Patient's question:
Half-year problem description: High fever that doesn't break, Coma,.........................Doctor's answer:
Hello:(1) General Treatment
Early-stage cases should be hospitalized for treatment, with bed rest, and supplied with nutrient-rich foods high in vitamins (A, D, C) and protein. For comatose patients, feeding should be administered via nasogastric tube. If swallowing is possible, oral feeding can be attempted. The ward should be ventilated and disinfected regularly to maintain fresh air and good lighting. Attention should be paid to eye, nose, and oral care, turning the patient regularly to prevent the occurrence of varicose veins and pulmonary venous stasis.
(2) Anti-Tuberculosis Treatment
Anti-tuberculosis drugs should be selected to have strong penetration and high cerebrospinal fluid concentration. During treatment, toxic and side effects should be monitored, and drugs with the same side effects should be avoided as much as possible. The commonly used combination regimens include:
① Isoniazid, streptomycin, and ethambutol, or para-aminosalicylic acid;
② Isoniazid, rifampicin, and streptomycin;
③ Isoniazid, rifampicin, and ethambutol.
Specific dosages, methods, and treatment durations are shown in Table 8-4.
(3) Use of Adrenal Cortex Hormones
Adrenal cortex hormones can inhibit inflammatory responses and have an anti-fibrotic effect. They can reduce arteriolar, thereby rapidly alleviating toxic symptoms and meningeal irritation. They can lower intracranial pressure, reduce cerebral edema, and prevent spinal canal obstruction. They serve as an effective adjuvant treatment for anti-tuberculosis drugs. Early use generally yields better results. Prednisone can be administered orally at a dose of 1–2 mg/kg daily for a course of 6–12 weeks, with gradual tapering and discontinuation 4–6 weeks after improvement. Alternatively, dexamethasone can be administered intravenously in divided doses at a dose of 0.25–1 mg/kg daily. During the acute phase, hydrocortisone can be administered intravenously at a dose of 5–10 mg/kg for 3–5 days, followed by a switch to oral prednisone.
(4) Symptomatic Treatment
1. Increased Intracranial Pressure
(1) 20% mannitol at 5–10 ml/kg administered rapidly intravenously; if necessary, repeat every 4–6 hours. 50% glucose at 2–4 ml/kg can be administered intravenously alternately with mannitol.
(2) Acetazolamide at 20–40 mg/kg, divided into 2–3 doses, for 3 days, followed by a 4-day break.
(3) If necessary, cerebrospinal fluid drainage can be performed, with a daily maximum of 200 ml, continuing for 2–3 weeks.
2. High Fever and Seizures
Refer to the following chapter for treatment.
3. In cases of vomiting, insufficient intake, and cerebral hyponatremia, adequate water and sodium supplementation should be provided.
(5) Intrathecal Medication
For late-stage severe cases with high intracranial pressure, severe hydrocephalus, spinal canal obstruction, or persistently low cerebrospinal fluid glucose or high protein levels, intrathecal injection can be considered. Before administering medication, an equal volume of cerebrospinal fluid should be drained. The commonly used medication is dexamethasone:
- Under 2 years old: 0.25–0.5 mg per dose
- Over 2 years old: 0.5–5 mg per dose
Diluted with saline to 5 ml. Administered slowly intrathecally, once every other day. After improvement, reduce to once weekly. A course of 7–14 injections is recommended. Long-term use is not advisable.
Isoniazid can penetrate the cerebrospinal fluid effectively to reach therapeutic concentrations, so it is generally not used for intrathecal injection. However, it may still be used for severe late-stage cases, at a dose of 25–50 mg per dose, once every other day, for a course of 7–14 injections, followed by discontinuation after improvement.