eMedicine Specialties > Neurology > Neurological Infections

Tuberculous Meningitis: Follow-up

Author: Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Contributor Information and Disclosures

Updated: Dec 4, 2008

Follow-up

Deterrence/Prevention

  • BCG vaccination offers a protective effect (approximately 64%) against TBM. Improvement in weight for age was associated with a decreased risk of the disease; however, further studies are needed to evaluate the association, if any, between nutritional status and vaccine efficacy.
  • TB of any form is a notifiable disease in the United States. Mandatory notification of the appropriate health department is the responsibility of the physician who makes the diagnosis.
  • Treatment defaulters must be identified and every effort must be made to locate them and promptly reinstitute therapy or observation
    • Treatment defaulters are those who fail to attend supervised daily or biweekly chemotherapy or fail to collect their supply of drugs for self-administered oral chemotherapy.
    • Review defaulters are those who fail to attend a follow-up appointment for review of sputum or other examinations, for progress review, and for further management after the examinations have been completed. Patients also tend to default review while undergoing investigations to rule out active TB.
    • Defaulter contacts could be made by phone, mail, and, if the yield is negative, a home visit. Home visits are made for defaulter retrieval, health education of newly diagnosed patients and their families, and contact investigation. The nurse, physician assistant, nurse practitioner, medical social worker, or public health inspector of the health facility generally makes home visits. When facilities are not available for home visiting, the treating physician has the responsibility to notify the health department.
  • Patients should be asked for information about their contacts so that these individuals may be traced and investigated.
    • Household contacts who admit to having cough lasting for more than 2 weeks and children without a noticeable BCG scar during home visits should be advised to attend the nearest health facility for further investigations.
    • All family contacts must be investigated.
  • The effectiveness of the treatment guidelines is determined by 2 major factors: (1) the cure rate and (2) the level of acquired drug resistance. The cure rate is defined, for all registered patients whose sputum smear or culture result is positive, as the proportion of patients who completed treatment and had negative sputum cultures at 4 months and at the end of the treatment period. It is evaluated from the result of the cohort analysis performed yearly by the National Tuberculosis Control Program. The cure rate is the most important factor in determining final outcomes and is related inversely to the rate of acquired drug resistance and directly to the rate of noncompliance with treatment.

Complications

TBRM is a complication of TBM that has been reported only rarely in the modern medical literature. It develops at various intervals after TBM, even in adequately treated patients after sterilization of the CSF. For details, please refer to the earlier section on TBRM (see History).

Prognosis

  • Prediction of prognosis of TBM is difficult because of the protracted course, diversity of underlying pathological mechanisms, variation of host immunity, and virulence of M tuberculosis. Prognosis is related directly to the clinical stage at diagnosis.
    • Initially, only clinical indices were used for predicting the outcome, such as level of consciousness, stage of meningitis, BCG vaccination status, CSF findings, and evidence of raised intracranial pressure.
    • After CT scanning became available, radiological findings, such as hydrocephalus, infarction, severity of exudate, and tuberculoma, also were considered for predicting the prognosis of TBM.
  • Few studies on neurophysiological changes are reported in TBM. EEG has been reported to be useful in assessing the gravity of lesions and was reported recently to help in prediction of outcome. Motor evoked potentials and somatosensory evoked potentials also have been reported recently to predict a 3-month outcome of TBM. Misra et al found that focal weakness, Glasgow Coma Scale score, and somatosensory evoked potential findings were the best predictors of 6-month outcome in patients with TBM.30
  • Hydrocephalus was the only factor shown to be significant in predisposing patients with TBM who had positive culture results to a poorer outcome. A trend toward a poorer prognosis was also seen in those with advanced stages of the disease.
  • While clinical features in children with TBM who were also infected with HIV and those who were not co-infected with HIV were not markedly different, abnormal radiological findings were more common in the HIV-infected group and outcomes were considerably worse. Coexisting HIV encephalopathy and diminished immune competence undoubtedly contributed to the more severe clinical and neuroradiological features.
  • A recent study that looked at clinical parameters, laboratory studies, and CT scan features in 49 adults and children with TBM used a multivariate logistic regression model to show that the most significant variables for predicting outcome in TBM were age, stage of disease, focal weakness, CN palsy, and hydrocephalus. Children with advanced disease with neurological complications have poor outcomes. TBM is a very critical disease in terms of fatal outcome and permanent sequelae, requiring rapid diagnosis and treatment.
  • The occurrence of SIADH secretion is common and is also linked to a poor prognosis.

Patient Education

  • Health education efforts must be directed at the patients to make them more informed and aware of all aspects of the disease and its treatment.
  • Patients must be informed of the basic rules to prevent spreading the infection to others in the family or the community.
  • Educating medical, nursing, and paramedical personnel should include instruction in the epidemiologic, clinical, laboratory, therapeutic, preventive, and public health aspects of the disease.
  • While one end of the spectrum is directed toward the health-related behavior of the general public, the other end should attempt to gain the support of those who influence health policies and funding of governments and institutions. To achieve this, information, education, and communication (IEC) campaigns should be designed to act as an intermediary between the 2 groups. This strategy includes social marketing, health promotion, social mobilization, and advocacy programs.
  • We do have a successful model of smallpox eradication; if all interested and influential partners come together in a concerted effort, we could and would eliminate TB.
  • For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center, Brain and Nervous System Center, and Procedures Center. In addition, see eMedicine's patient education articles Tuberculosis, Meningitis in Adults, Meningitis in Children, and Spinal Tap.

Miscellaneous

Medicolegal Pitfalls

  • TBM still poses a diagnostic problem. TBM closely mimics other meningoencephalitides, in particular partially treated meningitis. A high index of clinical suspicion is absolutely essential. Acid-fast bacilli are seen in only approximately 25% of CSF smears. CSF culture is time-consuming and seldom yields positive results. The sensitivities of many of the new tests are still under study, and these tests may not become generally available for some time; when they do, they are likely to prove costly.
  • Obviously, concerns regarding transmission of other infectious diseases have led to legal constraints including quarantine, variably obligatory vaccinations, and exclusion from immigration. In the US legal system, the model indicates that if persons with potentially transmissible TB refuse to take treatment, they can and should be quarantined to protect the public. Directly observed therapy is gaining popularity, with the broadening perception that directly observed therapy should be the standard of practice.

Special Concerns

  • As drug resistance becomes more prevalent, the requirement of rapid sensitivity testing becomes more urgent. This is particularly so in TBM because inappropriate treatment can be fatal. TBM should be a strong consideration when a patient presents with a clinical picture of meningoencephalitides, especially in high-risk groups, including persons with malnutrition, those who abuse alcohol or drugs, homeless persons, people in correctional facilities, residents of long-term care facilities, and patients with known HIV infection.
  • New research avenues include research into vaccine design, mechanisms of drug resistance, and virulence determinants. Rapid sensitivity testing using bacteriophages considers the problem of drug resistance.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Pieter R Kark, MD, to the development and writing of this article.



More on Tuberculous Meningitis

Overview: Tuberculous Meningitis
Differential Diagnoses & Workup: Tuberculous Meningitis
Treatment & Medication: Tuberculous Meningitis
Follow-up: Tuberculous Meningitis
Multimedia: Tuberculous Meningitis
References
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Further Reading

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Keywords

tuberculous meningitis, TBM, TB, Mycobacterium tuberculosis, M tuberculosis, tuberculosis, Rich foci, extrapulmonary tuberculosis, tuberculous spinal meningitis, tuberculous spondylitis, tuberculous radiculomyelitis, TBRM, tuberculous meningitis, CNS infection, Pott disease, spinal caries, skeletal tuberculosis

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Contributor Information and Disclosures

Author

Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Abbott Labs  Honoraria Consulting; Teva Marion Honoraria Consulting; Boeringer-Ingelheim Honoraria Speaking and teaching

Medical Editor

Frederick M Vincent Sr, MD, Clinical Professor, Department of Neurology and Ophthalmology, Michigan State University Colleges of Human and Osteopathic Medicine
Frederick M Vincent Sr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Legal Medicine, American College of Physicians, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Michael K Racke, MD, Professor of Neurology and Molecular Virology, Immunology, and Medical Genetics, Chairman of Neurology, Chief of Neurology Service, Ohio State University Medical Center
Michael K Racke, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association for the Advancement of Science, American Association of Immunologists, and American Neurological Association
Disclosure: Teva Neuroscience Consulting fee Consulting; Peptimmune Inc. Consulting fee Consulting; Bristol Myers Squibb Consulting fee Consulting; EMD Serono Honoraria Speaking and teaching

 
 
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