Lec 5.pdf tuberculosis miliary tuberculosis meningitis

Miliary tuberculosis.
Tuberculous meningitis.
Lecture № 5
The Department of Tuberculosis of KSMA
Doc. Fydorova S.V.
http://mbbshelp.com WhatsApp: +1 (402) 235-1397

Miliary TB
is consequence of acute hematogenous
dissemination, which usually occurs during
the early phase of tuberculous infection.
Miliary TB is more frequent in infants, but
may develop in any age.
Milium (lat.) – «millet», because tuberculous
nodi look like millet-grains.

Pathogenesis and
pathomorphology of miliary TB
Source of hematogenous spreading of TB-
infection is usually tuberculous lymph
node. Caseous necrosis can rupture into
blood stream, so MBT spread and enter
into different organs and tissues.

Pathogenesis and
MBT cause allergic changes of blood
capillaries’ wall. It loss it’s smoothness,
becomes rough and penetrative, so MBT sit
down on the capillaries’ wall, and than they
enter into interstitial space through the
vessel’s wall. Tuberculous granulomas form
in the capillaries’ wall and in the interstitial
tissue.

Pathogenesis and
They look like millet-
grains. They have
mainly productive
reaction, so their
borders are clear, they
don’t fuse together and
cavitations don’t form.
Miliary foci are located
in subpleural areas,
where is the highest
number of blood
capillaries.

The main clinical forms of
miliary TB
⚫ acute tuberculous sepsis
⚫ pulmonary form
⚫ typhoidal form
⚫ meningitic form or tuberculous meningitis

Clinical picture of acute
tuberculous sepsis
It is the most severe generalized form of
miliary TB. It usually develops in infants or
immunosuppressive patients (especially
HIV/AIDS). The disease usually begins
suddenly with strong dry cough, chest pain,
high fever (to 40ºC and more), cyanosis,
severe symptoms of general intoxication.
Breathlessness and intoxication increase.
Outcome may be fatal after some days.

Clinical picture of acute
tuberculous sepsis
Diagnose is usually
confirmed by
pathomorphological
examination. Miliary
foci are usually found in
many different organs:
lung, pleura, brain,
liver, spleen, kidneys
etc.

Clinical picture of pulmonary
form
There are chest pain, dry cough or a little of
sputum, breathlessness, cyanosis, high fever,
weakness, sweetness, symptoms of lung
affection predominate. Percussion:
tympanitis.
Auscultation: bronchial timbre of breathing,
sometimes a little of fine moist rales or
wheezes may be listened.

Clinical picture of typhoidal
form
Severe intoxication is similar to typhus, so
this form is called typhoidal. Patient has got
pulmonary symptoms, but severe symptoms
of intoxication predominate. Lever
dysfunction, consciousness abnormalities:
delirium, hallucinations, infection psychosis,
cramps, collapse, and even toxic shock with
fatal outcome.

Clinic of meningitic form
is clinic of tuberculous meningitis.

X-ray picture of miliary TB
Diffuse bilateral
interstitial changes of
lung picture occur
during the first days.
Then diffuse small
miliary foci appear in
the X-ray film after 10-
14 days. Mediastinal
enlarged lymph nodes
may be also detected,
especially by computed
scan.

Differential diagnosis
⚫ typhus
⚫ disseminated carcinoma
⚫ lymphogranulomatosis
⚫ sarcoidosis
⚫ connective tissue diseases
etc.

Differential diagnosis
In difficult diagnostic cases diagnostic
thoracotomy with lung tissue biopsy may be
necessary to confirm diagnose.

Tuberculous meningitis
is inflammation of the soft membrane of brain
caused by MBT. May develop in all ageing
groups.

TB meningitis
occurs rarely in BCG-employment period.
When early detection of TB meningitis takes
place, it usually finishes with recovery in 93-
96% of cases.

Often TB meningitis is
complication of other forms of TB
⚫ primary tuberculous complex, tuberculosis of
intrathoracic lymphatic nodes in children
⚫ tuberculosis of intrathoracic lymphatic nodes,
disseminated tuberculosis in adolescence
⚫ disseminated TB, infiltrative TB, fibrous-
cavernous TB in adults
are frequently complicated with TB meningitis

Pathogenesis of TB meningitis
Three conditions are necessary for the
development of TB meningitis:
⚫ common nonspecific sensibilization
⚫ specific sensibilization caused by MBT
⚫ hematogenous spreading of tuberculous
infection

TB meningitis may develop by
three different ways
⚫ Hematogenous way of pathogenesis:
⚫ The first period:
⚫ TB infection
⚫ general hypersensibilization
⚫ hematogenous spreading of TB-infection
⚫ rupture of TB-infection through the
hematoencephalitic barrier
⚫ TB-infection enters into the vessel’s net of the
soft membrane of brain

TB meningitis may develop by
three different ways
⚫ Hematogenous way of
pathogenesis:
⚫ The second period:
⚫ TB-infection runs through
the blood vessel’s wall
and enters into the
subarachnoid space
⚫ MBT sits down on the soft
membrane of the brain’s
basis
⚫ miliary lesions form on the
membrane of brain’s
basis.

Liquorogenous way of
pathogenesis
Small dense caseous foci may form in the
brain tissue or soft membrane during initial
TB-infection period. Such persons don’t
have any clinical symptoms, because TB-
infection is latent (semidormant). These
focal lesions are called Rich’s foci.

Liquorogenous way of
pathogenesis
⚫ But if immune response
decreases, MBT leave
from Rich’s focus to
subarachnoid and
liquorogenous spreading
occurs. Then areas of
specific tuberculous
inflammation may form in
the soft membrane or brain
tissue. Sometimes spinal
TB may be source of
liquorogenous spreading of
TB-infection.

Neurogenous way of
pathogenesis
When tuberculoma of brain takes place MBT
can spread along the nervous and cause
tuberculous lesions in distant sites of the
brain tissue.

Pathomorphology of TB
meningitis
specific inflammation appears in the brain
basis. Specific changes may spread from
chiazma opticus and frontales lobes to the
medulla oblongata. Tuberculous granulomas
and foci form in blood vessels’ walls and
brain tissue. Necrosis of vessels’ wall,
thrombosis and hemorrhages develop.
Brain’s membrane and tissue of the spinal
cord involve.

There are three periods of TB
meningitis
⚫ prodromal period (it’s duration is from 2 to 6
weeks)
⚫ clinical period (it’s duration is usually 4
weeks)
⚫ terminal period with fatal outcome

Prodromal period
It’s onset is gradual: weakness, loss of appetite,
headache, subfebrile fever, constipation, apathy.
During this period children may visit a doctor until 20
times. And clinical diagnose may be: acute viral
respiratory infection, allergy, poisoning, biliary
dyskinesia, gastrointestinal infection etc. At the end
of prodromal period hypersensitiveness to the light,
noise, touch appears, dysfunction of vegetative
nervous system, diffuse red dermographism
develop, sometimes Trusso’s spots appear.

Main clinical forms of
tuberculous meningitis
⚫ serous meningitis
⚫ basilar meningitis
⚫ menigoencephalitis
⚫ spinal form

Serous meningitis
Corresponds to the 1st week of clinical
period:
⚫ All symptoms of prodromal period strongly
increase
⚫ fever is high
⚫ headache becomes severe, continuous, there
is not effect of medicines
⚫ vomiting appears, it doesn’t relate with meal
and it doesn’t relief patient’s condition

Basilar meningitis
corresponds to the
second week of clinical
period:
⚫ forced position of the
patient, positive
meningeal symptoms
(Brudzinsky upper,
medium, lower; Kernig)
⚫ affection of cranial
nervous: nn.
oculomotorius,
abducence, trochlearis,
hypoglossus,
glossopharingeus

Basilar meningitis
⚫ eye’s fundus affection – ophthalmologist may
detect miliary lesions (granulomas) along
vessels of eye’s bottom. This symptom is
very rare, but it is confirmation of diagnose of
TB meningitis.

Menigoencephalitis
Corresponds to the third week of clinical
period.
⚫ «Focal» symptoms of brain’s tissue affection
– paralysis, convulsions, loss of speech, loss
of memory, violations of intellect, affection of
respiratory and cardiovascular centers with
fatal outcome may develop.

Spinal meningitis
usually corresponds to the fourth week of
clinical period.
⚫ Peripheral paralysis, impairment of pelvic
organs function.

Cerebrospinal fluid (CSF) in TB
meningitis
⚫ The fluid is clear, transparent, colourless.
Intracranial pressure is high, so fluid flows out
as stream. Thin film appears on the surface
of fluid after 24-36-48 hours. Cells increase
until some hundreds per mm³ with
predomination of lymphocytes. Protein level
is high (more than 0.3 g/l). The level of
glucose is low (lower than 2. 96 mmol/l),
chlorides level decreases too (lower than
115mmol/l). MBT may be detected in 6 –
20% of cases.

Diagnosis of TB meningitis
⚫ analysis of CSF
⚫ changes of eye’s
fundus
⚫ chest X-ray
⚫ computerized
tomography of brain
Computerized tomography of the
skull in young adult patient with
cerebral TB, with hydrocephaly,
hypodense central areas, and
atrophic lesions.

Differential diagnose
⚫ viral meningitis
⚫ fungal meningitis
⚫ syphilitic meningitis
⚫ oncological diseases of central nervous
system
⚫ HIV-infection
⚫ trauma
⚫ brain stroke
etc.

The mortality of untreated TB
meningitis is 100%
so treatment should be started immediately

Prognosis
⚫ Treatment started during prodromal period or
serous meningitis – recovery without
complications occurs in nearly 100% of cases
⚫ Treatment started during basilar meningitis –
recovery in nearly 100% of cases, but
complications (paralysis, blindness,
deafness, hydrocephaly etc.) develop in
nearly 50% of cases

Prognosis
⚫ Treatment started during menigoencephalitis
– nearly 50% of patients die, in 50% of
patients complications develop and residual
changes stay, which may cause disablement
⚫ Treatment started during spinal meningitis –
usually 100% of patients die

Thank you
for your attention!

Lec 5.pdf tuberculosis miliary tuberculosis meningitis

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