Patient's question:
Half-year problem description: High fever not subsiding, drowsiness,.........................Doctor's answer:
Hello:(1) General Treatment
Early cases should be hospitalized for treatment, with bed rest, and provided with nutrient-rich foods containing high vitamins (A, D, C) and high 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 hemorrhoids and pulmonary atelectasis.
(2) Anti-Tuberculosis Treatment
Anti-tuberculosis drugs should be selected based on strong penetration and high cerebrospinal fluid concentration. During treatment, toxic and adverse reactions should be monitored, and the combination of drugs with similar toxic effects should be avoided as much as possible. Currently, 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 detailed in Table 8-4.
(3) Use of Corticosteroids
Corticosteroids can suppress inflammatory responses, inhibit fibrous tissue formation, reduce arteriolar, thereby rapidly alleviating toxic symptoms and meningeal irritation. They can lower intracranial pressure, reduce cerebral edema, and prevent spinal canal obstruction, serving as an effective adjuvant therapy 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 clinical improvement. Alternatively, dexamethasone can be administered intravenously in divided doses at a dose of 0.25–1 mg/kg daily. During acute phases, 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 rest period.
(3) If needed, cerebrospinal fluid drainage can be performed, with a daily maximum of 200 ml, continuing for 2–3 weeks.
2. High Fever and Seizures
Treat according to the procedures in the following chapter.
3. Hypertonic Hyponatremia Due to Vomiting or Insufficient Intake
Sufficient water and sodium supplements should be administered.
(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 administration, an equal volume of cerebrospinal fluid should be drained. The commonly used medication is dexamethasone:
- Under 2 years: 0.25–0.5 mg per dose;
- Over 2 years: 0.5–5 mg per dose.
Dilute with saline to 5 ml and administer slowly intrathecally, once every other day. After clinical 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 intrathecal injection is generally unnecessary. 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.