Chapter 20 : Central Nervous System Tuberculosis

Abstract:

Central nervous system (CNS) tuberculosis (TB) is among the least common yet most devastating forms of human mycobacterial infection. Conceptually, clinical CNS infection is seen to comprise three categories of illness: subacute or chronic meningitis, intracranial tuberculoma, and spinal tuberculous arachnoiditis. All three forms are seen with about equal frequencies in high-prevalence regions of the world where postprimary, extrapulmonary clinical infection is encountered commonly among children and young adults ( 1 ). Meningitis syndrome predominates in low-prevalence countries such as the United States and in Europe, where extrapulmonary TB is encountered primarily in older adults with reactivation disease. The natural history of tuberculous meningitis (TBM) is that of insidious onset and subacute progression, prone to rapid acceleration once neurologic deficits supervene, leading to stupor, coma, and, finally, death within 5 to 8 weeks of the onset of illness. Consequently, in order to achieve a favorable therapeutic outcome, it is important to begin treatment promptly, empirically during the early stages of illness, relying on clinical suspicion and a presumptive diagnosis rather than awaiting laboratory confirmation. Of necessity, this requires some knowledge of the causes and clinical features of granulomatous meningitis, the pathology that subserves the neurologic manifestations of disease, and the expected radiographic and laboratory (chiefly cerebrospinal fluid [CSF]) findings.