The classical ct features of basal exudates, hydrocephalus, infarcts and granulomas have been mostly reported in younger individuals. Tuberculous meningitis tbm is the most severe form of infection caused by mycobacterium tuberculosis, causing death or disability in more than half of those affected. When allowed to progress without treatment, coma and death almost always ensue. Characteristic cerebrospinal fluid csf findings of tbm include a lymphocyticpredominant pleiocytosis, elevated protein, and low. A case of miliary tuberculosis with tuberculous meningitis. Important infective causes include partially treated bacterial. In as many as one third of cases, no cause is found. It is the most severe form of extrapulmonary mycobacterium tuberculosis. Tuberculous meningitis is the most severe form of tb, difficult to diagnose and treat, and with a grim prognosis.
Tuberculous meningitis tbm is a debilitating form of cns tuberculosis with a high morbidity and mortality in spite of treatment. Magnetization transfer mr imaging in cns tuberculosis. Tb meningitis typically causes a thick basilar exudate that is associated with meningeal enhancement. Chronic meningitis is defined as the persistence of clinical symptoms and signs of meningitis, with or without abnormal cerebrospinal fluid, for more than four weeks. Mri brain revealed multiple tuberculoma with thick basal meningeal enhancement. Focal basal meningeal enhancement may produce a confusing ct picture in children with suspected tuberculous meningitis tbm. Tbm is rare in developed countries with about 100 to 150 cases. In most patients with tuberculous meningitis there is a history of vague ill health lasting 28 weeks prior to the development of meningeal irritation. The fact remains that there is still no single diagnostic method which is both sufficiently rapid and sensitive. Tuberculosis tb is an infectious disease usually caused by mycobacterium tuberculosis mtb bacteria. However, meningeal nodules or plaques showing contrast enhancement on imaging may be difficult to distinguish from meningitides of bacterial or malignant origins without appropriate history and investigations. A total of 107 tuberculomas in seven patients with or without meningitis. Meningitis is inflammation of the subarachnoid space, the fluid bathing the brain. Spinal cord involvement in tuberculous meningitis spinal cord.
Disseminated tuberculosis manifesting as pulmonary, meningeal. List of tuberculous meningitis medications 7 compared. Tuberculosis remains a global health problem, with an estimated 10. Cns tuberculosis may simulate other granulomas and meningitis on mr images. Although the incidence of tuberculous meningitis tbm is low in highincome countries, it remains one of the most severe and eventually fatal infectious conditions especially in times of increasing use of. The diagnosis is based on clinical, radiological and laboratory features. Tuberculous meningitis tbm can occur as the sole manifestation of tb or concurrent with pulmonary or other extrapulmonary sites of infection. The most lethal and disabling form of tuberculosis is tuberculous meningitis tbm, for which more than 100,000 new cases are estimated to occur per year. Tuberculous meningitis radiology reference article. Tuberculous meningitis tbm is the most frequent form of central nervous system cns tuberculosis. Clinicoradiological features of tuberculous meningitis in. Tuberculous meningitis tm is difficult to diagnose and treat. Tuberculosis, meningeal definition of tuberculosis.
Comprehensive prevention effort, prompt diagnosis and rational treatment are all keys to improving treatment outcomes. Characteristic cerebrospinal fluid csf findings of tbm include a lymphocyticpredominant pleiocytosis, elevated protein, and low glucose. The prodromal symptoms in infants include irritability, drowsiness, poor feeding, and abdominal pain. Localized basal meningeal enhancement in tuberculous. Liquoral findings strongly suggested a diagnosis of tuberculous meningitis, and culture results were positive for mycobacterium tuberculosis. Tuberculous meningitis is an infection of the tissues covering the brain and spinal cord meninges. Dec 07, 2017 liquoral findings strongly suggested a diagnosis of tuberculous meningitis, and culture results were positive for mycobacterium tuberculosis. Spinal cord involvement in tuberculous meningitis spinal.
Encephalitis is inflammation of the brain tissue itself. Correlation between meningeal signal abnormalities and parenchymal signal abnormalities and clinical setting is mandatory for appropriate differential diagnosis. Twentysix patients with intracranial tuberculosis tb 10 with acute meningitis, 5 with chronic meningitis, 5 with meningitic sequelae and 6 with localized tuberculomas were examined with mr before and after gddtpa enhancement 0. Tuberculous meningitis an overview sciencedirect topics. Meningeal enhancement was seen in 48% of the ct studies with intravenous contrast medium and in 3 cases studied with mri and iv gadolinium dpta, in 2 of which ct was negative. The most lethal and disabling form of tuberculosis is. The purpose of this study was to improve the characterization of lesions in cns tuberculosis and to assess the disease load using magnetization transfer mt imaging. On examination, the patient had positive kernigs sign, right third. Meningeal tuberculosis is also known as tubercular meningitis or tb meningitis. Tuberculous meningitis is caused by mycobacterium tuberculosis.
Tuberculous meningitis is an important global medical problem which gives rise to high morbidity and mortality. Meningeal infection with mycobacterium tuberculosis is the example par excellence of a form of meningitis where difficulties in diagnosis and management regularly occur. The patient received antitubercular therapy with initial treatment with steroids and he improved clinically at the end of a 9month treatment. In general, treatment should be at least nine months in duration and should be comprised of at least four agents to which the m. Disseminated tuberculosis is characterised by concurrent tubercular involvement of two or more noncontiguous organs. The aim of this study is to assess the current epidemiology, clinical features, diagnostic procedures, treatment and outcome in patients with tuberculous meningitis in denmark, a country with a. A rare complication of central nervous system tuberculosis siavash vaziria, saeed soleimanmeigoonib, jalil rajabic, ali asgaric adepartment of infectious diseases, faculty of medicine, kermanshah university of medical sciences, kermanshah, iran binfectious diseases research center, aja university of medical sciences, tehran, iran. When collecting csf for suspected tb meningitis, a minimum of 1ml of fluid should be taken preferably 5 to 10ml. Ct brain findings in children with tuberculous meningitis meningeal enhancement is more common in this study.
Focal neurologic findings and seizures are more characteristic of encephalitis, whereas meningeal irritation is more. This case report describes the presentation and management issues of mtb along with tb meningitis in icu. Treatment includes four drugs, which were developed more than 30 years ago, and prevents death or disability in less than half of patients. Difficult and recurrent meningitis journal of neurology. Basal enhancement 89% on contrast enhanced ct was reported as most sensitive feature of tbm in a study and the same study reported hyperdensity 100% of non contrast ct being most specific. We investigated for other possible diagnoses such as pyogenic and fungal brain abscess, toxoplasmosis, and endocarditis by serologic and routine microbiological assays.
Miliary tuberculosis mtb is very rare in the intensive care unit icu and carries a significant risk of death. Predictors of stroke in patients of tuberculous meningitis. Apr 21, 2015 meningeal tuberculosis was present in 5. Pdf tuberculous meningitis basal cistern enhancement. Mri contribution to diagnosis 373 figure 1 axial t1weighted mr image after administration of iv gadolinium showing basilar meningeal enhancement with tuberculomas of the olfactory bands and two cerebellar lesions. Gddtpa enhanced mr imaging in intracranial tuberculosis.
The bacteria spread to the brain and spine from another place in the body, usually the lung. Onethird of the worlds population is infected with latent tb. The csf usually has a high protein, low glucose and a raised number of lymphocytes. The dura mater or pachymeninx corresponds to the outer meningeal layer. Disseminated tuberculosis manifesting as pulmonary. Here we report a rare case of diffuse leptomeningeal glioneuronal tumor dlgnt in a 62yearold male patient misdiagnosed as having tuberculous meningitis. Ultrasound neck revealed saccular aneurysm measuring 4 x 3 cm, located in between common carotid arteries with an eccentric thrombus. In patients who are coinfected with hiv1, tbm has a mortality approaching 50%.
Classic features of bacterial meningitis, such as stiff neck and fever, may be absent. Diagnosis, initial management, and prevention of meningitis. Ct was normal in one quarter, the most frequent findings being hydrocephalus 51% and meningeal enhancement 41%, commonly seen together 31. Tuberculosis generally affects the lungs, but can also affect other parts of the body. Due to its rarity and radiologic findings of leptomeningeal enhancement in the basal cisterns on magnetic resonance imaging mri similar to tuberculous meningitis, dlgnt in this patient was initially diagnosed as communicating. Due to its rarity and radiologic findings of leptomeningeal enhancement in the basal cisterns on magnetic resonance imaging mri similar to tuberculous meningitis, dlgnt in this patient was initially diagnosed as. Uncommonly tuberculosis can be limited to the pachymeninges dura mater, it is called tuberculous pachymeningitis and is discussed separately. The external layer, corresponding to the periosteum of the inner table, is highly vascularized and 2 the internal layer corresponding to the true meningeal dura mater. Medications for tuberculous meningitis medication list about tuberculous meningitis.
Cerebrospinal fluid was positive for mycobacterium tuberculosis. Acidfast bacilli are sometimes seen on a csf smear, but more commonly, m. Sometimes it may present with cranial nerve deficits, or it may have a more indolent course involving headache, meningismus, and altered mental status. Tuberculous meningitis is a bacterial infection of the membranes covering the brain and spinal cord meninges, caused by mycobacterium tuberculosis. Rheumatoid meningitis is a rare, potentially treatable condition that can mimic a wide range of neurological conditions, including vascular syndromes and encephalopathies. The presence of meningeal enhancement is non specific. Background focal basal meningeal enhancement may produce a confusing ct picture in children with suspected tuberculous meningitis tbm. Cns imaging computed tomography ct hydrocephalus 90% basal meningeal enhancement infarcts, tuberculoma mri more sensitive than ct hydrocephalus basal meningeal enhancement infarcts, tuberculoma especially of brainstem. Tuberculosis tb is one of the most important infectious diseases and one of ten most common causes of death globally,1 with almost 10 million new cases per year and 1. Chronic and recurrent meningitis practical neurology.
Background tuberculous meningitis is a severe extra pulmonary complications of tuberculosis, with high morbidity and mortality rates objectives to assess the relationship between presenting clinical characteristic and outcomes of pediatric tuberculous meningitis methods we present a case. Meningeal tb should be suspected in patients who have signs and symptoms of tb disease e. It is an unusual presentation of tuberculosis, especially in the absence of immunodeficiency. Here we describe a patient with rheumatoid meningitis who presented to a hyperacute stroke unit with. Pdf localized basal meningeal enhancement in tuberculous. To demonstrate the incidence, distribution and appearance of localized. Tuberculous meningitis is the most common presentation of intracranial tuberculosis, and usually refers to infection of the leptomeninges. When diagnosed promptly, tbm can be cured with supervised medication. Study of tbm pathogenesis is hampered by a lack of experimental models. However, outcome of tuberculous meningitis in our study was also found to be associated with many other factors such as cranial nerve and focal neurologic deficits, vision impairment, meningeal enhancement, advanced stage of tuberculous meningitis, low glasgow coma scale score, baselinemodified rankin scale and high protein content of csf. All three categories are encountered frequently in regions of the world where the incidence of tb is high and the prevalence of postprimary dissemination is common among. Tuberculous meningitis can cause significant permanent disability and high mortality, despite prompt administration of therapy.
The early diagnosis of localized basal meningeal enhancement in children with tuberculous meningitis tbm, however, remains difficult tbm. Uncommonly tuberculosis can be limited to the pachymeninges dura mater, it is called tuberculous pachymen. Presentation material is for education purposes only. Dec 21, 2011 meningitis is the most deadly form of tb, particularly in persons coinfected with hiv. The clinical features of tbm are the result of basilar meningeal fibrosis and vascular inflammation. The mri shows the presence, in and over the sellar seat, with parasellar left extension, of tissue with irregular margins, marked inhomogeneous enhancement, and compression of optic chiasm and of the. Tuberculosis of the central nervous system postgraduate. These nonspecific symptoms include malaise, anorexia, fatigue, fever, myalgias, and headache. Ct scans of patients with 2, and delays in diagnosis and treatment are directly definite culture proven. It results in brain edema manifested by effacement of sulci. Tbm is typically a subacute disease with symptoms that may persist for weeks before diagnosis. The most lethal and disabling form of tuberculosis is tuberculous meningitis tbm, for which more than 100,000 new cases are estimated to occur per. Risk factors tb and tb meningitis can develop in children and adults of all ages.
These individuals are not clinically affected but carry a lifetime risk of 10% for developing active disease. A case of miliary tuberculosis with tuberculous meningitis in. Early diagnosis and treatment can dramatically reduce the high mortality associated with this disease. Tbm is associated with a high frequency of neurologic sequelae and mortality if not treated promptly 15. The detection of meningeal pathology on mri is based on the demonstration of dural andor leptomeningeal enhancement.
Objective to demonstrate the incidence, distribution and appearance of localized basal meningeal enhancement in. At the cerebral convexity, it is composed of two layers 1. Central nervous system cns tuberculosis tb includes three clinical categories. In the remainder, infective, neoplastic and socalled aseptic disorders may be identified.
Background tuberculosis tb is an important health concern of developing nations. Miliary tb, tb meningitis or both 1 y pleural disease 3 y peripheral lymphadenitis 110 y. At the spinal level, only the internal dural layer is present that extends laterally into. Despite a concurrent history of rheumatoid arthritis, patients often have no active synovitis.
Tuberculosis tb is a highly prevalent global human infection caused by mycobacterium tuberculosis mtb. Tb meningitis tuberculous meningitis can display symptoms such as aches and pains, loss of appetite and tiredness, with a persistent headache, there are around 150 200 cases of tb meningitis reported each year in the uk. However, a combination of basal meningeal enhancement, infarction and hydrocephalus was found to have a high specificity for the diagnosis of tb meningitis, whereas basal meningeal enhancement was. Tuberculous meningitis tbm is the most common form of central nervous system tuberculosis tb and has very high morbidity and mortality. To summarise, tbm can present as isolated interhemispheric exudates. We describe a young, immunocompetent patient who presented with fever, cough, headache, diplopia and paraparesis. Tuberculosis tb is one of the commonest causes of death due to infection worldwide.
Tuberculosis tb of the central nervous system is the most severe manifestation of extrapulmonary tb and constitutes approximately 1% of all new cases annually. Tuberculous meningitis tbm is caused by mycobacterium tuberculosis m. Tb meningitis may cause communicating or noncommunicating hydrocephalus, infarctions secondary to tuberculous periarteritis. Tuberculous meningitis is the most severe manifestation of extrapulmonary tuberculosis with a high mortality rate and a high rate of sequelae among survivors.