial attempts to manage hyponatremia with fluid restriction (to rule out SIADH), the patient remained unresponsive. Diagnosis of TBM with cerebral salt wasting was made. Treatment with anti-tuberculous therapy (ATT), 3% hypertonic saline, and fludrocortisone led to improvement in serum sodium levels and clinical condition.

Conclusion

This case underscores the diagnostic complexities of hyponatremia in pediatric tuberculous meningitis, particularly the manifestation of cerebral salt wasting. The successful management with a tailored approach, including ATT, hypertonic saline, and mineralocorticoids, emphasizes the need for adaptable treatment strategies in managing multifaceted complications.

Fact Check

1. Patient Age: The patient was a 10-year-old female. (Confirmed in text)
2. Initial Serum Sodium: The patient's serum sodium level on admission was 128 mEq/l. (Confirmed in text)
3. GeneXpert Result: GeneXpert detected rifampicin-resistant Mycobacterium tuberculosis. (Confirmed in text)

Mind Map