A 4-year-old girl is brought to the emergency department due to fever and lethargy. Her parents say she has been withdrawn and less playful over the last 2 weeks. She has also had several days of low-grade fever and headaches. Since yesterday morning, the patient has mostly slept and seems to be increasingly confused. She has no significant prior medical problems and is up to date with recommended vaccinations. Her grandfather, who is visiting the family from South Asia, is being evaluated for cough; otherwise, the patient has no sick contacts. The family has a pet cat. Temperature is 38 C (100.4 F). The patient is somnolent and responds to painful stimuli. There is resistance to passive neck flexion. Her right eye is deviated medially, and funduscopic examination reveals several ill-defined, raised, yellow-white nodules near the bilateral optic discs. CT scan of the head reveals basilar meningeal enhancement. Lumbar puncture is performed, and cerebrospinal fluid analysis results are as follows: The patient's cerebrospinal fluid samples are sent for acid-fast bacilli staining and culture. The parents note that the patient's grandfather also tested positive for sputum acid-fast bacilli. Which of the following is most accurate about the management of this child?

Question

A 4-year-old girl is brought to the emergency department due to fever and lethargy.  Her parents say she has been withdrawn and less playful over the last 2 weeks.  She has also had several days of low-grade fever and headaches.  Since yesterday morning, the patient has mostly slept and seems to be increasingly confused.  She has no significant prior medical problems and is up to date with recommended vaccinations.  Her grandfather, who is visiting the family from South Asia, is being evaluated for cough; otherwise, the patient has no sick contacts.  The family has a pet cat.  Temperature is 38 C (100.4 F).  The patient is somnolent and responds to painful stimuli.  There is resistance to passive neck flexion.  Her right eye is deviated medially, and funduscopic examination reveals several ill-defined, raised, yellow-white nodules near the bilateral optic discs.  CT scan of the head reveals basilar meningeal enhancement.  Lumbar puncture is performed, and cerebrospinal fluid analysis results are as follows:  The patient's cerebrospinal fluid samples are sent for acid-fast bacilli staining and culture.  The parents note that the patient's grandfather also tested positive for sputum acid-fast bacilli.  Which of the following is most accurate about the management of this child?

Quizplus · Accepted Answer

Explanation: This patient with acid-fast bacilli in her cerebrospinal fluid (CSF) has tuberculous meningitis. Prolonged treatment is required with 2 months of 4-drug therapy (isoniazid, rifampin, pyrazinamide, and either a fluoroquinolone or injectable aminoglycoside), followed by 9-12 months of continuation therapy (isoniazid plus rifampin) (Choice E). As antitubercular treatment can result in a transient worsening of central nervous system inflammation, patients with tuberculous meningitis are typically given 8 weeks of adjuvant glucocorticoid therapy (dexamethasone or prednisone). This significantly reduces morbidity and mortality. (Choice B) Patients should be initiated on antitubercular treatment and glucocorticoids as soon as tuberculous meningitis is strongly suspected (eg, basilar enhancement, characteristic CSF findings). Delaying for bacterial confirmation, which often takes several days, increases the risk of morbidity. (Choice C) Isoniazid, rifampin, and pyrazinamide are all bactericidal with good CSF penetration; intrathecal medications are not required. (Choice D) Tuberculous meningitis is associated with a high risk of long-term neurologic sequelae. Prompt treatment reduces this risk, but many patients have permanent neurologic damage. Educational objective: Patients with suspected tuberculous meningitis should be initiated on treatment prior to bacteriologic confirmation. Treatment involves 2 months of 4-drug therapy with isoniazid, rifampin, pyrazinamide, and either a fluoroquinolone or injectable aminoglycoside, followed by 9-12 months of continuation therapy with isoniazid plus rifampin. Patients should also receive adjuvant glucocorticoids to reduce treatment-associated central nervous system inflammation.

A 4-Year-Old Girl Is Brought to the Emergency Department Due