Tuberculous meningitis

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Tuberculous meningitis

  1. 1. Tuberculous MeningitisSANJAY GEORGE
  2. 2. Epidemiology India has one fifth of the world’s TB burden. 2 million new cases in 2009. Around 10% develop CNS disease.
  3. 3. Etiology Mycobacterium tuberculosis. Risk Factors: Delay in diagnosis and treatment HIV, Immunocompromised state.
  4. 4. Pathophysiology 50% cases : History present, Hematogenous spread Seed meninges or brain – Sub-pial/Sub-ependymal foci ofmetastatic caseous lesion – Rich Foci. Proximity to S.A Space determines type of CNS involvemeny. Rupture into S.A space – Meningitis Deep in parenchyma cause Tuberculoma or Abscesses.
  5. 5. Contd. Paresis of C.N nerves common as involvement more at base ofbrain. Disease evolves over 1-2 weeks. Thick gelatinous exudate infiltrates the cortical, meningeal bloodvessels, producing inflammation, obstruction, or infarction. Ultimate evolution to coma, with hydrocephalus and intracranialhypertension.
  6. 6. Clinical Features Headache Vomiting Low Grade Fever Malaise, Anorexia, Irritability Severe Headache Confusion Lethargy Altered Sensorium Neck RigidityInitiallyLate
  7. 7. Signs Meningism (maybe absent) Occulomotor palsies Papilloedema Depression of conscious level Focal hemisphere signs.
  8. 8. Differential Diagnosis Other Infectious causes of meningitis Acute hemorrhagic leukoencephalopathy Behçet disease Chemical meningitis Chronic benign lymphocytic meningitis Neoplastic: metastatic, lymphoma Systemic lupus erythematosus Vascular: Multiple emboli, subacute bacterial endocarditis, sinusthrombosis Vasculitis Vogt-Koyanagi-Harada syndrome
  9. 9. Investigations Lumbar Puncture: High leucocyte count (upto 1000/μL) with lymphocytic predominance. Elevated Protein (100-800 mg/dL). Mildly Decreased Glucose Concentration (20 – 40 mg/dL) AFB – 1/3rd cases CSF culture (Gold Standard) – diagnostic in 80% cases. PCR Imaging Studies – MRI, CT
  10. 10. Management Initiate if high index of suspicion. Initial Therapy: Isoniazid – 300mg/d Rifampicin – 10mg/kg/d Pyrazinamide – 30mg/kg/d Ethambutol – 15-25 mg/kg/d Pyridoxine – 50mg/d Good Response : Discontinue Pyrazinamide after 2 months continueH & R for 6 – 12 months Inadequate Resolution : Continue for 9 – 12 months Dexamethasone in HIV –ve Patients. 12 -16mg/day for 3weeks, tapered over next 3 weeks
  11. 11. Contd. Obstructive hydrocephalus and neurological deterioration :ventricular drain or ventriculoperitoneal or ventriculoatrial shunt. Prevention: BCG Vaccine

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