para>Streptomycin is not recommended.
Breastfeeding is not contraindicated.
‚
ADDITIONAL THERAPIES
Corticosteroids reduce death and residual neurologic deficits in HIV-negative people with tuberculous meningitis among those who survive. Insufficient evidence to support similar conclusions for those who are HIV positive. ‚
SURGERY/OTHER PROCEDURES
Reserved for treatment failures or if diagnosis is in doubt. ‚
- Tuberculous meningitis: surgical diversion of CSF for tuberculous meningitis associated with symptomatic elevated intracranial pressure (ICP) and noncommunicating hydrocephalus (ventriculoperitoneal shunt or external drainage)
- Tuberculoma
- Decompression or debulking recommended for large, symptomatic tuberculomas
- Surgery is considered for treatment failures or to relieve elevated ICP. Antituberculous therapy is continued to prevent seeding of meninges.
- Tubercular abscess: puncture, continuous drainage, fractional drainage, repeat aspiration through burr hole, stereotactic aspiration, or total excision
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Seizures control if present
- Isolation if pulmonary disease is present or until the patient has three negative sputum smears for AFB.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Look for other foci of infection.
- Institute seizure precautions.
- Neuropsychological surveillance
- Treat concurrent HIV infection, if present.
Patient Monitoring
- Assess for peripheral neuropathy and hepatotoxicity.
- Measure LFT monthly (or if symptomatic) for patients with preexisting liver disease or who develop abnormal LFT that does not require discontinuation of drug.
- Monthly visual acuity and red " “green color discrimination testing if receiving EMB; refer to ophthalmology if abnormal.
- Observe for possible drug " “drug interactions
- Contrast-enhanced CT scan in patients with tuberculoma on medical treatment every 3 to 6 months until lesions stabilize and symptoms resolve.
- Hormonal evaluation (e.g., thyrotropin, cortisol, prolactin) in pituitary TB
DIET
Pyridoxine supplementation (25 mg/day) in patients may prevent neuropathy (poor nutritional status, diabetes, HIV infection, pregnancy, alcohol use), especially if taking isoniazid. ‚
PATIENT EDUCATION
Emphasize the importance of adherence to drug therapy. Discuss common adverse effects of anti-TB medications and common drug " “drug interactions. ‚
PROGNOSIS
- Adults
- Stage/grade I: alert and oriented without focal neurologic deficits; mortality rate is 18%.
- Stage/grade II: Glasgow Coma Scale (GCS) 11 to 14 or 15 with focal neurologic deficits; mortality rate is 34%.
- Stage/grade III: GCS ≤10; mortality rate of 72%
- Children
- Stage/grade I: nonspecific constitutional symptoms (headache, nausea, fussiness, fever); mortality rate is 0%.
- Stage/grade II: CN palsies (especially CN III, VI, VII) and signs of meningeal irritation; mortality rate of 12%
- Stage/grade III: altered mental status with signs of increased ICP; mortality rate of 49%
COMPLICATIONS
Visual deterioration, focal deficits, cognitive deterioration, paraplegia, hormonal deficiencies, shunt block or infection, or side effects of therapy ‚
REFERENCES
11 Thuong ‚ NT, Hawn ‚ TR, Thwaites ‚ GE, et al. A polymorphism in human TLR2 is associated with increased susceptibility to tuberculous meningitis. Genes Immun. 2007;8(5):422 " “428.22 Trunz ‚ BB, Fine ‚ P, Dye ‚ C. Effect of BCG vaccination on childhood tuberculous meningitis and miliary tuberculosis worldwide: a meta-analysis and assessment of cost-effectiveness. Lancet. 2006;367(9517):1173 " “1180.33 Thwaites ‚ G, Fisher ‚ M, Hemingway ‚ C, et al. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect. 2009;59(3):167 " “187.44 Denkinger ‚ CM, Schumacher ‚ SG, Boehme ‚ CC, et al. Xpert MTB/RIF assay for the diagnosis of extrapulmonary tuberculosis: a systematic review and meta-analysis. Eur Respir J. 2014;44(2):435 " “446.55 Prasad ‚ K, Singh ‚ MB. Corticosteroids for managing tuberculous meningitis. Cochrane Database Syst Rev. 2008;(1):CD002244.66 Thwaites ‚ GE, van Toorn ‚ R, Schoeman ‚ J. Tuberculous meningitis: more questions, still too few answers. Lancet Neurol. 2013;12(10):999 " “1010.
ADDITIONAL READING
- DeLance ‚ AR, Safaee ‚ M, Oh ‚ MC, et al. Tuberculoma of the central nervous system. J Clin Neurosci. 2013;20(10):1333 " “1341.
- Kadhiravan ‚ T, Deepanjali ‚ S. Role of corticosteroids in the treatment of tuberculosis: an evidence-based update. Indian J Chest Dis Allied Sci. 2010;52(3):153 " “158.
- Nelson ‚ CA, Zunt ‚ JR. Tuberculosis of the central nervous system in immunocompromised patients: HIV infection and solid organ transplant recipients. Clin Infect Dis. 2011;53(9):915 " “926.
- van der Harst ‚ JJ, Luijckx ‚ GJ. Treatment of central nervous system tuberculosis infections and neurological complications of tuberculosis treatment. Curr Pharm Des. 2011;17(27):2940 " “2947.
CODES
ICD10
- A17.9 Tuberculosis of nervous system, unspecified
- A17.0 Tuberculous meningitis
- A17.81 Tuberculoma of brain and spinal cord
- A17.82 Tuberculous meningoencephalitis
- A17.1 Meningeal tuberculoma
- A17.83 Tuberculous neuritis
- A17.89 Other tuberculosis of nervous system
ICD9
- 013.90 Unspecified tuberculosis of central nervous system, unspecified
- 013.00 Tuberculous meningitis, unspecified
- 013.20 Tuberculoma of brain, unspecified
- 013.60 Tuberculous encephalitis or myelitis, unspecified
- 013.80 Other specified tuberculosis of central nervous system, unspecified
- 013.50 Tuberculous abscess of spinal cord, unspecified
- 013.30 Tuberculous abscess of brain, unspecified
- 013.10 Tuberculoma of meninges, unspecified
- 013.40 Tuberculoma of spinal cord, unspecified
SNOMED
- tuberculosis of central nervous system (disorder)
- Tuberculosis of meninges (disorder)
- Tuberculosis of brain
- Tuberculous encephalitis
- Tuberculoma of spinal cord
CLINICAL PEARLS
- Include four drugs (isoniazid, rifampin, pyrazinamide, and ethambutol) for 2 months for initial treatment of CNS TB, followed by isoniazid and rifampin for 10 months.
- Adjunctive dexamethasone or prednisolone is recommended for tuberculous meningitis and tuberculoma.