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55. Tuberculous meningitis
Epidemiology. The disease most often develops within six months after infection with tuberculosis.
Pathophysiology and pathomorphology. Hematogenous generalization of infection, characteristic of this disease, leads to the formation of metastatic foci of tuberculosis infection. In the central nervous system, solitary tubercular foci (tuberculomas) may occur, the membranes of the brain and spinal cord are affected. Tuberculous meningitis occurs when tuberculous tubercles localized subependymal or large tuberculous foci located near the meninges break into the subarachnoid space, emptying their infected contents into it. In this case, a severe inflammatory reaction develops in the immune organism, primarily from the side of the central nervous system.
Clinical manifestations. Symptoms of the disease develop gradually. There are three stages of the process:
1) the prodromal phase, characterized by nonspecific symptoms: apathy, mood deterioration, poor school performance, loss of appetite, nausea, vomiting, and low-grade fever;
2) the stage of onset of clinical symptoms, which occurs after a couple of weeks and is characterized by the appearance of neurological symptoms. Irritability increases, older children complain of a headache. Neck stiffness may appear in combination with Kernig's and Brudzinski's symptoms. Loss of function of the cranial nerves is characteristic: pathology of pupillary reactions, diplopia, decreased visual acuity, hearing impairment, facial paralysis. Often there are speech disorders, aphasia, disorientation, hemiplegia, ataxia, involuntary movements and convulsions. Intracranial pressure at this stage of the disease is increased. At the same time, there may be an increase in the volume of the head, bulging of the fontanelles, and in older children - swelling of the nipple of the optic nerve;
3) the stage of impaired consciousness up to stupor and coma, characterized by an increase in signs of diffuse cerebral dysfunction. Stupor, coma, decerebration or decortication, irregular breathing, pupils fixed or dilated develop.
Diagnosis. In all doubtful cases, after a thorough and comprehensive study of the anamnesis, clinical examination, it is necessary to resort to diagnostic lumbar puncture, to the study of cerebrospinal fluid for mycobacterium tuberculosis, direct bacterioscopy using the flotation method or using crops and infection of the guinea pig.
Treatment. Isoniazid and rifampicin are recommended for the first 2 months of treatment with additional streptomycin or ethambutol. Subsequently, treatment with isoniazid and rifampicin is continued for another 10 months.
Author: Pavlova N.V.
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