TB Meningitis

9/29/2009 Morning Report

Maggie Davis Hovda
Incidence
2005: In the US there were 186 cases of
meningeal TB, which accounted for 6.3% of
all extrapulmonary TB
In NC, there were 5 cases, 6.9%
2007: In the US, there were 170 cases of
meningeal TB, again 6.3% of cases
In NC, there were 5 cases, 6.9%
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, meningitis is more of an adult disease.
Pathogenesis
TB Bacillemia (primary or late reactivation)
subependymal tubercles rupture into
the subarachnoid space meningitis

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

neuropathology.neoucom.edu
Tuberculous Meningitis. Donald and Shoerman,
NEJM. 351:17. 10/21/2004
Clinical Presentation
3 Stages
1 - Pts lucid at presentation w/o focal neuro signs
or hydrocephalus; prodromal, lasts 2-3 wks and
characterized by insidious onset of malaise, HA,
low-grade fever
2 Meningitic phase w/ meningismus, V,
lethargy, confusion, CN palsies, hemiparesis
3 Paralytic phase advance to stupor, coma,
seizure, hemiparesis.
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
Diagnosis
Other Studies
Brain imaging demonstrates hydrocephalus,
basilar exudates and inflammation,
tuberculoma, cerebral edema, cerebral infarction
CXR
Abnormal, sometimes miliary pattern

Differential Diagnosis
Fungal Meningitis
Crypto, Histo, Blasto, Cocci
Viral meningoencephalitis HSV, mumps
Parameningeal Infection
Sphenoid sinusitis, brain abscess, spinal epidural abscess
Incompletely treated Bacterial meningitis
Neurosynphilis
Neoplastic Meningitis Lymphoma
Neurosarcoid
Neurobrucellosis
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,
Rifampin, Pyrazinamide, and Ethambutol or
Streptomycin for 2 months
Continuation Phase: Isoniazid and Rifampin for
another 7 10 months
Treatment: Adjunctive Therapy
Glucocorticoids Indicated with:
rapid progression from one stage to the next
elevated OP on LP, 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
TB Meningitis in HIV population
Study in S Africa compared 20 HIV + pts vs. 17 HIV - pts
Similar findings in both groups:
Presentation: HA, neck stiffness, fever
CSF analysis: Similar amounts of lymphocytes, neutrophils,
protein, glucose, ADA levels
Outcomes predicted by GCS score upon admission
-Differences
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 - pts
Outcomes
Overall Poor
Pts presenting in Stage I have 19% mortality
Pts presenting in Stage III have 69% mortality
Only 1/3 - 1/2 of patients demonstrate complete
neurologic recovery
Up to 1/3 of patients have residual severe
neurologic deficits such as hemiparesis,
blindness, seizure DO
References
http://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table2
7.pdf
Donald, PR and Schoerman, JF. Tuberculous Meningitis.
NEJM, 351:17. 2004.
Schutte, CM. Clincial, Cerebrospinal Fluid and Pathological
Findings and Outcomes in HIV-Positive and HIV-negative
Patients with Tuberculous Meningitis. Infection 2001: 29:
213-217.
Jacob, H et al. Acute Forms of Tuberculosis in Adults. The
American Journal of Medicine (2009) 122, 12-17.
Principles and Practice of Infectious Diseases. 4th Ed, c
1995.
Central Nervous System Tuberculosis. www.uptodate.com