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Tuberculosis Research and Treatment
Volume 2011 (2011), Article ID 798764, 9 pages
http://dx.doi.org/10.1155/2011/798764
Review Article

Tuberculous Meningitis: Diagnosis and Treatment Overview

1Department of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, CO 80045, USA
2Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, CO 80045, USA
3Denver Veterans Affairs Medical Center, Denver, CO 80220-3808, USA
4Department of Medicine, National Jewish Health, Denver, CO 80206, USA
5Program in Cell Biology, National Jewish Health, Denver, CO 80206, USA

Received 3 September 2011; Revised 16 November 2011; Accepted 18 November 2011

Academic Editor: Carlo Garzelli

Copyright © 2011 Grace E. Marx and Edward D. Chan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis (TB) and has very high morbidity and mortality. TBM is typically a subacute disease with symptoms that may persist for weeks before diagnosis. Characteristic cerebrospinal fluid (CSF) findings of TBM include a lymphocytic-predominant pleiocytosis, elevated protein, and low glucose. CSF acid-fast smear and culture have relatively low sensitivity but yield is increased with multiple, large volume samples. Nucleic acid amplification of the CSF by PCR is highly specific but suboptimal sensitivity precludes ruling out TBM with a negative test. Treatment for TBM should be initiated as soon as clinical suspicion is supported by initial CSF studies. Empiric treatment should include at least four first-line drugs, preferably isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol; the role of fluoroquinolones remains to be determined. Adjunctive treatment with corticosteroids has been shown to improve mortality with TBM. In HIV-positive individuals with TBM, important treatment considerations include drug interactions, development of immune reconstitution inflammatory syndrome, unclear benefit of adjunctive corticosteroids, and higher rates of drug-resistant TB. Testing the efficacy of second-line and new anti-TB drugs in animal models of experimental TBM is needed to help determine the optimal regimen for drug-resistant TB.