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
 Tuberculous Meningitis. Donald and Shoerman,
NEJM. 351:17. 10/21/2004

neuropathology.neoucom.edu
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