Tuberculous Meningitis in Adults: A Review of a Decade of Developments Focusing on Prognostic Factors for Outcome

Abstract

Tuberculous meningitis (TBM) is the most severe form of TB. Despite treatment, mortality and long-term disability remain unacceptably high. Prevention, early recognition, diagnosis and treatment are fundamental to improving outcomes. However, an effective vaccine remains elusive, initial symptoms are nonspecific, and sensitive diagnostic tests are not available. There has been progress in our understanding of the immunopathology of TBM, and several factors have been found to be associated with susceptibility to infection, disease progression and clinical outcome. However, these have not yet impacted on treatment. Early treatment initiation and uninterrupted continuation, severity on presentation, seizures, stroke, cranial nerve involvement, cerebrospinal fluid cell count and lactate levels, hyponatreamia and coinfection with HIV are all found to be important prognostic factors for outcome. Pathogen lineage (Beijing genotype) and host genetics (polymorphisms in TLR2, TIRAP and LTA4H genes) can influence susceptibility to TBM. However, these findings have not yet impacted on treatment. Progress in vaccine development, opportunities for better diagnostic tests, novel insights into pathogenesis and an increasing evidence base for improving treatment should impact the current high mortality and morbidity, if translated to global and local guidelines.

Linezolid Manifests a Rapid and Dramatic Therapeutic Effect for Patients with Life-Threatening Tuberculous Meningitis

“…Diagnosis and management differ significantly between TBM and pulmonary TB (1,17). Acid-fast bacilli (AFB) have been found in fewer than 20% of patients with TBM (18), and the culture of cerebrospinal fluid (CSF), although considered the gold standard for diagnosis, is positive in only about 40% of cases (19).…”

A Case of Tuberculous Cerebrospinal Meningitis with Atypical Multiple Lesions

“…The gold standard for diagnosis of TBM is the isolation of Mycobacterium tuberculosis in CSF, either by direct microscopy or culture (4,5). However, the sensitivity of acid-fast smear varies between 10% and 60%; culture of CSF is positive between 25 and 75% of cases, and takes two to six weeks (1). According to the Thwaites criteria, patients can be defined as "possible" and "probably" TBM cases based by the symptom duration, biochemical marker changes of CSF and evidence of tuberculosis at other sites (4,5).…”

“…As for the CSF changes, neutrophils can reach a high proportion since a neutrophilic response is predominant in the early stage of infection (1); glucose and chlorine can be normal (7) and protein reflects the TBM grade and may be low in the first stage (1). Sensitivity and specificity of tuberculosis-specific antibody in CSF are 52%-93% and 58%-99%, respectively (2).…”

Neues bei HIV und Neuro-Aids

“…Die Sensitivität der Mikroskopie nach Ziehl-Nehlsen liegt bei weniger als 10 % und die Chance auf eine kulturelle Erregeranzucht bei weniger als 20 %. Am sensitivsten ist noch der PCR-Nachweis von mykobakterieller Nukleinsäure mit maximal 50 % Sensitivität bei repetitiven Untersuchungen [87,88]. Nicht selten findet sich eine Koinfektion mit Treponema pallidum bei HIV-Patienten.…”