Beruflich Dokumente
Kultur Dokumente
Meningitis,
diagnosis
and
Ahmad Rizal
Department
of Neurology
treatment
Hasan Sadikin Hospital
Bandung
TBM, introduction
The most severe extrapulmonary TB
Diagnosis remains difficult
Early recognition is crucial for better
outcome
High mortality rate; sequalae in survivors
Optimal treatment has not been
established
HIV increases, TBM increases
92.5%
82.5%
90%
Diagnostic algorithms
Diagnostic categories
Diagnostic algorithms
Diagnostic categories
Ogawa (1987)
Thwaites (2005)
Diagnostic categories
Ogawa (1987)
Thwaites (2005)
Definite TBM:
Clinical meningitis
and
Abnormal CSF parameters
and
Acid-fast bacilli in CSF (microscopy) and/or
culture positive for M. tuberculosis
Diagnostic categories
Ogawa (1987)
Thwaites (2005)
Probable TBM:
Clinical meningitis
and
Abnormal CSF parameters
and
At least 1 of the following:
Suspected active pulmonary tuberculosis (chest
radiography)
AFB found in any sample other than from the CSF
Diagnostic algorithms
Diagnostic categories
Thwaites (2005)
Possible TBM:
Clinical meningitis
and
Abnormal CSF parameters
and
At least 4 of the following:
History of tuberculosis
MN predominance in the CSF
Illness of > 5 days in duration
CSF:blood glucose ratio < 0.5
Altered consciousness
Yellow (xanthochromic) CSF
Focal neurological signs
Grade II
GCS 10 14 + focal neurological deficit
OR
GCS 15 with focal neurological deficit
Grade III
GCS < 10 with or without focal
neurological deficit
TBM, diagnostics
What is expected
Reliable
Easy access
Easy to be done
TBM, treatment
Optimal TBM treatment has not
been established in clinical trials
Same drug
Different pharmacokinetics
Various guidelines
Intensive phase of 4 drugs (RHZ+S or E
or ethionamide)
Continuation phase of 2 drugs (RH)
Treatment duration 9 12 months
TBM
Cryptococcal meningitis
Co-administration of ART
and OAT
HIV infection significantly
complicates the treatment of TB
Co-administration of ART
and OAT
Recommended guideline
CD4 > 100:
ART starts after 2 months of OAT
HIV-associated TBM
Thwaites et al (JID, 2005)
96 HIV-infected and 432 HIV-uninfected
patients
No difference in clinical presentation
HIV ~ more EPTB
No differences in relapses or adverse
events
HIV reduces survival rates
HIV-positive
(n=41)
HIV-negative
(n=111)
27 (65.9%)
96 (86.5%)
123 (80.9%)
Definite TBM
59
66
Probable TBM
20
37
57
12 (29.3%)
1 (0.9%)
13 (8.6%)
10 (9%)
10 (6.6%)
2 (4.8%)
4 (3.6%)
6 (3.9%)
Diagnosis
Tuberculous meningitis
Cryptococcal meningitis
Probable bacterial meningitis
Unknown cause
Alive
(n=91)
28 / 61 (45.9)
13 / 91 (14.3)
33 / 55 (60)
27/89 (30.3)
Fever on presentation*
27/56 (48.2)
25/86 (29.1)
35 (57.4)
37 (40.7)
30 (49.2)
45 (49.4)
32/56 (57.1)
39/88 (44.3)
41/57 (71.9)
61/89 (68.5)
30/49 (61.2)
64/87 (73.6)
Characteristics
HIV positive**
** p<0.01; * p<0.05
Crude
Odds Ratio
(95% CI)
HIV positive
5.09 (2.35-11.03)
3.44 (1.70-6.96)
2.45 (1.13-5.29)
2.54 (1.10-5.84)
Fever on presentation
2.27 (1.13-4.58)
.63 (.29-1.35)
.59 (.26-1.36)
1.96 (1.02-3.79)
1.52 (.71-3.25)
1.74 (.76-3.96)
.99 (.52-1.89)
1.68 (.85-3.29)
1.71 (.57-2.44)
.57 (.27-1.20)
6.26 (2.50-15.72)
HIV-negative
HIV-positive
days
Conclusion
Clinical meningitis with abnormal CSF
pattern, and supporting evidence of
extraneural TB significant for
diagnosis
Diagnostics: Lab! volume is
important for positive CSF result
Treatment ~ other EPTB: different PK
Give adjunctive corticosteroid
Conclusion
Influence of HIV in the development of
TBM anticipated burden to health
system
HIV dramatically decreases the survival
rate of TBM patients
High prevalence of HIV HIV
screening to any meningitis case
High mortality rate warrants further
studies