TUBERCULOUS MENINGITIS

Dr. Steven, M.Si.Med, Sp.S

§ Commonest manifestation of tuberculous
infection of the nervous system
§ In children : TB milier à bacteraemia à
meningitis
§ In adult :
- occur many years after the primary
infection
- Following bacteraemia, metastatic foci of
infection lodge in: meninges, cerebral or
spinal tissue, choroid plexus
- Rupture à into the subarachnoid space
(spontaneously or impaired immunity)
 Clinical features

Stage 1 (early) Stage 2 (intermediate) Stage 3 (advanced)

Non-specific symtoms Confusion Coma
- Fever (in 80%) Cranial nerve pares is
Meningism
- Lethargy
Vasculitis à Hemiparesis
Ataxia
Dysarthria

Staging is useful for predicting outcome

§ Seizures may occur at the onset
§ Involuntary movement (chorea, Myoclonus)
occur in 10%
§ Arachnoidit is inflammatory exudate may result in
hydrocephalus
Investigations
§ General : anaemia, leucocytosis, hyponatraemia
(if inappropriate ADH)
§ Cerebrospinal f luid
§ Xanthocrome, pellicle (+)
§ Cell count is elevated, predominant ly
lymphocytes
§ Glucose is depressed (<50% blood sugar)
§ Protein elevated
§ Culture for M. tuberculosis (50
(50--80% +)
§ PCR
§ Tuberculin skin t est
Positive in 50% of cases
§ Chest x-x-ray
infiltrate / cavitation / effusion / scar
§ Ct scan and MRI (+ contrast)
Hydrocephalus,
basal meningeal thickening,
infarct, oedema, tuberculoma
 Treatment
§ Recomemended treatment programme:
Normal regime:

INH (300 mg daily) INH

2 months
Rifampicin (600 mg daily) Rifampicin 6 months
PZA (15-30 mg/kg daily)

Drug resistance suspected due to previous antituberculous

therapy, eg: - developing countries
- history of previous inf ection
àAdd a fourth drug – streptomycin (1 g daily) or ethambutol
(25 mg/kg daily)
 Antiturberculous Drug Penetrati on to CSF

Drug Inflamed Non Inflamed

• Streptomicin Good Poor
• INH Good Good
• Rifampicin Good Poor
• Pyrazinamid Good Good
• Ethionamid Good Good
• Cycloserin Good Good
• Ethambutol Good Poor
§ Side effects:
- INH – peripheral neuropathy à pyridoxine 50
mg daily
- Ethambutol – optic atrophy
- Streptomysin – 8th cranial nerve damage
- All antituberculous drugs à nausea, vomiting,
abnormal liver function and skin rashes
Steroid tend to be given when :
- conscious level declines
- neurological sign progress
- Spinal block develops