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TB Meningitis

9/29/2009 Morning Report Maggie Davis Hovda

there were 5 cases.Incidence  2005: In the US there were 186 cases of meningeal TB. which accounted for 6.3% of all extrapulmonary TB  In NC. 6. 6.9% . again 6.9%  2007: In the US.3% of cases  In NC. there were 170 cases of meningeal TB. there were 5 cases.

meningitis is more of an adult disease.Incidence  In underdeveloped countries with higher overall incidence of TB. . TB meningitis is more of a pediatric disease whereas in developed countries with lower incidence of TB.

Pathogenesis  TB Bacillemia (primary or late reactivation)  subependymal tubercles  rupture into the subarachnoid space  meningitis .

hemiplegia.Pathogenesis  Dense gelatinous exudate develops at the base of the brain  surround arteries and CN at the base of the brain  hydrocephalus. vasculitis  infarction. quadriplegia .

edu .Tuberculous Meningitis. Donald and Shoerman.neoucom. 10/21/2004 neuropathology. 351:17. NEJM.

HA. coma. hemiparesis. low-grade fever 2 – Meningitic phase w/ meningismus. lethargy.Pts lucid at presentation w/o focal neuro signs or hydrocephalus. lasts 2-3 wks and characterized by insidious onset of malaise.Clinical Presentation  3 Stages    1 . V. . prodromal. hemiparesis 3 – Paralytic phase – advance to stupor. CN palsies. confusion. seizure.

Clinical Presentation  Most common clinical findings:       Fever HA Vomiting Nuchal Rigidity AMS CN Palsies. esp CN III .

Diagnosis  CSF Examination  Usually lymphocytic pleocytosis  Paradoxic change from lymphocytic to neutrophilic predominance over 48 hr pathognomonic for TB meningitis    Elevated protein with severely depressed glucose Repeated specimens for AFB culture necessary ADA level .

tuberculoma. sometimes miliary pattern  CXR  . cerebral infarction Abnormal.Diagnosis  Other Studies  Brain imaging – demonstrates hydrocephalus. basilar exudates and inflammation. cerebral edema.

brain abscess. spinal epidural abscess   Incompletely treated Bacterial meningitis Neurosynphilis Neoplastic Meningitis – Lymphoma Neurosarcoid Neurobrucellosis . mumps Parameningeal Infection  Sphenoid sinusitis. Cocci Viral meningoencephalitis – HSV. Blasto. Histo.Differential Diagnosis       Fungal Meningitis  Crypto.

Pyrazinamide. Rifampin.Treatment: Antimicrobial Therapy   Start as soon as there is suspicion for TB meningitis Same Guidelines as those for pulmonary TB   Intensive Phase: 4 drug regimen of Isoniazid. and Ethambutol or Streptomycin for 2 months Continuation Phase: Isoniazid and Rifampin for another 7 – 10 months .

CT evidence of cerebral edema worsening clinical signs after starting antiTb meds increased basilar enhancement. or moderate to advancing hydrocephalus on head CT   Glucocorticoid Dosing: Dexamethasone 12 mg/d x 3 weeks followed by a slow taper Surgery: Ventriculostomy placement .Treatment: Adjunctive Therapy  Glucocorticoids Indicated with:     rapid progression from one stage to the next elevated OP on LP.

17 HIV . glucose.pts Similar findings in both groups:    Presentation: HA. neck stiffness.TB Meningitis in HIV population   Study in S Africa compared 20 HIV + pts vs. ADA levels Outcomes predicted by GCS score upon admission Both groups showed same incidence of abnormal Head CT. but HIV + more likely to have ventricular dilatation and infarct HIV + patients were more likely to suffer no neurologic deficit on discharge than HIV . neutrophils.pts  -Differences   . fever CSF analysis: Similar amounts of lymphocytes. protein.

seizure DO .Outcomes      Overall Poor Pts presenting in Stage I have 19% mortality Pts presenting in Stage III have 69% mortality Only 1/3 . blindness.1/2 of patients demonstrate complete neurologic recovery Up to 1/3 of patients have residual severe neurologic deficits such as hemiparesis.

JF. c 1995. Principles and Practice of Infectious Diseases. The American Journal of Medicine (2009) 122. Acute Forms of Tuberculosis in Adults. Tuberculous Meningitis. Clincial. Schutte. 351:17. www. CM.uptodate. H et al.gov/TB/statistics/reports/surv2005/PDF/table2 7. 12-17.References       http://www. Jacob. Central Nervous System Tuberculosis.pdf Donald. 4th Ed.com . Infection 2001: 29: 213-217. NEJM.cdc. PR and Schoerman. 2004. Cerebrospinal Fluid and Pathological Findings and Outcomes in HIV-Positive and HIV-negative Patients with Tuberculous Meningitis.