STAGING OF TBM

TBM is classified into 3 stages according to the British Medical Research

Council (MRC) criteria
Stage I: Prodromal phase with no definite neurologic symptoms.
Non-specific prodrome of malaise, weight loss, low-grade
fever, and gradual onset of headache over 1–2 weeks
Stage II: Signs of meningeal irritation with slight or no clouding of
sensorium and minor (cranial nerve palsy) or no neurological
deficit. Worsening headache, vomiting, variable degrees of
neck stiffness; cranial nerve palsies (VI>III>IV>VII)
Stage III: Severe clouding of sensorium, convulsions, focal
neurological deficit and involuntary movements.
INVESTIGATIONS: CSF ANALYSIS
• Predominantly lymphocytic pleocytosis, with increased
proteins and low CSF/ blood glucose ratio.
• CSF protein (> 150 mg/dl) should always raise the
suspicion of tuberculosis or fungal infection, rarely seen in
viral meningitis.
• Repeat CSF frequently shows a falling glucose level, a
rising protein concentration and a shift to mononuclear
predominance.
• PCR more widely used, sensitivity 80%, 10% false
positive rate
 INVESTIGATIONS: IMAGING
• CT/ MRI confirm the presence and extent of basal arachnoiditis,
cerebral oedema, infarction, ventriculitis and hydrocephalus.
• Abnormalities depend upon stage of disease:
I (normal in 30%), II (Normal in 10%), III (Abnormal in all).
• Hydrocephalus (70-85%), basal meningeal enhancement (40%),
infarction (15-30%), tuberculoma (5-10%).
• Precontrast hyperdensity in basal cisterns is the most specific
radiological sign.
• The triad of hydrocephalus, infarct, and basal meningeal enhancement
make up the CT imaging features of TBM
 DIAGNOSTIC CRITERIA FOR TBM
Class Definition
Definite Acid-fast bacilli seen in the cerebrospinal fluid.
Probable Patients with one or more of the following:
i. Suspected active pulmonary TB on chest radiography.
ii. AFB found in any specimen other than the CSF.
iii. Clinical evidence of extrapulmonary tuberculosis.
Possible Patients with at least four of the following:
i. History of tuberculosis.
ii. Predominance of lymphoytes in the cerebrospinal fluid.
iii. A duration of illness of more than six days.
iv. A ratio of CSF glucose to plasma glucose of less than 0.5.
v. Altered consciousness
vi. Turbid cerebrospinal fluid.
vii. Focal neurologic signs.

Thwaites GE et al. Diagnosis of adult tuberculosis meningitis by use of clinical and laboratory features.
Lancet 2002; 360: 1287-92.