Tuberculous meningitis: Difference between revisions
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*Confusion, coma |
*Confusion, coma |
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− | === |
+ | ===Thwaites Index=== |
− | * |
+ | *Used to differentiate bacterial from tuberculous meningitis in adults before results of CSF culture are available[[CiteRef::thwaites2002di]] |
− | * |
+ | *Tuberculous more likely if score ≤4; bacterial more likely if score ≥5 |
− | ** |
+ | **Sensitivity 86% and specificity 79% |
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+ | === Complications and Prognosis === |
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+ | **Mental retardation, psychiatric disorders, [[seizure]], blindness, deafness, ophthalmoplegia, hemiparesis |
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*[[Fungal meningitis]] |
*[[Fungal meningitis]] |
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*[[Sarcoidosis]] |
*[[Sarcoidosis]] |
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*[[Neoplasm]] |
*[[Neoplasm]] |
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+ | *Other causes of [[chronic meningitis]] |
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==Investigations== |
==Investigations== |
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*CT head |
*CT head |
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− | == |
+ | ==Diagnosis== |
− | * |
+ | *Gold standard is mycobacterial culture (71% sensitive, 100% specific) |
− | ** |
+ | **Sensitivity increases with volume and number of samples |
− | * |
+ | *Microscopy for acid-fast bacilli is 20-80% sensitive and 100% specific |
− | * |
+ | *PCR is 85-95% sensitive and 98% specific |
− | ** |
+ | **Used to confirm but not exclude the diagnosis |
==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 [[HIV medications|antiretrovirals]] by 8 weeks, though) |
*Standard HREZ x2mo then HR x7-10mo |
*Standard HREZ x2mo then HR x7-10mo |
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− | **Can replace ethambutol with a fluoroquinolone |
+ | **Can replace [[ethambutol]] with a [[fluoroquinolone]] |
+ | *Adjunctive steroids for high risk of IRIS |
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− | *Dexamethasone 3mg po qid x2wk then taper over 6-8wks |
+ | **[[Dexamethasone]] 3mg po qid x2wk then taper over 6-8wks |
− | **High risk of IRIS |
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+ | **[[Prednisolone]] 120 mg PO daily x1wk, 90 mg x1wk, 60 mg x1wk, 30 mg x1wk, 15 mg x1wk, 5 mg x1wk |
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− | ==Prognosis== |
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− | **Mental retardation |
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− | **Psychiatric disorders |
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− | **Seizures |
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− | **Blindness |
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− | **Deafness |
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− | **Ophthalmoplegia |
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− | **Hemiparesis |
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==Further Reading== |
==Further Reading== |
Latest revision as of 11:47, 13 March 2023
- 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 consciousness, significant focal neurological deficits
- Stage 3: seizures, comatose
Epidemiology
- About 1% of TB cases in Canada
Risk Factors
- Young
- Female
- Originally from endemic country
- Previous TB
Clinical Manifestations
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
Thwaites Index
- Used to differentiate bacterial from tuberculous meningitis in adults before results of CSF culture are available1
- Tuberculous more likely if score ≤4; bacterial more likely if score ≥5
- Sensitivity 86% and specificity 79%
Item | Score |
---|---|
Age ≥36 years | +2 |
Blood WBC ≥15 | +4 |
≥6 days of illness | -5 |
CSF WBC ≥900x103 | +3 |
CSF % PMN ≥75 | +4 |
Complications and 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, seizure, blindness, deafness, ophthalmoplegia, hemiparesis
Differential Diagnosis
- Fungal meningitis
- Sarcoidosis
- Neoplasm
- Other causes of chronic meningitis
Investigations
- Lumbar puncture
- Increased lymphocytes, decreased glucose, and increased protein
- Need 3-5mL of CSF for culture
- May need serial LPs
- CT head
Diagnosis
- Gold standard is mycobacterial culture (71% sensitive, 100% specific)
- Sensitivity increases with volume and number of samples
- Microscopy for acid-fast bacilli is 20-80% sensitive and 100% specific
- PCR is 85-95% sensitive and 98% specific
- Used to confirm but not exclude the diagnosis
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
- Adjunctive steroids for high risk of IRIS
- Dexamethasone 3mg po qid x2wk then taper over 6-8wks
- Prednisolone 120 mg PO daily x1wk, 90 mg x1wk, 60 mg x1wk, 30 mg x1wk, 15 mg x1wk, 5 mg x1wk
Drug | Dose | Duration | CSF penetration |
---|---|---|---|
Rifampin | 10 mg/kg (max 600 mg) | 12 months | 10-20% |
Isoniazid | 5 mg/kg (max 300 mg) | 12 months | 80-90% |
Pyrazinamide | 25 mg/kg | 2 months | 90-100% |
Ethambutol | 15 mg/kg | 2 months | 20-30% |
Second-line treatments | |||
Levofloxacin | 10-15 mg/kg | Throughout treatment | 70-80% |
Moxifloxacin | 400 mg | Throughout treatment | 70-80% |
Amikacin | 15 mg/kg (max 1 g) | Intensive phase only | 10-20% |
Kanamycin | 15 mg/kg (max 1 g) | Intensive phase only | 10-20% |
Capreomycin | 15 mg/kg (max 1 g) | Intensive phase only | Probably very low |
Ethionamide or prothionamide | 15-20 mg/kg (max 1 g) | Throughout treatment | 80-90% |
Cycloserine | 10-15 mg/kg (max 1 g) | Throughout treatment | 80-90% |
Linezolid | 600 mg | Throughout treatment | 30-70% |
Other drugs with uncertain benefit | |||
Clofazimine | 100 mg daily | Probably low | |
p-aminosalicylic acid | 200-300 mg/kg | Probably very low | |
Bedaquiline | Probably very low | ||
Delamanid | No data |
Further Reading
- Treatment of Tuberculous Meningitis and Its Complications in Adults. Curr Treat Options Neurol. 2018;20(3):5. doi: 10.1007/s11940-018-0490-9
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.