Tuberculosis of Brain and Spine

The diagnosis of tuberculous meningitis is made by examination of the spinal fluid. The classic spinal fluid abnormalities in tuberculous meningitis are as follows: (1) elevated opening pressure, (2) lymphocytic pleocytosis, (3) an elevated protein concentration in the range of 100 to 500 mg/dL, and (4) a decreased glucose concentration. A CSF glucose concentration between 45 and 35 mg/dL in combination with a lymphocytic pleocytosis and an unrelenting headache, stiff neck, fatigue, night sweats, and fever is highly suspicious for tuberculous meningitis. At an early stage in the clinical illness, polymorphonuclear leukocytes may predominate in the spinal fluid, but typically lymphocytes become the predominant cell type within 48 hours. The CSF glucose concentration is only mildly decreased. The last tube of fluid collected at lumbar puncture is the best tube to send for smear for acid-fast bacilli. Culture of CSF takes 4 to 8 weeks to identify the organism, except in cases of fulminant tuberculous meningitis where culture is often positive in 1 to 2 weeks. There is a polymerase chain reaction (PCR) available for M. tuberculosis ribosomal ribonucleic acid (rRNA). Neuroimaging abnormalities are nonspecific and include enhancement of the meninges postcontrast administration, communicating and/or obstructive hydrocephalus, and infarctions typically in the basal ganglia. Patients should have chest radiographs and in-tradermal tuberculin skin test. The tuberculin skin test may be negative because patients with central nervous system (CNS) tuberculosis are immunosuppressed. With treatment, the skin test may become positive. Treatment of tuberculous meningitis includes a combination of isoniazid, rifampin, pyrazinamide, ethambutol, and pyridoxine. Dexamethasone therapy is recommended for patients who develop hydrocephalus. This complication may also require a ventriculostomy or a ventriculoperitoneal shunt.

Tuberculomas manifest as space-occupying lesions. On computed tomography (CT) scan, they often have the appearance of a central nidus of calcification surrounded by a ring of enhancement and/or edema. Tuberculomas may develop during the course of therapy for tuberculous meningitis. The treatment of tuberculomas includes a three- or four-drug regimen similar to the treatment of tuberculous meningitis. Superficial tuberculomas can be surgically excised if they do not respond to antituberculous chemotherapy.

Pott disease refers to vertebral tuberculosis or tuberculous spondylitis. Two or more adjacent vertebral bodies are often involved, and infection can spread to the disk and/or the epidural space. The thoracic and lumbar spine are the most commonly affected areas, and thus the clinical presentation is with back pain in the thoracic or lumbar area and fever. When the epidural space is involved, signs and symptoms of progressive spinal cord compression can develop. Diagnosis is made by stereotactic aspiration of the lesion. Treatment includes antituberculous chemotherapy and surgical decompression if spinal cord compression is present.

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