tuberculous meningitis
DESCRIPTION
Powerpoint on TB Meningitis.TRANSCRIPT
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Tuberculous MeningitisSANJAY GEORGE
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Epidemiology
India has one fifth of the world’s TB burden.
2 million new cases in 2009.
Around 10% develop CNS disease.
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Etiology
Mycobacterium tuberculosis.
Risk Factors: Delay in diagnosis and treatment
HIV, Immunocompromised state.
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Pathophysiology
50% cases : History present, Hematogenous spread
Seed meninges or brain – Sub-pial/Sub-ependymal foci of metastatic caseous lesion – Rich Foci.
Proximity to S.A Space determines type of CNS involvemeny. Rupture into S.A space – Meningitis
Deep in parenchyma cause Tuberculoma or Abscesses.
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Contd.
Paresis of C.N nerves common as involvement more at base of brain.
Disease evolves over 1-2 weeks.
Thick gelatinous exudate infiltrates the cortical, meningeal blood vessels, producing inflammation, obstruction, or infarction.
Ultimate evolution to coma, with hydrocephalus and intracranial hypertension.
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Clinical Features
Headache
Vomiting
Low Grade Fever
Malaise, Anorexia, Irritability
Severe Headache
Confusion
Lethargy
Altered Sensorium
Neck Rigidity
Initially
Late
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Signs
Meningism (maybe absent)
Occulomotor palsies
Papilloedema
Depression of conscious level
Focal hemisphere signs.
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Differential Diagnosis
Other Infectious causes of meningitis
Acute hemorrhagic leukoencephalopathy
Behçet disease
Chemical meningitis
Chronic benign lymphocytic meningitis
Neoplastic: metastatic, lymphoma
Systemic lupus erythematosus
Vascular: Multiple emboli, subacute bacterial endocarditis, sinus thrombosis
Vasculitis
Vogt-Koyanagi-Harada syndrome
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Investigations
Lumbar Puncture: High leucocyte count (upto 1000/μL) with lymphocytic predominance.
Elevated Protein (100-800 mg/dL).
Mildly Decreased Glucose Concentration (20 – 40 mg/dL)
AFB – 1/3rd cases
CSF culture (Gold Standard) – diagnostic in 80% cases.
PCR
Imaging Studies – MRI, CT
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Management
Initiate if high index of suspicion.
Initial Therapy: Isoniazid – 300mg/d
Rifampicin – 10mg/kg/d
Pyrazinamide – 30mg/kg/d
Ethambutol – 15-25 mg/kg/d
Pyridoxine – 50mg/d
Good Response : Discontinue Pyrazinamide after 2 months continue H & R for 6 – 12 months
Inadequate Resolution : Continue for 9 – 12 months
Dexamethasone in HIV –ve Patients. 12 -16mg/day for 3 weeks, tapered over next 3 weeks
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Contd.
Obstructive hydrocephalus and neurological deterioration : ventricular drain or ventriculoperitoneal or ventriculoatrial shunt.
Prevention: BCG Vaccine
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