Tuberculous meningitis of acute onset

Natural course of epilepsy concomitant with CNS tuberculomas

BACKGROUND

Epilepsy is relatively common in CNS tuberculomas, but its natural course is unclear.

AIM

To determine the prevalence and prognosis of epilepsy in patients with seizures related to CNS tuberculomas.

METHODS

We retrospectively reviewed the charts of patients with CNS tuberculomas who presented at our institution between 1983 and 2001.

RESULTS

Seizures occurred in 22 of 93 (23.6%) of the patients with CNS tuberculomas. These patients were treated with standard antituberculous therapy for a period varying between 6 and 20 months. Sixty-three out of 93 patients were cured of tuberculosis, and 21 of the 63 (33%) who had concomitant epilepsy became seizure-free. TB recurred in 3 patients, and 1 out of 22 who had concomitant epilepsy continued to have seizures; 3 died and 24 were lost to follow-up. Anti-epileptic medications were discontinued after completion of the anti-TB course.

CONCLUSION

Seizures are commonly associated with CNS tuberculomas and most often resolve after successful treatment of the underlying CNS tuberculosis.

Unusual presentation of tuberculous meningitis

We present 4 cases of tuberculous meningitis with atypical clinical features and CSF findings. Two patients had initially normal CSF examination, one developed internuclear ophthalmoplegia, while the other had deterioration of consciousness. The third patient presented with paranoid psychosis, and the fourth had a picture mimicking acute bacterial meningitis and he developed right hemianopia due to a tuberculoma detected by MRI. All recovered completely with anti-tuberculous treatment.

Cerebrospinal fluid investigations in tuberculous meningitis

The results of conventional cerebrospinal fluid (CSF) investigations (CSF cell count, protein and glucose concentrations and Pandy's test for CSF globulin) obtained on admission and sequentially from weekly follow-up lumbar punctures for 4 weeks were evaluated in 99 children (median age 28 months) with stage II (50 children) and stage III (49 children) tuberculous meningitis. On admission, six children (6%) had a CSF cell count greater than 500 x 10(6)/l and nine (9%) a polymorphonuclear predominance. A CSF protein less than 0.8 g/l was found in 17 children (18%) of 97 in whom CSF protein was evaluated. Globulin was either absent or present as a trace only in 26 children (27%). CSF glucose was less than 2.2 mmol/l in 58 cases (60%) and less than 2.5 mmol/l in 67 (69%). In 63 children weekly CSF specimens obtained for the 1st 4 weeks of therapy showed an uninterrupted decline in cell count in 23 (37%), a fluctuating downward trend in 27 (43%) and a fluctuating upward trend in 13 (21%). Sequential CSF protein values in 57 children showed an uninterrupted rise in three (5%), a fluctuating upward course in 19 (33%), an uninterrupted downward trend in seven (12%), and a fluctuating downward course in 28 (49%). Of the 61 children in whom sequential CSF glucose concentrations were available, 11 (18%) experienced fluctuating concentrations, values falling to less than 2.2 mmol/l after being greater than 2.2 mmol/l on admission or after having risen to greater than 2.2 mmol/l.(ABSTRACT TRUNCATED AT 250 WORDS)

Idiopathic granulomatous meningitis

A 69 year old female presented with eight discrete episodes of paraparesis over a period of six weeks. Each episode lasted between 10 and 30 minutes and resolved spontaneously. The cause of her symptoms was not established during life and at necropsy she was found to have granulomatous meningitis of the cerebral convexites. The clinical and pathological aspects of this rare condition are discussed.

Tuberculous meningitis: a retrospective survey of 22 cases

Clinical and biological findings likely to constitute prognostic factors were analyzed in a retrospective survey of 22 cases of tuberculous meningitis. In particular, associations between clinical and biological findings (clinical grade on admission, normal and abnormal CSF protein and glucose values) and outcome of illness were sought. On admission 16 patients had altered consciousness, 11 hemiparesis and 7 sixth cranial nerve paresis. Meningeal signs were present in all subjects. 7 had a positive culture for Mycobacterium tuberculosis. 9 patients recovered completely, 7 had serious late sequelae, 6 died. Prognosis appeared to be correlated to neurological status at admission.

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.

Tuberculous meningitis

Tuberculous meningitis arises from the discharge of bacilli from a subjacent caseous focus into the subarachnoid space. Meningeal involvement is most marked at the base of the brain. The clinical spectrum is very broad and the outcome of therapy depends mainly on the stage of disease at the time treatment is instituted.

[Intracranial tuberculous arachnoiditis: report of a case]

The case of a 28-year-old male affected by intracranial tuberculous arachnoiditis with unusual aspects is reported. The patient presented bilateral amaurosis and complete ophthalmoplegia with intrinsic muscle sparing in both sides. The routine laboratory findings showed only persistent leucocytosis and a Mantoux test of 10 mm. Several radiologic studies of the lungs were always normal. The spinal fluid, tomography of the cranial base and carotid angiography were normal. The diagnosis was made by histologic study after craniotomy.

Tuberculous meningitis

Ten patients with confirmed tuberculous meningitis were seen at Meilahti Hospital, University of Helsinki, in 1966--1977. Six of the patients had a positive CSF culture for M. tuberculosis, and a positive CSF smear for acid-fast bacilli was found in one case. On admission, seven patients had an altered state of consciousness, five complained of headache, and nuchal rigidity was noted in two. Five patients recovered completely, three had persistent late sequelae, and two of the patients died. The most important fact influencing the prognosis was an early institution of adequate antituberculous chemotherapy.

Invasion of the leptomeninges by tumour: the differential diagnosis from tuberculous meningitis

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