Chapter 20 : Central Nervous System Tuberculosis

MyBook is a cheap paperback edition of the original book and will be sold at uniform, low price.

Preview this chapter:
Zoom in

Central Nervous System Tuberculosis, Page 1 of 2

| /docserver/preview/fulltext/10.1128/9781555819866/9781555819859_Chap20-1.gif /docserver/preview/fulltext/10.1128/9781555819866/9781555819859_Chap20-2.gif


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 ( ). 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.

Citation: Leonard J. 2017. Central Nervous System Tuberculosis, p 331-341. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0044-2017
Highlighted Text: Show | Hide
Loading full text...

Full text loading...


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.

Citation: Leonard J. 2017. Central Nervous System Tuberculosis, p 331-341. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. 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).

Citation: Leonard J. 2017. Central Nervous System Tuberculosis, p 331-341. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0044-2017
Permissions and Reprints Request Permissions
Download as Powerpoint


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) : 177.[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]


Generic image for table
Table 1

Presenting symptoms and signs of TBM

Citation: Leonard J. 2017. Central Nervous System Tuberculosis, p 331-341. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0044-2017
Generic image for table
Table 2

Differential diagnosis of TBM

Citation: Leonard J. 2017. Central Nervous System Tuberculosis, p 331-341. In Schlossberg D (ed), Tuberculosis and Nontuberculous Mycobacterial Infections, Seventh Edition. ASM Press, Washington, DC. doi: 10.1128/microbiolspec.TNMI7-0044-2017

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