1. Tuberculosis Meningitis
10 April, 2009

2. Ⅰ overview TBM is the most serious type in children with tuberculosis
TBM is an early primary complications in Primary tuberculosis
the incidence is significantly decreased after BCG vaccination

3. Ⅱ Epidemiology Age of Onset：More common in 1 ~5 year-old
1180 TBM in Beijing Children's Hospital
<3y 56.7%，<1y 48.5% (half the number)
Onset in Season ： common in Winter or spring

4. Ⅲ Pathogenesis Hematogenous dissemination： blood-CSF path main
Brain , meningeal tuberculosis rupture secondly
Tuberculosis in nearly organize direct spread occasionally

5. Ⅳ Pathology Extensive lesions 病变以脑底部最明显 “脑底脑膜炎”
Lesions in the bases of skull “basilar meningitis” (most obvious)
病变以脑底部最明显 “脑底脑膜炎”
leptomeningeal hyperemia, edema, Inflammatory exudate
The inflammatory exudate is accumulated in the subarachnoid（ cistern in pavimentum cerebri ）
cranial nerve lesion
cerebrovascular disorder。
Pyocephalus and Hydrocephalus。
Tuberculoma

6. Ⅴ Clinical manifestation
Most typical cases ----slow onset
nervous system
symptom
General
symptom
Tuberculosis
toxic symptom
meningeal irritation sign
cranial nerve lesion
irritative or destructive symptoms of encephalon
intracranial hypertension
spinal cord disorder symptom

7. ⅤClinical manifestation
prodromal period
（prophase）
meningeal irritation
period
（metaphase）
coma period
（advanced stage）
intracranial hypertension
meningeal irritation sign
cranial nerve lesion
irritative or destructive symptoms of encephalon
pyramid sign;pyramidal sign
convulsion
Tuberculosis toxic symptom
Headache
vomiting
Personality change
symptom increased
go into coma
spinal cord dysfunction

8. Ⅵ Diagnoses (Ⅰ)History： Age, Seasons, (Ⅱ)clinical feature：
History of exposure and BCG vaccination,
History of infectious diseases
(Ⅱ)clinical feature：

9. (Ⅲ) CSF Examination ： 1、routine： 2、biochemistry： 3、film preparation：
Appearance：Like ground-glass ， floccule or membrane
High pressure
Cell count（Lymphocytes）：50～500×106/L
2、biochemistry：
Protein  、glucose and chloride 
3、film preparation：
precipitum acid-fast stain positive 30%

10. (Ⅲ) CSF Examination ： 3、Others 1）tubercle bacillus antigen detection
2）anti-tuberculosis antibody
（one of the early diagnosis evidence）
3）adenosine deaminase （ADA）activity
TBM：ADA  >9μ/L
4）immunoglobulin：IgG 
5）detect DNA fragment
6）tubercle bacillus culture
film preparation and cultivation
--- may be have a clear diagnosis

11. (Ⅳ) X-ray examination (Ⅴ)CT or MRI early: normal (Ⅵ) PPD-Test
Chest X-ray: About 85% have tuberculose focus
(Ⅴ)CT or MRI
early: normal
progression：Shadow of the basal ganglia enhanced, cistern density  , fuzzy, calcification, ventricular dilatation, cerebral edema or infarct foci
(Ⅵ) PPD-Test

12. 枕区环形增强灶、侧脑室室管膜异常增强、侧脑室明显扩大 图2 ：同一病人的冠状面T1W
枕区环形强化灶
图1 T1W横断面：注射造影剂后显示
枕区环形增强灶、侧脑室室管膜异常增强、侧脑室明显扩大
图2 ：同一病人的冠状面T1W
a. Transverse T1W image after contrast administration reveals ringlike enhancement in occipital region and abnormal enhancement of the ependymal of the ventricles
b. coronal T1W image of same patient
（同一病人的冠状面T1W）

13. Ⅶ Differential Diagnosis
1、purulent meningitis
2、Viral Encephalitis
3、Cryptococcus neoformans meningitis
4、cerebral abscess
鉴别诊断
1、化脑
2、病毒性脑炎
3、新型隐球菌脑膜炎
4、脑脓肿

14. Ⅷ treatment bed rest （Ⅰ）General treatment Nutrition Nursing Care
Coma Patients：nasogastric feeding、
pressure sore prevention
attention Water-Electrolyte Balance
（Ⅰ）一般治疗
卧床休息
加强营养
护理、空气
昏迷病人鼻饲、翻身拍背、防褥疮
注意水电解质平衡

15. Ⅷ treatment （Ⅱ）Anti-tuberculosis therapy Principle：Early , Complete
Intensification
treatment
INH+RFP（早、中期）
INH+RFP+SM
INH+RFP+SM+PZA
3~4M
(Ⅱ)抗结核治疗
原则：早期、彻底治疗
强化治疗:
INH+RFP（早、中期）
INH+RFP+SM ~4个月
INH+RFP+SM+PZA
INH 15~25mg/kg.d RFP 10~20mg/kg.d
SM 15~20mg/kg.d PZA 20~30mg/kg.d
INH 15~25mg/kg.d RFP 10~20mg/kg.d
SM 15~20mg/kg.d PZA 20~30mg/kg.d

16. （Ⅱ）Anti-tuberculosis therapy
Consolidation
treatment
INH+RFP
巩固治疗INH+RFP
总疗程不<12月
或CSF正常后继续治疗6月
course of treatment≥12M
or when CSF normal, continue treatment 6M

17. Ⅷ treatment CSF secretion：lateral ventricles choroid（占70%）
（Ⅲ）decrease intracranial hypertension
CSF secretion：lateral ventricles choroid（占70%）
Ependyma、encephalon
----TBM， Inflammatory stimulation, secretion
absorption：arachnoid granulations
---- TBM， absorb disturbance
circulation：
---- TBM, inflammatory in base of skull, pathway blocked ↑
（ Ⅲ ）降低颅高压
CSF分泌：侧脑室脉络膜丛（占70%）
室管膜和脑实质----TBM时，炎症刺激，分泌
吸收：蛛网膜颗粒---- TBM时，回收障碍
循环： ---- TBM时，颅底炎症，通路受阻

19. 1、dehydrant （Ⅲ）decrease intracranial hypertension
20%mannitol：0.5~1.0(2.0)g/kg.次 iv q4h~q6h
2、adrenocortical hormone Dx 0.2~0.4mg/kg.d
3、lateral ventricular puncture
4、lumbar puncture decompression, intrathecal injections：
INH、Dx
5、Surgery：
Ventriculoperitoneal shunt or external drainage
1、脱水剂
20%甘露醇：0.5~1.0(2.0)g/kg.次 iv q4h~q6h
2、肾上腺皮质激素
Dx 0.2~0.4mg/kg.d
3、侧脑室穿刺引流
4、腰穿减压、鞘注 INH、Dx
5、外科手术 脑室腹腔分流术或外引流术

20. 1、Control convulsions、Antipyretic
（Ⅳ）adrenocortical hormone therapy
Dx 0.2~0.4mg/kg.d
Prednison 1~2mg/kg.d
（ 4 weeks after decreasing，course：8~12 weeks ）
（Ⅴ）others
1、Control convulsions、Antipyretic
2、Water-Electrolyte Balance disturbances
Hyponatremia（dilutional, Cerebral ）
Hypokalemia
（Ⅵ）follow observation
at least 3～5years
（四）肾上 腺皮质激素治疗
Dx 0.2~0.4mg/kg.d
Prednison 1~2mg/kg.d（ 四周后渐减量，疗程8~12周）
（五）对症处理
1、抗惊厥、退热
2、水、电解质紊乱的处理
低钠血症（稀释性、脑性）
低钾血症
（六）随访观察 至少3～5年

21. criterion of cure Symptoms disappeared CSF normal No recurrence
(2 years After the end of Treatment)
治愈标准
症状消失
脑脊液正常
疗程结束后2年无复发

22. Ⅸ Prognosis (Relevant factors)
age
Time of therapy--- early or late
The degree of brain damage
Therapeutic method--- correct？
Tubercle bacillus--- resistance？
九、预后（相关因素）
1、年龄
2、治疗时间早晚
3、脑实质损害程度
4、治疗方法正确与否
5、结核杆菌是否耐药