Tuberculous meningitis: symptoms, features of treatment. Tuberculous meningitis: causes and consequences It should be distinguished - varieties of the disease

Inflammatory disease of the meninges of the brain, which occurs when there is a focus of tuberculosis in the body, is called tuberculous meningitis. As a rule, it is secondary.

Forms

There are 3 clinical types of this disease:

Incubation period

This disease is divided into two stages:

The development of tuberculosis after the pathogen enters the body.
After the development of the underlying disease, the incubation period for meningitis is 5 to 7 days.

Causes and risk groups

How is the disease transmitted? Tuberculosis can affect various parts and systems of the body. With the penetration of mycobacteria of this disease into the membranes of the brain, meningitis occurs.

The anamnesis, the severity of meningeal symptoms, the indicators of tuberculin tests, the presence and timing of BCG vaccination, and revaccination are being studied. The final diagnosis is possible after the analysis of cerebrospinal fluid, examination of the fundus, CT and MRI, radiography.

Liquor

The amount of cerebrospinal fluid in this disease is always increased by 4-6 times, globulin reactions are clearly positive, the percentage of sugar is low, the protein content is increased.

A special sign of tuberculous etiology is lymphocytic or lymphocytic-neutrophilic cytosis.. There is a characteristic loss after 12-24 hours of a fibrinous film, in which tubercle bacilli are found.

Read more about collecting liquor in this article.

micropreparation

Tuberculous tubercles are not always visible in the choroid plexuses and in the substance of the brain. There is swelling of the brain, its edema, expansion of the ventricles of the brain, ventriculitis, ependymatitis, periarteritis, endarteritis.

The latter is located in the form of clutches of lymphoid and epithelioid cells around the vessels, in which the formation of blood clots is possible. Insufficient therapy of anti-TB drugs, as well as late diagnosis, lead to the development of fibroplastic processes.

Treatment of tuberculous meningitis

A phthisiatrician, together with a neurologist, diagnoses and prescribes a course of treatment for this disease. Isoniazid, rifampicin, pyrazinamide and ethambutol are considered optimal.. If the use of funds gives the desired effect, after 2-3 months the dose of isoniazid is reduced, ethambutol and pyrazinamide are canceled. Reception of drugs lasts at least 9 months. In parallel, the necessary complex of treatment is prescribed by a neurologist.

It includes:

dehydration therapy - furosemide, acetazolamide, mannitol, hydrochlorothiazide;
detoxification - infusion of dextran, saline solutions;
glutamic acid;
vitamins C, group B;
in severe conditions - glucocorticoid therapy.

In the presence of paresis, neostigmine, ATP are added, and in the case of atrophy of the optic nerve - nicotinic acid, papaverine, heparin, pyrogenal. Bed rest lasts about two months, by the end of the third month the patient is allowed to walk. Massage and exercise therapy are recommended not earlier than 4-5 months of the disease.

Tuberculous meningitis is treated strictly under the supervision of specialists. Folk or alternative remedies do not exist, the time lost on them can aggravate the patient's condition.

Rehabilitation

Patients with paresis and paralysis are prescribed massage and exercise therapy as early as 5 weeks after the removal of acute symptoms. To restore neuromuscular conduction, prozerin is administered intramuscularly, dibazol is administered orally. Physiotherapeutic appointments, vitamin therapy are also recommended.

After completing the full course of treatment, the patient is sent to a specialized sanatorium. for 3 months or longer for aftercare and rehabilitation. In the future, you may have to undergo anti-relapse courses, the timing of which depends on the doctor's recommendations.

IMPORTANT! Monitoring and prescribing rehabilitation measures for tuberculous meningitis will be carried out by an anti-tuberculosis dispensary institution.

Complications

From the onset of meningeal symptoms to the tenth day, it is important to diagnose the disease and initiate active therapy. In this case, there are practically no undesirable complications.

With delayed treatment, the main residual effects will be:

decreased clarity of vision;
convulsive seizures on the background of epileptic syndrome;
mental status disorders;
cognitive impairment;
paralysis and paresis;
blindness;
mental disability.

Prevention

Primary prevention of the disease includes.

Tuberculous meningitis is the most common form of damage to the central nervous system, accounting for 5% of cases of extrapulmonary infections with mycobacteria. Most often, children under 4 years of age and adult carriers of HIV infection suffer.

Signs of the disease are difficult to distinguish from typical meningoencephalitis. Only with the appearance of a coma, seizures, increased intracranial pressure and hemiparesis, the diagnosis becomes obvious, but the prognosis is usually poor.

Symptoms of childhood tuberculous meningitis may resemble severe intoxication with high fever, cough, vomiting, malaise, and weight loss. After 6 days, neurological signs appear: apathy, irritability, impaired consciousness, bulging of the anterior fontanel in infants, cranial nerve palsy, optic nerve atrophy, abnormal movements and focal neurological signs, such as hemiplegia. Convulsions in children occur more often than in later life.

In adults, the prodromal period with low-grade fever, malaise, weight loss, followed by a gradual increase in headaches lasts 1-2 weeks. Then the pain progresses, vomiting, confusion and coma are added. After 6 days, there is a stiff neck, paresis of the VI, III and IV cranial nerves. Focal neurological lesions, such as monoplegia, hemiplegia, paraplegia, urinary retention, are additional clinical signs.

Tuberculous meningitis should be suspected in all children with fever, irritability, neck stiffness, drowsiness and night sweats, headaches, and vomiting. Convulsions, confusion of consciousness are more accurate symptoms. Recent contact with a person who has or is at risk of developing tuberculosis should be suggestive of infection.

Paralysis of cranial nerves, atrophy of the optic nerve, pathological extrapyramidal disorders are more characteristic of tuberculous meningitis. The study showed that it is the changes in the optic nerve that are independent predictors of the pathology of tuberculous nature.

Difficulties in diagnosis

A number of studies confirm that 70-90% of children have had recent contact with an infected person. During the prodromal period, approximately 28% of patients complained of headaches, another 25% had vomiting, and 13% had fever. Only 2% of patients experienced signs of meningitis. For example, photophobia was a clinical manifestation.

A variety of complications can be seen based on an understanding of the lesions and pathology of tuberculous meningitis. Spikes lead to cranial nerve palsies (especially II and III, IV and VI, VII and VIII), narrowing of the internal carotid artery provokes strokes, and obstruction of CSF outflows increases intracranial pressure. Heart attacks occur in 30% of cases, but hemiparesis with motor impairment is more common. Seizures due to inadequate secretion of antidiuretic hormone are common in children and the elderly. Spastic or flaccid paralysis, loss of sphincter control suggest meningitis.

Tuberculous meningitis in older patients manifests itself atypically and is more often characterized by spontaneous attacks of circulatory disorders or nervous functions.

Factors of infection with tuberculosis are as follows:

Close contact with an infected person for a year.

Birth in a region with a high prevalence of infection. These areas include Africa, Southeast Asia, the Eastern Mediterranean, and the Western Pacific.

Contact with HIV-infected, homeless, drug addicts or prisoners - people who are at high risk of infection.

People who work or travel to countries with a high prevalence of TB should talk to their doctor about the need for vaccination. In regions with a high epidemiological risk, tuberculous meningitis is more common in children under 5 years of age. If the incidence rate is low, then CNS damage occurs more often in adults.

The mechanism of development of meningitis

Tuberculosis bacteria enter the body by airborne droplets: when breathing, coughing or sneezing an infected person. Then they multiply in the lungs and, once in the bloodstream, "travel" to other parts of the body. Bacteria penetrate the blood-brain barrier and form small pustules in the brain tissues. Abscesses are destroyed, which leads to the development of tuberculous meningitis. This can happen immediately or several months after the initial infection. During illness, intracranial pressure increases, so nerve damage is the most severe.

Tuberculous meningitis develops according to three stages:

In the prodromal period, the state of health deteriorates sharply, headaches bother.
At the stage of excitation, stiff neck, vomiting, confusion and hallucinations appear, headaches and muscle pain intensify.
At the stage of oppression, paralysis and paresis appear, the onset of coma is possible.

Laboratory research

CSF analysis is the "gold standard" for detecting tuberculous meningitis. There is an increase in lymphocytes (50 - 450 cells per microliter), protein (0.5 - 3 g / l) and a decrease in glucose (CSF / plasma< 0,5). Иногда развивается картина с нормальным цитозом, но увеличенными нейтрофилами. О туберкулезном менингите говорит количество клеточных элементов выше 900 – 1000 на мл, нейтрофилов – менее 30 – 75% и концентрация белка более 1 г/л.

Detection of acid-fast mycobacteria is mandatory. But microscopy finds signs of only one-third and half of patients. Therefore, PCR diagnostics and the Interferon Gamma Release Assay, or IGRA, are more often used for differential diagnosis.

It is necessary to identify foci of mycobacteria outside the central nervous system using chest x-ray, abdominal ultrasound. In addition, the gastric secretion, the contents of the lymph nodes, ascitic fluid, bone marrow, and liver are examined. Auxiliary tests include a positive tuberculin test.

Tuberculous meningitis often needs to be staged by diagnostic imaging. Brain CT or magnetic resonance imaging can detect hydrocephalus, which occurs in 80% of children and rarely in adults or adolescents. Enlargement of the basal meninges occurs in 75% of patients. Diagnosis also shows tuberculomas and heart attacks.

The combination of hydrocephalus, expansion of the basal meninges, infarcts is a specific sign of tuberculous meningitis, as well as induration in the basal cisterns in children. Against the background of HIV infection, heart attacks and massive brain damage occur more often.

Fundamentals of Therapy

In practice, treatment of tuberculous meningitis is required before a definitive diagnosis can be made.

Two treatment strategies are used:

The appointment of streptomycin at the rate of 40 mg per kilogram of body weight for two months, followed by a dose reduction to 20 mg for up to a year.
Combined use of three or four antibiotics. If the patient's condition improves after three months, then one drug is canceled.

In international practice, the treatment of drug-susceptible tuberculous meningitis involves an intensive phase using four drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol or Streptomycin) for two months, followed by a switch to two drugs (Isoniazid "and" Rifampicin "), which are taken in short courses all year round.

The greatest safety of "Ethambutol" for children of all ages is confirmed. "Pyridoxine" (vitamin B6) helps in eliminating the side effects of drug therapy.

After the intensive phase, drugs are taken twice or thrice a week for outpatient treatment. Patients are usually isolated. In almost 10% of patients with tuberculous meningitis, symptoms paradoxically worsen a few weeks or months after the start of treatment, which does not at all indicate erroneous prescription of drugs. Sometimes corticosteroids are added.

Most neurological complications develop due to inflammation caused by damage and swelling of the brain. Systemic corticosteroids help reduce morbidity and mortality. Mycobacterium tuberculosis is more likely to infect tissue macrophages against the background of an increased level of anti-inflammatory cytokines and chemokines. The use of corticosteroids suppresses the production of inflammatory mediators. It is recommended to prescribe to children 12 mg per day of Dexamethasone (8 mg with a body weight of less than 25 kg).

Against the background of the disease, the production of antidiuretic hormone increases, which leads to the development of cerebral edema. So far, water restriction has been the mainstay of treatment, although the administration of B2 receptor antagonists, along with a decrease in anti-inflammatory molecules, increases diuresis.

Hydrocephalus is a common complication of tuberculous meningitis. Surgical treatment of tuberculous meningitis with ventriculoperitoneal shunting helps relieve increased intracranial pressure.

Consequences of the disease

The onset of death and complications are determined by the neurological stage at which treatment is started. Late-stage therapy is associated with a 50% mortality rate. However, the time between the first symptoms and diagnosis can be as long as 2 to 365 days. But most often, in 60% of cases, the disease is determined in three weeks. The average hospitalization time is one month.

After discharge, about a third of patients have neurological symptoms, and in 10% they persist for six months. Remains cranial nerve palsy, hemiparesis and paraparesis. Patients with hydrocephalus require neurosurgical intervention, but all signs of pathology disappear in 4-5 months. At an earlier age, nerve damage and tuberculoma increase the risk of neurological complications. For example, they are fraught with hearing loss.

Why does the disease develop?

Meningitis is a complication of tuberculosis. During infection, bacteria colonize macrophages to disperse throughout the lymphatic system. Extensive bacteremia increases the likelihood of CNS involvement. Bacteria concentrate in the parenchyma and meninges of the brain during the initial systemic spread. Their rupture leads to vascular occlusion and cerebral ischemia. Due to the obstruction of the basal cisterns, hydrocephalus is formed.

Patients develop intracranial tuberculomas or granulomatous masses consisting of epithelioid cells surrounded by lymphocytes. Necrotic areas within the nodes contain mycobacteria. When the tuberculoma core liquefies, an abscess develops.

Tuberculosis is a common disease with 8.8 million new cases each year. The epidemic broke out in developed countries with renewed vigor due to migration due to HIV infection and multidrug resistance. Approximately 5 - 15% of cases of extrapulmonary tuberculosis are neurological pathologies, but more often - in children and patients with HIV.

New developments

The study of the genome of mycobacteria strain H37Rv allows expanding research in the field of vaccine development, drug resistance mechanisms, and virulence factors. Some bacteriological substances can bind to specific receptors, which simplifies the damage to the meninges.

Instead of skin tests, a cytokine test is performed in response to Mycobacterium tuberculosis, which allows not only to detect infections, but also to predict the response to vaccination. Rapid drug sensitivity tests using bacteriophages solve the problem of choosing an effective therapy.

Tuberculous meningitis is a secondary inflammation of the membranes of the spinal cord and brain in people with tuberculosis of various organs.

This disease, which is now rare, mainly affects people between 40 and 65 years of age and children under 5 years of age, although this rarely occurs because children are required to be vaccinated against meningitis.

The causative agent of the disease is Mycobacterium tuberculosis. This form is especially difficult, because the body was previously affected by tuberculosis - the immune system is weakened, there is no strength to fight the "scourge".

How the infection is transmitted

The cause of tuberculous meningitis is an infection from organs with tuberculosis: lungs, bones, genitals, mammary gland, kidneys, larynx and others. Rarely is infection by contact.

In the presence of tuberculosis of the bones of the skull or spine, the infection can go to the membranes of the brain. In about 17% of cases, infection occurs through the lymph.

Risk factors for developing the disease include:

age- Elderly people and children under 5 years of age have a weak immune system;
seasonality– autumn and spring are the period of epidemics;
other body infections, intoxication,.

Distinguish between different types of disease

Tuberculous meningitis has different forms, differing in symptoms and appropriate treatment:

Basal- has cerebral meningeal symptoms in the form of an inability to pull the head to the chest due to hardening of the occipital muscles, impaired craniocerebral innervation and tendon reflexes.
tuberculous- the most severe form of the disease, there are cerebral and meningeal symptoms (vomiting, paralysis of the limbs, etc.), as well as abnormal craniocerebral innervation.
Tuberculous leptopachimeningitis- develops extremely rarely, at the beginning of the disease there are almost no symptoms or they are hardly noticeable.
If one or more symptoms are detected, having a provoking factor (tuberculosis of one of the organs), you should immediately seek help from a doctor. Tuberculous meningitis is dangerous for its complications and adverse effects.

meningeal symptoms

Children at risk

More often, tuberculous meningitis develops in young children due to the lack of developed immunity or the refusal of parents to tuberculosis vaccinations.

Suffer mainly infants, debilitated and premature, as well as children from 3 to 5 years. Only in babies up to a year old, the disease begins in an acute form, the temperature rises sharply, vomiting begins, convulsions, hydrocephalic syndrome and bulging of a large fontanel are noted.

In children older than a year, it usually starts with malaise, loss of appetite, drowsiness. Then the temperature rises, and vomiting begins - this happens within a week. Usually meningeal symptoms appear after 1-3 weeks.

Features of the clinical picture

Symptoms of tuberculous meningitis are divided into three stages:

prodromal period- lasts up to 6-8 weeks. Symptoms appear gradually: apathy, lethargy, drowsiness, weakness, and frequent headaches, which gradually become stronger, the temperature rises to 38 degrees, nausea and vomiting begin.
- the signs of the disease intensify, the temperature rises, headaches in the back of the head, constipation, photophobia, intolerance to sounds, the appearance and disappearance of spots on the body. On the 6th-7th day of this period, meningeal symptoms occur: neck stiffness, Kernig and Brudzinsky symptom, hearing loss, vision problems, speech impairment, decreased sensitivity of the extremities, hydrocephalus, increased sweating and salivation.
Terminal period- the last stage of the disease, paralysis also begins, the heartbeat becomes more frequent, loss of consciousness, difficulty breathing, temperature up to 40 degrees. The last stage of the disease ends with the death of a person.

In young children, the symptoms are similar to those in adults, only their development occurs in an acute form and the periods are shortened.

The main symptoms characteristic of tuberculous meningitis that develops in children are convulsions, vomiting, fever, the child screams, the fontanel swells and pulsates on the 2nd day.

In older children, the disease occurs gradually, the manifestation of symptoms is blurred. You can determine meningitis by the way the child lies, if he constantly lies on his side, his legs tucked to his stomach, and his head thrown back - this is a sure sign of the disease.

Goals and methods of diagnosis

Establishing a diagnosis of this disease within 10 days is considered timely, after 15 days - late. The disease is determined by three signs: the presence of symptoms, the definition of the source of infection and the study of cerebrospinal fluid.

Tuberculosis infection can be in any organ of the patient, therefore:

on examination, pay attention to the presence of tuberculosis of the lymph nodes;
conduct x-rays of the lungs, aimed at detecting tuberculosis;
diagnose an enlarged liver and spleen;
examination of the fundus is carried out.

The selection of cerebrospinal fluid indicates tuberculous meningitis, if the cerebrospinal fluid comes in a stream or fast drops. A complete examination for changes in the fluid indicates an accurate diagnosis.

In addition, blood is taken for general and biochemical analysis, and lungs and other organs are also carried out.

Health care

The therapy lasts a very long time and is carried out only in stationary conditions. After the treatment, which lasts up to a year, the patient is sent to a specialized sanatorium.

All treatment is aimed at the destruction of the tubercle bacillus and is carried out especially intensively in relation to young children.

For example, if Streptomycin can be administered intramuscularly to an adult patient, then a child needs to do this in the spinal canal, because in infants the disease is acute, and the slightest delay can cost life.

The goal of treating tuberculous meningitis is to eliminate the focus of tuberculosis, treat inflammation of the meninges and exclude it, prevent complications, stop CNS lesions, and relieve intoxication.

conservative medicine

Treatment is carried out in a complex with the use of specialized drugs: Streptomycin, PASK, Ftivazid and Saluzid.

Complex treatment prevents the emergence of resistant Macobacterium tuberculosis and has a beneficial effect on the removal of the inflammatory process, because all these drugs have an anti-inflammatory effect. The combination and dosage is prescribed by the doctor depending on the severity of the disease, the tolerance of drugs, the patient's condition.

At the same time, general strengthening therapy is prescribed: glucose systems, vitamins C, B1, B6, aloe. In case of complications, drugs are prescribed to eliminate them.

Even with mild forms of the disease, the patient is discharged from the hospital only after six months, if the patient has a good general condition and normal parameters of cerebrospinal fluid tests. After discharge, treatment for tuberculosis and complications of meningitis continues.

Dispensary supervision is carried out within 2-3 years. Immediately after the sanatorium, the patient is enrolled in group 1 of the dispensary at the place residence and then translated into 2 and 3.

Children are observed by a phthisiatrician for a year in group A, then 2 years in group B, and the last 7 years in group C. If complications are noted, then follow-up with a neuropathologist, ophthalmologist, and psychiatrist continues. The first 2-3 years, preventive courses are carried out for 3 months with Isoniazid in combination with Ethambutol.

Patients continue their labor activity if they do not have a disability. Light work is needed, mental stress is unacceptable for a year after treatment.

ethnoscience

Folk remedies in the treatment of tuberculous meningitis perform a supporting function and alleviate the suffering of the patient. But you can use them after consulting with your doctor.

Decoctions and tinctures of herbs are recommended: lungwort, marshmallow, elecampane root. In the room where the patient is located, you can put a pot of wisteria - the phytoncides secreted by it disinfect the air and kill the tubercle bacillus.

At home, to alleviate the suffering of the patient, he should be provided with peace, both spiritual and bodily, because he has an acute sensitivity to hearing, vision and touching the skin.

It is necessary to close the windows with curtains, isolate the patient from sounds and touches to the body. Put ice or rags moistened with cold water on the head and limbs (arms and legs), periodically changing them as they heat up. It is important to know that the patient should be hospitalized as soon as possible so that treatment can begin immediately.

Is it dangerous?

The prognosis for the treatment of tuberculous meningitis is favorable in 90% of cases if the diagnosis is made on time. If the diagnosis is made after 15 days of illness, then the consequences can be the saddest. If the patient was immediately taken to the hospital, then a complete cure is possible even in young children.

A common complication is, (paralysis of one side of the body), visual impairment, blindness. With the spinal form of meningitis, there may be paresis of the limbs and the development of pathologies of the pelvic organs.

In order to prevent

There are the following preventive actions that prevent infection with tuberculosis:

Taking precautions can reduce the risk of infection. If, nevertheless, it happened, you should not self-medicate, but you should immediately consult a doctor.

Tuberculous meningitis is a pathology that is characterized by the development of inflammation in the lining of the brain. The source of the disease is mycobacterium.

Features of the disease

Tuberculosis of the brain is another name for this disease. The disease appears suddenly. In adults and children, the state of health deteriorates sharply, hyperthermia, headache, nausea, urge to vomit occur, the work of the cranial nerves is disturbed, a disorder of consciousness appears, a meningeal symptom complex.

An accurate diagnosis is based on a comparison of clinical data and the results of a study of cerebrospinal fluid. The patient is waiting for a long and complex therapy, which includes anti-tuberculosis, dehydration, detoxification medical enterprises. In addition, symptomatic treatment is also carried out.

The risk group mainly includes people whose immunity is weakened by HIV, malnutrition, alcoholism, drug addiction.

The disease affects people of advanced age. In 9 out of 10 cases, tuberculosis of the meninges is a secondary disease. It occurs against the background of the development of the disease in other human organs. In more than 75% of cases, the pathology is initially localized in the lungs.

If the location of the primary source of the disease could not be determined, tuberculous meningitis is called isolated.

How the disease is transmitted: tuberculosis of the brain develops as a result of penetration into the meninges of the Koch stick. In some cases, it is possible to get infected by contact. In the case of infection with tuberculosis of the bones of the skull, the causative agent of the disease enters the cerebral membranes. In tuberculosis of the spine, the bacterium penetrates the membrane of the spinal cord. According to statistics, about 15% of cases of tuberculous meningitis occur due to lymphogenous infection.

The main route of spread of Koch's bacillus to the meninges is hematogenous. This is the way in which pathogenic microorganisms are carried by the circulatory system throughout the body. The penetration of a harmful bacterium into the cerebral membrane is due to an increase in the permeability of the blood-brain barrier.

Initially, the vascular network of the soft membrane is damaged, after which pathogenic microorganisms enter the cerebrospinal fluid, which provokes the development of inflammation of the arachnoid and soft membranes.

Predominantly, the membranes of the base of the brain are damaged, which leads to the development of basilar meningitis. Inflammation gradually indulges in the membranes of the hemispheres. Further, the inflammatory process affects the substance of the brain, a disease occurs, known as tuberculous meningoencephalitis.

Morphologically, a serous-fibrous inflammatory process of the membrane occurs with the presence of characteristic tubercles. A pathological change in the blood vessels (fibrosis or thrombosis) can lead to circulatory disorders in a certain area of the medulla. After undergoing a course of treatment, the inflammatory process can be localized, as a result, adhesions and scars are formed. Affected children often develop hydrocephalus.

Flow periods

There are several periods of tuberculous meningitis:

premonitory;
irritation:
paresis and paralysis.

The prodromal period lasts from one to two weeks. It is the presence of this phase of the disease that distinguishes the tuberculous form of meningitis from the usual one. The prodromal stage of the development of the disease is characterized by the appearance of a headache in the evening or at night. The general well-being of the patient worsens. He becomes irritable or lethargic. Gradually, the headache intensifies, the patient begins to feel sick. There is a steady rise in body temperature. Due to such specific symptoms, it is very difficult to make an accurate diagnosis at this stage.

The irritation period begins with an exacerbation of symptoms with a sharp increase in body temperature up to 39 ° C. Headaches become more intense, there is an excessive susceptibility to light (photophobia), sound, tactile sensations are exacerbated. The patient has constant lethargy and a feeling of drowsiness. Red spots appear and disappear on the skin in different areas of the body. The last symptom can be explained by a violation of the innervation of the vessels.

At this stage in tuberculous meningitis, the symptoms become meningeal. There is a tension of the occipital muscles, manifestations of symptoms of Brudzinsky and Kernig are observed. At first, these signs are not clearly expressed, but over time they intensify. At the end of this period (1-2 weeks after it began), the patient has lethargy, confusion, the person involuntarily assumes a characteristic meningeal posture.

During the period of paresis and paralysis, the patient completely loses consciousness, central paralysis and sensory disorders occur. Respiratory and cardiac rhythm failures occur. Cramps of the extremities may appear, the body temperature rises up to 41 ° C or, conversely, drops to abnormally low rates. If a person is not given effective treatment, he will die within a week.

The cause of death is most often paralysis of the part of the brain responsible for the regulation of breathing and heartbeat.

There are several clinical forms of this pathology.

Tuberculous basilar meningitis

Tuberculous basilar meningitis in more than 2/3 of cases develops gradually, has a prodromal period of up to 1 month. During the irritation stage, a growing smut pain appears, signs of anorexia are observed, the patient is constantly sick, severe drowsiness and lethargy occur.

The manifestation of meningeal syndrome occurs along with disorders of the cranial nerves. For this reason, the patient may develop strabismus, blurred vision, hearing loss, anisocoria, drooping of the upper eyelid. In less than half of the cases, ophthalmoscopy determines the stagnation of the optic nerve head. A disorder of the facial nerve may occur, causing facial asymmetry.

As the disease progresses, dysarthria, dysphonia, and choking appear. These symptoms indicate further damage to the cranial nerves. In the absence of effective treatment, the disease passes into a period of paresis and paralysis.

Tuberculous meningoencephalitis

The occurrence of tuberculous meningoencephalitis most often occurs in the third period of meningitis. Symptoms are similar to those of encephalitis. Paresis and spastic paralysis appear, one- or two-sided hyperkinesis develops. In this state, the patient is completely unconscious.

At the same time, arrhythmia, tachycardia, respiratory distress can be detected in him, in some cases Cheyne-Stokes breathing is noted. With further progression, the disease leads to the death of the patient.

spinal meningitis

Tuberculous spinal meningitis is observed infrequently. The manifestation of this form of the disease begins with symptoms of damage to the cerebral membranes. Then there are girdle pain sensations, which are caused by the spread of inflammation to the spinal roots.

In some cases, the pain syndrome can be so strong that even narcotic analgesics cannot remove it. With the development of the disease, a disorder of the stool and urination begins. The appearance of peripheral flaccid paralysis, para- or monoparesis is observed.

Diagnosis and treatment

Diagnostic measures are carried out by the joint efforts of phthisiatricians and neurologists. The main step in the diagnostic process is the examination of the spinal cord fluid, a sample of which is obtained using a lumbar puncture.

Liquor in tuberculous meningitis is released with increased pressure up to 500 mm of water. Art. There is the presence of cytosis, which in the early stages of the pathology has a neutrophil-lymphocytic character, but later tends more towards lymphocytic. Quantitative indicators of chlorides and glucose decrease.

The lower the glucose concentration, the more difficult the upcoming treatment. Based on this, doctors choose the appropriate method of therapy. Differential diagnosis of tuberculous meningitis is carried out using CT and MRI of the brain.

At the slightest suspicion of a tuberculous origin of meningitis, doctors resort to prescribing specific anti-tuberculosis therapy.

Treatment of tuberculous meningitis is carried out with the use of Isoniazid, Rifampicin, Ethambutol and Pyrazinamide. If therapy gives positive results, the dosage of drugs is gradually reduced. With a successful course of treatment, after 3 months they refuse Ethambutol and Pyrazinamide. Reception of other drugs in reduced doses should last at least 9 months.

In parallel with anti-tuberculosis drugs, treatment is carried out with dehydration and detoxification drugs. Glutamic acid, vitamin C, B1 and B6 are prescribed. In some cases, they resort to treatment with glucocorticosteroid agents. In the presence of seizures, neostigmine will be included in the therapy. In case of atrophy of the optic nerve, nicotinic acid, Papaverine and Pyrogenal are prescribed.

Tuberculous meningitis is understood as a secondarily current inflammatory process of the meninges in patients who have confirmed tuberculosis of one form or another. Tuberculous meningitis can affect many organs and body systems, including the central nervous system.

Koch wand

Despite modern diagnostics and the ability to identify the disease in the early stages of its manifestation, tuberculous meningitis poses a serious danger to the quality of life of the patient until his death. The main share of the risk of developing tuberculous meningitis is children under 5 years of age, adolescents, elderly patients and patients with immunodeficiency diseases. Most of the diseases occur in the winter or spring, but do not forget that there is always a chance of contracting tuberculous meningitis in adults and young children.

The main causative agent of the disease is Mycobacterium tuberculosis (in the abbreviation MBT). The appearance of the disease is characterized by infection of the meninges with tuberculosis in the presence of existing tuberculosis of any localization. It seems possible to establish the focus of the primary lesion with tuberculosis only in 5% of all clinical cases. The defeat is carried out in two stages:

Hematogenous route (through the blood), when the choroid plexus of the meninges becomes infected.
CSF spread, when mycobacterium tuberculosis pathogenically affects the meninges of the base of the brain, followed by allergic reactions in the vessels.

Almost 85% of patients have active tuberculosis at the moment or cured tuberculosis of absolutely any localization.

Classification by clinical factors

The tuberculous form of meningitis is able to spread and concentrate in absolutely any anatomical zones. Therefore, there are three basic forms of tuberculous meningitis:

Basal. The form is characterized by clearly manifested meningeal symptoms, expressed by various neuralgia, muscle tension in the occipital region, changes in craniocerebral innervation, reflex reactions of tendons to mechanical influences.
Meningoencephalitis and meningoencephalomyelitis. It is characterized by a particularly aggravated course, when severe vomiting, headaches of extensive localization, confusion, unsteady gait, severe paresis of the limbs, hydrocephalus, and other symptoms appear.
Tuberculous leptopachimeningitis. The disease is extremely rare, and proceeds with symptoms gradually increasing in intensity.

When the primary symptoms that characterize tuberculous meningitis appear, you should consult a doctor and begin treatment in a hospital.

Symptoms in young children and adults differ little in the overall clinical picture. The treatment process often takes a long time (6 months or more).

Causes, pathogenesis

There are the most vulnerable groups of people in terms of the incidence of tuberculous meningitis

The onset of a disease does not occur spontaneously in a perfectly healthy organism. The main risk group consists of the following groups of patients:

having a reduced immune response to external stimuli;
affected by various viral infections, especially in autumn or spring;
patients with intoxication of the body of various etiologies;
who have suffered traumatic brain injury.

The development of a pathogenic state in young children and adults occurs after infection with mycobacteria of the patient's nervous system due to a violation of the vascular barrier protection. This occurs due to the high sensitivity of the vessels of the brain, its membranes to external influences or weak immunity (often in the elderly). Such mycobacteria can be found throughout the living world. They are found in both humans and cattle. With the primary attachment of the MBT to the tissues of the brain and meningeal membranes, microtuberculomas occur, which can also be localized in the spine, in the bone tissue of the skull. Such tuberculomas can provoke the following:

cause a focal abscess in the meningeal membranes;
form an effusion and adhesive process at the very base of the brain;
cause inflammation of important arteries, narrowing of their lumens, which can lead to local brain disorders.

Tuberculous meningitis is characterized by these main factors, which, in turn, form the overall clinical picture of its development and course. The destructive process involves not only the membranes of the spinal cord or brain, but also the vascular system. A similar situation is typical for sick children of early age, the elderly.

Symptoms of the disease

Headache in tuberculous meningitis is usually very intense

Important symptoms that characterize tuberculous meningitis are signs that are constantly growing in duration and intensity of manifestations. The incubation period of the disease can last up to six weeks, and the patient at this time can observe minor or pronounced changes in the psychosomatic state:

the occurrence of apathy or, on the contrary, increased excitability;
high fatigue even from a slight load (physical, mental, while awake);
deterioration in the quality of sleep, loss of appetite;
the occurrence of severe headaches, aggravated by nightfall;
temperature increase (sometimes to high values);
vomiting, severe malaise.

Meningeal syndrome manifests itself in stiff neck muscles along with severe headaches, Kerning's symptom (determined in the patient in the supine position).

Rigidity of the muscles of the occipital region, at the same time, is considered the earliest sign of tuberculous meningitis. This applies to the symptoms of the disease in young children, adults. If the doctor quickly and reliably determines the meningeal syndrome in the complex of symptoms, then this significantly increases the chances of an accurate diagnosis almost instantly.

Checking Kernig's sign

The main signs of health problems in meningeal syndrome in adults or young children, adolescents:

disorders and violations of secretory functions (excessive sweating, increased saliva);
persistent disturbances in breathing (intermittent breathing is noted, as if the patient does not have enough air);
sharp jumps in blood pressure in the direction of increasing or decreasing;
alternation of high temperature (up to 40 °C) and low temperature (up to 35 °C);
photophobia, reaction to minor noises;
coma, confusion.

It is worth noting that vomiting, coma, confusion with high fever are signs of a late stage in the development of the disease. Here, tuberculous meningitis usually ends in the death of the patient as a result of paralysis of the respiratory and vasomotor centers.

Diagnostic measures

Diagnosis of the disease is conventionally divided into two stages:

Timely detection of the disease (within 10 days from the date of infection);
Late diagnosis, when 15 days have passed since the onset of the disease.

Diagnosis of the disease includes taking an anamnesis, examination and additional research methods.

There is a set of indicators on the basis of which it is possible to make a diagnosis - tuberculous meningitis in adults and children:

prodromal syndrome (factors preceding the disease);
signs of general intoxication;
functional disorders of the urinary system and intestines;
nausea, vomiting, the head is thrown back, the stomach is pulled in (visually resembles the shape of a boat);
manifestation of symptoms from the cranial nerves;
cerebrospinal fluid (CSF) has characteristic changes in cytosis and biochemical composition;
clinical dynamics with a progressive course.

Making a final diagnosis requires additional research methods and medical examinations of both adults and children, due to the presence of a different localization of mycobacterium tuberculosis:

determination of tuberculosis of the lymph nodes;
analysis of x-ray examination for signs of miliary or focal tuberculosis of the lung tissue;
examination of the spleen and liver for changes in volume (usually upward);
fundus examination for possible detection of chorioretinal tuberculosis.

Performing a lumbar puncture

Analysis of cerebrospinal fluid (CSF) and indicators characteristic of tuberculous meningitis:

increase in pressure;
a study of CSF for transparency, which after a day can form a fibrin mesh;
parameters of the cellular composition vary from 200 to 800 mm3, when the norm is 3-5;
increased protein content;
lowering sugar up to 90% (this condition is common with AIDS);
bacteriological analysis of cerebrospinal fluid, the presence of Mycobacterium tuberculosis.

It is important to properly conduct a study for the subsequent differentiation of tuberculous meningitis from bacterial, viral and HIV-cryptococcal.

Treatment and prevention

The treatment of the disease for both adults and children is carried out urgently and only within the walls of a specialized medical institution, where it is possible to quickly perform the necessary additional diagnostics (lumbar puncture, X-ray, biological material studies) and conduct special methods of anti-tuberculosis therapy.

If there is no treatment for tuberculosis meningeal infection or the tactics are inadequate, then the disease can provoke not only serious complications, but in some cases lead to the death of the patient.

Treatment of tuberculous meningitis is reduced to the use of specific and non-specific agents.

There are no other outcomes for untreated disease.

The main preventive measures include:

conducting regular examinations and notifications in the event of an epidemiological situation with tuberculosis;
early diagnosis, isolation of TB patients from society for further treatment;
periodic professional examinations of applicants for production activities in livestock farms and farms;
the need to allocate separate housing for patients with tuberculosis in the active phase;
timely vaccination in children, and primary in newborns.

The prognosis for tuberculous meningitis often depends on prompt, reliable diagnosis, and timely treatment. In such cases, there is practically no risk of complications, and the adult patient can continue his usual lifestyle. In children, the course of the disease can provoke persistent disorders in mental and physical development.