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TUBERCULOUS MENINGITIS

ICHWAN SAPTA HADI


NUR AHMAD THABRI

INTERNAL MEDICINE DEPARTMENT OF


MEDICAL FACULTY HASANUDDIN

INTRODUCTION
Meningitis is a clinical condition
characterized inflammation of meninges in
the central nervous system.
Menigitis can be caused by bacteria,
viruses, fungi, parasites, and noninfectious causes.
Tuberculous meningitis (TBM) is caused by
Mycobacterium tuberculosis and is the
most common form of central nervous
system (CNS) tuberculosis (TB).

EPIDEMIOLOGY
In worldwide, 8.8 million new TB cases
every year until 2010, of which 1.45
million died.
India, China, Indonesia, Nigeria and South
Africa have the most number of cases.
Prevalence is high 206 from 100.000
population
10 % TB patients also have CNS TB, most
commonly meningitis.

EPIDEMIOLOGY
TB Meningitis has high morbidity and
mortality.
Increased mortality and neurological
sequels caused by delaying in
diagnosis and treatment.

CLINICAL MANIFESTATION
The modified British Medical Research Council clinical
criteria for TM severity grades
Grade I

PATHOPHYSIOLOGY
1836

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

DIAGNOSIS

DIAGNOSIS
Symptom (proportion of patients affected)
Headache (5080%)
Fever (6095%)
Vomiting (3060%)
Photophobia (510%)
Anorexia (6080%)
Clinical sign (proportion of patients affected)
Neck stiffness (4080%)
Confusion (1030%)
Coma (3060%)
Any cranial nerve palsy (3050%)
Cranial nerve III palsy (515%)
Cranial nerve VI palsy (3040%)
Cranial nerve VII palsy (1020%)
Hemiparesis (1020%)
Paraparesis (510%)
Seizures (children: 50%; adults: 5%)
CSF (proportion or range)
Appearance (8090% clear)
Opening pressure (50% 25 cm H20)
Total leucocyte count (51000 x 103/ml)
Neutrophils (1070%)
Lymphocyte (3090%)
Protein (45250 mg/dL)*
Lactate (510 mmol/L)
CSF glucose to blood glucose ratio (<0,5 in 95%)

DIAGNOSIS

RADIOLOGY

LABORATORIUM
A. Lumbal Punction analysis CSF
Can Found Pleositosis dominated with
lymphocite cell, protein increase, low
glucose, lactat increase. AFB and
culture Mycobacterium tuberculosis.

B. XPERT/MTB-RIF
Recent meta-analysis calculated that
commercial nucleic acid amplification
(NAA) assays for the diagnosis of TBM
were 56% sensitive and 98% specific can
confirm cerebral tuberculosis, but cannot
rule it out.

Box A (risk factor in CNS TB)


- HIV atau imunocompromise

Box B (Common symptoms/signs of TBM)


- Insidious onset of fever

Suspect
Suspect TBM
TBM ifif risk
risk factor
factor for
for
CNS
TB
(Box
A)
and
symptoms
CNS TB (Box A) and symptoms
dan
dan signs
signs (Box
(Box B)
B)

- Born and live in high prevalence country


-Recent contact with Pulmonary TB (especially
children)

-Neurological abnormality
-Headache
-Vomiting/poor feeding
-Weight loss
-Irritability/lethargy
-Seizure (more in children)
-Confusing/coma
-Neck Stiffness
-Cranial nerve palsy
-Hemiparesis

Immediate Investigations
CXR
CT head ( with contrast) **
FBC, RF, LFT, electrolyte,
CRP, ESR
Blood culture*
HIV test

Box C (features strongly suggestive of


TBM))
- > 5 days of symptomps
-WBC in blood < 15 x 109/L
-WBC in CSF (5-750/mm3)
-CSF neutrophil < 90 %
-CSF glukosa < 50 % plasma
-Imaging evidence of : Basal meningeal
enhancement, Hydrocephalus, cerebral
infarction.

Box D (Lumbal puncture)


- CSF microscopy, culture and sensitivity
-Protein
-Glucose ( pair CSF and blood)
-Semar and culture for AFB
-PCR for mycobacteria
-Test for cryptococcus if HIV Positive

Lumbal puncture
Microbiology Lab
Take > 6 ml CSF for
mycobacterial studies (box
D)

No
AFB seen or PCR
positif in CSF
Are 2 or more of the following
pressent?
pressent? (consider
(consider repeating
repeating LP)
LP)
1 risk factor for CNS TB (Box A)

33 features
features suggestive
suggestive of
of TBM
TBM
(Box
(Box C)
C)
Evidence of TB elsewhere

No
Repeat LP within 48
hours
Expand search for TB
elsewhere
Consider MRI head

Yes

Are
Are 22 or
or more
more of
of the
the following
following
pressent? (consider repeating LP)
1 risk factor for CNS TB (Box A)

33 features
features suggestive
suggestive of
of TBM
TBM
(Box
(Box C)
C)
Evidence of TB elsewhere

No

Yes

Start
Start treatment
treatment

Yes

Yes
Does
Does patient
patient have
have unexplain
unexplain
meningitis,
meningitis, with
with low
low CSF
CSF
glucose,
glucose, falling
falling GCS,
GCS, or
or new
new
focal
focal neurology?
neurology?

Continue
Continue to
to investigate
investigate
with
with low
low threshold
threshold
empirical
empirical therapy
therapy

No

TREATMENT
ANTI TB agent

TREATMENT
Recomendation anti TB agent for TBM

TREATMENT
Corticosteroid therapy

Box A Risk assessment for


MDR TB

Decision
Decision
for
for start
start
treatment
treatment
for
for TBM
TBM

High Risk
1. Known MDR contact
2. Likely infected in E Eropa,
old Soviet union, or S Afrika
3 Failed or failing treatment (ie.
never responded)

Risk
Risk
Assesment
Assesment
MDR
MDR TB
TB
(Box
(Box A)
A)

Medium Risk
1. Previously treated treated for
TB
2. HIV infected

Box B. Standard initial


therapy for adults
Isoniazid 300 mg od
Rifampicin 450 mg/600 mg
od
Pyrazinamid 1500/2000 mg
od
Ethambutol 15 mg/kgbb/hari

Std
Std therapy
therapy
anti
anti TB
TB and
and
Steroid
Steroid (box
(box
B
B dan
dan D)
D)

Yes
No

High risk
for MDR
TB?

Yes

Review after
8weeks

TB culture
positif?

Yes

TB sensitivity
result available?

No

Fully sensitifve

Yes
No

Konsul
Konsul
neurologist
neurologist dan
dan
ahli
ahli Meningitis
Meningitis
TB
TB

Apply MDR
infection
control
procedure

Yes

Change
Change to
to std
std
continuation
continuation
treatment
(
Box
treatment ( Box
C
C dan
dan E)
E)

Plan
Plan to
to stop
stop
treatment
treatment at
at
52
52 weeks
weeks

Testing for genotype


evidence of drug
resistant, contact
MDR TB expert

Box F. Treatment for patients with


infection resistant to isoniazid or
rifampicin

Yes

Good response
to treatment?

Box E Standard continuation


tehrapy for children
Isoniazid 10-20 mg/kgbb/day (max
500 mg)
Rifampicin 10-20 mg/kgbb/day
(max 600 mg)

Evidence
of PTB on
CXR

No

No coma and focal sign


Dexametason 0,3
mg/kgbb/day, max 24 mg
Steroid withdrawn over 6
weeks
Coma and focal sign
Dexametason 0,4
mg/kgbb/day, max 24 mg
Steroid withdrawn over 8
weeks

Box C. Standard continuation


tehrapy for adults
Isoniazid 300 mg od
Rifampicin 450 mg/600 mg od

Box D Standar initial therapy for


children
Isoniazid 10-20 mg/kgbb/day (max 500 mg)
Rifampicin 10-20 mg/kgbb/day (max 600
mg)
Pyrazinamid 30-50 mg/kgbb/day (max 2 g)
Ethambutol 15-20 mg/kgbb/day (max 1 g)
Prednisolon 4 mg/kgbb/day

No

Change
Change to
to non
non
std
std continuation
continuation
treatment(
Box
treatment( Box
F)
F)

Isoniazid monoresisten
- Add quinolon at initial phase of
treatment
-Continuation therapy with rifampicin,
pyrazinamid, and fluorquinolon
-Planned treatment course of 12 months
-In case of oreganism with low level
resistance to isoniazid consider
continuing isoniazid throughout.
Rifampicin monoresisten
-Substitue quinolon for rifampicin in
initial phase of treatment
-Continuation treatment with isoniazid,
pyrazinamide, and fluorquinolon
-Planned treatment course of 18 months
Resistant with Isoniazid and
Rifampicin
- Consult MDR TB expert

Ventriculoperitoneal shunt

Endoscopic third ventriculostomy

PROGNOSIS
Prognosis TBM time presentation,
neurologic status, and time to initial
treatment. TBM has high morbidity and
mortality, 7-65%.
Delayed in diagnosis and treatment will
increase mortality and neurologic sequele.

SUMMARY
TBM has high morbidity and mortality.
Clinical manifestation varies individually.
Pathophysiology of TBM, caused by hematogenous
spreading of tuberculous bacili, and formation of multiple
tuberculous nodules in the meningeal blood-vessels ,
discharge of tuberculous bacilli in the subarachnoid space,
and diffuse exsudative inflamation in the meninges .
Diagnosis TBM can work up with clinical score,
laboratorium and radiology.
Management TBM give anti tuberkulosis agent,
cortikosteroid, and surgery if there hydrocephalus and
probably increase patient outcome.
Poor Prognosis if delayed in diagnosis and treatment.

THANK YOU