1887
No metrics data to plot.
The attempt to load metrics for this article has failed.
The attempt to plot a graph for these metrics has failed.

Central Nervous System Tuberculosis

MyBook is a cheap paperback edition of the original book and will be sold at uniform, low price.
Buy this Microbiology Spectrum Article
Price Non-Member $15.00
  • Author: John M. Leonard1
  • Editor: David Schlossberg2
  • VIEW AFFILIATIONS HIDE AFFILIATIONS
    Affiliations: 1: Department of Medicine—Infectious Disease, Vanderbilt University Medical Center, Nashville, TN 37232; 2: Philadelphia Health Department, Philadelphia, PA
  • Source: microbiolspec March 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0044-2017
  • Received 30 September 2016 Accepted 23 January 2017 Published 10 March 2017
  • John M. Leonard, john.m.leonard@vanderbilt.edu
image of Central Nervous System Tuberculosis
    Preview this microbiology spectrum article:
    Zoom in
    Zoomout

    Central Nervous System Tuberculosis, Page 1 of 2

    | /docserver/preview/fulltext/microbiolspec/5/2/TNMI7-0044-2017-1.gif /docserver/preview/fulltext/microbiolspec/5/2/TNMI7-0044-2017-2.gif
  • Abstract:

    Central nervous system tuberculosis (CNS-TB) takes three clinical forms: meningitis (TBM), intracranial tuberculoma, and spinal arachnoiditis. TBM predominates in the western world and presents as a subacute to chronic meningitis syndrome with a prodrome of malaise, fever, and headache progressing to altered mentation and focal neurologic signs, followed by stupor, coma, and death within five to eight weeks of onset. The CSF formula typically shows a lymphocytic pleocytosis, and low glucose and high protein concentrations. Diagnosis rests on serial samples of CSF for smear and culture, combined with CSF PCR. Brain CT and MRI aid in diagnosis, assessment for complications, and monitoring of the clinical course. In a patient with compatible clinical features, the combination of meningeal enhancement and any degree of hydrocephalus is strongly suggestive of TBM. Vasculitis leading to infarcts in the basal ganglia occurs commonly and is a major determinant of morbidity and mortality. Treatment is most effective when started in the early stages of disease, and should be initiated promptly on the basis of strong clinical suspicion without waiting for laboratory confirmation. The initial 4 drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol) covers the possibility of infection with a resistant strain, maximizes antimicrobial impact, and reduces the likelihood of emerging resistance on therapy. Adjunctive corticosteroid therapy has been shown to reduce morbidity and mortality in all but late stage disease.

  • Citation: Leonard J. 2017. Central Nervous System Tuberculosis. Microbiol Spectrum 5(2):TNMI7-0044-2017. doi:10.1128/microbiolspec.TNMI7-0044-2017.

Key Concept Ranking

Magnetic Resonance Imaging
0.4676716
Brain Lesions
0.4547658
0.4676716

References

1. Bahemuka M, Murungi JH. 1989. Tuberculosis of the nervous system. A clinical, radiological and pathological study of 39 consecutive cases in Riyadh, Saudi Arabia. J Neurol Sci 90:67–76. [PubMed]
2. Centers for Disease Control and Prevention. 2010. Data and statistics. Centers for Disease Control and Prevention, Atlanta, GA. http://www.cdc.gov/tb/surv/statistics/default.htm.
3. Centers for Disease Control and Prevention. October 2015. Reported Tuberculosis in the United States, 2014. Centers for Disease Control and Prevention, Atlanta, GA. http://www.cdc.gov/tb/statistics/reports/2014.
4. Centers for Disease Control and Prevention. 2005. Extrapulmonary tuberculosis cases and percentages by site of disease: reporting areas, 2005. Centers for Disease Control and Prevention, Atlanta, GA. http://www.cdc.gov/tb/surv2005/PDF/tabl27.pdf.
5. Rieder HL, Snider DE, Jr, Cauthen GM. 1990. Extrapulmonary tuberculosis in the United States. Am Rev Respir Dis 141:347–351. [PubMed]
6. Rich AR, McCordock HA. 1933. The pathogenesis of tuberculous meningitis. Bull Johns Hopkins Hosp 52:5–37.
7. Sharma SK, Mohan A, Sharma A, Mitra DK. 2005. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis 5:415–430. [PubMed]
8. Slavin RE, Walsh TJ, Pollack AD. 1980. Late generalized tuberculosis: a clinical pathologic analysis and comparison of 100 cases in the preantibiotic and antibiotic eras. Medicine (Baltimore) 59:352–366.
9. Dastur DK, Manghani DK, Udani PM. 1995. Pathology and pathogenetic mechanisms in neurotuberculosis. Radiol Clin North Am 33:733–752. [PubMed]
10. Goldzieher JW, Lisa JR. 1947. Gross cerebral hemorrhage and vascular lesions in acute tuberculous meningitis and meningo-encephalitis. Am J Pathol 23:133–145. [PubMed]
11. Chan KH, Cheung RT, Lee R, Mak W, Ho SL. 2005. Cerebral infarcts complicating tuberculous meningitis. Cerebrovasc Dis 19:391–395. [PubMed]
12. Poltera AA. 1977. Thrombogenic intracranial vasculitis in tuberculous meningitis. A 20 year “post mortem” survey. Acta Neurol Belg 77:12–24. [PubMed]
13. Bhargava S, Gupta AK, Tandon PN. 1982. Tuberculous meningitis—a CT study. Br J Radiol 55:189–196. [PubMed]
14. Hinman AR. 1967. Tuberculous meningitis at Cleveland Metropolitan General Hospital 1959 to 1963. Am Rev Respir Dis 95:670–673. [PubMed]
15. Kennedy DH, Fallon RJ. 1979. Tuberculous meningitis. JAMA 241:264–268. [PubMed]
16. Kent SJ, Crowe SM, Yung A, Lucas CR, Mijch AM. 1993. Tuberculous meningitis: a 30-year review. Clin Infect Dis 17:987–994. [PubMed]
17. Farinha NJ, Razali KA, Holzel H, Morgan G, Novelli VM. 2000. Tuberculosis of the central nervous system in children: a 20-year survey. J Infect 41:61–68. [PubMed]
18. Porkert MT, Sotir M, Parrott-Moore P, Blumberg HM. 1997. Tuberculous meningitis at a large inner-city medical center. Am J Med Sci 313:325–331. [PubMed]
19. Verdon R, Chevret S, Laissy JP, Wolff M. 1996. Tuberculous meningitis in adults: review of 48 cases. Clin Infect Dis 22:982–988. [PubMed]
20. Udani PM, Dastur DK. 1970. Tuberculous encephalopathy with and without meningitis. Clinical features and pathological correlations. J Neurol Sci 10:541–561.
21. Braun MM, Byers RH, Heyward WL, Ciesielski CA, Bloch AB, Berkelman RL, Snider DE. 1990. Acquired immunodeficiency syndrome and extrapulmonary tuberculosis in the United States. Arch Intern Med 150:1913–1916. [PubMed]
22. Bishburg E, Sunderam G, Reichman LB, Kapila R. 1986. Central nervous system tuberculosis with the acquired immunodeficiency syndrome and its related complex. Ann Intern Med 105:210–213. [PubMed]
23. Berenguer J, Moreno S, Laguna F, Vicente T, Adrados M, Ortega A, González-LaHoz J, Bouza E. 1992. Tuberculous meningitis in patients infected with the human immunodeficiency virus. N Engl J Med 326:668–672. [PubMed]
24. Dubé MP, Holtom PD, Larsen RA. 1992. Tuberculous meningitis in patients with and without human immunodeficiency virus infection. Am J Med 93:520–524. [PubMed]
25. Katrak SM, Shembalkar PK, Bijwe SR, Bhandarkar LD. 2000. The clinical, radiological and pathological profile of tuberculous meningitis in patients with and without human immunodeficiency virus infection. J Neurol Sci 181:118–126.
26. Perez Blazquez E, Montero Rodriguez M, Mendez Ramos MJ. 1994. Tuberculous choroiditis and acquired immunodeficiency syndrome. Ann Ophthalmol 26:50–54. [PubMed]
27. Smith J, Godwin-Austen R. 1980. Hypersecretion of anti-diuretic hormone due to tuberculous meningitis. Postgrad Med J 56:41–44. [PubMed]
28. Karandanis D, Shulman JA. 1976. Recent survey of infectious meningitis in adults: review of laboratory findings in bacterial, tuberculous, and aseptic meningitis. South Med J 69:449–457. [PubMed]
29. Kocen RS, Parsons M. 1970. Neurological complications of tuberculosis: some unusual manifestations. Q J Med 39:17–30. [PubMed]
30. Thwaites GE, Chau TT, Farrar JJ. 2004. Improving the bacteriological diagnosis of tuberculous meningitis. J Clin Microbiol 42:378–379. [PubMed]
31. Bonington A, Strang JI, Klapper PE, Hood SV, Rubombora W, Penny M, Willers R, Wilkins EG. 1998. Use of Roche AMPLICOR Mycobacterium tuberculosis PCR in early diagnosis of tuberculous meningitis. J Clin Microbiol 36:1251–1254. [PubMed]
32. Kaneko K, Onodera O, Miyatake T, Tsuji S. 1990. Rapid diagnosis of tuberculous meningitis by polymerase chain reaction (PCR). Neurology 40:1617–1618. [PubMed]
33. Noordhoek GT, Kolk AH, Bjune G, Catty D, Dale JW, Fine PE, Godfrey-Faussett P, Cho SN, Shinnick T, Svenson SB, Wilson S, van Embden JA. 1994. Sensitivity and specificity of PCR for detection of Mycobacterium tuberculosis: a blind comparison study among seven laboratories. J Clin Microbiol 32:277–284. [PubMed]
34. Pai M, Flores LL, Pai N, Hubbard A, Riley LW, Colford JM, Jr. 2003. Diagnostic accuracy of nucleic acid amplification tests for tuberculous meningitis: a systematic review and meta-analysis. Lancet Infect Dis 3:633–643.
35. World Health Organization. 2015. Implementing tuberculosis diagnostics. Policy framework. World Health Organization, Geneva, Switzerland. http://www.who.int/tb/publications/implementing_TB_diagnostics/en/.
36. Bernaerts A, Vanhoenacker FM, Parizel PM, Van Goethem JW, Van Altena R, Laridon A, De Roeck J, Coeman V, De Schepper AM. 2003. Tuberculosis of the central nervous system: overview of neuroradiological findings. Eur Radiol 13:1876–1890. [PubMed]
37. Kumar R, Kohli N, Thavnani H, Kumar A, Sharma B. 1996. Value of CT scan in the diagnosis of meningitis. Indian Pediatr 33:465–468. [PubMed]
38. Lamprecht D, Schoeman J, Donald P, Hartzenberg H. 2001. Ventriculoperitoneal shunting in childhood tuberculous meningitis. Br J Neurosurg 15:119–125. [PubMed]
39. Schoeman J, Donald P, van Zyl L, Keet M, Wait J. 1991. Tuberculous hydrocephalus: comparison of different treatments with regard to ICP, ventricular size and clinical outcome. Dev Med Child Neurol 33:396–405. [PubMed]
40. Ozateş M, Kemaloglu S, Gürkan F, Ozkan U, Hoşoglu S, Simşek MM. 2000. CT of the brain in tuberculous meningitis. A review of 289 patients. Acta Radiol 41:13–17. [PubMed]
41. Kingsley DP, Hendrickse WA, Kendall BE, Swash M, Singh V. 1987. Tuberculous meningitis: role of CT in management and prognosis. J Neurol Neurosurg Psychiatry 50:30–36. [PubMed]
42. Schoeman J, Hewlett R, Donald P. 1988. MR of childhood tuberculous meningitis. Neuroradiology 30:473–477. [PubMed]
43. Dastur DK. 1983. Neurosurgically relevant aspects of pathology and pathogenesis of intracranial and intraspinal tuberculosis. Neurosurg Rev 6:103–110. [PubMed]
44. van Dyk A. 1988. CT of intracranial tuberculomas with specific reference to the “target sign.” Neuroradiology 30:329–336. [PubMed]
45. Weisberg LA. 1984. Granulomatous diseases of the CNS as demonstrated by computerized tomography. Comput Radiol 8:309–317.
46. Whelan MA, Stern J. 1981. Intracranial tuberculoma. Radiology 138:75–81. [PubMed]
47. Teoh R, Humphries MJ, O’Mahony G. 1987. Symptomatic intracranial tuberculoma developing during treatment of tuberculosis: a report of 10 patients and review of the literature. Q J Med 63:449–460. [PubMed]
48. Traub M, Colchester AC, Kingsley DP, Swash M. 1984. Tuberculosis of the central nervous system. Q J Med 53:81–100. [PubMed]
49. Bagga A, Kalra V, Ghai OP. 1988. Intracranial tuberculoma. Evaluation and treatment. Clin Pediatr 27:487–490. [PubMed]
50. Harder E, Al-Kawi MZ, Carney P. 1983. Intracranial tuberculoma: conservative management. Am J Med 74:570–576. [PubMed]
51. Tandon PN, Bhargava S. 1985. Effect of medical treatment on intracranial tuberculoma—a CT study. Tubercle 66:85–97. [PubMed]
52. Wadia NH, Dastur DK. 1969. Spinal meningitides with radiculo-myelopathy. 1. Clinical and radiological features. J Neurol Sci 8:239–260. [PubMed]
53. Naim-ur-Rahman. 1980. Atypical forms of spinal tuberculosis. J Bone Joint Surg Br 62-B:162–165. [PubMed]
54. Mitchison DA. 2000. Role of individual drugs in the chemotherapy of tuberculosis. Int J Tuberc Lung Dis 4:796–806. [PubMed]
55. Ellard GA, Humphries MJ, Allen BW. 1993. Cerebrospinal fluid drug concentrations and the treatment of tuberculous meningitis. Am Rev Respir Dis 148:650–655. [PubMed]
56. Somner AR, British Thoracic Association. 1981. A controlled trial of six months chemotherapy in pulmonary tuberculosis. First report: results during chemotherapy. Br J Dis Chest 75:141–153.
57. Chatterjee VKK, Buchanan DR, Friedmann AI, Green M. 1986. Ocular toxicity following ethambutol in standard dosage. Br J Dis Chest 80:288–291. [PubMed]
58. American Thoracic Society, CDC, Infectious Diseases Society of America. 2003. Treatment of tuberculosis. MMWR Recommend Rep 52(RR-11):1–77. [PubMed]
59. Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O’Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. 2016. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: treatment of drug-susceptible tuberculosis. Clin Infect Dis 63:e147–e195.
60. Thwaites GE, Lan NT, Dung NH, Quy HT, Oanh DT, Thoa NT, Hien NQ, Thuc NT, Hai NN, Bang ND, Lan NN, Duc NH, Tuan VN, Hiep CH, Chau TT, Mai PP, Dung NT, Stepniewska K, White NJ, Hien TT, Farrar JJ. 2005. Effect of antituberculosis drug resistance on response to treatment and outcome in adults with tuberculous meningitis. J Infect Dis 192:79–88. [PubMed]
61. Berning SE, Cherry TA, Iseman MD. 2001. Novel treatment of meningitis caused by multidrug-resistant Mycobacterium tuberculosis with intrathecal levofloxacin and amikacin: case report. Clin Infect Dis 32:643–646.
62. Girgis NI, Farid Z, Kilpatrick ME, Sultan Y, Mikhail IA. 1991. Dexamethasone adjunctive treatment for tuberculous meningitis. Pediatr Infect Dis J 10:179–183. [PubMed]
63. Humphries M. 1992. The management of tuberculous meningitis. Thorax 47:577–581. [PubMed]
64. Schoeman JF, Van Zyl LE, Laubscher JA, Donald PR. 1997. Effect of corticosteroids on intracranial pressure, computed tomographic findings, and clinical outcome in young children with tuberculous meningitis. Pediatrics 99:226–231.
65. Thwaites GE, Nguyen DB, Nguyen HD, Hoang TQ, Do TT, Nguyen TC, Nguyen QH, Nguyen TT, Nguyen NH, Nguyen TN, Nguyen NL, Nguyen HD, Vu NT, Cao HH, Tran TH, Pham PM, Nguyen TD, Stepniewska K, White NJ, Tran TH, Farrar JJ. 2004. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med 351:1741–1751. [PubMed]
microbiolspec.TNMI7-0044-2017.citations
cm/5/2
content/journal/microbiolspec/10.1128/microbiolspec.TNMI7-0044-2017
Loading

Citations loading...

Loading

Article metrics loading...

/content/journal/microbiolspec/10.1128/microbiolspec.TNMI7-0044-2017
2017-03-10
2017-06-29

Abstract:

Central nervous system tuberculosis (CNS-TB) takes three clinical forms: meningitis (TBM), intracranial tuberculoma, and spinal arachnoiditis. TBM predominates in the western world and presents as a subacute to chronic meningitis syndrome with a prodrome of malaise, fever, and headache progressing to altered mentation and focal neurologic signs, followed by stupor, coma, and death within five to eight weeks of onset. The CSF formula typically shows a lymphocytic pleocytosis, and low glucose and high protein concentrations. Diagnosis rests on serial samples of CSF for smear and culture, combined with CSF PCR. Brain CT and MRI aid in diagnosis, assessment for complications, and monitoring of the clinical course. In a patient with compatible clinical features, the combination of meningeal enhancement and any degree of hydrocephalus is strongly suggestive of TBM. Vasculitis leading to infarcts in the basal ganglia occurs commonly and is a major determinant of morbidity and mortality. Treatment is most effective when started in the early stages of disease, and should be initiated promptly on the basis of strong clinical suspicion without waiting for laboratory confirmation. The initial 4 drug regimen (isoniazid, rifampin, pyrazinamide, ethambutol) covers the possibility of infection with a resistant strain, maximizes antimicrobial impact, and reduces the likelihood of emerging resistance on therapy. Adjunctive corticosteroid therapy has been shown to reduce morbidity and mortality in all but late stage disease.

Highlighted Text: Show | Hide
Loading full text...

Full text loading...

Figures

Image of FIGURE 1
FIGURE 1

Computerized axial tomogram for a patient with TBM. Note the enlarged ventricles and effacement of sulci, indicating raised intracranial pressure.

Source: microbiolspec March 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0044-2017
Permissions and Reprints Request Permissions
Download as Powerpoint
Image of FIGURE 2
FIGURE 2

MRI of the same patient as for Fig. 1 . After contrast enhancement, showing two dense, bilateral inflammatory masses (tuberculomas) in the region of the thalamus; T-2 weighted image showing inflammatory edema and possible ischemic changes of vasculitis in the basal region of the temporal lobe (arrowhead).

Source: microbiolspec March 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0044-2017
Permissions and Reprints Request Permissions
Download as Powerpoint

Tables

Generic image for table
TABLE 1

Presenting symptoms and signs of TBM

Source: microbiolspec March 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0044-2017
Generic image for table
TABLE 2

Differential diagnosis of TBM

Source: microbiolspec March 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0044-2017

Supplemental Material

No supplementary material available for this content.

This is a required field
Please enter a valid email address
Please check the format of the address you have entered.
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error