Guidelines for treatment of drugsusceptible tuberculosis. Intensified treatment for tuberculous meningitis in adult patients with enhanced rifampicin and levofloxacin. Several important recommendations are being promoted in this new edition. A complete medical evaluation for tuberculosis tb must include a medical history, a physical examination, a chest xray and microbiological examination of sputum or some. Central nervous system cns tuberculosis tb includes three clinical categories. Towards improved treatment outcomes for tuberculosis.
Towards improved treatment outcomes for tuberculosis meningitis rethinking the regimen rajeswari ramachandran1 and muniyandi m2 1consultant neurologist, dr kamakshi memorial hospital, india 2scientistc, national institute for research in tuberculosis, indian council of medical research, india submission. Tuberculous meningitis is a bacterial infection of the membranes covering the brain and spinal cord meninges, caused by mycobacterium tuberculosis. Guidelines for treatment of drugsusceptible tuberculosis and. However, tuberculosis affects populations in every country and all neurologists need to be vigilant for possible cases of tuberculous meningitis presenting to their medical facilities. Tuberculous meningitis tbm is a global health problem. Choose the one best answer and write the letter for. Tuberculous meningitis diagnosis and treatment in adults.
Hence, treatment for majority of tbm patients is started even before the confirmation of the diagnosis. Guidelines for treatment of drugsusceptible tuberculosis and patient care 2017 update pdf, 500. Fourth, diagnosing mdrtb cases among previously treated patients and providing effective treatment will greatly help in halting the spread of mdrtb. The most lethal and disabling form of tuberculosis is. The treatment of tb meningitis is isoniazid, rifampicin, pyrazinamide and ethambutol for two months, followed by isoniazid and rifampicin alone for a further ten months. This is normally caused by infection but can also have noninfectious causes. Tuberculous meningitis or tb meningitis can be prevented by controlling tuberculosis infection. Being a subacute illness, early symptoms may be missed leading to clinical deterioration and late presentation. Mar 18, 2020 tuberculous meningitis tbm in children may mimic bacterial meningitis in the early stages.
Tuberculous meningitis is caused by mycobacterium tuberculosis. Characteristic cerebrospinal fluid csf findings of tbm include a lymphocyticpredominant pleiocytosis, elevated protein, and low glucose. Treatment of tuberculous meningitis and its complications in adults. Neurologists are often the first medical providers to evaluate patients with possible infectious meningitis. The combination of tbm and hiv infection poses additional management challenges because of the need to treat both infections and the complications associated with them.
Treatment for bacterial meningitis usually involves intravenous iv antibiotics. The clinical features, treatment, prognosis, and prevention of bacterial meningitis in adults and children and issues related to chronic and recurrent meningitis are discussed separately. Tuberculosis is diagnosed by finding mycobacterium tuberculosis bacteria in a clinical specimen taken from the patient. Dec 31, 2018 tuberculous meningitis or tb meningitis can be prevented by controlling tuberculosis infection. Steroids help reduce the risk of death in those without hiv. Treatment outcomes of childhood tuberculous meningitis. Tuberculous meningitis is important to consider in patients who present with confusion, especially in those with a history of pulmonary tuberculosis, alcohol abuse, homelessness, hiv infection, or chronic steroid treatment.
Knowledge of the clinical presentations and cerebrospinal fluid, microbiologic, and neuroimaging findings for different etiologies is essential to make a prompt diagnosis and initiate appropriate treatment. The bacteria crosses blood brain barrier bbb from the lungs to cause meningitis. Tuberculous meningitis tbm is the most common form of central nervous system tuberculosis tb and has very high morbidity and mortality. Tuberculous meningitis an overview sciencedirect topics. The mri shows the presence, in and over the sellar seat, with parasellar left extension, of tissue with irregular margins, marked inhomogeneous enhancement, and compression of optic chiasm and of the.
Abstract tuberculosis remains a global health problem, with an estimated 10. Tuberculous meningitis tbm is the most common form of central nervous. Liquoral findings strongly suggested a diagnosis of tuberculous meningitis, and culture results were positive for mycobacterium tuberculosis. Six months therapy for patients with tuberculous meningitis. The pattern of tuberculous meningitis in the population is different in different areas of the world. Despite antituberculosis treatment, adult tuberculous meningitis has very. The diagnosis of tuberculosis meningitis based on the discovery of m. Pathogenesis dissemination of bacilli to the meninges and brain occurs as a complication of the primary infection, or as a complication of an existing tb lesion tuberculoma, miliary tb or reactivation of. Treatment of culturepositive pulmonary tuberculosis general conclusions from the literature 26 wksis the minimum duration of treatment 6 month regimens require a rifamycin throughout and pza for the first 2 months 6 month regimens are effective without inh treatment of culturepositive pulmonary tuberculosis. No guidelines exist as to the components and duration of treatment in.
Intensified treatment with high dose rifampicin and levofloxacin compared to standard treatment for adult patients with tuberculous meningitis tbmit. The most lethal and disabling form of tuberculosis is tuberculous meningitis tbm, for which more than 100,000 new cases are estimated to occur per year. Evidence or general agreement that the treatment or a diagnostic approach is not useful or effective, and in some cases may be harmful. The who guidelines for treatment of drugsusceptible tuberculosis and patient care 2017 update contains policy recommendations on priority areas in the treatment of drugsusceptible tb and patient care. It is characterized by fever, loss of appetite and headache. The bacteria spread to the brain and spine from another place in the body, usually the lung. Dexamethasone for the treatment of tuberculous meningitis in. Bcg vaccine can offer protection against some forms of tuberculosis and help in tb meningitis. Dec 07, 2017 tuberculous meningitis tbm develops in 2 steps. List of tuberculous meningitis medications 7 compared. Most international guidelines recommend longer antituberculous treatment att regimens for tbm than for pulmonary tuberculosis disease to prevent relapse. For children living in areas where this infection is more common, bcg vaccine is an important vaccine in the recommended immunization schedule. Tbhiv considerations for antiretroviral use in patients. It causes severe neurologic deficits or death in more than half of cases.
The american thoracic society, centers for disease control and prevention, and infectious diseases society of america jointly sponsored the development of this guideline for the treatment of drugsusceptible tuberculosis, which is also endorsed by the european respiratory society and the us national tuberculosis controllers association. This article discusses the challenges of diagnosing and treating tuberculous meningitis and. Management involves use of medications as well as placement of a shunt. The pathophysiology of tuberculous meningitis has bacilli root itself to the brain parenchyma, which causes the formation of small subpial focus. Tuberculous meningitis tbm in children may mimic bacterial meningitis in the early stages. Pdfcdc pdf pdf icon 492 kb provisional cdc guidelines for the use and safety monitoring of bedaquiline fumarate sirturo for the treatment of multidrugresistant tuberculosis mmwr 20. In addition to antibiotics, dexamethasone a steroid may also be given to children over six weeks of age who have acute bacterial meningitis. The peripheral white blood cell count alone is not help. In areas with much tuberculosis, tuberculous meningitis usually affects young children. Guidelines for the treatment of tbm in adults and children have been. Meningitis, tuberculous nord national organization for. Clinical pathologist, the hospital for sick children, great ormond street, london streptomycin is the antibiotic principle pre pared from streptomyces griseus, and it is active against a wide range of bacteria. Treatment highlights of drugsusceptible tuberculosis. Tuberculous meningitis tbm can occur as the sole manifestation of tb or.
These vague symptoms can last for several weeks before the more specific symptoms of meningitis such as severe headache, dislike of bright lights, and neck. While other investigations may strongly suggest tuberculosis as the diagnosis, they cannot confirm it. The current therapy of tbm is based on the treatment of pulmonary tuberculosis, which may not be ideal. Tbm is typically a subacute disease with symptoms that. We assessed treatment outcome for 1600 children diagnosed with tb meningitis in 10 different countries in a 50 year period. First, the recommendation to discontinue the regimen based on just 2 months of rifampicin. Tuberculous meningitis is the most severe form of tuberculosis.
Pdfcdc pdf pdf icon 1 mb managing drug interactions in the treatment of hivrelated tuberculosis june 20. Previous studies have been too small to determine whether adjunctive treatment with corticosteroids can reduce the risk of disability or death among adults with tuberculous meningitis, and the effect of coinfection with the human immunodeficiency virus hiv. Tuberculous meningitis is the severest form of infection with mycobacterium tuberculosis, causing death or severe neurologic deficits in more than half of those affected in spite of antituberculosi. Culture of tuberculosis from cerebrospinal fluid takes at least 2 weeks. Extensive guidance is provided for the treatment of drugsensitive and drugresistant tuberculosis and tuberculous meningitis. Current who guidelines for tbm are based on those developed to treat ptb and suggest treatment with 2 months of rifampicin rmp, isoniazid. Who guideline on treatment of tuberculosis fourth edition who 2010 pdf who guideline on treatment of tuberculosis in children second edition who 2014 pdf who guideline on xpert mtbrif assay for diagnosis of pulmonary and extrapulmonary tb in adults and children who 20 pdf. Tuberculosis meningitis is caused by mycobacterium tuberculosis infection of the meninges. Pathogenesis and pathophysiology of bacterial meningitis. All three categories are encountered frequently in regions of the world where the incidence of tb is high and the prevalence of postprimary dissemination is common among. The term miliary was coined in 1700 by john jacobus manget, who likened the appearance of the involved lung to millet seeds, with its surface covered with small, firm white nodules.
While sm or emb are traditionally used as the fourth antitb agent in tbm. British infection society guidelines for the diagnosis and treatment of tuberculosis of. Hence, if pza cannot be tolerated, the treatment course for tbm should be lengthened to a total of 18 months. The infection usually begins elsewhere in the body, usually in the lungs, and then travels through the bloodstream to the meninges where small abscesses called microtubercles are formed.
Tuberculosis tb meningitis meningitis research foundation. Dec 21, 2011 tuberculous meningitis tbm is the most common form of central nervous system tuberculosis tb and has very high morbidity and mortality. Recommendations for the treatment of patients with tb meningitis and tb pericarditis are also provided in the guidelines. Miliary tuberculosis tb refers to clinical disease resulting from hematogenous dissemination of mycobacterium tuberculosis. Sep 11, 2017 as the most severe form of tuberculosis tb, tb meningitis disproportionately affects developing countries and results in significant morbidity and mortality. May 30, 2018 meningitis occurs when the membranes that cover the brain and spinal cord become inflamed.
This disease is treated by a number of medications. The duration of antimicrobial therapy for tuberculous meningitis tbm. Approximately 23% of the worlds population has tuberculosis tb, with a 5% to 10% lifetime risk of progressing to active disease. Empiric treatment should include at least four firstline drugs, preferably isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol. Localized infection escalates within the lungs, with dissemination to the regional lymph nodes. The earlier the treatment is initiated, the better your childs outcome. Tb meningitis tends to be more severe than other forms of meningitis. Case definition of suspected acute meningitis duration of symptoms. Pdf tuberculous meningitis tbm is the most common form of central nervous system tuberculosis tb and has very high morbidity and.
Shortly after the first report on streptomycin by waksman and his associates, 1 feldman and hinshaw observed that the drug exerted a pronounced effect upon the course of tuberculous infections in guinea pigs. Four month treatment regimen is adequate for the treatment of adult patients who are not infected with hiv and who have afb smear and culturenegative pulmonary tb recommendation 9. Medications for tuberculous meningitis medication list about tuberculous meningitis. Guidelines for the management of acute meningitis in children and adults in south africa useful and effective. We are committed to sharing findings related to covid19 as quickly and safely as possible. Tuberculous meningitis tbm is the main form of tuberculosis that affects the central nervous system and is associated with high rates of death and disability. Pza has excellent penetration into the csf and is a key drug in reducing the total treatment time for drugsusceptible tb 41. Tuberculous meningitis tbm is the most lethal and disabling form of tuberculosis. Dec 07, 2017 liquoral findings strongly suggested a diagnosis of tuberculous meningitis, and culture results were positive for mycobacterium tuberculosis. Young children and people living with hiv continue to be at highest risk for tb meningitis.
Tuberculous meningitis causes, symptoms, diagnosis. Guidelines for the management of acute meningitis in. Clinicians and researchers will find the beginning chapters on immunopathology and epidemiology of great use in their efforts to develop new strategies for the diagnosis and treatment of tuberculous meningitis. Tuberculous meningitis definition tuberculous meningitis tbm is a chronic infection of the meninges caused by mycobacterium tuberculosis. This is fourth edition of treatment of tuberculosis. Tubercles rupture in subarachnoid area causes meningitis. This edition also addresses the prevention of acquired mdrtb, especially among new tb patients who already have isoniazidresistant mycobacterium tuberculosis when they start treatment. Tuberculous tb meningitis occurs when tuberculosis bacteria myobacterium tuberculosis invade the membranes and fluid surrounding the brain and spinal cord.
Placebocontrolled phase iii trial of intensified treatment for tuberculosis meningitis in adult patients with high dose rifampicin and levofloxacin aim. Then there is an increase in size of rich focus until rupture. As the most severe form of tuberculosis tb, tb meningitis disproportionately affects developing countries and results in significant morbidity and mortality. Classic symptoms of meningitis, such as stiff neck, headache, and light sensitivity, are not always present in meningeal tuberculosis.
Intensified treatment for tuberculous meningitis in adult. Treatment outcomes of tuberculous meningitis in adults. Tuberculosis meningitis list of high impact articles. Mycobacterium tuberculosis bacilli enter the host by droplet inhalation. Diagnosis, initial management, and prevention of meningitis. Tuberculous meningitis is very rare in the united states. Who guideline on treatment of tuberculosis fourth edition who 2010 pdf who guideline on treatment of tuberculosis in children second edition who 2014 pdf. Choose the one best answer and write the letter for the correct answer on the line next to the. Tbm is typically a subacute disease with symptoms that may persist for weeks before diagnosis. Treatment with antibiotics and other drugs is usually effective against the infection. Dexamethasone for the treatment of tuberculous meningitis. Official american thoracic societycenters for disease. Tuberculosis is a common cause of meningitis in developing countries with a high prevalence of pulmonary tuberculosis. Tuberculosis remains a global health problem, with an estimated 10.
Practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances. Tuberculous meningitis tbm is a form of meningitis characterized by inflammation of the membranes meninges around the brain or spinal cord and caused by a specific bacterium known as mycobacterium tuberculosis. As the disease progresses, the symptoms will become more serious. Treatment generally lasts for about a year, involving intensive treatment with three or four antibiotics at first and continually with two antibiotics for about 10 more months. In 2017, approximately 10 million people developed tb worldwide, of whom more than 100,000 new cases of tbm are estimated to occur per year.