9.29.09 davis-hovda tb meningitis
Post on 02-Jun-2018
219 Views
Preview:
TRANSCRIPT
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
1/16
TB Meningitis9/29/2009 Morning Report
Maggie Davis Hovda
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
2/16
Incidence
2005: In the US there were 186 cases of
meningeal TB, which accounted for 6.3% of
all extrapulmonary TB In NC, there were 5 cases, 6.9%
2007: In the US, there were 170 cases of
meningeal TB, again 6.3% of cases
In NC, there were 5 cases, 6.9%
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
3/16
Incidence
In underdeveloped countries with higher
overall incidence of TB, TB meningitis is
more of a pediatric disease whereas indeveloped countries with lower incidence of
TB, meningitis is more of an adult disease.
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
4/16
Pathogenesis
TB Bacillemia (primary or late reactivation)
subependymal tubercles rupture into
the subarachnoid space
meningitis
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
5/16
Pathogenesis
Dense gelatinous exudate develops at the
base of the brain surround arteries and
CN at the base of the brain
hydrocephalus, vasculitisinfarction,
hemiplegia, quadriplegia
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
6/16
neuropathology.neoucom.edu
Tuberculous Meningitis. Donald and Shoerman,
NEJM. 351:17. 10/21/2004
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
7/16
Clinical Presentation
3 Stages
1 - Pts lucid at presentation w/o focal neuro signs
or hydrocephalus; prodromal, lasts 2-3 wks and
characterized by insidious onset of malaise, HA,
low-grade fever
2 Meningitic phase w/ meningismus, V,
lethargy, confusion, CN palsies, hemiparesis 3 Paralytic phase advance to stupor, coma,
seizure, hemiparesis.
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
8/16
Clinical Presentation
Most common clinical findings:
Fever
HA Vomiting
Nuchal Rigidity
AMS
CN Palsies, esp CN III
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
9/16
Diagnosis
CSF Examination
Usually lymphocytic pleocytosis
Paradoxic change from lymphocytic to neutrophilicpredominance over 48 hr pathognomonic for TB
meningitis
Elevated protein with severely depressed
glucose Repeated specimens for AFB culture necessary
ADA level
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
10/16
Diagnosis
Other Studies
Brain imaging demonstrates hydrocephalus,
basi lar exudates and inf lammation,
tuberculoma, cerebral edema, cerebral infarction
CXR
Abnormal, sometimes miliary pattern
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
11/16
Differential Diagnosis
Fungal Meningitis Crypto, Histo, Blasto, Cocci
Viral meningoencephalitis HSV, mumps
Parameningeal Infection Sphenoid sinusitis, brain abscess, spinal epidural abscess
Incompletely treated Bacterial meningitis
Neurosynphilis
Neoplastic Meningitis
Lymphoma Neurosarcoid
Neurobrucellosis
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
12/16
Treatment: Antimicrobial Therapy
Start as soon as there is suspicion for TBmeningitis
Same Guidelines as those for pulmonaryTB Intensive Phase: 4 drug regimen of Isoniazid,
Rifampin, Pyrazinamide, and Ethambutol orStreptomycin for 2 months
Continuation Phase: Isoniazid and Rifampin foranother 7 10 months
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
13/16
Treatment: Adjunctive Therapy
Glucocorticoids Indicated with:
rapid progression from one stage to the next
elevated OP on LP, CT evidence of cerebral edema
worsening clinical signs after starting antiTb meds
increased basilar enhancement, or moderate to advancing
hydrocephalus on head CT
Glucocorticoid Dosing: Dexamethasone 12
mg/d x 3 weeks followed by a slow taper
Surgery: Ventriculostomy placement
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
14/16
TB Meningitis in HIV population
Study in S Africa compared 20 HIV + pts vs. 17 HIV - pts
Similar findings in both groups:
Presentation: HA, neck stiffness, fever
CSF analysis: Similar amounts of lymphocytes, neutrophils,protein, glucose, ADA levels
Outcomes predicted by GCS score upon admission
-Differences
Both groups showed same incidence of abnormal Head CT, butHIV + more likely to have ventricular dilatation and infarct
HIV + patients were more likely to suffer no neurologic deficit ondischarge than HIV - pts
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
15/16
Outcomes
Overall Poor
Pts presenting in Stage I have 19% mortality
Pts presenting in Stage III have 69% mortality Only 1/3 - 1/2 of patients demonstrate complete
neurologic recovery
Up to 1/3 of patients have residual severe
neurologic deficits such as hemiparesis,blindness, seizure DO
-
8/11/2019 9.29.09 Davis-Hovda TB Meningitis
16/16
References
http://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdf
Donald, PR and Schoerman, JF. Tuberculous Meningitis.NEJM, 351:17. 2004.
Schutte, CM. Clincial, Cerebrospinal Fluid and PathologicalFindings and Outcomes in HIV-Positive and HIV-negativePatients with Tuberculous Meningitis. Infection 2001: 29:213-217.
Jacob, H et al. Acute Forms of Tuberculosis in Adults. TheAmerican Journal of Medicine (2009) 122, 12-17.
Principles and Practice of Infectious Diseases. 4th Ed, c1995.
Central Nervous System Tuberculosis. www.uptodate.com
http://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdfhttp://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdfhttp://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdfhttp://www.cdc.gov/TB/statistics/reports/surv2005/PDF/table27.pdf
top related