Tuberculous meningitis: Difference between revisions
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= Definition = |
== Definition == |
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* Meningeal infection by ''Mycobacterium tuberculosis'' |
* Meningeal infection by ''Mycobacterium tuberculosis'' |
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= Classification = |
== Classification == |
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* Stage 1: normal level of consciousness, no focal neurological deficits |
* Stage 1: normal level of consciousness, no focal neurological deficits |
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* Stage 3: seizures, comatose |
* Stage 3: seizures, comatose |
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= Epidemiology = |
== Epidemiology == |
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* About 1% of TB cases in Canada |
* About 1% of TB cases in Canada |
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= Differential Diagnosis = |
== Differential Diagnosis == |
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* Fungal meningitis |
* Fungal meningitis |
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* Neoplasm |
* Neoplasm |
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= Risk Factors = |
== Risk Factors == |
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* Young |
* Young |
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* Previous TB |
* Previous TB |
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= Presentation = |
== Presentation == |
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== History == |
=== History === |
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* Prodrome (1-3 weeks) |
* Prodrome (1-3 weeks) |
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* Seizures |
* Seizures |
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== Physical Exam == |
=== Physical Exam === |
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* Meningeal symptoms |
* Meningeal symptoms |
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* Confusion, coma |
* Confusion, coma |
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= Investigations = |
== Investigations == |
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* Lumbar puncture |
* Lumbar puncture |
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* CT head |
* CT head |
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= Management = |
== Management == |
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* Rule out neoplasm and fungus, then start empiric treatment |
* Rule out neoplasm and fungus, then start empiric treatment |
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** High risk of IRIS |
** High risk of IRIS |
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= Prognosis = |
== Prognosis == |
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* Depends on stage at presentation |
* Depends on stage at presentation |
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Revision as of 15:31, 17 August 2019
Definition
- Meningeal infection by Mycobacterium tuberculosis
Classification
- Stage 1: normal level of consciousness, no focal neurological deficits
- Stage 2: decreased level of counsciousness, significant focal neurological deficits
- Stage 3: seizures, comatose
Epidemiology
- About 1% of TB cases in Canada
Differential Diagnosis
- Fungal meningitis
- Sarcoidosis
- Neoplasm
Risk Factors
- Young
- Female
- Originally from endemic country
- Previous TB
Presentation
History
- Prodrome (1-3 weeks)
- Personality changes
- Low-grade fever
- Malaise
- Weight loss
- Gradual onset of worsening headache
- Headache
- Fevers
- Vomiting
- Confusion
- Personality changes
- Photophobia (only 5-10%)
- Seizures
Physical Exam
- Meningeal symptoms
- Fevers
- Vomiting
- Meningismus
- Focal neurological deficits
- Cranial nerve palsies in VI, III, and IV
- Hemiplegia, paraplegia
- Urinary retention
- Confusion, coma
Investigations
- Lumbar puncture
- Increased lymphocytes, decreased glucose, and increased protein
- Need 3-5mL of CSF for culture
- May need serial LPs
- CT head
Management
- Rule out neoplasm and fungus, then start empiric treatment
- HIV test (delay antiretrovirals by 8 weeks, though)
- Standard HREZ x2mo then HR x7-10mo
- Can replace ethambutol with a fluoroquinolone
- Dexamethasone 3mg po qid x2wk then taper over 6-8wks
- High risk of IRIS
Prognosis
- Depends on stage at presentation
- Mortality is high
- Stage 1: 10-20%
- Stage 2: 20-40%
- Stage 3: 60%
- Morbidity is high, with about 20% of patient being left with significant neurological sequelae
- Mental retardation
- Psychiatric disorders
- Seizures
- Blindness
- Deafness
- Ophthalmoplegia
- Hemiparesis
References
- ^ GE Thwaites, TTH Chau, K Stepniewska, NH Phu, LV Chuong, DX Sinh, NJ White, CM Parry, JJ Farrar. Diagnosis of adult tuberculous meningitis by use of clinical and laboratory features. The Lancet. 2002;360(9342):1287-1292. doi:10.1016/s0140-6736(02)11318-3.
