Presentation of Tuberculosis of the Central Nervous System in Children

Symptoms

Tuberculous meningitis

• Stage I (prodromal phase): The child is lucid without focal neurological signs or hydrocephalus. Usually this stage lasts 2–3 weeks and is characterized by the insidious onset of malaise, lassitude, headache, low-grade fever (80%), and personality change. A prior history of TB is present in approximately 50% of children with TB meningitis and 10% of adult patients.
• Stage II (meningitic phase): In this phase the child develops more pronounced neurological features such as meningismus, protracted headache, vomiting, lethargy, confusion, and varying degrees of cranial nerve and long-tract signs/hemiparesis. Cranial nerve palsies occur in 20–30% of patients and may be the presenting manifestation of TB meningitis. The sixth cranial nerve is most commonly affected. Vision loss due to optic nerve involvement/optochiasmatic arachnoiditis may occasionally be a dominant and presenting illness.
• Stage III (paralytic phase): In this advanced phase of the illness confusion gives way to stupor and coma, seizures, and often hemiparesis. For most untreated patients, death ensues within 5–8 weeks of the onset of illness.

Tuberculomas/tuberculous abscess

• Rare: TB abscess occurs in only 4–8% of patients with CNS TB who do not have HIV infection but in 20% of patients who do have HIV infection.
• Symptoms depend on location: Children usually present with headache, seizures, papilledema, or other signs of increased ICP. The focal neurological deficits depend on the location of abscess.
• Short duration of symptoms: Usually brain abscesses have a more acute presentation (1 week to 3 months) than tuberculomas but are slower in onset than pyogenic brain abscesses.

Spinal tuberculosis

• Less than 1% of patients with TB: Spinal TB can be secondary to Pott’s spine, non-osseous spinal cord seeding, or spinal TB meningitis. Involvement of the spinal cord and its roots is unusual.
• Meningeal exudate: A meningeal exudate can encase and then invade the spinal cord and its roots. Symptoms and signs include a subacute onset of nerve root and cord compression: spinal or radicular pain, hyperesthesia or paresthesias; lower motor neuron paralysis; and bladder or rectal sphincter dysfunction.
• Vasculitis: Vasculitis may lead to thrombosis of the anterior spinal artery and infarction of the spinal cord.
• Pott’s paraplegia: As the spine infection progresses, there can be compression by an epidural mass of granulation tissue, extradural or intradural tuberculoma, or an epidural abscess.

Intervention

Stabilization

• Steroids: Steroids are typically used to manage symptoms of meningeal inflammation that lead to intracranial hypertension, cranial and vascular compromise.
• Management of hydrocephalus: An EVD, ventriculoperitoneal shunt, or ETV are treatment options that have been used to manage symptomatic hydrocephalus present at the time of presentation (24, 25).
• Pretreatment with antibiotics: Early anti-TB therapy must be considered for all cases of suspected TB abscess, even before surgery, to reduce the risk of postoperative meningitis. Patients should be treated for a minimum of 10 months with a 4-drug combination in the initial phase followed by a 2-drug combination in the continuation phase. Therapy should be extended to at least 12 months for those patients who fail to respond or if treatment interruptions have occurred for any reason (26).

Admission Orders

• Manage hydrocephalus with an EVD: EVD is the procedure of choice for treating obstructive hydrocephalus and communicating hydrocephalus that does not respond to medical management. It is an easy way to reduce ICP, to assess whether clinical improvement correlates with reduction of ICP, and to indeed establish whether there is raised ICP in children with significant ventriculomegaly. Hence, it is easy to decide which children may benefit from a permanent CSF diversion procedure, be it ETV or ventriculoperitoneal shunt. In children who do not improve with ventricular drainage, an early clamping trial may be attempted (27).
• Infectious disease consultation: In cases of uncertain diagnosis, infectious disease experts might be consulted.
• Nutrition consultation: Most patients are malnourished and would need a high-protein diet for convalescence.