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Tuberculous meningitis. NCCT scan of the brain(a) shows effacement of basal cisterns by isodense exudates. CECT scan(b) shows dense enhancement of thickened and inflamed basal meninges along the basal cisterns (giving characteristic spider leg appearance), tentorium and the sylvian fissure with evidence of hydrocephalus and periventricular ooze.
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Central nervous system (CNS) tuberculosis includes three clinical entities: tuberculous meningitis, intracranial tuberculoma, and spinal tuberculous arachnoiditis. All three categories are encountered frequently in regions of the world where the incidence of TB is high. Meningeal tuberculosis is a medical emergency: it is the most severe, lethal an...
HIV infection has changed the scenario of infectious disease. HIV-associated immunodeficiency resulted in a wide spectrum of new opportunistic infections. After introduction of antiretroviral therapy (ART), immune reconstitution inflammatory syndrome (IRIS) became an important challenge in management of 10% to 25% of the patients. Meta-analyses of...
Central nervous system tuberculosis (CNS) is a rare but extremely dangerous condition that has been reported in 5%-10% of extrapulmonary tuberculosis cases and accounts for approximately 1% of all tuberculosis cases. We present 2 cases of isolated central system tuberculosis in immunocompetent patients: a 57-year-old female and a 22-year-old young...
Background
Understanding the pathophysiology of central nervous system tuberculosis (CNS-TB) is hampered by the lack of a good pre-clinical model that mirrors the human CNS-TB infection. We developed a murine CNS-TB model that demonstrates neurobehavioral changes with similar immunopathology with human CNS-TB.
Methods
We injected two Mycobacterium...
Citations
... In later stages of the disease, the outermost meningeal layer (i.e., the dura mater encephali) can also be affected [72,73]. Besides the small tubercles primarily formed in the leptomeninges and later also in the dura mater encephali, enhancing basal meningeal exudate, progressive hydrocephalus, and vasculitis of the blood vessels adjacent to or traversing the exudate are also characteristic pathological features of TBM [43,68,[70][71][72][73][74][75][76][77][78]. In the initial stage of TBM, the granulomatous inflammatory reaction results in the formation of a thick, gelatinous exudate between the two layers of the leptomeninges [64,66,67,69,72,75,79,80]. The inflammatory exudate is primarily located along the ...
... Besides the small tubercles primarily formed in the leptomeninges and later also in the dura mater encephali, enhancing basal meningeal exudate, progressive hydrocephalus, and vasculitis of the blood vessels adjacent to or traversing the exudate are also characteristic pathological features of TBM [43,68,[70][71][72][73][74][75][76][77][78]. In the initial stage of TBM, the granulomatous inflammatory reaction results in the formation of a thick, gelatinous exudate between the two layers of the leptomeninges [64,66,67,69,72,75,79,80]. The inflammatory exudate is primarily located along the ...
... Endocranial abnormally pronounced digital impressions in relation to tuberculous meningitis inferomedial surface of the frontal lobes, the anteromedial surface of the temporal lobes, the floor of the third ventricle, and the superior aspect of the cerebellum [64,75,77,79,81]. From here, it can rapidly extend towards the basal cisterns (i.e., the interpeduncular and chiasmatic cisterns) [64,74,75,77,78,[80][81][82]. ...
Abnormally pronounced digital impressions (APDIs) on the endocranial surface develop secondary to a prolonged rise in the intracranial pressure. This can result from a number of pathological conditions, including hydrocephalus due to tuberculous meningitis (TBM). APDIs have been described with relation to TBM not only in the modern medical literature but also in several paleopathological studies. However, APDIs are not pathognomonic for TBM and their diagnostic value for identifying TBM in past human populations has not been evaluated in identified pre-antibiotic era skeletons. To assess the diagnostic value of APDIs for the first time, a macroscopic investigation was performed on skeletons from the Terry Collection (Smithsonian Institution, Washington, DC, USA). Our material consisted of 234 skeletons with tuberculosis (TB) as the cause of death (TB group) and 193 skeletons with non-tuberculous (NTB) causes of death (NTB group). The macroscopic examination focused on the stage of the prominence and frequency of APDIs in the TB group and NTB group. To determine the significance of difference (if any) in the frequency of APDIs between the two groups, χ2 testing of our data was conducted. We found that APDIs were twice as common in the TB group than in the NTB group. The χ2 comparison of the frequencies of APDIs revealed a statistically significant difference between the two groups. In addition, APDIs with more pronounced stages were recorded more frequently in the TB group. Our results indicate that APDIs can be considered as diagnostic criteria for TBM in the paleopathological practice. With suitable circumspection, their utilization provides paleopathologists with a stronger basis for identifying TB and consequently, with a more sensitive means of assessing TB frequency in past human populations.
... In the paleopathological literature [e.g., 19,[23][24][25][26][29][30][31], since the late 20 th century only a few endocranial alteration types, including ABVIs and PAs, were described as probable signs of TBM. TB involvement of the leptomeninges (i.e., the pia and arachnoid mater), also known as leptomeningitis tuberculosa, is the most common form of central nervous system (CNS) TB, accounting for about 70-80% of the cases [54][55][56][57][58][59][60]. TBM usually develops subsequent to the rupture of one or more meningeal, subpial, and/or subependymal caseating tubercles into the subarachnoid space or into the ventricular system, both occupied by the cerebrospinal fluid (CSF) [54][55][57][58][59][60][61][62][63][64][65][66][67][68][69]. ...
... TB involvement of the leptomeninges (i.e., the pia and arachnoid mater), also known as leptomeningitis tuberculosa, is the most common form of central nervous system (CNS) TB, accounting for about 70-80% of the cases [54][55][56][57][58][59][60]. TBM usually develops subsequent to the rupture of one or more meningeal, subpial, and/or subependymal caseating tubercles into the subarachnoid space or into the ventricular system, both occupied by the cerebrospinal fluid (CSF) [54][55][57][58][59][60][61][62][63][64][65][66][67][68][69]. The release of sufficient numbers of TB bacteria into the CSF triggers the onset of diffuse granulomatous inflammation of the leptomeninges, with strong predilection for the basal areas of the brain [54][55]62,[65][66][67][68]70]. ...
... Nonetheless, not only the pia and arachnoid mater but additionally, the outermost meningeal layer (i.e., the dura mater) can be affected by the disease [71]. Besides the small tubercles primarily formed in the leptomeninges and later also in the dura mater, characteristic pathological features of TBM include enhancing basal meningeal exudate, progressive hydrocephalus, and vasculitis of the blood vessels adjacent to or traversing the exudate [57,[59][60]62,64,67,[69][70][71]. In TBM, not only the intracranial arteries and veins but also the meningeal vessels and dural venous sinuses can become inflamed, occasionally resulting in hemorrhages [72][73]. ...
Although endocranial abnormal blood vessel impressions (ABVIs) and periosteal appositions (PAs) have been considered as paleopathological diagnostic criteria for tuberculous meningitis (TBM) based on findings of previous studies, they are not pathognomonic for tuberculosis (TB). Therefore, their utilization in the paleopathological practice can be questioned, especially in consideration that most of the previous studies were not performed on identified skeletal collections but on osteoarchaeological material and did not include statistical data analysis. To fill the aforementioned research gap, for the first time, a macroscopic investigation was conducted on identified pre-antibiotic era skeletons from the Terry Collection. A sample set of 234 individuals who died of TB (TB group) and 193 individuals who died of non-tuberculous causes (NTB group) were examined. The frequency of ABVIs and PAs, as well as other probable TB-related lesions was recorded. To determine the significance of difference (if any) in the frequencies of ABVIs and PAs between the two groups, χ2 testing of our data was performed. We found that ABVIs, PAs, and their co-occurrence with each other and with other probable TB-related lesions were more common in the TB group than in the NTB group. In addition, the χ2 comparative frequencies of ABVIs and PAs revealed a statistically significant difference between individuals who died of TB and individuals who died of NTB causes. Our findings strengthen those of previous studies that ABVIs and PAs are not specific to TBM but can be of tuberculous origin. Therefore, they do have a diagnostic value in the identification of TB in human osteoarchaeological material, especially when they simultaneously occur with other probable TB-related lesions. Their prudent utilization provides paleopathologists with a stronger basis for diagnosing TB and consequently, a more sensitive means of assessing TB frequency in past human populations.
... At any age, TBM is one of the most severe extra-pulmonary manifestations of TB, with high short-term mortality and substantial excess morbidity among survivors: approximately one-third of the affected individuals die of the disease and up to one-half of the survivors remain with serious neurological sequels, despite the initiation of anti-tuberculosis therapy [43][44]48,58,61]. Early, accurate diagnosis and prompt, adequate treatment are crucial in determining the clinical outcome of TBM [43,53,56,59,62]. If left untreated, TBM usually leads to death within 4-6 weeks after the onset of its symptoms [63]; nonetheless, in some cases [e.g., [64][65][66][67][68][69][70], the disease has a protracted course that can last for several months or even years. ...
Paleopathological diagnosis of tuberculosis (TB) essentially relies on the identification of macroscopic lesions in the skeleton that can be related to different manifestations of TB. Among these alterations, granular impressions (GIs) on the inner skull surface have been considered as pathognomonic features of tuberculous meningitis (TBM). GIs may be established by pressure atrophy of the tubercles formed on the outermost meningeal layer during later stages of TBM. Although GIs were used as diagnostic criteria for TBM in the paleopathological practice since the late 20th century, their diagnostic value has been questioned. To contribute to strengthening the diagnostic value of GIs, a macroscopic investigation–focusing on the macromorphological characteristics and frequency of GIs–was performed on skeletons of known cause of death from the Terry Collection. The χ² analysis of our data revealed that GIs were significantly more common in individuals who died of TB than in individuals who died of non-TB causes. Furthermore, GIs were localized on the inner surface of the skull base and of the lower lateral skull vault. The localization pattern and distribution of GIs on the endocranial surface resemble that of the tubercles observed in the affected meninges during the pathogenesis of TBM. Our results strengthen the tuberculous origin of GIs and imply that they can be considered as specific signs of TBM. Therefore, GIs can be used as diagnostic criteria for TBM in the paleopathological practice, and the diagnosis of TBM can be established with a high certainty when GIs are present in ancient human bone remains.
... Clinical manifestations of CNS TB vary from meningitis, basilar arachnoiditis, tuberculoma, and encephalitis owing to devastating vasculopathy 2 . Tuberculous hypophysitis is a rare entity 3 , and secondary central insipidus diabetes due to sellar-suprasellar tuberculomas has been described elsewhere 3 . In 2015, the TB incidence rate in Brazil was 33.2 cases/100,000 inhabitants. ...
The involvement of Mycobacterium tuberculosis in the central nervous system (CNS) is an uncommon and devastating manifestation of tuberculosis. We report a case of disseminated tuberculosis presenting as meningoencephalitis, hypothalamic involvement with extension to the hypophysis, and secondary insipidus diabetes diagnosed at autopsy. © 2018, Sociedade Brasileira de Medicina Tropical. All rights reserved.
... Tuberculoma can be found anywhere in the brain parenchyma and also extra-axially in cisterns and fissures. 5 Though tuberculomas are rare in developed countries, in developing countries they constitute 5-30% of all intracranial mass lesions. 6 The pandemic of HIV has led to the resurgence of CNS tuberculosis worldwide. ...
Objective:
The present study was aimed to evaluate patients of suspected intracranial tuberculomas with diffusion-weighted imaging (DWI), magnetic resonance spectroscopy (MRS) and susceptibility-weighted imaging (SWI).
Methods:
The present study evaluated 116 patients known or suspected of having central nervous system tuberculosis with advanced MRI techniques comprising of DWI, MRS and SWI in addition to the conventional MRI.
Results:
Apparent diffusion coefficient value of tuberculomas was not significantly different (p > 0.05) from apparent diffusion coefficient value of metastatic lesions and high-grade gliomas. MRS revealed that NAA/Cr and NAA/Cho ratios of tuberculomas were not significantly different (p > 0.05) from that of malignant brain lesions. However, Cho/Cr ratio of tuberculomas (1.36 ± 0.41) was significantly lower from that of malignant brain lesions (2.63 ± 0.99). SWI revealed a complete and regular hypointense peripheral ring in 42 cases of tuberculomas (58%) and in none of the malignant brain lesions.
Conclusion:
DWI offers no clear advantage in differentiating tuberculomas from metastasis and gliomas. Tuberculomas may be differentiated from metastases and gliomas by their unique metabolite pattern on MRS. Presence of a complete and regular peripheral hypointense ring in SWI favors the diagnosis of tuberculomas. Advancesin knowledgeE: The results from the present study suggest promising role of SWI in the discrimination of tuberculomas from metastatic brain lesions and gliomas with the presence of a complete and regular peripheral hypointense ring favoring the diagnosis of tuberculomas.
Tuberculosis (TB) is a bacterial infection that is well-known in the palaeopathological record because it can affect the skeleton and consequently leaves readily identifiable macroscopic alterations. Palaeopathological case studies provide invaluable information about the spatio-temporal distribution of TB in the past. This is true for those archaeological periods and geographical regions from when and where no or very few TB cases have been published until now–as in the Sarmatian period (1 st –5 th centuries CE) in the Barbaricum of the Carpathian Basin. The aim of our paper is to discuss five newly discovered TB cases ( HK199 , HK201 , HK225 , HK253 , and HK309 ) from the Sarmatian-period archaeological site of Hódmezővásárhely–Kenyere-ér, Bereczki-tanya (Csongrád-Csanád county, Hungary). Detailed macromorphological evaluation of the skeletons focused on the detection of bony changes likely associated with different forms of TB. In all five cases, the presence of endocranial alterations (especially TB-specific granular impressions) suggests that these individuals suffered from TB meningitis. Furthermore, the skeletal lesions observed in the spine and both hip joints of HK225 indicate that this juvenile also had multifocal osteoarticular TB. Thanks to the discovery of HK199 , HK201 , HK225 , HK253 , and HK309 , the number of TB cases known from the Sarmatian-period Carpathian Basin doubled, implying that the disease was likely more frequent in the Barbaricum than previously thought. Without the application of granular impressions, the diagnosis of TB could not have been established in these five cases. Thus, the identification of TB in these individuals highlights the importance of diagnostics development, especially the refinement of diagnostic criteria. Based on the above, the systematic macromorphological (re-)evaluation of osteoarchaeological series from the Sarmatian-period Carpathian Basin would be advantageous to provide a more accurate picture of how TB may have impacted the ancestral human communities of the Barbaricum.
Background and aims:
Early diagnosis and treatment of central nervous system tuberculosis are important because of high mortality and morbidity. Airways must be carefully evaluated in differential diagnosis.
Methods:
We present a rare case of intracranial-endobronchial tuberculosis mimicking lung cancer with brain metastasis.
Results:
A vegetative mass lesion, confirmed as necrotic granulomatous inflammation, originating from the entrance of the right upper lobe entry, was coagulated and extracted by argon plasma coagulation and cryotherapy to prevent permanent upper lobe atelectasis. Mycobacterium tuberculosis complex was detected in bronchoscopic material. A four-drug initial anti-tuberculous treatment regimen was given in 2 months. The upper lobe atelectasis was resolved at the fourth month of therapy despite upper lobar bronchus patency. The patient was doing well and completed the two-drug maintenance therapy of 7 months with complete resolution.
Conclusion:
In such cases, tissue diagnosis should be achieved as early as possible and anti-tuberculous treatment was commenced along with advanced interventional techniques.
ZET Gelişmekte olan ülkelerde seyrek olmayarak görülen santral sinir sistemi (SSS) tüberkülozunun önemi pekçok ül-kede 1980'lerden itibaren HIV enfeksiyonu ile birlikte giderek artm ıştır. Tüberküloz menenjit tan ısı alan has-taların % 10-28'inde serebral tüberküloma görüldüğü bildirilmiştir. Etrafindan haberdar olmadığı , anlamsız ko-nuştuğu ve idrar kaçırdık', için acil polikliniğe getirilen 43 yaşında erkek hastanın şikayetlerinin 15 gün önce ateşli bir enfeksiyonla birlikte başlayıp progresif olarak ağırlaştığı öğrenildi. Yap ılan incelemeler sonucu se-rebral tüberküloma düşünülen hastada başka bir aktif organ tüberkülozu veya tüberküloz menenjit bulgusu sap-tanmadı. Antitüberküloz tedavi uygulanan hastan ın mevcut lezyonlar ı kranial BT ile takip edildi. Takip süresince klinik tabloda progresif düzelme gözlenen hastan ın son kranial BT'sinde başlangıçta mevcut olan lezyonlar ının tama yakınının kaybolduğu saptandı. Kliniğimizde 1.5 y ıldır izlenmekte olan olgu, ba şvurudaki klinik tablosu, MRI bulguları ve tedaviye iyi cevap vermi ş olmasa açılanndan sunulmaya değer bulunarak, olgu literatür bil-gileri ışığında tartışılmıştır. Anahtar kelimeler: Serebral tüberküloma Düşünen Adam; 1998, 11 (1): 58-61 SUMMARY In developing countries, central nervous system (CNS) tuberculosis is seen frequently and since 1980 with the increase of HIV infections, it is also an important problem in developed countries. Almost everytime, CNS tu-berculosis is accompanied by another organ tuberculosis. CNS tuberculosis is frequently seen in childhood and adolescence. It is reported that, 10-28 % of the tuberculose meningitis patients also have cerebral tuberculoma. 43 years old, male patients was brought to emergency clinic with the following complaints; encoherant speech, incontinance and desorientation. His complaints have begun 15 days ago with a feverish infection and prog-ressively worsen. After clinical investigations, the patients received the di ııgnosis of cerebral tuberculoma and he neither had active organ tuberculosis nor tuberculous menengitis. The patient was giyen antituberculous me-dication and his lesion was followed by cranial computerized tomography (CT). With progressive improvement in his clinical state; the last CT of the patient did seen very smc ıller lesions of cerebral tuberculoma. We pre-sented this patient because of his interesting clinical symptoms and neuroimaging findings.
Background: Tuberculous brain abscess is an extremely rare manifestation of tuberculous involvement of the central nervous system. In countries such as India where tuberculosis is fairly common, few cases of tuberculous brain abscess have been reported. Patient: The patient was an 8-year old boy presented with the diagnosis of cystic fibrosis and a history of tonic and clonic convulsions since 2 years ago with normal brain CT scan. Two months ago he became febrile and complained of severe headache that often awakened him up. Diagnosis of intracranial abscess was made clinically and the patient received ceftriaxon, amikacin and clindamycine; however, 2 weeks of treatment failed to show improvement. During craniotomy multiple cystic lesions and a mass of 9×3×8cm in frontoparietal area was found. After operation the patient developed severe hepatitis with elevated enzymes and bilirubin level due to anesthesia and anti-tuberculous treatment. Drugs were discontinued but fever persisted and he started a downhill course. While hepatitis was going to resolve, restarting antituberculous drugs flared up hepatitis and 3 days later he expired because of hepatic failure. Conclusion: Meningitis is an entity of tuberculous infection in subjects living in countries of high burden tuberculosis, thus, it should be kept in mind for suspicious subjects.
