Brain biopsy in tuberculoma: the risks and benefits

In developing countries, 5 to 8% of the space-occupying lesions of the central nervous system are tuberculomas. Diagnosis can be difficult in the absence of extracranial tuberculosis; computed tomography is suggestive only. To assess the value of brain biopsies in tuberculomas, the records of 15 patients aged 6 to 80 years were reviewed. Histological confirmation was obtained in 15 patients, and acid-fast bacilli were cultured from 12 patients. Intracranial hypertension was the principal sign in 11 patients; other neurological signs were related to the location of the tuberculoma. One patient had evidence of extracranial tuberculosis. Biopsy-related complications consisted of an epidural hematoma in 1 patient and hydrocephalus in another; both required additional surgery. One case of tuberculous meningitis was probably related to surgery and poor drug compliance. There was no postoperative mortality. Thirteen patients (2 were lost to follow-up) were cured after an average of 16 months of antituberculous therapy. It was concluded that the brain biopsy is useful in diagnosing tuberculoma but that there is some associated risk.

[BCG-vaccination and its complications. How great are the benefits of vaccination today?]

This paper intends to present an overview concerning the risks and benefits of BCG-immunisation basing on a research of the actual literature. The historical controversy is well known, but regarding the epidemiological situation with respect to morbidity and mortality of tuberculosis in Middle and Western Europe by now it seems to be necessary again to reflect on vaccination recommendations. While complications after vaccination may be serious or even life-threatening, immunization with BCG seems to have a beneficial effect on the incidence of infantile leukemia. Nevertheless, this effect is discussed controversially on recent research. In addition there should be drawn special attention to the problem of life-vaccines, in particular of BCG under the view of the increasing number of children with acquired immunodeficiencies.

Tuberculosis in living related donor renal transplant recipients

Ten out of 237 patients who underwent renal transplantation between 1975 and October 1986 developed tuberculosis. Most patients presented with vague symptoms, and typical symptoms commonly associated with tuberculosis were not common. Six had positive urine cultures. One patient had positive sputum and urine cultures and one had positive sputum and cerebrospinal fluid cultures for tuberculosis. In this last patient cryptococcus was also cultured from the sputum and CSF. Nine of the 10 patients responded well to antituberculosis therapy and was cured of the infection. The patient with associated cryptococcal infection died 2 months after presentation. Side effects of antituberculous therapy was minimal and easily resolved on stopping the offending drug.

Tuberculous meningitis due to BCG in two previously healthy children

Tuberculous meningitis with favourable outcome has been observed in two immunocompetent previously healthy children. The mycobacteria isolated from the cerebrospinal fluid of both patients proved to be Mycobacterium bovis BCG. The patients had been inoculated with BCG, one 5 and the other 6 months before onset of the disease.

Tuberculous meningitis

Tuberculous meningitis is a grave, yet curable, illness. It is a rare condition nowadays and may present special problems when the clinical picture is untypical. Clinical awareness, early diagnosis and vigorous treatment are the key to therapeutic success.

[Bacterial meningitis]

After a presentation of purulent and liquoral bacterial meningites with an examination of their pathogenesis, a personal case series is presented. Particular attention is paid to the liquoral transfer of antibiotics and it is considered that the treatment of purulent bacterial meningitis cannot be standardised. In contrast tubercolar meningitis can be subjected to standardised treatment. Currently the results obtained in the treatment of purulent bacterial meningitis are less satisfactory than those obtained in tubercular meningitis though certainly better than in the recent past.

CNS tuberculosis

Tuberculous meningitis is a rare, treatable neurologic disorder, in which early recognition is paramount because outcome depends greatly on the speed with which therapy is initiated. Patients with meningitis and CSF findings of low glucose, elevated protein and pleocytosis with evidence of tuberculosis elsewhere in the body (chest radiographs, positive tuberculin skin test), or a history of exposure to tuberculosis should be treated immediately with antituberculous medication. When the diagnosis remains uncertain, serial examination of the CSF for tuberculous organisms will often yield positive results. The CT scan may show hydrocephalus, a basilar arachnoiditis, or intraparenchymal lesions: tuberculomas. Hydrocephalus may respond to early shunting. Tuberculomas are best treated medically. Therapy should include INH and rifampin; ethambutol and pyrazinamide are suggested for the first 2 months of therapy. Steroids may be useful in diminishing the inflammatory response when altered consciousness or focal neurologic signs are present.

Central nervous system tuberculosis with the acquired immunodeficiency syndrome and its related complex

Central nervous system tuberculosis occurred in three patients with the acquired immunodeficiency syndrome (AIDS) and seven patients with AIDS-related complex who were evaluated for 48 months. Nine patients were intravenous drug abusers and one was Haitian. Five patients had cerebral-ring-enhancing lesions and three had hypodense areas. The clinical spectrum included meningitis in two patients, multiple cerebral abscesses in one, and tuberculomas in four. All Mycobacterium tuberculosis isolates were sensitive to standard antituberculous drugs. All patients received treatment with isoniazid, rifampin, and pyrazinamide; six patients also received streptomycin. Three patients with AIDS died of opportunistic infection preceded by central nervous system tuberculosis. Among the patients with the AIDS-related complex, three improved with treatment, three were lost to follow-up, and one died. Tuberculosis should be considered in the differential diagnosis of central nervous system mass lesions in intravenous drug abusers with AIDS or AIDS-related complex. Because patients with tuberculosis can be cured, biopsy of accessible brain mass lesions should be mandatory. Preventive therapy may be indicated in drug abusers without disease.

Mycobacterial meningitis. Retrospective analysis from 1970 to 1983

The clinical presentation and course of tuberculous meningitis in 21 patients treated between 1970 and 1983 are analyzed. Tuberculous meningitis may present as acute, subacute, or chronic meningitis. Although characteristic cerebrospinal fluid findings of lymphocytic pleocytosis, low glucose level, and elevated protein level occur in the majority of cases, there are many atypical presentations. The protein level, glucose level, and white blood cell count may be normal, and there may be a predominance of polymorphonuclear cells rather than lymphocytes in the cerebrospinal fluid. Poor prognostic factors in this series were age greater than 65, underlying diseases, and stage 3 presentation. Incorrect or inadequate therapy had a disastrous outcome. Nontuberculous mycobacteria rarely are involved in central nervous system disease. Tuberculous meningitis must be considered in the differential diagnosis of any patient with fever and change in sensorium. A deteriorating mental status and falling cerebrospinal fluid glucose level in the presence of negative findings on bacterial culture and india ink preparation should lead to strong consideration for empiric initiation of anti-tuberculous therapy.

Bacterial meningitis. Specific etiologic diagnosis on the basis of distinctive epidemiologic, pathogenetic, and clinical features

The purpose of this paper is to point out a clinical approach to the etiologic diagnosis of bacterial meningitis in cases in which it is not possible to define the cause by microscopic studies of spinal fluid in the very early stage of the disease. The striking differences in epidemiology, pathogenesis, clinical behavior, complications, and prognosis permit identification of the etiology in many instances.

Tuberculous meningitis following pericardiectomy for constrictive pericarditis

We report a ease of recurrent calcified chronic constrictive pericarditis of 31 years' duration, complicated by the development of tuberculous meningitis two weeks after a third pericardiectomy. It is suggested that all patients undergoing pericardiectomy for constrictive pericarditis should have anti-tuberculous therapy even in the absence of an established tuberculous aetiology.

Symptomatology of the most severe form of tuberculous meningitis

Seven cases of the most severe form of tuberculous meningitis, in which a midbrain syndrome developed, are reported. Three different types of progress were observed. Exudative inflammation and cerebral edema dominated in the first group, causing the rapid development of the acute midbrain syndrome, which may turn into a bulbar syndrome. In the second group the development of the midbrain was delayed and an apallic syndrome followed. The morphological examination disclosed local diencephalic and midbrain lesions caused by herniation and specific vasculitis and vascular compression. The third group showed disintegration of cortical function as a result of parenchymal lesions, apart from local midbrain symptoms which never fully intensified into the midbrain syndrome. Observation of the progress of the disease proved that late diagnosis and delayed therapy were decisive in cases of the most severe form of tuberculous meningitis.