A case of tuberculosis meningitis found in waist-hard joint anesthesia

The patient, male, 87 years old, urethra difficulties with abnormal kidney function for 11 years, leg trauma more than 1 month, to "chronic kidney disease 5, right femur neck fracture" admitted to the hospitalImprove related examinations: X-rays show fractureof the right femur neck; biochemical and hemostatic semaglunoininin90mol/L, hemoglobin 61g/L, C-reactive protein 67mg/L; chest CT shows chronicinfection of right lung, left upper lunglesions, tuberculosis cannot be ruled out; ECG shows normal range; heart ultrasound main artery valve, two-tip valve closed not fully accompanied by anti-flow blood(patients with a slightly indifferent mind, call to respond, family members complain edifying their history of intermittent fever, denying thehistory ofchronic diseases such ashigh blood pressureanddiabetes, denying the history of cardiovascularcardiovascular diseases, and the pathological signs of the nervous systemAfter admission to the hospital anti-inflammatory, atomization, blood transfusion treatment 1 week later, multidisciplinary consultation, the patient's lung inflammation, anemia and kidney function improved, ready for waist-hard joint anesthesia downward right femoral bone replacement, at the same time before surgery 1d againhemodialysisdialysis treatmentsurgery on the morning of the day to review the blood clotting index is normal, the operation is normal, the normal operation, after entering the room routine electrocardiogram monitoring, arterial puncture tube, there is blood pressure monitoring, arterial blood gas analysis shows Hb93g/L, PCO2 41mmHg, PO2 72mmHg Right-hand lying L2-3 gap line vertebral tube puncture, puncture smooth, lumbar hemp needle through the cobweb membrane, back to see the yellow green cerebrospinal fluid, then draw out 3 ml of cerebrospinal fluid sent to check, exit puncture needle, tell the patient to lie flat emergency cerebrospinal fluid test results: micro-turret, Pan test positive, cerebrospinal fluid protein 38 453.8 mg/L, cerebrospinal fluid glucose 5.76mmol/L, suspected infection exist, surgery suspended The results of bacterial culture of cerebrospinal fluid in patients with 7d show tuberculosis meningitis The patient's surgical condition is stable and the surgical treatment is not considered for the time being in consultation with the family discussion the development of elderly patients with tuberculosis meningitis and the body's immune reduction has a certain correlation Older patients are more likely to miss misdiagnosis than in middle-aged tb meningitis patients Analysis of the cause: (1) some patients with seuple The incidence of tuberculosis meningitis in old age is mainly acute or subacute, accounting for 74.19%, this case of this non-chronic, non-hidden incidence is easy to mislead clinical practitioners to diagnose its viral meningitis, septic meningitis (2) provide sexist differences between the patient's actual medical history By carefully asking patients about their medical history, most elderly patients with tuberculosis meningitis provide a medical history shorter than their actual duration of the disease, or some patients can not even provide a rough time of onset, easy to affect the of clinical physicians on the disease diagnosis , leading to the misdiagnosis of elderly tuberculosis meningitis (3) is associated with underlying diseases Elderly patients are prone to combined coronary atherosclerotic heart disease, hypertension , chronic bronchitis, diabetes and other patients concurrent typical clinical symptoms of these diseases, will make physicians ignore the diagnosis of other diseases such as geriatric tuberculosis meningitis in addition to the physiological and pathological causes of elderly patients, in recent years, the abuse of antibiotic leads to more atypical clinical symptoms of geriatric cohorting, and the rate of misdiagnosis is increased This case patients without nausea, vomiting and neck strength, a little indifference, has been considering with the elderly, kidney failure, language communication disorders related, intermittent fever consideration and lung infection and lower limb trauma related, and preoperative chest CT has been indicated that nodules can not be ruled out, if combined with clinical, please consult the relevant departments may be found as soon as possible, for the associated disease more, complex old patients should be systematic, serious visits Puncture site infection is a taboo in the intravertebral tube anesthesia, systemic infection patients with careful use of intravertebral anesthesia central nervous system diseases, especially spinal cord or spinal neuropathy, after anesthesia may be long-term paralysis, suspected intracranial hypertension should be listed as taboo It has been reported that the intracranial pressure increase signs in patients with tuberculosis meningitis are obvious, and symptoms and signs such as spinal nerve stimulation or spinal cord compression, spinal blockage, etc can occur Therefore, surgery in such patients is recommended to avoid intravertebral anesthesia, can consider nerve block or full hemp summarized this case, tuberculosis meningitis is a serious central nervous system infectious disease, due to early clinical characteristics and cerebrospinal fluid changes are not typical, the pathogen detection rate is low, so in the diagnosis of tuberculosis meningitis, the patient's clinical performance, cerebrospinal fluid-related indicators, head imaging examination and the existence of extracranial tuberculosis, etc For patients with non-nervous system tb clinical manifestations, such as chronic long-term low fever, chest imaging show can not exclude TB, TB bacteria (PPD) test positive, it is recommended to walk a walking head CT or even cerebrospinal fluid test, reduce the rate of missed diagnosis the idea of early diagnostic anti-TB treatment for people suspected of TB meningitis is worthy of promotion Elderly patients are prone to misdiagnosis of tuberculosis meningitis due to different onset of disease, inaccurate collection of medical history, many associated underlying diseases, misleading imaging results and other reasons Remind the first thing in the anesthesia to emphasize comprehensive and detailed preoperative visit consultation, surgical clinical work to fully grasp the diagnosis of tuberculosis meningitis and differential diagnosis, especially for some special multi-incidence elderly patients, should be carefully asked about the medical history, seriously do a good job of physical examination, anesthesia at all times to maintain a high degree of vigilance, ready to deal with emergencies