NATURAL HISTORY AND PATHOGENESIS OF MILIARY AND MENINGEAL TUBERCULOSIS IN CHILDREN

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In preparation for a program of treatment of miliary and meningeal tuberculosis with streptomycin and other antituberculous drugs, 163 consecutive cases admitted to the Los Angeles Children's Hospital in the 15 years between 1933 and 1948 were analyzed. Twenty-one infants and children had miliary tuberculosis, 58 had tuberculous meningitis and 84 had both diseases. Of 145 patients who received only symptomatic treatment, all died. The usual frequency of these diseases in the spring was not observed in this series. Anergy to tuberculin was uncommon; only 2% of the patients reacted negatively to 1.0 mg. O.T. Forty-eight per cent of the cases occurred before the age of 2 years, and two thirds before the age of 4 years. There was pathologic evidence that tuberculous meningitis occurs commonly within a few months of the primary infection; 82% of the autopsied cases showed evidence of fresh primary tuberculosis. Vague symptoms such as vomiting, fever and lethargy were most common in early tuberculous meningitis and rarely stimulated a prompt diagnosis. Headache was a frequent complaint in children over 4 years, but was uncommon in those under 4 years. The average duration of life of patients with tuberculous meningitis from onset of symptoms to death was 20 days; the duration of symptoms until a correct diagnosis was made averaged over 11 days. Caseous tuberculous foci antedating the meningitis were demonstrated in the central nervous system in 27 out of 70 cases in which careful pathologic examination was made. Thirty-five per cent of the autopsied cases of tuberculous meningitis had no acute hematogenous dissemination elsewhere in the body. Hydrocephalus was found in 25 out of 80 brains examined and tended to appear early in the course of the disease. Possible precipitating factors were found in the histories of 15% of the 163 patients. Suggestions are made as to possible means of preventing the development of miliary and meningeal tuberculosis in infants and children and the need for prompt diagnosis and treatment is stressed.