n CME : Your SA Journal of CPD - Tuberculous meningitis : main article




The incidence of TB is increasing, partly because of the increasing incidence of HIV. <BR>Compared with pulmonary TB, which has been the subject of many clinical trials, the pathogenesis, diagnosis and treatment of TBM have received little attention. <BR>It has been estimated that about 10% of patients with extrapulmonary TBM have CNS involvement. <BR>The development of TBM is a two-step process - the bacteria first enter the lungs and then the brain. Most CNS TB is due to <I>M. tuberculosis.</I><BR>TBM is usually preceded by a prodromal period of 2 - 4 weeks of nonspecific symptoms such as fever, malaise, myalgia, and headache. <BR>Neck stiffness is reported by about 25% of patients, but meningismus is detected in a higher number. <BR>TBM can also cause metabolic complications; the commonest, hyponatraemia, affects more than 50% of patients with the disease. <BR>TBM cannot be diagnosed on history and clinical assessment alone. Useful features are a history of recent exposure to TB (particularly in children), and signs of active extrameningeal TB. <BR>Isoniazid kills most of the rapidly replicating bacilli in the first 2 weeks of treatment, with some additional help from streptomycin and ethambutol. Thereafter rifampicin and pyrazinamide become important. Empirical therapy should be instituted as early as possible to reduce morbidity and mortality. The aim of treatment is to kill both intracellular and extracellular organisms and requires the use of several drugs to avoid the development of resistance. <BR>BCG vaccination provides the best prophylaxis against severe forms of TB, mainly meningitic and miliary. <BR>HIV does not alter the clinical presentation of TBM, but may affect the number and nature of complications.


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