Localização da lesão e achados do líquido cefalorraqueano na meningite tuberculosa: diferenças nos compartimentos lombar, cisternal e ventricular

Abstract

A meningite tuberculosa, doença infecciosa do sistema nervoso central (SNC) causada pelo Mycobacterium tuberc u l o s i s, apresenta-se como uma c o mplicação precoce da tuberculose primária (primoinfecção), ocorrendo mais freqüentemente nos prim e i ros seis meses após a infecção 1 . A tuberculose p e rmanece como uma das doenças infecciosas mais freqüentes no mundo. Oito milhões de pessoas desenvolvem a doença e 3 milhões morrem, anualmente . R e t a rdos no d i a gnóstico e tratamento da meningite tuberculosa são f a t o res que contribuem diretamente para a alta mort a l i d a d e 4 . A decisão de tratar um paciente para meningite tuberculosa é freqüentemente empírica, independentemente das facilidades diagnósticas disponíveis aos médicos assistentes 4 . Durante o curso da doença, ocorre formação de exsudato inflama- RESUMO -A tuberculose permanece como uma das doenças infecciosas mais freqüentes no mundo. No presente estudo, relatamos um caso de meningite tuberculosa, que evoluiu com bloqueio do fluxo do líquido c e f a l o rraqueano (LCR), causando dificuldade diagnóstica. Discute-se a importância da localização da lesão e sua influência no exame do LCR como apoio ao diagnóstico da meningite tuberculosa. No caso relatado, a pesquisa do bacilo álcool-ácido resistente foi positiva no LCR cisternal e negativa no LCR lombar e ventricular, demonstrando que a maior acurácia do teste esteve relacionada a maior proximidade da lesão inflamatória.PALAVRAS-CHAVE: meningite tuberculosa, líquido cefalorraqueano, LCR, fluxo do LCR, punção cisternal.Location of the lesion and the cere b rospinal fluid findings in tuberculous meningitis: diff e re n c e s in the lumbar, cisternal and ventricular compartiments ABSTRACT -Tuberculosis remains one of the most prevalent infectious diseases worldwide. In the present s t u d y, we describe a case of tuberculous meningitis that caused cere b rospinal fluid (CSF) flow block, leading to difficulties in the diagnosis. The importance of the lesion site and its influence on CSF analysis as a support for the diagnosis of tuberculous meningitis is discussed. In this case, the search for acid-fast bacilii was positive in the cisternal CSF, but not in the ventricular and lumbar CSF, demonstrating the relationship between the accuracy of the test and the location of the inflamatory lesion disease.

Normal ventricular-CSF may confound the diagnosis of tuberculous meningitis hydrocephalus

“…Some authors suggest that these differences in CSF protein and cell count might also be explained by compartmentalization of the subarachnoid spaces occasioned by infection 6 . Divergences in composition of CSF from these compartments have also been attributed to the diverse location of the infecting focus 6 .…”

“…Some authors suggest that these differences in CSF protein and cell count might also be explained by compartmentalization of the subarachnoid spaces occasioned by infection 6 . Divergences in composition of CSF from these compartments have also been attributed to the diverse location of the infecting focus 6 . Similar differences in ventricular and spinal fluid have been reported in cases of neurocysticercosis, tuberculous and pneumococcal meningitis, and in children with leptomeningeal spread of CNS tumors 4,6,9,14 .…”

“…Divergences in composition of CSF from these compartments have also been attributed to the diverse location of the infecting focus 6 . Similar differences in ventricular and spinal fluid have been reported in cases of neurocysticercosis, tuberculous and pneumococcal meningitis, and in children with leptomeningeal spread of CNS tumors 4,6,9,14 . Interestingly, Heringer et al have reported one case with negative ventricular and lumbar CSF cultures, in which only the cisternal CSF yielded acid-fast bacilli 6 .…”

“…It has been estimated that approximately 10% of cases with meningitis may have a normal CSF, which is related with the duration of the disease and with the precocity of the lumbar puncture 12 . Several authors have emphasized the difficulties in diagnosing tuberculous meningitis and publicized diagnostic methods for this condition, aspects that are beyond the scope of our paper 3,6,7 . Early diagnosis and prompt treatment are key in reducing morbidity and mortality from meningitis.…”

Tuberculous Meningitis: a case report of a late diagnosis

“…Prodromal period is characterized by fever, lethargy and anorexia, with coughing or not. Subsequently occur headache, vomiting, paralysis of cranial pairs, meningeal signs, paresis, drop in the level of consciousness and coma (9).…”