Tuberculosis meningitis

Abstract

Treatment of tuberculous meningitis should begin with an anti-tuberculous regimen of at least three drugs: isoniazid, pyrazinamide, and rifampin. Early in the course of therapy, ethambutol or streptomycin may be of some added benefit. If the local incidence of drug resistance to Mycobacterium tuberculosis is greater than 4%, or is unknown, then a fourth drug (ethambutol or streptomycin) should be added. If the patient is from an area with organisms resistant to multiple drugs, or is likely to be infected with a multiply resistant organism for any reason, then the patient should be on enough drugs to insure that at least two active anti-tubercular drugs are included in the therapy. An expert should be consulted Length of therapy is not standardized. For sensitive organisms, a regimen of three drugs daily for 2 months, followed by two-drug therapy (isoniazid and rifampin) has been recommended. The American Thoracic Society (ATS) and the Centers for Disease Control (CDC) have recommended a minimum of 12 months of therapy for tuberculous meningitis. If cultures remain positive for extended periods, or signs or symptoms respond slowly, therapy should be extended to 18 months. Patients with HIV also may need longer courses of therapy. The severity of tuberculous meningitis can be classified based on a system devised by the British Medical Research Council. Stage I patients are fully conscious, rational, and do not have neurologic signs. Stage II patients are confused or have neurologic signs such as cranial nerve palsy or hemiparesis. Stage III patients are comatose or stuporous with more severe neurologic signs. Corticosteroids are recommended if the patient is mentally confused, has neurologic signs, or is comatose (Stages II and III). In patients with moderate disease (Stage II), corticosteroids appear to improve neurologic sequelae and survival. Dexamethasone 6 to 12 mg per day and prednisone 60 to 80 mg per day tapered over 4 to 8 weeks has been used. Symptoms of central nervous system (CNS) inflammation may recur if the corticosteroid taper is implemented too soon or too fast. Steroids and diuretics such as furosemide and acetazolamide are sometimes used to treat hydrocephalus. Ventriculoperitoneal or ventriculoatrial shunting may be required to relieve signs and symptoms of hydrocephalus.

Role of Microglia in Central Nervous System Infections

“…So far, dexamethasone, a glucocorticoid which potently inhibits the generation of many inflammatory mediators by activated microglia, has been demonstrated to be effective as adjunctive therapy for pneumococcal meningitis (359) and tuberculous meningitis (56). Trials of dexamethasone and other anti-inflammatory agents should be considered for other CNS infections where activated microglia appear to contribute to brain damage.…”

Fulminant Tuberculous Meningitis

“…However, isoniazid freely passes into CSF, and the other two agents can enable penetrate under inflammatory conditions. 18) Although recent reports indicate the efficacy of corticosteroid infusion 3,15) for TBM, the effect may be restricted and ameliorate mortality but not morbidity. 16) Further study is required to establish the second line of treatment if TBM is resistant to anti-TB agents and corticosteroid administration.…”

Intradural, Eextramedullary Tuberculoma of the Spinal Cord as a Complication of Tuberculous Meningitis

“…Finally, the unsatisfactory response could be related to the possible development of drug resistance during the treatment period, although the patient had started with a combination of four first-line anti-TB drugs in order to minimize the risk of drug resistance developing [10]. However, the addition of two second-line anti-TB drugs (ofloxacin and cycloserine) in the conventional anti-TB scheme and the prolongation of treatment for over 12 months resulted in the improvement of the patient's clinical status as well as in a CSF protein concentration decline [11][12][13]. The adjunctive administration of methylprednisolone probably also had a beneficial effect on the healing process by acting anti-inflammatory, relieving spinal cord pressure due to interstitial edema and restricting perilesional granulomatous vasculitis.…”

“…The adjunctive administration of methylprednisolone probably also had a beneficial effect on the healing process by acting anti-inflammatory, relieving spinal cord pressure due to interstitial edema and restricting perilesional granulomatous vasculitis. [3,9,11,13].…”