Tuberculous meningitis

The time course over which tuberculous meningitis (TBM) develops is usually longer than purulent meningitis, up to three weeks in children and rather longer in adults. In some cases, however, the onset may be acute and exactly similar to purulent meningitis, so TB must be considered in each case.75 Indeed, given the highly variable clinical presentation of TBM and the frequent absence of fever and/or signs of meningism, a high degree of suspicion of TBM is required in many neurological presentations.

CT and MRI of the brain show changes of meningitis and no specific diagnostic features. Hydrocephalus is common, as is basal meningeal thickening. Tuberculomas may be seen. Low-density changes of infarction are common.119-121 CSF is typically under increased pressure and is clear or slightly turbid. Rarely, it may look frankly purulent. There is moderate pleocytosis, often in the hundreds, with eventual lymphocyte predominance, but polymorphs may be in the majority at the onset. CSF protein is elevated, sometimes to very high levels, and the glucose content is reduced, although generally not to the levels seen with pyogenic meningitis.75,122 If tubercle bacilli are seen, the diagnosis is confirmed, but several samples may be required for organisms to be identified, and even then as many as 30-50% of cases are negative. In these cases it may be possible to diagnose TBM by PCR, although the place of this has still not been fully evaluated in TBM.75

If TBM is suspected, treatment must be given promptly, as delay worsens morbidity and mortality.123 Details of treatment regimens may be found elsewhere.124 Chemotherapy is given for between 6 and 18 months, dependent upon the guidelines followed and the drugs used.124-126 Even though corticosteroids are often given routinely to those with more severe disease and may be useful for preventing arachnoiditis or other severe residual disability, a Cochrane Review suggested that further large studies were needed to confirm any benefits.127 Dexamethasone for a short time in high dose is useful to reduce cerebral oedema. Hydrocephalus commonly develops, sometimes acutely, and should be treated early by surgical drainage.

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