Tuberculous meningitis: Difference between revisions
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* High mortality, often needs empiric treatment even before confirmed diagnosis |
* High mortality, often needs empiric treatment even before confirmed diagnosis |
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== |
== Background == |
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=== 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 2: decreased level of counsciousness, significant focal neurological deficits |
* Stage 2: decreased level of counsciousness, significant 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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* Sarcoidosis |
* Sarcoidosis |
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* Neoplasm |
* Neoplasm |
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== Risk Factors == |
=== Risk Factors === |
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* Young |
* Young |
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* Female |
* Female |
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* Previous TB |
* Previous TB |
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== Presentation == |
== Clinical Presentation == |
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=== History === |
=== History === |
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=== Physical Exam === |
=== Physical Exam === |
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* Meningeal symptoms |
* Meningeal symptoms |
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* Fevers |
* Fevers |
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== Investigations == |
== Investigations == |
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* Lumbar puncture |
* Lumbar puncture |
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** Increased lymphocytes, decreased glucose, and increased protein |
** Increased lymphocytes, decreased glucose, and increased protein |
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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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* HIV test (delay antiretrovirals by 8 weeks, though) |
* HIV test (delay antiretrovirals by 8 weeks, though) |
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== Prognosis == |
== Prognosis == |
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* Depends on stage at presentation |
* Depends on stage at presentation |
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* Mortality is high |
* Mortality is high |
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Revision as of 00:54, 21 January 2020
- Meningeal infection by Mycobacterium tuberculosis
- High mortality, often needs empiric treatment even before confirmed diagnosis
Background
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
Clinical 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.
