1. Paediatric Tuberculose Meningitis (TBM)
Robyn Smith
Department of Physiotherapy
UFS
2012

2. Pathogenesis of TB
Ancient disease – described by early Indian & Chinese writings
Two (2) billion persons infected worldwide
20% are children
The prevalence 1st world countries 10/
Prevalence 3rd world countries /
Western Cape, South Africa has the highest world wide prevalence at 510/
Prevalence of TB in South Africa is very high, and treatment costs is a significant financial burden to the country’s government

4. What is TBM? is a life threatening infectious disease condition
causes inflammation of the meninges around brain & spinal cord

5. Aetiology of TBM TBM most dangerous and severe of the TB complications
Significant mortality and morbidity in children
Common cause for cerebral palsy in developing countries
TBM is most prevalent in the age group from 6 months to 3-4 years

6. Aetiology of TBM
NB Infants and children are to be considered to be at increased risk if:
Born high-incidence area
Born into poor socio-economic conditions
Positive TB contact home
Children who have not had their BCG vaccination
HIV positive, TB is also closely associated with HIV and it is estimated that approximately 70% of all TB patients are also HIV positive.

7. Pathogenesis Caused by Mycobacterium Tuberculosis
Primary site is elsewhere, usually the lungs.
2% of cases bacteria travels via the bloodstream to the brain.
Lead to the formation of a focal lesion called a Rich focus
Expanding tubercle ruptures into subarachnoid space
Resulting eliciting an inflammatory response
TBM develops slowly can be at least 3-6 months after initial infection

8. Pathogenesis
Initially symptoms are vague –loss appetite, malaise, headache. History of poor weight gain is relevant (van Well et al., 2009).
Symptoms may last for severely weeks before more specific symptoms of meningitis develop – vomiting, photophobia, neck stiffness and confusion

9. Pathogenesis
Arteries of the cortex/meninges develop inflammation, obstruction or infarction
Vasculitis, encephalitis and myelitis
Obstruction basal cisterna result build up of CSF resulting in associated hydrocephalus
May have brainstem involvement
Tuberculoma formation may occur and in cases of poor host resistance it may result in brain abscess formation.

11. What is a Tuberculoma? Rare TB lesion
Rounded tumour like non-neoplastic mass
= space occupying lesion
Caused by localised TB infection of the brain
May be single or multiple lesions
Can reach considerable size
Lead to abscess formation

12. Staging of TBM Stage I ( 100% survival) Signs of menigeal irritation
Lethargy
Conscious, rational
No focal neurological signs
No hydrocephalus
Stage II (85% survival)
Confusion
Focal neurological signs e.g. squint (CN VI), hemiparesis
Stage III (50% survival)
Stupor/delirium
Neurological signs
Myeloradiculopathy with radicular pain

13. “ No place for a wait and see approach”
Staging of TBM
If untreated the child TBM may lead to death within three weeks
NB from the staging it is evident that early and correct diagnosis and appropriate medical management is imperative in order to ensure a good neurological outcome
“ No place for a wait and see approach”
if TBM is a possibility the child is to be immediately started on TB treatment
PROBLEM WITH ENSURING EARLY MANAGAEMENT IN DEVELOPING COUNTRIES :
Symptoms vague and non specific resulting in delayed referral
Lack of access to medical services
Misdiagnosis by medical personnel resulting in delayed treatment

14. Link between clinical signs and outcome?
Study by van Well et al.(2009) published in journal of Paediatrics which was a retrospective study on 20 years of paediatric TBM in Western Cape found the following correlations between clinical signs and poor outcome

15. The study by van Well et al
The study by van Well et al. (2009) in Western Cape found the following clinical signs could be linked to poor outcome at 6 months:
African ethnicity
Young age
HIV co-infection
Stage III TBM
Increased ICP
Convulsions
Decreased LOC
Motor deficits
Brainstem dysfunctions
Cranial nerve palsies
Hydrocephalus

16. Diagnosis
Lumbar Puncture : culturing of TB basilli in the CSF using Ziehl- Neelson stain. TB culture often takes a long time to yield results and further delays treatment
Clinical diagnosis: is often used to an indication to commence treatment:
Positive TB contact
Mantoux skin test positive/ sputum positive
CXR shows signs of primary pulmonary TB
RT brain showing infarct, tuberculoma’s, hydrocephalus

17. Poor compliance often results in resistance to therapy !!!!!
Medical management
Poor compliance often results in resistance to therapy !!!!!
Anti- TB medication:
Rifampicin (RMP)
Ethionamide
Pyrazimide (PZA)
Isoniazid (INH)
Adjunct steroid (Prednisone) therapy may be beneficial to reduce inflammation
Antibiotic therapy:
Amicin

19. Surgical management
Obstructive hydrocephalus and neurological deterioration due to TBM the prompt surgical insertion of a ventriculo-peritoneal (VP) or ventriculo-atrial (VA) shunt
Shunting often delayed due to high CSF protein levels

21. Precautions NB !!!!!!!!!!!!!!!!! Barrier care:
All health professionals to wear a N95 mask when working with these patients until the diagnosis has been made and for the first week while on treatment and when treating patients in the isolation unit.
Mask single use. Do not carry it around with you between patients and wards.
Treat TB last during the day to prevent cross infection to other vulnerable patients.

22. Physiotherapy management
NB:
Aims of therapy influenced by the staging of the disease

23. Physiotherapy in the acute phase
First 3-4 weeks
Severe meningeal irritation
Active and passive movements may lead to increased tension on the meningeal structures leading to severe meningeal pain
Present severe headaches and increased intracranial pressure. Any movement may aggravate these symptoms.
The child tends to lie in side lying with extension of the head and back to ease the tension on the meningeal structures.
Treatment during the acute phase may include:
Positioning is very important as neutral position as possible
Passive mobilization and stretches are important within limits pain
Tone influencing techniques can also be used if indicated
NB allow yourself to be guided by the patients level of pain and irritation

24. Physiotherapy in the sub-acute & chronic phase
As soon as the child appears less irritable
Passive mobilization, stretches and neural mobilization is to be done through full ROM
Tone influencing techniques can be applied where indicated
NDT treatment principles are applied in accordance with the patients clinical picture in order to regain and improve functional abilities
Active and assisted mobilization – get the child up and out of bed

25. Hearing loss Some of the drugs are ototoxic and may result in deafness
All patients on long term TB treatment must be referred to an audiologist for a hearing test

26. References Paediatric dictate for Physiotherapy, UFS (2009)
Images courtesy of GOOGLE images (2009)
Coovadia, H.M. & Wittenberg, D.F Paediatrics and Child Health. A manual for health professionals in developing countries. 4ed. Oxford University Press: Cape town pp
Van Well, G.T.J ; Paes, B.F.; Terwee, C.B; Springer, P; Roord, J.j; donald, P.R.; van Furth,A.M. & Schoeman, J. F twenty years of paediatric tuberculous meningitis: A retrospective study in the Western Cape of south Africa. Paediatrics vol. 123 January pp e1-e8