TBM

Dr. C. Kannan, Resident, MGMCRI

1. TUBERCULOUS MENINGITS Dr. C. Kannan Post Graduate Department of Pediatrics MGMCRI

2. TUBERCULOUS MENINGITS (TBM) M ost common form of CNS tuberculosis If untreated, high frequency of N eurologic sequelae and Mortality TBM complicates 0.3% of untreated TB infections in children. Common between 6 mns and 4 yr of age Clinical progression of TBM may be rapid or gradual Rupture of 1 or more Subependymal tubercle Rapid progression more often in infants and young children Occasionally, TBM occurs many years after the infection Tuberculous Meningitis 2

3. PATHOLOGY Primary infection Lymphohematogenous dissemination Metastatic caseous lesion in the cerebral cortex or meninges Discharges few tubercle bacilli into the subarachnoid space Forms gelatinous exudate Infiltrates the corticomeningeal blood vessels Inflammation, obstruction & infarction of cerebral cortex Brainstem (commonest site) Interferes CSF flow Dysfunction of CN III, VI, and VII Hydrocephalus Tuberculous Meningitis 3

4. CLINICAL FEATURES # MRC STAGING First stage Lasts for 1-2 week - Nonspecific symptoms Fever Headache Irritability Drowsiness Malaise Stagnation or loss of developmental milestones Focal neurologic signs are absent Tuberculous Meningitis 4

5. Second stage Begins more abruptly Lethargy Nuchal rigidity / Hypertonia Seizures Positive Kernig and Brudzinski signs Cranial nerve palsies / Focal neurologic signs Hydrocephalus / Vasculitis Some with encephalitis Disorientation Movement disorders Speech impairment Tuberculous Meningitis 5

6. Third stage Coma Hemi or paraplegia Hypertension Decerebrate posturing Deterioration of vital signs Death Tuberculous Meningitis 6

7. DIAGNOSIS TST – Nonreactive in up to 50% of cases CXR - 20-50 % of children have a normal findings HIV serology Lumbar CSF study Polymerase chain reaction (PCR ) Cultures of other body fluids can help confirm the diagnosis Other Radiographic studies Tuberculous Meningitis 7

8. CSF Study CSF cells - leukocyte 10-500 cells/µl Lymphocytes predominates CSF glucose - <40 mg/dl CSF Protein - markedly high (400-5,000 mg/dl) Early stage 1 Viral aseptic meningitis then progress severely Success of CSF study related to its volume 5-10 mL of lumbar CSF Acid-fast stain positive in up to 30% of cases culture is positive in 50-70% of cases Tuberculous Meningitis 8

9. Radiographic studies CT or MRI - brain Normal during early stages of the disease As disease progresses Basilar enhancement Communicating hydrocephalus Signs of cerebral edema One or several clinically silent tuberculomas Most often in the cerebral cortex or thalamic regions Tuberculous Meningitis 9

10. TUBERCULOMA Another manifestation of CNS tuberculosis Tumor-like mass Formed by aggregation of caseous tubercles Singular / multiple Clinically manifests as a brain tumor Account for up to 30% of brain tumors Tuberculous Meningitis 10

11. Location Supratentorial in adult Infratentorial in children At the base of the brain near the cerebellum Clinical features Headache Vomiting Fever Focal neurologic findings Convulsions Tuberculous Meningitis 11

12. Diagnosis TST is usually reactive Chest radiograph is usually normal CT or MRI – brain Discrete lesions with surrounding edema Contrast medium enhancement shows ring-like lesion Surgical excision To distinguish tuberculoma from other causes of brain tumor Tuberculous Meningitis 12

13. Treatment Corticosteroids Alleviates severe clinical signs and symptoms Used during 1st few weeks of treatment or In immediate post - op period to decrease cerebral edema Surgical removal is not necessary Most tuberculomas resolve with medical management (Later) Tuberculous Meningitis 13

14. Tuberculoma Neurocysticercosis Any age Rare before 3 years Progressive neurological deficit No Progressive neurological deficit Size >20 mm smaller Irregular outline Regular rounded outline Marked cerebral edema Less cerebral edema Supra / infratentorial Usually Supratentorial Midline shift seen Midline shift not seen MRS has lipid peak MRS has no lipid peak Tuberculous Meningitis 14

15. Tuberculous Meningitis 15

16. NCC Tuberculous Meningitis 16

17. COMPLICATIONS Hydrocephalus Stroke Opticochiasmatic – Arachnoiditis Visual loss – During treatment with ATT / Withdrawal of steroids Seizures Tuberculous Meningitis 17

18. PROGNOSIS OF TBM Correlates most closely with Clinical stage of illness at the time treatment is initiated Most with 1st stage have an excellent outcome Most with 3rd stage, who survive have permanent disabilities Blindness Deafness Paraplegia Diabetes insipidus Mental retardation Prognosis for young infants is worse than for older children Tuberculous Meningitis 18

19. TREATMENT ATT for 12 months Intensive (2 months) + continuous phase (10 months) Why ? (Routine ATT regimen is 6 months) High dosage for penetration of BBB To prevent relapse rates Children with TBM should be hospitalized Preferably for first 2 months / Until clinically stabilized Tuberculous Meningitis 19

20. Internationally accepted ATT for TBM/Tuberculoma Intensive phase Four drugs ( RHZE/S) are recommended for 2 months Continuation phase Isoniazid and Rifampicin are recommended for 10 months Corticosteroids (usually prednisone) HIV Negative All children with TB meningitis at 2 mg/kg daily for 4 weeks Then gradually tapered over 1– 2 weeks before stopping HIV Positive Advised in the absence of life threatening opportunistic infections Tuberculous Meningitis 20

21. TAKE HOME MESSEGE ATT to be considered for any child who develops Basilar meningitis Hydrocephalus Cranial nerve palsy stroke with no other apparent etiology Often the key to the correct diagnosis Identifying an adult with TB who is in contact with the child TBM has short incubation period / Rapid progression Needs high index of suspicion Tuberculous Meningitis 21

22. REFERENCES Nelson textbook of pediatrics National guidelines for Extra pulmonary TB Index TB guidelines Google images Tuberculous Meningitis 22

23. THANK YOU Tuberculous Meningitis 23

24. Tuberculous Meningitis 24

25. TUBERCULIN SKIN TEST Induration ≥5 mm Close contact - known/suspected contagious people with TB Children suspected to have TB Findings on CXR consistent with active/previously TB disease Clinical evidence of tuberculosis disease Children receiving Immunosuppressive therapy or Immunosuppressive conditions - HIV infection Tuberculous Meningitis 25

26. Induration ≥10 mm Children at increased risk of disseminated TB Children younger than 4 yr of age Children - Hodgkin disease/Lymphoma/DM/CRF/Malnutrition Children with increased exposure to tuberculosis disease Children often exposed to adults who are HIV infected / homeless / Users of illicit drugs Residents of nursing homes / Migrant farm workers Children who travel to high-prevalence regions of the world Tuberculous Meningitis 26

27. Induration ≥15  mm Children ≥4 yr of age without any risk factors Tuberculous Meningitis 27