A 20-year-old patient complains of a severe headache, double vision, weakness, fever, irritability. Objectively: body temperature is 38.1°C, the patient is reluctant to contact, sensitive to stimuli. There are ptosis of the left eyelid, exotropia, anisocoria S>D, and pronounced meningeal syndrome. On lumbar puncture the cerebrospinal fluid flowed out under a pressure of 300 mm Hg, the fluid is clear, slightly opalescent. 24 hours later there appeared a fibrin film. Protein - 1.4 g/L, lymphocytes - 600 per me, glucose - 0.3 mmol/L. What is the provisional diagnosis?

Answer options

1. Mumps meningitis
2. Tuberculous meningitis
3. Lymphocytic (Armstrong's) meningitis
4. Meningococcal meningitis
5. Syphilitic meningitis

Explanation

A 20-year-old patient complains of severe headache, double vision, weakness, fever, irritability. Objectively: body temperature is 38,1C the patient is reluctant to contact, sensitive to stimuli. There are ptosis of the left eyelid, exotropia, anisocoria S>D, pronounced meningeal syndrome. On lumbar puncture the cerebrospinal fluid flowed out under a pressure of 300 mm Hg, the fluid is clear, slightly opalescent. 24 hours later there appeared fibrin film. Protein – 1,4 g/l, lymphocytes – 600/mm 3 sugar – 0,3 mmol/l. What is the provisional diagnosis?A. Tuberculous meningitis is also known as TB meningitis or tubercular meningitis. Tuberculous meningitis is Mycobacterium tuberculosis infection of the meninges -the system of membranes that envelop the central nervous system. It cannot be diagnosed or excluded based on clinical findings. The typical CSF abnormalities in patients with TB meningitis are: raised intracranial pressure, raised CSF protein, lymphocytosis, low CSF glucose. B. Meningococcal meningitis belongs to purulent bacterial meningitis and is characterized by a cloudy (whitish-yellow) character of the cerebrospinal fluid, neutrophils (80-100%) predominate from 1-50 thousand to 10-15 thousand cells in mm3, protein content 0.8-16.0 g/l, sugar content reduced to 0.3-0.4 g/l, characterized by the formation of a coarse fibrinous film, often in the form of a precipitate. C. Armstrong’s lymphocytic meningitis is characterized by anisoreflexia (asymmetry of the expression of tendon and/or skin reflexes from both sides of the body), pyramidal signs, accommodation disorder. Cerebrospinal fluid analysis: a clear character of the cerebrospinal fluid, lymphocyte character (up to 95%) 100- 1500 in 1mm3, the protein content is 0.3-0.8 g/l, the sugar content is normal, the formation of a fibrinous film on the surface of the CSF is not typical. D. Syphilitic meningitis (spinal cord, neurosyphilis), which often occurs with secondary recurrence of syphilis, it is characterized by such changes in cerebrospinal fluid: clear, slight pleocytosis is noted, lymphocytes predominate, from 200 to 1000 in 1 mm3, the amount of protein is normal. E. Epidemic mumps can be classified as serious viral meningitis, which is sometimes characterized by damage to the facial and auditory nerves, ataxia, hyperkinesis, parotitis, CSF analysis: clear, first mixed cytosis, then lymphocyte, 100-1500 mm3, protein content 0.33-1,0 g/l, the glucose level within the normal range, the formation of a fibrinous film on the surface of the CSF occurs in 3-5% of cases. Considered CSF abnormalities in this patient, such as opalescent clear cerebrospinal fluid, raised intracranial pressure, raised CSF protein, lymphocytosis, low CSF glucose, appeared fibrin film, it could be concluded final diagnosis tuberculosis meningitis.