Challenges in management of CNS tuberculosis

Abstract

CNS Tuberculosis is the most deadly infection with high morbidity and mortality. Challenges are at level of establishing diagnosis as well as treatment. Diagnosis is mainly clinical and is based on clinical history, CSF examination, microbiological tests, Neuroradiology findings and evidence of tuberculosis elsewhere in the body. Clinical manifestations are variable with subacute or chronic presentation of headache, fever, vomiting, cranial nerve palsies, seizures and focal deficits. CSF usually shows high proteins, low sugar and increased cells mainly lymphocytes. Unusual CSF findings with mild increase in protein ,few cells and sometimes polymorphonuclear response in early stage are also observed. Finding of AFB in CSF is confirmatory but the yield is low as CNS Tuberculosis is a paucibacillary disease. CSF geneXpert Ultra has much higher sensitivity than GeneXpert, but this new facility is not available in most centers. CSF culture is gold standard, however it takes long time. Neuroimaging reveals basal exudates, tubeculoma, infarcts and hydrocephalus. There are no controlled trials for the treatment regimen or duration of treatment. Standard protocol is to start on 4 antituberculous drugs with steroids. Intracerebral tuberculoma may require longer duration of treatment up to 2 years and still in some patients the lesions may not resolve. Hydrocephalus, infarcts and Hyponatremia are important complications. In high endemic areas, treatment can be started empirically. Associated comorbid infections like HIV is seen is less than 10 % cases. After initial improvement, some patients show paradoxical response with deterioration clinically and radiologically. Treatment failure and drug resistance is another issue. Early diagnosis and initiation of treatment is the key for cure and prevention of complications.