1 / 16

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

lysandra-bullock
Download Presentation

TB Meningitis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related