Neurologic Complications of Tuberculosis

Abstract

PURPOSE OF REVIEW: This article describes the current epidemiology, common clinical characteristics, and up-to-date evidence-based approaches to the diagnosis and management of the most common neurologic complications of tuberculosis (TB): tuberculous meningitis, intracranial tuberculoma, and spinal TB.RECENT FINDINGS: Central nervous system (CNS) TB remains common and associated with significant mortality and neurologic sequelae worldwide. Human immunodeficiency virus (HIV) co-infection is strongly associated with both the development of and mortality due to CNS TB. Strongyloides co-infection is associated with reduced CNS inflammation and improved outcomes in the setting of tuberculous meningitis. Stroke remains a common complication of tuberculous meningitis, and emerging evidence suggests aspirin may be used in this context. Although a recent nucleic acid amplification test has demonstrated suboptimal sensitivity in the diagnosis of CNS TB, emerging diagnostic techniques include cell-free DNA, peripheral blood microRNA, metagenomic next-generation sequencing, and advanced imaging techniques, but these are not yet well validated. CNS TB is associated with high mortality even with current treatment regimens, although novel, promising strategies for treatment are under investigation, including a combination of IV isoniazid and ethambutol and high-dose rifampicin.SUMMARY: TB can affect the nervous system in various ways and is associated with high mortality. Diagnosis remains challenging in endemic settings, with empiric treatment often initiated without a definitive diagnosis. Furthermore, optimal treatment regimens remain uncertain because current treatment for all forms of CNS TB is extrapolated from trials of tuberculous meningitis whereas the role of steroids in people with HIV and tuberculous meningitis remains controversial.

Health Equity in Neurosciences

“…This is relevant to neurologic disease because of the strong association of HIV with various neurologic presentations [13]. Tuberculosis may also infect the nervous system, can be very difficult to recognize clinically, and requires prolonged treatment [14]. It is associated with high mortality particularly when co-existing HIV infection is present [14].…”

Infections of the Spine and Spinal Cord

“…Myeloradiculitis is a common manifestation of spinal tuberculosis in areas of high HIV and tuberculosis prevalence 23 . For further discussion of neurologic manifestations of tuberculosis, refer to the article “Neurologic Complications of Tuberculosis” by Deanna Saylor, MD, MHS, 24 in this issue of Continuum .…”

“…For most patients with tuberculous spondylodiscitis, multidrug antimycobacterial therapy is given for 9 months 29 . For regimens, refer to the article “Neurologic Complications of Tuberculosis” by Deanna Saylor, MD, MHS, 24 in this issue of Continuum . Operative intervention should be considered in patients who do not respond to medical therapy alone or if cord compression or spinal instability is present.…”

Infections of the Peripheral Nervous System

“…Tuberculosis is a special concern in patients who are immunocompromised or in a high-risk population, such as those who are incarcerated or from an endemic area. For more details, see the article “Neurologic Complications of Tuberculosis” by Deanna Saylor, MD, MHS, 20 in this issue of Continuum .…”