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INTRODUCTION
Meningitis is a clinical condition
characterized inflammation of meninges in
the central nervous system.
Menigitis can be caused by bacteria,
viruses, fungi, parasites, and noninfectious causes.
Tuberculous meningitis (TBM) is caused by
Mycobacterium tuberculosis and is the
most common form of central nervous
system (CNS) tuberculosis (TB).
EPIDEMIOLOGY
In worldwide, 8.8 million new TB cases
every year until 2010, of which 1.45
million died.
India, China, Indonesia, Nigeria and South
Africa have the most number of cases.
Prevalence is high 206 from 100.000
population
10 % TB patients also have CNS TB, most
commonly meningitis.
EPIDEMIOLOGY
TB Meningitis has high morbidity and
mortality.
Increased mortality and neurological
sequels caused by delaying in
diagnosis and treatment.
CLINICAL MANIFESTATION
The modified British Medical Research Council clinical
criteria for TM severity grades
Grade I
PATHOPHYSIOLOGY
1836
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
DIAGNOSIS
DIAGNOSIS
Symptom (proportion of patients affected)
Headache (5080%)
Fever (6095%)
Vomiting (3060%)
Photophobia (510%)
Anorexia (6080%)
Clinical sign (proportion of patients affected)
Neck stiffness (4080%)
Confusion (1030%)
Coma (3060%)
Any cranial nerve palsy (3050%)
Cranial nerve III palsy (515%)
Cranial nerve VI palsy (3040%)
Cranial nerve VII palsy (1020%)
Hemiparesis (1020%)
Paraparesis (510%)
Seizures (children: 50%; adults: 5%)
CSF (proportion or range)
Appearance (8090% clear)
Opening pressure (50% 25 cm H20)
Total leucocyte count (51000 x 103/ml)
Neutrophils (1070%)
Lymphocyte (3090%)
Protein (45250 mg/dL)*
Lactate (510 mmol/L)
CSF glucose to blood glucose ratio (<0,5 in 95%)
DIAGNOSIS
RADIOLOGY
LABORATORIUM
A. Lumbal Punction analysis CSF
Can Found Pleositosis dominated with
lymphocite cell, protein increase, low
glucose, lactat increase. AFB and
culture Mycobacterium tuberculosis.
B. XPERT/MTB-RIF
Recent meta-analysis calculated that
commercial nucleic acid amplification
(NAA) assays for the diagnosis of TBM
were 56% sensitive and 98% specific can
confirm cerebral tuberculosis, but cannot
rule it out.
Suspect
Suspect TBM
TBM ifif risk
risk factor
factor for
for
CNS
TB
(Box
A)
and
symptoms
CNS TB (Box A) and symptoms
dan
dan signs
signs (Box
(Box B)
B)
-Neurological abnormality
-Headache
-Vomiting/poor feeding
-Weight loss
-Irritability/lethargy
-Seizure (more in children)
-Confusing/coma
-Neck Stiffness
-Cranial nerve palsy
-Hemiparesis
Immediate Investigations
CXR
CT head ( with contrast) **
FBC, RF, LFT, electrolyte,
CRP, ESR
Blood culture*
HIV test
Lumbal puncture
Microbiology Lab
Take > 6 ml CSF for
mycobacterial studies (box
D)
No
AFB seen or PCR
positif in CSF
Are 2 or more of the following
pressent?
pressent? (consider
(consider repeating
repeating LP)
LP)
1 risk factor for CNS TB (Box A)
33 features
features suggestive
suggestive of
of TBM
TBM
(Box
(Box C)
C)
Evidence of TB elsewhere
No
Repeat LP within 48
hours
Expand search for TB
elsewhere
Consider MRI head
Yes
Are
Are 22 or
or more
more of
of the
the following
following
pressent? (consider repeating LP)
1 risk factor for CNS TB (Box A)
33 features
features suggestive
suggestive of
of TBM
TBM
(Box
(Box C)
C)
Evidence of TB elsewhere
No
Yes
Start
Start treatment
treatment
Yes
Yes
Does
Does patient
patient have
have unexplain
unexplain
meningitis,
meningitis, with
with low
low CSF
CSF
glucose,
glucose, falling
falling GCS,
GCS, or
or new
new
focal
focal neurology?
neurology?
Continue
Continue to
to investigate
investigate
with
with low
low threshold
threshold
empirical
empirical therapy
therapy
No
TREATMENT
ANTI TB agent
TREATMENT
Recomendation anti TB agent for TBM
TREATMENT
Corticosteroid therapy
Decision
Decision
for
for start
start
treatment
treatment
for
for TBM
TBM
High Risk
1. Known MDR contact
2. Likely infected in E Eropa,
old Soviet union, or S Afrika
3 Failed or failing treatment (ie.
never responded)
Risk
Risk
Assesment
Assesment
MDR
MDR TB
TB
(Box
(Box A)
A)
Medium Risk
1. Previously treated treated for
TB
2. HIV infected
Std
Std therapy
therapy
anti
anti TB
TB and
and
Steroid
Steroid (box
(box
B
B dan
dan D)
D)
Yes
No
High risk
for MDR
TB?
Yes
Review after
8weeks
TB culture
positif?
Yes
TB sensitivity
result available?
No
Fully sensitifve
Yes
No
Konsul
Konsul
neurologist
neurologist dan
dan
ahli
ahli Meningitis
Meningitis
TB
TB
Apply MDR
infection
control
procedure
Yes
Change
Change to
to std
std
continuation
continuation
treatment
(
Box
treatment ( Box
C
C dan
dan E)
E)
Plan
Plan to
to stop
stop
treatment
treatment at
at
52
52 weeks
weeks
Yes
Good response
to treatment?
Evidence
of PTB on
CXR
No
No
Change
Change to
to non
non
std
std continuation
continuation
treatment(
Box
treatment( Box
F)
F)
Isoniazid monoresisten
- Add quinolon at initial phase of
treatment
-Continuation therapy with rifampicin,
pyrazinamid, and fluorquinolon
-Planned treatment course of 12 months
-In case of oreganism with low level
resistance to isoniazid consider
continuing isoniazid throughout.
Rifampicin monoresisten
-Substitue quinolon for rifampicin in
initial phase of treatment
-Continuation treatment with isoniazid,
pyrazinamide, and fluorquinolon
-Planned treatment course of 18 months
Resistant with Isoniazid and
Rifampicin
- Consult MDR TB expert
Ventriculoperitoneal shunt
PROGNOSIS
Prognosis TBM time presentation,
neurologic status, and time to initial
treatment. TBM has high morbidity and
mortality, 7-65%.
Delayed in diagnosis and treatment will
increase mortality and neurologic sequele.
SUMMARY
TBM has high morbidity and mortality.
Clinical manifestation varies individually.
Pathophysiology of TBM, caused by hematogenous
spreading of tuberculous bacili, and formation of multiple
tuberculous nodules in the meningeal blood-vessels ,
discharge of tuberculous bacilli in the subarachnoid space,
and diffuse exsudative inflamation in the meninges .
Diagnosis TBM can work up with clinical score,
laboratorium and radiology.
Management TBM give anti tuberkulosis agent,
cortikosteroid, and surgery if there hydrocephalus and
probably increase patient outcome.
Poor Prognosis if delayed in diagnosis and treatment.
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