CNS Tuberculosis in developing countries
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Dr. Lekhjung Thapa is a neurologist in Nepal specializing in conditions like stroke, epilepsy, and movement disorders. He has over 50 publications and will be giving a presentation on central nervous system (CNS) tuberculosis. The objectives of the presentation are to discuss what CNS tuberculosis is, its burden in Nepal, challenges in diagnosis, treatment approaches, outcomes, and provide a summary. CNS tuberculosis can manifest as tuberculosis meningitis, intracranial tuberculoma, or tuberculosis arachnoiditis. It is difficult to diagnose due to inability to visually identify the tuberculosis bacilli in cerebrospinal fluid samples. High index of clinical suspicion, cerebrospinal fluid analysis
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This document summarizes key aspects of central nervous system tuberculosis (CNS TB), including its three main types, pathogenesis, risk factors, clinical manifestations in different phases, diagnosis, treatment approaches, and considerations for HIV coinfection. CNS TB can manifest as tuberculous meningitis, intracranial tuberculomas, or spinal tuberculous arachnoiditis. Diagnosis involves examination of cerebrospinal fluid and imaging studies. Treatment involves prolonged antibiotic therapy according to standardized guidelines, with adjunctive steroids in some cases.
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Tuberculous meningitis is caused by Mycobacterium tuberculosis infection of the meninges. It most commonly occurs after primary infection in childhood or with miliary tuberculosis. Symptoms include headache, vomiting, fever and behavioral changes. Signs include meningism, cranial nerve palsies and decreased consciousness. Diagnosis involves lumbar puncture showing lymphocytic pleocytosis and decreased glucose. Treatment involves antitubercular drugs for 6-9 months with corticosteroids to reduce mortality and neurological damage. Miliary tuberculosis results from hematogenous dissemination and presents with non-specific symptoms like fever and weight loss. Diagnosis involves chest x-ray showing millet seed lesions and treatment is standard antituberc
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Central nervous system tuberculosis (CNS TB) is a severe form of TB infection that can affect the brain and spinal cord. It is most common in children under 5 years old. Left untreated, CNS TB has an almost 100% fatality rate and can cause permanent neurological damage even with treatment. Diagnosis involves examination of cerebrospinal fluid which shows increased white blood cells and protein with low glucose. Brain imaging also helps with diagnosis. Treatment requires a multi-drug regimen administered over 9-12 months. Adjunctive steroids are also often used to reduce inflammation and complications. Even with treatment, CNS TB has poor outcomes with only one third of patients fully recovering neurologically.
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Tuberculous meningitis (TBM) is a serious form of tuberculosis infection that affects the membranes (meninges) surrounding the brain and spinal cord. It is difficult to diagnose due to nonspecific symptoms in early stages. The diagnosis requires a high index of suspicion and is confirmed through cerebrospinal fluid analysis, imaging, and culture. Prompt treatment with a combination of antituberculosis drugs for 6-9 months as well as corticosteroids is needed but prognosis depends on the stage at presentation, with advanced stages having worse outcomes. BCG vaccination provides some protection against TBM.
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Tuberculosis meningitis is an inflammatory disease of the membranes surrounding the brain and spinal cord caused by the Mycobacterium tuberculosis bacteria. The bacteria typically enter the body through inhalation and can spread from the lungs to the central nervous system. Symptoms include headache, vomiting, and neck stiffness. Diagnosis involves lumbar puncture, MRI or CT scan. Treatment requires a prolonged multi-drug antibiotic regimen along with physiotherapy. Outcomes depend on early diagnosis and treatment, with complications including seizures, brain damage and death if left untreated. Prevention involves BCG vaccination of high-risk groups like children and healthcare workers.
Cns TB
1. CNS tuberculosis is caused by Mycobacterium tuberculosis and can manifest as tuberculous meningitis, tuberculomas, or tuberculous brain abscesses.
2. It spreads hematogenously from a primary pulmonary infection and the bacilli can infect microglial cells in the brain.
3. Clinical features include fever, headache, meningismus, seizures, and focal neurological deficits that vary depending on the location and size of lesions in the brain or meninges.
Tuberculous meningitis
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The two types of diabetes are referred to as type 1 and type 2 Former names for these conditions were insulin dependent and non-insulin dependent diabetes, or juvenile onset and adult onset diabetes.
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Tuberculous meningitis is caused by the Mycobacterium tuberculosis bacteria spreading from another part of the body to the brain and spinal cord membranes. It presents with symptoms like neck stiffness, fever, nausea, and mental status changes. Left untreated, it can cause complications like seizures, brain damage, and death. Diagnosis involves tests of cerebrospinal fluid and imaging scans. Treatment consists of a combination of antibiotics administered for 12 months.
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This document provides information about tuberculous meningitis (TB meningitis). It discusses the anatomy and physiology of the central nervous system and meninges. Key points include:
1) TB meningitis is caused by Mycobacterium tuberculosis infection of the meninges and results in inflammation concentrated at the base of the brain.
2) Symptoms include fever, seizures, headaches, and stiff neck. Diagnosis involves lumbar puncture and analysis of cerebrospinal fluid.
3) Treatment requires a prolonged course of multiple antitubercular drugs as well as steroids to reduce inflammation and potential complications like hydrocephalus.
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Cerebral tuberculomas are a rare form of tuberculosis that spreads to the brain via the bloodstream, affecting approximately 1% of all tuberculosis patients. Treatment involves high doses of corticosteroids combined with a multi-drug antibiotic regimen of INH, rifampisin, and pyrazinamide for the first two months followed by INH and rifampisin for 10 additional months. Surgery may also be required to address complications such as hydrocephalus or spinal cord tuberculosis.
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1. A 62-year-old man presented with 10 days of dizziness, vomiting, and 2 days of fever and headache. Examination revealed neck stiffness, delirium, and signs of meningitis.
2. CSF analysis showed elevated white blood cells and protein with low glucose, consistent with tuberculous meningitis. CT head and MRI brain showed basilar enhancement.
3. Tuberculous meningitis was diagnosed and treatment initiated with a four drug antitubercular regimen along with corticosteroids. Prognosis depends on stage at diagnosis and risk factors like HIV co-infection impact outcomes.
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1. Tuberculous meningitis accounts for 5% of extrapulmonary TB and has a high mortality rate of 30% despite treatment.
2. Diagnosis is challenging as bacterial yield from CSF is low. Imaging and laboratory tests also have limited sensitivity and specificity.
3. The recommended treatment for CNS TB is a 2 month intensive phase of isoniazid, rifampin, pyrazinamide, and ethambutol followed by a 10 month continuation phase of isoniazid and rifampin. Adj
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Pathophysiology
TB meningitis
Clinical presentation
Symptoms of TBM
Diagnosis of TBM
Lumbar puncture for CSF
CSF examination
Xpert MTB/RIF
HIV status / chest x ray
Neuroimaging : CECT/MRI
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Referral
Follow up
Drug resistant cases
Complications of TBM
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Optico-chiasmatic arachnoiditis
Seizures
CNS tuberculoma
Clinical presentation
Presumptive CNS tuberculoma
HIV status
Neuroimaging
CSF examination
Stereotactic or open biopsy
Tuberculoma differential diagnosis
CNS Tuberculoma vs Neurocysticercosis
Treatment of CNS Tuberculoma
Duration
Paradoxical reaction
Treatment failure
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This document provides information about intracranial tuberculosis. It begins by stating that tuberculosis meningitis is common in India, accounting for 2-5% of pediatric hospital admissions. It then discusses that tuberculosis meningitis is caused by the tuberculosis bacterium infecting the central nervous system and its coverings. Common risk factors include pulmonary tuberculosis and a weakened immune system. Signs and symptoms vary depending on age, but may include fever, headache, neck stiffness, vomiting, and neurological deficits. Diagnosis involves examinations of cerebrospinal fluid, sputum, and other specimens, along with imaging tests. Treatment primarily consists of a combination of antibiotic medications like rifampin and isoniazid.
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A 70-year-old male presented with a 5-year history of intermittent fever and a more recent 2-week history of behavioral changes and severe headaches. Imaging showed evidence of basilar meningitis and hydrocephalus. Cerebrospinal fluid analysis found lymphocytic pleocytosis with low glucose and high protein, consistent with tuberculous meningitis. The patient was started on empiric anti-tuberculosis treatment given the clinical suspicion while further diagnostic tests were pending. Tuberculous meningitis requires a prolonged multi-drug treatment regimen to reduce the risk of complications like hydrocephalus, infarctions, and neurological deficits.
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TB Meningitis
This document discusses tuberculous meningitis (TBM), the most common form of central nervous system tuberculosis. TBM can have rapid or gradual progression and commonly affects children between 6 months and 4 years old. Diagnosis involves lumbar CSF study, which typically shows lymphocytic pleocytosis and high protein levels. Treatment involves 12 months of anti-tuberculosis medications including an intensive initial phase with four drugs for 2 months followed by isoniazid and rifampin for 10 months. Prognosis depends on the clinical stage at treatment initiation, with those in the first stage having the best outcomes and those in the third stage often having permanent disabilities if they survive.
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Central nervous system tuberculosis (CNS TB) can manifest in several ways, including tuberculous meningitis, tuberculomas, tuberculous abscesses, and spinal infections. Tuberculous meningitis is the most common manifestation and presents with nonspecific symptoms like headache, fever and neck stiffness. Imaging may show basal meningeal enhancement and hydrocephalus. Left untreated, complications can include cranial nerve palsies, infarcts and altered mental status. Neurologists and radiologists should be familiar with the clinical and imaging presentation of CNS TB to facilitate timely diagnosis and treatment.
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1. CNS tuberculosis is caused by Mycobacterium tuberculosis and can manifest as tuberculous meningitis, tuberculomas, or tuberculous brain abscesses.
2. It spreads hematogenously from a primary pulmonary infection and the bacilli can infect microglial cells in the brain.
3. Clinical features include fever, headache, meningismus, seizures, and focal neurological deficits that vary depending on the location and size of lesions in the brain or meninges.
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This document provides information about tuberculous meningitis (TB meningitis). It discusses the anatomy and physiology of the central nervous system and meninges. Key points include:
1) TB meningitis is caused by Mycobacterium tuberculosis infection of the meninges and results in inflammation concentrated at the base of the brain.
2) Symptoms include fever, seizures, headaches, and stiff neck. Diagnosis involves lumbar puncture and analysis of cerebrospinal fluid.
3) Treatment requires a prolonged course of multiple antitubercular drugs as well as steroids to reduce inflammation and potential complications like hydrocephalus.
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3. Tuberculous meningitis was diagnosed and treatment initiated with a four drug antitubercular regimen along with corticosteroids. Prognosis depends on stage at diagnosis and risk factors like HIV co-infection impact outcomes.
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This document discusses central nervous system tuberculosis, including tuberculous meningitis, tuberculomas, and other forms. Some key points:
1. Tuberculous meningitis accounts for 5% of extrapulmonary TB and has a high mortality rate of 30% despite treatment.
2. Diagnosis is challenging as bacterial yield from CSF is low. Imaging and laboratory tests also have limited sensitivity and specificity.
3. The recommended treatment for CNS TB is a 2 month intensive phase of isoniazid, rifampin, pyrazinamide, and ethambutol followed by a 10 month continuation phase of isoniazid and rifampin. Adj
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Dr Abdullah Ansari
MBBS, MD Medicine
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Spectrum of CNS TB
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Pathophysiology
TB meningitis
Clinical presentation
Symptoms of TBM
Diagnosis of TBM
Lumbar puncture for CSF
CSF examination
Xpert MTB/RIF
HIV status / chest x ray
Neuroimaging : CECT/MRI
MRC staging
Treatment
Referral
Follow up
Drug resistant cases
Complications of TBM
Hydrocephalus
Ventriculo-peritoneal shunt
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Optico-chiasmatic arachnoiditis
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CNS tuberculoma
Clinical presentation
Presumptive CNS tuberculoma
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Neuroimaging
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This document discusses tuberculous meningitis, which is caused by Mycobacterium tuberculosis infecting the meninges and brain. India has a high burden of tuberculosis cases, with around 10% of TB patients developing central nervous system involvement like tuberculous meningitis. Risk factors include delays in diagnosis and treatment as well as immunocompromised states. Clinically, patients initially experience headaches, vomiting and fever, progressing to altered mental status. Diagnosis involves lumbar puncture showing lymphocytic predominant meningitis as well as imaging and culture of cerebrospinal fluid. Treatment involves a combination of anti-tuberculosis drugs administered for 9-12 months.
Intracranial tuberculosis
This document provides information about intracranial tuberculosis. It begins by stating that tuberculosis meningitis is common in India, accounting for 2-5% of pediatric hospital admissions. It then discusses that tuberculosis meningitis is caused by the tuberculosis bacterium infecting the central nervous system and its coverings. Common risk factors include pulmonary tuberculosis and a weakened immune system. Signs and symptoms vary depending on age, but may include fever, headache, neck stiffness, vomiting, and neurological deficits. Diagnosis involves examinations of cerebrospinal fluid, sputum, and other specimens, along with imaging tests. Treatment primarily consists of a combination of antibiotic medications like rifampin and isoniazid.
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Now a days TBM is super most disease in Indian children.
Tuberculous meningitis (TBM) is difficult to diagnose, and a high index of suspicion is needed to make an early diagnosis.
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Chronic meningitis
Chronic meningitis is defined as meningitis symptoms lasting 4 or more weeks. It can have various causes including infectious, malignant, or autoimmune etiologies. Common infectious causes are bacterial, mycobacterial, spirochetal, or viral agents. Evaluation involves examination of cerebrospinal fluid and serological testing to identify the specific etiology. Empiric treatment with antitubercular therapy or antivirals may help in cases where an etiology cannot be identified.
TB Meningitis
This document discusses tuberculous meningitis (TBM), the most common form of central nervous system tuberculosis. TBM can have rapid or gradual progression and commonly affects children between 6 months and 4 years old. Diagnosis involves lumbar CSF study, which typically shows lymphocytic pleocytosis and high protein levels. Treatment involves 12 months of anti-tuberculosis medications including an intensive initial phase with four drugs for 2 months followed by isoniazid and rifampin for 10 months. Prognosis depends on the clinical stage at treatment initiation, with those in the first stage having the best outcomes and those in the third stage often having permanent disabilities if they survive.
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count.Material & Methods : 50 patients who were in the age goup18-55 years, had HIV infection and history
suggestive of Nervous system manifestations were included. The HIV patients with past/present history of
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examination. For all the patients have done routine investigations, and specific investigations like CT/MRI
Brain, Nerve Conduction Studies, CSF Analysis,EEG and Specific antibodies for organisms or parasite done
only wherever it is required. All the patients were correlated with the CD4 T cell count.Results:: Among 50
patients, Commonest age group affected was 26-35 yrs with male predominance(62%). Most common symptom
was non specific headache(38%).Most common opportunistic infetction was Tuberculous meningitis(34%).
Toxoplasmsa encephalitis was the most common space occupying lesion(20%).More number of patients were
seen in the CD4 range in between 51-200 cells/mic.L(72%) with all the diseases had correlation with CD4 T cell
activityCONCLUSION: In the present study, Opportunistic infections were the leading cause in patients
infected with HIV having Neurological manifestastions, usually occurs when the patients had severe
immunosuppresion (CD4 count< 200 cells/μL).
Key words: HIV Positive patients, CD4 T cell count, Neurological manifestation
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CNS Tuberculosis in developing countries
- 1. Dr. Lekhjung Thapa, MD, DM (Neurology) National Institute of Neurological and Allied Sciences, KTM Neuro & Allied Clinic, Anchalpur, Bhairahawa Area of expertise: • Stroke, Epilepsy, Headache, Movement Disorder, CNS infections Researches: • Over 50 publications in National and International Journals Languages: – Nepali, Hindi, English Speaker
- 2. Objectives 1. What is CNS tuberculosis? 2. What is the burden of CNS tuberculosis in Nepal? 3. Diagnosis and the challenges in diagnosis. 4. How to treat CNS tuberculosis? 5. Outcome of CNS TB. 6. Summary
- 3. What is CNS tuberculosis? 1. Three (03) conditions: 1. TB meningitis 2. Intracranial tuberculoma 3. TB arachnoiditis
- 4. How TB reaches Brain and Meninges? TB Bacilli 1. TB reaches Lungs by inhalation 2. TB reaches Meninges & Brain by Blood Intracranial Tuberculoma TB Meningitis TB Arachnoiditis CSF
- 5. What is the burden of CNS tuberculosis in Nepal? 1. Incidence: >100/100 000 [WHO 2016] Global Tuberculosis Report 2017, World Health Organization, p. 31
- 6. Diagnosis and the challenges in diagnosis 1. Clinical features: 1. Fever 2. Headache 3. Vomiting 4. LOC 5. Seizures
- 7. Diagnosis and the challenges in diagnosis 1. CSF analysis 1. CSF culture and sensitivity for MTB 2. CSF PCR for MTB 3. ADA 2. Mantoux test (Tuberculin skin test) 3. CT/MRI CNS TB is very difficult to diagnose. We can’t see TB bacilli in CSF. High index of suspicion is needed
- 8. Diagnosis and the challenges in diagnosis TB Meningitis Fig: Arachnoiditis (Arrow) Fig: Tuberculoma (Arrow)
- 9. How to treat CNS tuberculosis? 1. ATT for 7-10 months 1. If tuberculoma: ATT for 18 months 2. Steroids: 1. Dexamethasone or Prednisolone: 4-6 weeks 3. Surgery 1. Hydrocephalous 2. Tuberculoma (Biopsy)
- 10. Outcome of CNS TB 1. Poor prognosis: (50% die and about same with disability) 1. Late stage of TBM 2. Extremes of age 3. Malnutrition 4. Hydrocephalus 5. Focal neurological deficit 6. Miliary disease 7. Debilitating disease
- 11. Summary: CNS TB 1. Major cause of death and disability in Nepal 2. High index of suspicion is needed to diagnose 3. CSF analysis and CT/MRI will give us the clue to the diagnosis 4. Early diagnosis and treatment with ATT saves life
- 12. Are you the next Leader? Thank you