Key Points

• Most severe form of extrapulmonary TB
• Highest mortality rate among TB manifestations (15-40%)
• Peak age: 6 months to 4 years
• Early diagnosis critical for outcome
• Requires minimum 9-12 months of treatment

Epidemiology

• Global burden:
  • 1-2% of all TB cases
  • 5-10% of extrapulmonary TB
  • Higher in HIV-endemic regions
• Risk Factors:
  • Age < 5 years
  • Malnutrition
  • HIV infection
  • Recent TB contact
  • Absence of BCG vaccination
  • Primary immunodeficiencies

Detailed Pathophysiology

Disease Progression

• Primary Phase:
  • Hematogenous spread from primary focus
  • Formation of Rich foci in meninges/brain
  • Release of bacilli into subarachnoid space
• Secondary Phase:
  • Inflammatory response in CSF
  • Development of basal exudates
  • Vasculitis of cerebral vessels
  • Obstruction of CSF pathways

Pathological Changes

• Meningeal Changes:
  • Thick gelatinous exudate
  • Basal meningeal enhancement
  • Cranial nerve entrapment
• Vascular Changes:
  • Endarteritis
  • Thrombosis
  • Infarction

Clinical Manifestations and Staging

Prodromal Phase (2-8 weeks)

• Non-specific symptoms:
  • Low-grade fever
  • Personality changes
  • Poor feeding
  • Weight loss

British Medical Research Council Staging

• Stage I (Early):
  • GCS 15/15
  • No focal deficits
  • Normal mental status
  • Meningeal signs may be present
• Stage II (Intermediate):
  • GCS 11-14
  • Focal neurological signs
  • Behavioral changes
  • Cranial nerve palsies
• Stage III (Advanced):
  • GCS ≤10
  • Multiple cranial nerve palsies
  • Severe neurological deficits
  • Decerebrate/decorticate posturing

Age-specific Presentations

• Infants:
  • Bulging fontanelle
  • Poor feeding
  • Irritability
  • Seizures
  • Developmental regression
• Older Children:
  • Headache
  • Vomiting
  • Neck stiffness
  • Photophobia
  • Altered consciousness

Diagnostic Approach

CSF Analysis

• Opening Pressure: Usually elevated
• Typical Findings:
  • Clear/slightly turbid appearance
  • Lymphocytic pleocytosis (100-500 cells/μL)
  • Elevated protein (100-500 mg/dL)
  • Low glucose (<40 mg/dL)
  • High chloride levels
• Microbiological Tests:
  • AFB smear (sensitivity 10-20%)
  • Gene Xpert MTB/RIF (sensitivity 60-70%)
  • Culture (gold standard, but slow)
  • PCR for TB DNA

Neuroimaging

• MRI Findings:
  • Basal meningeal enhancement
  • Hydrocephalus
  • Tuberculomas
  • Infarcts
  • Cranial nerve enhancement
• CT Findings:
  • Pre-contrast hyperdensity
  • Post-contrast enhancement
  • Hydrocephalus
  • Basal cistern exudates

Other Investigations

• Chest X-ray (primary focus)
• Mantoux test
• IGRA
• HIV testing
• Complete blood count
• ESR and CRP
• Liver and kidney function tests

Treatment Protocol

Anti-tubercular Therapy

• Intensive Phase (2-3 months):
  • Isoniazid: 10-15 mg/kg/day
  • Rifampicin: 10-20 mg/kg/day
  • Pyrazinamide: 30-35 mg/kg/day
  • Ethionamide: 15-20 mg/kg/day
• Continuation Phase (7-10 months):
  • Isoniazid + Rifampicin
  • Total duration: 9-12 months

Adjunctive Therapy

• Corticosteroids:
  • Prednisolone: 2-4 mg/kg/day
  • Duration: 6-8 weeks with tapering
  • Mandatory in all stages
• Management of Raised ICP:
  • Mannitol/hypertonic saline
  • Head elevation
  • CSF diversion if needed
• Anticonvulsants if seizures

Neurosurgical Intervention

• Indications:
  • Hydrocephalus
  • Large tuberculomas
  • Brain abscess
  • Spinal arachnoiditis
• Procedures:
  • Ventriculoperitoneal shunt
  • External ventricular drainage
  • Endoscopic third ventriculostomy

Complications Management

Acute Complications

• Neurological:
  • Hydrocephalus (80%)
  • Cranial nerve palsies
  • Cerebral infarction
  • Status epilepticus
  • Brain herniation
• Systemic:
  • SIADH
  • Respiratory failure
  • Hepatotoxicity

Long-term Sequelae

• Cognitive impairment
• Learning disabilities
• Behavioral problems
• Motor deficits
• Epilepsy
• Visual impairment
• Hearing loss

Monitoring Protocol

Clinical Monitoring

• Daily in acute phase:
  • Consciousness level
  • Neurological examination
  • Vital signs
  • Head circumference (infants)
• Weekly/Monthly:
  • Growth parameters
  • Development assessment
  • Vision and hearing

Laboratory Monitoring

• CSF analysis:
  • Every 2-3 weeks until normal
  • Cell count
  • Protein/glucose
• Blood tests:
  • LFTs monthly
  • Electrolytes
  • Complete blood count

Imaging Follow-up

• CT/MRI:
  • At 3, 6, and 12 months
  • Earlier if deterioration
• Chest X-ray: 3 monthly

Prevention and Control

Primary Prevention

• BCG vaccination
• Contact screening
• INH prophylaxis for exposed

Prognostic Factors

• Better Outcome:
  • Early diagnosis
  • Stage I disease
  • Age >2 years
  • No hydrocephalus
• Poor Outcome:
  • Stage III disease
  • Young age
  • HIV co-infection
  • Drug resistance

Disclaimer

The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.

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