Fig.\u00a01<\/b> First patient\u2019s head computed tomography: A<\/b> ventriculitis and communicans hydrocephalus. B<\/b> subfalcine herniation to the left<\/p>\n The second patient was a 27-year-old Indonesian woman, primigravida, referred to our ICU with a chief complaint of seizures 3 days prior to admission with a high fever. The patient once experienced a seizure while she was sleeping; the preictal was unknown. During the seizure, the patient\u2019s eye and head were slightly moving to the left, along with her left hand and left foot also convulsing; the patient was unconscious during the seizure, which lasted for 2 minutes, and 3 hours after the seizure, the patient had an altered mental status and was initially treated in the ICU in another hospital before she was referred to the ICU of Cipto Mangunkusumo Hospital.<\/p>\n During physical examination in the ICU, the patient was sedated and intubated with a Glasgow coma scale of E2M4VT. Oxygen saturation was 93\u2013100% on a ventilator with FiO2 40%. There were clubbed fingers, as well as an increase in physiological reflex on the right side, positive nuchal rigidity, and positive Babinski reflex on the right side. Peripheral blood laboratory revealed leukocytosis of 1706\u2009\u00d7\u2009109\/L. Head CT scan revealed diffuse brain swelling (Fig.\u00a02<\/a>). Cerebrospinal fluid analysis for leukocytes and protein was elevated and glucose levels were decreased, indicating bacterial meningitis. The cerebrospinal fluid culture showed no growth of microorganisms. The patient had a weakly positive antinuclear antibody (ANA) test, a weakly positive lupus anticoagulant test, and an anti-ds-DNA 2.4 test result.<\/p>\n Fig.\u00a02<\/b> Second patient\u2019s head CT: A<\/b> hypodense lesion on the subcortical frontotemporoparietooccipital left lobe and B<\/b> frontal right lobe<\/p>\n The patient received vancomycin (500\u00a0mg every 6\u00a0hours, intravenous), meropenem (2\u00a0g every 8\u00a0hours, intravenous) for empirical therapy for 14\u00a0days and also dexamethasone (20 g every 24\u00a0hours, intravenous). The patient stayed in the ICU for 34\u00a0days. The patient\u2019s condition deteriorated throughout the second week of treatment; she had altered mental status to E1M3VT. After a few days, the intracranial infection condition resolved. The fetus was in good condition, and there were no indications of termination of pregnancy, although due to prolonged hospitalization the patient also had ventilator-associated pneumonia (VAP) and had to be tracheostomized to hasten ventilator weaning, and had a complication of pneumothorax after tracheostomy. After 3 days on a chest tube, on day\u00a032, the patient was able to be on spontaneous breathing trial (SBT), and on day\u00a034 she was discharged from the ICU.<\/p>\n The third case was a 19-year-old Indonesian woman, multigravida, referred to our ICU with chief complaint of loss of consciousness 1 week before admission. For 1 week prior to admission, the patient had been unable to communicate or respond to inquiries clearly. This was followed by involuntary movement of the right arm and drooping of the right eyelid. There had been a fever 2 weeks prior to admission and a headache 6 months prior to admission.<\/p>\n During the physical examination, the patient was sedated with a Glasgow coma scale of 9\u00a0T. Blood pressure was 185\/80\u00a0mmHg, with an irregular heart rate of 92\u00a0beats per minute, and saturation was 99% on a ventilator with FiO2 40%. Pupils were anisocoric (2\u00a0mm\/6\u00a0mm, slow reactive\/nonreactive). Nuchal rigidity was positive, with left eye\u2019s nervus III paresis, ophthalmoparesis of the left eye, bilateral proptosis, and bilateral positive Babinski reflexes. On the extremities, there were clubbed fingers and left-sided hemiparesis. Obstetric examinations were normal.<\/p>\n Laboratory results indicated leukocytosis of 1074\u2009\u00d7\u2009109\/L. Cerebrospinal fluid analysis for leukocytes and protein were elevated, and glucose levels were decreased, indicating bacterial meningitis. The cerebrospinal fluid test revealed negative acid-fast bacilli, and the cerebrospinal fluid culture revealed no growth of microorganisms. Head CT scan revealed hydrocephalus and basal enhancement (Fig.\u00a03<\/a>). The patient was treated for meningoencephalitis tuberculosis (METB) with antituberculosis medication, including isoniazid (300\u00a0mg every 24\u00a0hours, orally), rifampicin (450\u00a0mg every 24\u00a0hours, orally), ethambutol (1000\u00a0mg every 24\u00a0hours, orally), and meropenem (2\u00a0g every 8\u00a0hours, intravenous), as well as adjunctive therapy with dexamethasone (20\u00a0mg every 24\u00a0hours, intravenous). The patient additionally had a ventriculoperitoneal (VP) shunt to treat the hydrocephalus. On day 12, the patient had drug-induced liver injury (DILI). Her hepatic enzyme levels rose more than tenfold, from aspartate aminotransferase (AST) 74 U\/L and alanine aminotransferase (ALT) 80 U\/L to AST 1580 U\/L and ALT 1698 U\/L due to the antituberculosis regimen. Isoniazid and rifampicin were stopped on day\u00a013 due to elevated liver enzymes, and were switched for a modified antituberculosis medication, which includes levofloxacin (750\u00a0mg every 24\u00a0hours, intravenous), streptomycin (1\u00a0g every 24\u00a0hours, intravenous) and ethambutol (1 g every 24\u00a0hours, orally). On day\u00a016, the patient\u2019s condition improved, and she was discharged to the ward. However, on the next day (day\u00a017), the patient was readmitted to the ICU due to a seizure and septic shock. The patient\u2019s condition deteriorated, and the fetus was identified as IUFD on obstetric ultrasonography. This was later suspected to have caused sepsis due to intraabdominal infection due to the IUFD. The fetus was spontaneously delivered and evacuated on day\u00a023 of hospitalization. Rifampicin was reintroduced on day\u00a034, and isoniazid and pyrazinamide were reintroduced on day\u00a038. In the following days after the spontaneous delivery, the level of consciousness remained compromised and the seizure progressed to an epileptic state. The intensivist consented to elevate the antituberculosis drug dose for the meningitis. The patient\u2019s condition improved in the following days. Unfortunately, the patient was left with sequelae, including left-sided hemiparesis. On day\u00a056, the patient was discharged from the ICU (Table\u00a01<\/a>).<\/p>\n![\"figure](\"https:\/\/www.europesays.com\/ie\/wp-content\/uploads\/2025\/10\/13256_2025_5534_Fig1_HTML.jpg\")
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