Meningitis de etiología mixta: tuberculosa y bacteriana por germen no identificado / Meningitis of mixed ethiology (tuberculous and unindentified bacteria)

Se presenta un caso de paciente masculino de 54 años de edad, sin inmunosupresión ni evidencia de la misma durante su hospitalización, que consulta por cefalea y signos meníngeos. Se realiza Punción Lumbar (PL) compatible con meningitis bacteriana por lo que se indica tratamiento empírico con mejoría franca de la sintomatología con excepción de la esorientación. Una vez en mejores condiciones se reciben los valores de la ADA los cuales están elevados compatibles con Tuberculosis Meníngea (TBM). Se realiza nueva PL para confirmar dicho valor, lo que se logra y además se demuestra un aumento leve. A los 20 días de la hospitalización, y luego de la mejoría franca, el paciente presenta nuevamente cefalea, fiebre y bradilalia por lo que se inicia tratamiento anti TB con mejoría progresiva de los síntomas. Se presenta el caso y se revisa la literatura(AU)

We present a 54-year-old male patient, with no immunosuppression who consulted for headache and meningeal signs. Lumbar tap (LT) was compatible with bacterial meningitis and empirical treatment was startes with a clear improvement in symptomatology, except for disorientation. Then ADA values were received and its values were francly compatible with Meningeal Tuberculosis (TBM). A new LT was performed to confirm this value, also showeds a slight increase. Twenty days after the hospitalization, and after the frank improvement, the patient again presented again with headache, fever and bradylalia, thus initiating anti-TB treatment with progressive improvement of symptoms. The case is presented and the literature is reviewed(AU)

[Steroids for treating tuberculous meningite meningitis]

Tuberculous meningitis is a common form of central nervous system infections in many developing countries where tuberculosis is highly endemic. It constitutes the most grave form of mycobacterium tuberclosis infection. Despite anti-tuberculosus treatment, death or severe neurological disability occur in more than 50% of patients. To improve the prognosis of this disease, steroids were used as an adjuvant treatment for several decades. Its effect have remained controversial until recently there are more evidence of its effectiveness in terms of mortality and neurological sequelae among survivors. This paper is a synthesis of various studies on the effects of steroids in tuberculous meningitis

Brain stem auditory evoked responses and visual evoked responses in children with tubercular meningitis.

Thirty two patients between 6 months and 14 years of age with tubercular meningitis were evaluated for brain stem auditory evoked response (BAER) and Visual evoked responses (VER), within 7 days of admission. Absolute latencies and interpeak latencies were compared with values obtained from normal children. BAER abnormality was found in 56.25% and VER in 28%children, respectively. BAER abnormality correlated with Glasgow Coma Scale at admission and discharge, stage of meningitis, raised intracranial pressure, seizure activity, and poor outcome. VER abnormality correlated with abnormal fundus findings only.

Meningite tuberculosa: relato de 29 casos em população pediátrica no Brasil / Tuberculous Meningitis: report of 29 cases in Brazilian pediatric population

A prevalência de meningite tuberculosa (MTB) nos países em desenvolvimento mantém-se alta, e a doença continua a ter uma elevada taxa de morbimortalidade entre crianças. Neste trabalho, relatamos nossa experiência com casos de MTB, mostrando os achados clínicos, laboratoriais e radiológicos, assim como o tratamento e a seqüência após alta hospitalar. Foram revisados os registros de 29 pacientes com MTB ocorridos no período de 1o de janeiro de 1984 a dezembro de 2001. Houve predomínio do sexo masculino e da cor branca. A média de idade do início dos sintomas foi de 43 meses, variando de 2 meses a 12 anos. O esquema terapêutico mais freqüente foi rifampicina, isoniazida e pirazinamida. Seis pacientes evoluíram para óbito. Todos os pacientes realizaram exames culturais de líquido cefalorraquidiano para M tuberculosis, sendo positivos em 5 (17%). TB pulmonar foi detectada em 8 casos. O tempo médio de internação foi de 41 dias. Quinze de 21 pacientes pesquisados fizeram vacina BCG. Dezenove pacientes (66%) tinham história de contato íntimo com familiar com TB. Lesão cerebral motora foi a seqüela mais freqüente. Glicorraquia menor de 40 mg/dl foi relacionado como fator de risco para lesão cerebral motora, assim como idade menor de 4 anos de idade. Nossos achados mostram que a ocorrência de sinais meníngeos pode funcionar como um fator de proteção para a ocorrência de lesão cerebral motora assim como de proteinorraquia maior que 300 mg/dl (AU)

The prevalence of tuberculous meningitis (TBM) in the developing countries remains high, and this disease still has a elevated rate of morbimortality among children. In this study,we report our cases of TBM, describing clinical, laboratorial and radiological findings, as well the treatment and outpatient follow up. Medical charts from 29 patients interned with TBM from January 1984 to December 2001 were reviewed. There were predominance of male sex and white race. The mean age at the start of clinical manifestations was 43 months old, ranging from 2 months old to 12 years old. The more frequent tuberculostatic association was rifampin, isoniazid and pyrazinamide. Six patients died. Cerebrospinal fluid was collected from all patients, and the cultures for M tuberculosis were positive in five cases (17%). Pulmonary disease was detected in 8 cases. The mean time of hospitalization was 41 days. Fifteen from 21 patients has done BCG vaccine. Nineteen patients (66%) had contact with contaminated household. Motor cerebral lesion was the more frequent sequelae. Glucorrachia less than 40 mg/dl was related as a risk factor to motor cerebral lesion, as weel as age less than 4 years old. Our findings also point to the occurrence of meningeal signs and protein from cerebrospinal fluid above 300 mg/dl as protective factors for arising of motor cerebral lesion (AU)

Brainstem auditory evoked potentials in tubercular meningitis and their correlation with radiological findings.

The present study has been undertaken to describe brainstem auditory evoked potential (BAEP) changes in tubercular meningitis (TBM) and correlate these with CT scan and MRI findings. 24 patients with TBM were subjected to clinical evaluation and CT scan or MRI study. Outcome was defined by 3 month Barthel index score (BI) into poor (BI<12) and good (BI>or=12). The mean age of patients was 26.4+/-14.9 (range 10-62) years, 8 of them were females. Sixteen patients were in stage III, 5 in stage II and 3 in stage I meningitis. CT scan revealed hydrocephalus in 16, exudate in 9, infarction in 12 and tuberculoma in 3 patients. Brainstem was involved in 3 patients (2 infarction and 1 granuloma). BAEPs were unrecordable in one patient and abnormal in 15. The absolute latencies and inter peak latency (IPL) however were not significantly affected. The wave V/I amplitude ratio was abnormal on 12 sides. The BAEP abnormalities were not related to the stage of meningitis, level of consciousness, any specific CT or MRI changes or outcome at 3 months.

Meningoencefalite tuberculosa: conceito, terminologia, classificação, prioridades para os meios diagnósticos / Meningoencephalitis tuberculosis: concept, terminology, classification, priorytis for diagnosis media

A meningoencefalite tuberculosa (MET) é a forma mais grave das tuberculoses extrapulmonares, sendo o diagnóstico precoce a questão crucial para o bom êxito terapêutico. Com base em um estudo retrospectivo de 48 casos de MET, no HULW/UFPB, os autores observaram que a demora do paciente em procurar o atendimento médico, assim como a falta de padronização na abordagem do paciente com MET, contribuíram para o retardo do diagnóstico e do início da terapêutica tuberculostática específica e que a ocorrência de óbitos de seqüelas esteve relacionada ao estágio evolutivo da doença, independente do esquema terapêutico utilizado

Meningoencefalite tuberculosa: avaliação de 231 casos / Tubercular meningoencephalitis: evaluation of 231 cases

This study assessed 231 cases of tuberculous meningitis of which 62 (26.8%) had diagnostic confirmation against 169 (73.2%) with only clinical picture and laboratorial indication for this diagnosis. Fifty-five percent of the sample was male; ages ranged from one month to 68 years, 42% comprising children below four years. Clinical, demographic and liquoric characteristics were investigated and compared amongst those with likely and confirmed diagnosis. In conclusion, attention is drawn to the severity of this disease with high rates of lethality mainly within the age-range of 0-4 years, and to the possibility of misdiagnosis in the presentation of acute forms and predominance of neutrophils in the liquor.

Neste estudo foram avaliados 231 pacientes com meningoencefalite tuberculosa, sendo que 62 casos tiveram diagnóstico comprovado e 169 apresentavam quadro clínico e laboratorial compatíveis com este diagnóstico. Foram 127 (55%) pacientes do sexo masculino, a idade variou de 1 mês a 68 anos, com 97 (42%) na faixa etária igual ou inferior a um ano. As características clínicas, demográficas e liquóricas foram estudadas e comparadas entre os casos confirmados e os de diagnóstico provável. Em conclusão reafirmamos a gravidade desta doença, com altas taxas de letalidade principalmente na faixa etária de zero a quatro anos e a possibilidade de erros diagnósticos nas apresentações com formas agudas e predominância de neutrófilos no líquor.