Central nervous system tuberculosis in adult patients

Abstract

Central nervous system tuberculosis is the fifth most frequent and at the same time most severe form of extrapulmonary tuberculosis diseases. It presents with no typical signs, thus early diagnosis and treatment is of high importance concerning the outcome. Authors present the characteristics, diagnostic and therapeutic alternatives of central nervous system tuberculosis through a case report and a retrospective study of 15 patients. Authors performed a retrospective analysis of medical records of patients with central nervous system tuberculosis in an academic teaching hospital (Department of Neurology and Infectious Diseases, United Szent István-Szent László Hospital, Budapest, Hungary). Median age of patients was 54.5 years, and 6 (40%) were females. Cerebrospinal fluid findings at admission showed elevated protein (1.54 g/l; 95% confidence interval (CI): 1.01-2.05), cell count (mean: 337/μl; CI: 171.9-502.5), and decreased glucose index (0.32; CI: 0.15-0.52). 14 patients (93.3%) had hyponatremia. Average duration of symptoms were 16.3 days (1-40). On physical examination meningeal irritation was absent in 9 patients (60%). On admission headache and altered consciousness was present in 53%, while headache, fever, nuchal rigidity was present in only 33.3%. Diagnosis was culture and/or PCR confirmed in 46.7% of the cases. Two third of patients were followed-up at least for one year, and nine patients presented neurological sequel. Authors found that patients with central nervous system tuberculosis present with unspecific symptoms, but later progressive disorientation, cranial nerve palsies and convulsions may develop. Headache and altered consciousness proved to be the leading symptoms among these patients. Even today, diagnostic gold standard procedure is cultivating M. tuberculosis on solid and liquid medium. The polymerase chain reaction, which is known to have sensitivity between 27% and 86%, was positive in two of eight samples. Revealing predisposing factors (immunodeficiency, HIV infection, previous tuberculosis exposure) promotes setting up early diagnosis. Co-administration of four antituberculotic drugs for 12 months cured all patients, but authors note that even in cases with early diagnosis and optimal treatment various neurological impairment and seldom death can occur. Central nervous system tuberculosis is a rare but regularly emerging disease with unspecific signs and symptoms. The diagnosis may be difficult. It should be considered as a differential diagnostic issue in patients with uncharacteristic subacute conditions with headache, disorientation, elevated protein and low glucose in cerebrospinal fluid.