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TB Meningitis

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

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TB Meningitis

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  1. TB Meningitis 9/29/2009 Morning Report Maggie Davis Hovda

  2. 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%

  3. 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.

  4. Pathogenesis • TB Bacillemia (primary or late reactivation)  subependymal tubercles  rupture into the subarachnoid space  meningitis

  5. 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

  6. Tuberculous Meningitis. Donald and Shoerman, NEJM. 351:17. 10/21/2004 neuropathology.neoucom.edu

  7. 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.

  8. Clinical Presentation • Most common clinical findings: • Fever • HA • Vomiting • Nuchal Rigidity • AMS • CN Palsies, esp CN III

  9. 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

  10. Diagnosis • Other Studies • Brain imaging – demonstrates hydrocephalus, basilar exudates and inflammation, tuberculoma, cerebral edema, cerebral infarction • CXR • Abnormal, sometimes miliary pattern

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. References • http://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.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

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