Anesthetic management of a parturient with active tuberculous meningitis

Suman Rajagopalan ,Raja R Palvadi ,Chawla Latoya Mason

doi:10.15761/gapm.1000101

Abstract

Tuberculous meningitis (TBM) results from the infection of the meninges and the cerebrospinal fluid with Mycobacterium tuberculosis. The diagnosis and treatment of TBM is challenging due to its protean manifestations. We present the anesthetic management of a parturient with advanced TBM in whom urgent cesarean delivery was performed due to a non-reassuring fetal status. The patient’s disease course was remarkable for altered mental status, seizures, isoniazid-induced hepatitis and hydrocephalus requiring ventriculo-peritoneal shunt placement. General endotracheal anesthesia was successfully performed that resulted in the safe delivery of a live infant.

Highlights

Tuberculosis (TB) of the central nervous system is a severe form of extra-pulmonary TB and encompasses three clinical categories: tuberculous meningitis, intracranial tuberculoma, and spinal tuberculous arachnoiditis
The seeding of the bacilli to the meninges or brain parenchyma results in the formation of small subpial or subependymal foci of caseous lesions termed ‘Rich’s foci’ [9]. Rupture of these lesions into the subaracnoid space results in the infection of the meninges and leads to an intensive hypersensitivity reaction and inflammation that is most marked at the base of the brain [9,10].This leads to proliferative arachnoiditis that can result in cranial neuropathies, vasculitis that can cause strokes, and impedance to the flow of cerebrospinal fluid (CSF) that can lead to hydrocephalus [10]
The typical manifestations in Tuberculous meningitis (TBM) can be categorized into three phases: 1) Prodromal phase with malaise, headaches and a low-grade fever, 2) meningitis phase with signs of meningeal irritation, altered mental status, and entrapment cranial neuropathies, and 3) paralytic phase with progressive worsening that includes stupor, coma, seizures, and motor deficits that are a result of stroke [3,4,11]

Summary

Introduction

Tuberculosis (TB) of the central nervous system is a severe form of extra-pulmonary TB and encompasses three clinical categories: tuberculous meningitis, intracranial tuberculoma, and spinal tuberculous arachnoiditis. Tuberculous meningitis (TBM) results from the infection of the meninges and the cerebrospinal fluid (CSF) with the acid-fast bacillus Mycobacterium tuberculosis. The anesthetic management of a parturient with TBM can be challenging due to the increased risk of elevated intracranial pressure (ICP), seizures, and aspiration. A diagnosis of TBM was established based on the cerebrospinal fluid (CSF) examination that showed mononuclear pleocytosis, elevated protein, low glucose, and a polymerase chain reaction that revealed Mycobacterium tuberculosis nucleic acid. The decision to perform the delivery under general anesthesia was made based on the emergent nature of the delivery, mental status changes of the patient and active CNS infection. The patient was able to maintain her airway and was transferred to the floor for further care She was subsequently discharged home on 4 anti-TB drug regimen. Five months after the delivery, the patient expired due to complications of TBM [7,8]

Discussion

Findings

16. Treatment of tuberculosis