9.29.09 Davis-Hovda TB Meningitis

8/11/2019 9.29.09 Davis-Hovda TB Meningitis

1/16

TB Meningitis9/29/2009 Morning Report

Maggie Davis Hovda


2/16

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%


3/16

Incidence

In underdeveloped countries with higher

overall incidence of TB, TB meningitis is

more of a pediatric disease whereas indeveloped countries with lower incidence of

TB, meningitis is more of an adult disease.


4/16

Pathogenesis

TB Bacillemia (primary or late reactivation)

subependymal tubercles rupture into

the subarachnoid space

meningitis


5/16

Pathogenesis

Dense gelatinous exudate develops at the

base of the brain surround arteries and

CN at the base of the brain

hydrocephalus, vasculitisinfarction,

hemiplegia, quadriplegia


6/16

neuropathology.neoucom.edu

Tuberculous Meningitis. Donald and Shoerman,

NEJM. 351:17. 10/21/2004


7/16

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.


8/16

Clinical Presentation

Most common clinical findings:

Fever

HA Vomiting

Nuchal Rigidity

AMS

CN Palsies, esp CN III


9/16

Diagnosis

CSF Examination

Usually lymphocytic pleocytosis

Paradoxic change from lymphocytic to neutrophilicpredominance over 48 hr pathognomonic for TB

meningitis

Elevated protein with severely depressed

glucose Repeated specimens for AFB culture necessary

ADA level


10/16

Diagnosis

Other Studies

Brain imaging demonstrates hydrocephalus,

basi lar exudates and inf lammation,

tuberculoma, cerebral edema, cerebral infarction

CXR

Abnormal, sometimes miliary pattern


11/16

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


12/16

Treatment: Antimicrobial Therapy

Start as soon as there is suspicion for TBmeningitis

Same Guidelines as those for pulmonaryTB Intensive Phase: 4 drug regimen of Isoniazid,

Rifampin, Pyrazinamide, and Ethambutol orStreptomycin for 2 months

Continuation Phase: Isoniazid and Rifampin foranother 7 10 months


13/16

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


14/16

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, butHIV + more likely to have ventricular dilatation and infarct

HIV + patients were more likely to suffer no neurologic deficit ondischarge than HIV - pts


15/16

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


16/16

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 PathologicalFindings and Outcomes in HIV-Positive and HIV-negativePatients with Tuberculous Meningitis. Infection 2001: 29:213-217.

Jacob, H et al. Acute Forms of Tuberculosis in Adults. TheAmerican Journal of Medicine (2009) 122, 12-17.

Principles and Practice of Infectious Diseases. 4th Ed, c1995.

Central Nervous System Tuberculosis. www.uptodate.com
http://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdfhttp://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdfhttp://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdfhttp://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdf

9.29.09 Davis-Hovda TB Meningitis

Documents

Transcript of 9.29.09 Davis-Hovda TB Meningitis