Tuberculous meningitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Tuberculous meningitis is Mycobacterium tuberculosis infection of the meninges. It is the most common form of CNS tuberculosis.

Tuberculous meningitis is caused by Mycobacterium tuberculosis, the bacteria that causes tuberculosis. The bacteria spreads to the brain and spine from another site in the body. Tuberculous meningitis is a very rare disorder in the U.S.

Fever and headache are the cardinal features. Confusion is a late feature and coma bears a poor prognosis. Meningism is absent in a fifth of patients with TB meningitis. Patients may also have focal neurological deficits.

Diagnosis of TB meningitis is made by analysing CSF collected by lumbar puncture. When collecting CSF for suspected TB meningitis, a minimum of 1ml of fluid should be taken (preferably 5 to 10ml).

Imaging studies such as CT or MRI may show features strongly suggestive of TB meningitis, but cannot diagnose it.

The treatment of TB meningitis is isoniazid, rifampicin, pyrazinamide and ethambutol for two months, followed by isoniazid and rifampicin alone for a further ten months. Steroids are always used in the first six weeks of treatment (and sometimes for longer). A few patients may require immunomodulatory agents such as thalidomide. Treatment must be started as soon as there is a reasonable suspicion of the diagnosis. Treatment must not be delayed while waiting for confirmation of the diagnosis.

Hydrocephalus occurs as a complication in about a third of patients with TB meningitis and will require a ventricular shunt.

The BCG vaccine may help prevent severe forms of tuberculosis, such as meningitis, in very young children who live in areas where the disease is common.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Mycobacterium tuberculosis of the meninges is the most telling feature of tuberculous meningitis. Inflammation is concentrated towards the base of the brain. Infection begins in the lungs and may spread to the meninges by a variety of routes.

Blood-borne spread certainly occurs and 25% of patients with miliary TB have TB meningitis, presumably by crossing the blood-brain barrier^[1]; but a proportion of patients may get TB meningitis from rupture of a cortical focus in the brain (a so-called Rich focus); an even smaller proportion get it from rupture of a bony focus in the spine. It is rare and unusual for TB of the spine to cause TB of the central nervous system, but isolated cases have been described.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Tuberculous meningitis is caused by Mycobacterium tuberculosis, the bacteria that causes tuberculosis. The bacteria spreads to the brain and spine from another site in the body. Tuberculous meningitis is a very rare disorder in the U.S.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Risk factors include a history of:

• AIDS
• Excessive alcohol use
• Pulmonary tuberculosis
• Weakened immune system

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

• Brain damage
• Build-up of fluid between the skull and brain (subdural effusion)
• Hearing loss
• Hydrocephalus
• Seizures

Tuberculous meningitis is life threatening if untreated. Long-term follow-up is needed to detect repeated infections (recurrences).

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