Targeted Six-Week Intensive Physiotherapy for a Case of Tuberculous Meningitis With a Syndrome of Inappropriate Antidiuretic Hormone Secretion

Tuberculous meningitis (TBM) is a severe form of extrapulmonary tuberculosis (TB) characterized by the invasion of Mycobacterium tuberculosis into the meninges surrounding the brain and spinal cord. It triggers an intense inflammatory response, leading to neurological complications if not promptly and adequately managed. TBM often precipitates muscle weakness, neurological deficits, respiratory challenges, swallowing difficulties, joint contractures, and pain. Physiotherapy intervention is essential in treating these problems by personalized treatment strategies and treatment plans to enhance muscle strength, motor control, coordination, and overall mobility. This case report aims to highlight the significant role of physiotherapy in improving the quality of life (QOL) and functional abilities of patients with TBM. The current case report reviews the case of a 73-year-old male who presented with complaints of generalized weakness and difficulty in swallowing. The patient had a history of fever for the last six months. Magnetic resonance imaging (MRI) and high-resolution computed tomography (HRCT) diagnosed the case as TBM with miliary TB. Six weeks of targeted intensive rehabilitation program was designed according to the patient's impairments initiated from the intensive care unit (ICU) phase. The main goals of physiotherapy were to start early bed mobility, maintain joint integrity, improve postural strength and swallowing, and make the patient independent in transfer and activities of daily living (ADLs). After a six-week intensive physiotherapy (TIP-6) program, the patient exhibited significant improvements in muscle strength and independence in ADLs. This case highlights the critical role of physiotherapy in enhancing the QOL and functional abilities of patients with severe TB-related conditions.


Introduction
Tuberculous meningitis (TBM), miliary tuberculosis (TB), and multiple tuberculomas represent distinct yet interconnected clinical entities, each stemming from the insidious Mycobacterium tuberculosis infection.These TB manifestations reflect this pathogen's remarkable ability to disseminate through the bloodstream and lymphatic system, causing diverse clinical presentations with intricate diagnostic and therapeutic challenges [1].TBM is one of the most common and serious forms of TB in India.India has the highest burden of TB in the world, accounting for over 25% of global cases.Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a known complication of TBM, occurring in 5-30% of cases.Mycobacterium tuberculosis infiltrates the meninges around the brain and spinal cord, resulting in a severe type of extrapulmonary TB known as TBM.This invasion triggers an intense inflammatory response, leading to neurological complications if not promptly and adequately managed [2].TBM is notorious for its subtle initial symptoms, which often include fever, headache, and altered mental status, progressing to more severe manifestations such as cranial nerve deficits and focal neurological signs [3].Early diagnosis and initiation of anti-tubercular therapy are pivotal for favorable outcomes, as delays can result in significant morbidity and mortality [4].Hematogenous spread tuberculous bacilli, which spread widely throughout the body and produce multiple tiny granulomas in different organs, are the hallmarks of miliary TB.Numerous organ systems can be impacted by these minute granulomas, often known as "miliary" lesions, which cause the condition's varied clinical presentations [5].Individuals may have systemic signs that resemble other infectious or malignant processes, such as fever, weight loss, and sweats at night [6].Because of its complex clinical picture, miliary TB is often difficult to diagnose.On the other hand, multiple tuberculomas, which typically affect the brain and lungs, are localized accumulations of Mycobacterium tuberculosis within tissues or organs [7].These tuberculomas may cause localized neurological impairments or pulmonary symptoms, depending on where they are anatomically located [8].Sometimes, TBM or miliary TB coexists with multiple tuberculomas, complicating the clinical presentation and diagnostic assessment [9,10].
The ensuing cascade of events disrupts the blood-brain barrier, forms caseating granulomas, and releases pro-inflammatory cytokines, ultimately leading to neurological damage [8].TBM is diagnosed through a combination of clinical assessment and laboratory tests.Lumbar puncture is used to analyze the cerebrospinal fluid (CSF) for biochemical signs of TB infection such as low glucose, elevated proteins, and the presence of TB bacteria.Neuroimaging like computed tomography (CT) or magnetic resonance imaging (MRI) scans can reveal basilar meningeal inflammation indicative of TB infection.Microbiological tests like GeneXpert on the CSF can provide rapid evidence of TB bacteria.Evaluating for accompanying pulmonary TB through chest imaging and sputum evaluation is important for diagnosing and treating TBM.Assessing for exposure history or immunological evidence of latent TB is critical for determining if the meningeal TB represents primary infection or reactivation of old infection.Clinical findings like fevers, mental status changes, and hydrocephalus also aid diagnosis [11].Physiotherapy is crucial in the multidisciplinary approach to treating patients with TBM [12].TBM often inflicts severe neurological dysfunction in patients, causing muscle weakness, sensory disturbances, and cognitive impairments [13].In the comprehensive management of such complications, physiotherapy plays a crucial component in rehabilitation, focusing on physical aspects to restore functional independence and overall quality of life (QOL) [14].Physiotherapy uses various methods to treat patients with motor deficits, including passive and active range of motion (ROM) exercises [15].This is important because it prevents complications like joint stiffness and muscle contractures, which are frequently seen in individuals who have been immobilized.Physiotherapy aids in the restoration of mobility and functional independence by progressively increasing the ROM [5].
Moreover, physiotherapists focus on enhancing gait and balance, which are problems that individuals with neurological dysfunction often face.TBM survivors often experience challenges in walking and maintaining proper posture, making them susceptible to falls and related injuries [16].Through specialized training and exercises, physiotherapy is pivotal in helping patients achieve optimal balance and gait patterns, ultimately enhancing their overall mobility.Sensory deficits represent another neurological issue encountered by TBM patients.These deficits can significantly diminish patients' QOL.Physiotherapists employ sensory reeducation techniques to assist patients in regaining sensory perception, such as touch and proprioception.These methods are precious in reinstating normal function and reducing discomfort associated with sensory deficits [17].The main aim is to highlight the significant role of physiotherapy in improving QOL and functional abilities in a 73-year-old male diagnosed with TBM.A six-week targeted intensive rehabilitation program was initiated based on the patient's impairments.

Patient information
A 73-year-old male with right-hand dominance was admitted to the neurology intensive care unit (ICU) with complaints of generalized weakness and difficulty in swallowing.The patient had a history of recurrent fever occurring every month for the past six months and visited a private clinic where paracetamol was prescribed to him.In September, the patient's condition worsened as he started experiencing severe headaches, recurrent fever, chills, generalized weakness, and body pain.Subsequently, the patient was admitted for further evaluation.

Clinical findings
The first examination was done following the patient's and family's consent.The patient was conscious, cooperative, and well-oriented to time, place, and person.The patient's attitude of the limb was in supine lying, and the upper limb exhibited slight shoulder abduction with elbow flexion and a neutral wrist position while in a supine position.The lower limb showed external hip joint rotation, extended knee, and ankle plantarflexion.The Glasgow Coma Scale (GCS) was E4V5M6 on higher mental function evaluation.The patient was connected to external medical appliances, including a Foley catheter and a Ryles tube.On the sensory examination, the sensory functions in the upper extremities were intact, while superficial reflexes, including fine touch and pin-prick, were absent in the lower extremities.On motor examination, the muscle tone of the upper and lower extremities was normal.According to the Oxford grading system, manual muscle testing (MMT) showed 3/5 in the upper limb, which is full ROM against gravity without resistance; in the lower limb, it was 2/5, which is full ROM in gravity eliminated, shown in Table 1.Kernig's sign was positive.High-resolution CT (HRCT) of the thorax reveals diffusely scattered miliary nodules in bilateral lung parenchyma with a patch area of consolidation in the left lower lobe and mediastinal lymphadenopathymiliary TB.MRI of the brain reveals evidence of variable-sized round to oval lesions noted in the bilateral cerebral hemisphere and bilateral cerebellar hemisphere.The lesions appear hypointense on TI WI and hyperintense on T2 WI/FLAIR, showing blooming on SWI and no restriction on DWI suggestive of (s/o) partial calcification.There is the prominence of sulco-gyral space, ventricular system, Sylvian fissure, and cerebellar folia s/o age-related atrophic changes, as shown in Figure 1.

Pre-treatment
Post-treatment

FIGURE 1: MRI of the brain
The red circles show variable-sized round to oval lesions noted in the bilateral cerebral hemisphere and bilateral cerebellar hemisphere MRI: magnetic resonance imaging

Therapeutic intervention
A targeted six-week intensive physiotherapy (TIP-6) intervention was started as soon as the patient was in ICU.Table 2 shows the treatment protocol given to the patient for six weeks.Figure 2 and Figure 3 show the patient being rehabilitated.

Outcome measures
The TIP-6 was carried out for three weeks following the progression outcome measures, which showed improvement after the physiotherapy intervention.Outcome measures are mentioned in Table 3.

Discussion
In TBM, the inflammatory response often leads to muscle weakness and neurological deficits.As demonstrated by critical measurements, targeted intensive physiotherapy intervention made a significant difference in the patient's health.Initially, at 0/100, the Barthel Index increased to 40/100 after treatment, showing a substantial improvement in the patient's ability to do daily tasks without assistance.Furthermore, the Functional Outcome Swallowing Score (FOSS) improved from 3/4 to 1/4, indicating substantial progress in the patient's ability to swallow safely without the risk of aspiration.These results highlight the comprehensive impact of physiotherapy on the patient's overall well-being, encompassing gains in muscle strength, mobility, respiratory health, and ADLs.The results of this case report highlight the importance of incorporating rehabilitation programs into the management of TBM patients.Early initiation of rehabilitation, even while patients are in the ICU, can lead to improved outcomes and reduced disability.
The results align with similar studies on rehabilitating TBM patients.Suisan and Thohari presented two severe TBM cases who received a multimodal sensory stimulation program incorporating positioning, ROM exercises, and tactile and auditory stimuli during their ICU stay.After two weeks, both patients showed remarkable progress with GCS scores improving from E1V1M1 to E4V5M6, allowing transfer from ICU to high-dependency unit.The intensive early rehabilitation likely contributed to their neurological and functional improvements [18].
In a study by Wang et al., they discussed a case of an immunocompetent patient who had a brain abscess caused by TB.This patient developed problems like Gerstmann's syndrome and right-sided apraxia.However, following TB treatment and rehabilitation, the patient made a full recovery, resumed their regular activities, and even went back to work.This case highlights the importance of intensive rehabilitation, precise surgery (stereotactic surgery), and effective TB treatment when dealing with such conditions.However, after a meticulously thought-out six-week rehabilitation program, notable progress was observed, including the patient's ability to sit independently without assistance [7].

Conclusions
In this case, the patient had TBM with multiple tuberculoma with miliary TB with SIADH, and physical therapy was started when the patient was in the ICU.TIP-6 interventions improved the patient's abilities and independence while preventing respiratory and secondary complications.Total muscle strength had all improved significantly, as shown in the above scales.Physiotherapy helps the patient to enhance his ADLs and QOL.
info: All authors have declared that no financial support was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

FIGURE 2 :
FIGURE 2: Passive ROM exercise ROM: range of motion

FIGURE 3 :
FIGURE 3: Rolling facilitation Physiotherapy interventions play a pivotal role in improving muscle strength and mobility.By engaging in targeted exercises such as isometric muscle training and bodyweight squats, the patient regains muscular strength and re-establishes neural pathways.This neurological reconnection, facilitated by physiotherapy, aids in reversing muscle atrophy and promoting coordinated muscle function, ultimately countering the muscle weakness seen in TBM.Physiotherapy effectively addresses respiratory problems that may occur due to reduced lung function and weaker respiratory muscles in patients with TBM.Exercises that involve deep breathing, incentive spirometry, and other breathing methods aid in increasing lung capacity and regaining the function of the diaphragmatic muscle.Physiotherapy enhances the muscles that control breathing, increases endurance, and improves oxygen exchange.As a result, this intervention improves the patient's respiratory health in general, helping to improve oxygenation and avoiding problems such as pneumonia.Physiotherapy can help with balance and coordination problems, mobility challenges, and transfer difficulties.The exercises promote neural plasticity, allowing the patient to regain functional independence and improve overall mobility.Additionally, balance training fosters neural adaptations, enhancing stability and coordination, thus reducing the risk of falls.Physiotherapy's modifications to food textures and mealtime posture, combined with adaptive tools, help the patient improve their swallowing ability.By optimizing these aspects, physiotherapy ensures that the patient receives proper nutrition and reduces the risk of aspiration.Physiologically, these interventions enhance the coordination of swallowing muscles and reduce the chances of food or liquids entering the airway, ultimately preventing choking and improving the patient's overall nutritional status.

TABLE 2 : Targeted six-week intensive physiotherapy
DVT: deep vein thrombosis, QOL: quality of life, ROM: range of motion, PNF: proprioceptive neuromuscular facilitation, ADLs: activities of daily living

TABLE 3 : Outcome measures
ICU: intensive care unit