TB Meningitis , Tuberculoma, Spinal TB

1. CNS TUBERCULOSIS
Dr.R.KAVINKUMAR
MBBS.,DNB Resident
Dept of Medicine

2. 3 TYPES
• Tuberculous meningitis
• Intracranial tuberculoma
• Spinal tuberculous arachnoiditis

3. PATHOGENESIS
Primary infection or late reactivation TB
Bacteremia
Tubercles in the brain, meninges, or adjacent bone.
Rupture into subarachnoid space

4. Predisposing Factors
• Immune deficiency
Aging
Alcoholism
Malnutrition
Malignancy
HIV infection
Drugs

5. Basal Meningitis
• Spillage of tubercular protein in subarachnoid space
causes intense inflammation at base of brain
1) Proliferative arachnoiditis - CN & vascular injury
2) Vasculitis - thrombosis and stroke
3) Communicating hydrocephalus > Obstructive
hydrocephalus

6. Clinical manifestations
Prodromal phase
Meningitic phase
Paralytic phase

7. Prodromal phase
• Two to three weeks
• Insidious onset
• Malaise
• Lassitude
• Headache
• Low-grade fever
• Personality change.

8. Meningitic phase
• Meningismus
• Protracted headache
• Vomiting
• Lethargy
• Confusion
• Varying degrees of cranial nerve and long-tract signs.

9. Paralytic phase
• Stupor and Coma
• Seizures
• Hemiparesis
• Majority of untreated patients - death within five to eight
weeks of the onset of illness.

10. Stages of illness
• Stage 1 - lucid with no focal neurologic signs or evidence
of hydrocephalus
• Stage 2 - lethargy, confusion , mild focal signs( cranial
nerve palsy or hemiparesis).
• Stage 3 - advanced illness with delirium, stupor, coma,
seizures, multiple cranial nerve palsies, and/or dense
hemiplegia.

11. Choroid tubercles in TBM
• In 1/3rd of patients -
Choroid tubercules in
Fundus (multiple ill-defined
raised yellow-white
granulomas of varying size
near the optic disk )

12. Atypical presentations
• Rapidly progressive meningitic syndrome ( like pyogenic
meningitis)
• Slowly progressive dementia over months or years
• Encephalitic course without overt signs of meningitis

13. Paradoxical reaction
• Exacerbation of clinical signs (fever, change in mentation)
after beginning ATT
• One-third of patients
• Common in female gender, concomitant HIV infection,
shorter duration of illness

14. Diagnosis

15. CSF
• ↑ Protein (100- 500 mg/dL)
• ↓ Glucose (< 54 mg/dL)
• CSF cell count between 100 and 500 cells/microL
• Mononuclear pleocytosis
• ADA > 10 units / lit
• Early illness - cellular reaction is often atypical with only a
few cells or with neutrophil predominance.

16. NAAT in CSF
Xpert MTB/RIF assay
81% sensitivity
98% specificity
Not approved by US - FDA

17. Radiography
CT or MRI brain
1) Presence & extent of basilar arachnoiditis
2) Cerebral edema
3) Infarction
4) Hydrocephalus
5) Tuberculomas

18. MRI - Meningeal enhancement

19. MRI - Hydrocephalus

20. • Clinical features + CT or MRI evidence of basilar
meningitis + hydrocephalus - strongly suggestive of TBM
• 30 % patients of stage 1 meningitis - Normal CT
• Hydrocephalus + marked basilar enhancement -
advanced disease
• MRI is superior to CT - lesions of the basal ganglia,
midbrain, brainstem & spinal TB

21. Differential Diagnosis

22. • Fungal meningitis (cryptococcosis, histoplasmosis,
blastomycosis, coccidioidomycosis)
• Viral meningoencephalitis (herpes simplex, mumps)
• Parameningeal infection (sphenoid sinusitis, brain
abscess, spinal epidural abscess)
• Partially treated bacterial meningitis
• Neurosyphilis
• Neoplastic meningitis (lymphoma, carcinoma)
• Neurosarcoidosis
• Neurobrucellosis

23. Tuberculoma
• Central lesion - often asymptomatic
• Single or multiple
• May be calcified
• Headache , seizure, ↑ ICT , Hemiplegia
On CT
Early lesions - Hypo or iso dense
Late lesions - encapsulated , hyperdense , ring
enhancing

24. • Avoid LP - Herniation d/t raised ICT
• DD
1) Neurocysticercosis
2) Tumours

27. Spinal tuberculous arachnoiditis
• Subacute onset of nerve root and cord compression
1. Spinal or radicular pain
2. Hyperesthesia or paresthesias
3. LMN paralysis
4. Bladder or rectal sphincter dysfunction
• Vasculitis - ASA thrombosis
• Extra or Intra dural abscess or tuberculoma

29. TREATMENT

30. ATT - CDC Guidelines
Intensive phase
4 drug regimen (H,R,Z,E)
2 months
Ethambutol - poor CNS penetration
Continuation phase
2 drugs ( H,R)
7 - 10 months
RNTCP - H,R,E maintanence regimen
Tuberculoma - extended regimen ( 18 months )

31. HIV and CNS TB
• Delay ART for 8 weeks (irrespective of CD4)
• Initiate ATT asap
• avoid steroids

32. Steroids in TB
Indications
1. Progressive disease
2. acute encephalitis
3. High CSF opening pressure ( > 400 mm of water)
4. Therapeutic paradox
5. Spinal block ( protein > 500 mg/dl )
6. Basal enhancement or Hydrocephalus in CT
7. Tuberculoma with edema

33. Dexamethasone
0.3 to 0.4 mg/kg/day for two weeks,
0.2 mg/kg/day week 3,
0.1 mg/kg/day week 4, and taper
Total duration approximately eight weeks
Prednisolone
60 mg /day for 2 weeks
Taper 10 mg per week
Total duration - 8 weeks

34. Surgical intervention
• Hydrocephalus with coma or stupor - decompression
• Try a course of Steroid and LP - if no improvement -
surgery
• Rapid worsening - proceed immediately to surgery

35. • Be kind to everyone
because everyone you
meet is fighting a hard
battle in life