Tuberculosis - I.T. Piatnochka 2005

Extrapulmonary tuberculosis
Brain tuberculoma

Brain Tuberculoma is a form of Central Nervous system tuberculosis associated with the hematogenous dissemination of Mycobacterium tuberculosis from a primary tuberculous focus.

Tuberculoma accounts for 0.8–8.9% of all tuberculosis cases and 10–12% of tuberculous meningoencephalitis cases, primarily affecting young individuals under the age of 20. In children, brain tuberculomas occur 7–10 times more frequently than in adults.

Pathoanatomically, cerebral tuberculoma is analogous to Pulmonary tuberculoma. Macroscopically, it consists of tumor-like, yellowish-gray nodes of dense consistency, ranging in size from 0.5–1 to 4 cm.

Tuberculomas may undergo fibrosis and calcification. Alternatively, caseous softening may occur, leading to purulent breakdown and the transformation of the tuberculoma into a tuberculous abscess. Additionally, tuberculomas can cause chronic leptomeningitis or Tuberculous meningitis.

Solitary brain tuberculomas are observed more frequently, while multiple tuberculomas are less common.

When a tuberculoma is localized near the brain surface and progresses, the inflammatory process can spread to the pia mater, causing local and subsequently diffuse meningitis.

The disease begins with a prodromal period lasting an average of 1–2 months. The initial clinical manifestations include generalized weakness, lethargy, asthenia, behavioral disorders, sluggishness, tearfulness, and irritability. The onset of the disease may be acute, subacute, or characterized by a prolonged asymptomatic course.

In supratentorial tuberculomas, the onset of the disease manifests as focal symptoms and irritative phenomena in the form of seizure attacks and hallucinations.

With subtentorial localization, early general cerebral symptoms appear: headache, dizziness, vomiting, as well as papilledema.

Overall, The Nature of focal symptoms depends on the localization of the tuberculoma. The onset and course of the disease can vary. An acute onset with fever and the rapid development of brain injury symptoms is followed by an undulating course with prolonged low-grade fever. In such cases, meningitis or meningoencephalitis is frequently diagnosed. Alternatively, the disease may develop slowly with remissions. However, the course of tuberculomas is most commonly chronic. Remissions are observed more frequently when the process is subtentorial.

The Diagnosis is established based on the patient's medical history (presence of tuberculosis, slow progression, remissions), as well as clinical data, radiography, Electroencephalography, echoencephalography, and computed tomography.

Differential diagnosis is performed with Brain Tumors, syphilitic gummas, and neuroinfections.

Treatment: prolonged antimycobacterial therapy, and surgical intervention in select cases.

CONTROL QUESTIONS

1. Definition of tuberculous meningoencephalitis.

2. Pathogenesis and pathomorphology of tuberculous meningoencephalitis.

3. Clinical forms of tuberculous meningoencephalitis.

4. Five clinical components of tuberculous meningoencephalitis.

5. Most characteristic CEREBROSPINAL FLUID changes in tuberculous meningoencephalitis.

6. Cytology/practical/136.html">DIFFERENTIAL DIAGNOSIS OF tuberculous meningitis from meningitis of other etiologies (viral, meningococcal, secondary Purulent meningitis, and "meningism").

7. Treatment of tuberculous meningoencephalitis.

8. Complications of tuberculous meningoencephalitis.

9. Brain tuberculoma: Clinical Features, diagnosis, and treatment.

TESTS

1. Patient K., 30 years old, was treated two years ago for Pulmonary Tuberculosis (04.05.2001), segment I of the right lung (focal), Dest-, MBT-M-K-, Hist0, Cat3 Cog2(2001). Right-sided purulent otitis media was diagnosed 10 days ago. Currently, she complains of severe headache, vomiting, and general weakness. Contact with the patient is difficult to establish. X-ray Examination reveals two focal shadows of greater than medium intensity in segment I of the right lung. Cerebrospinal fluid analysis: turbid, Cell count — 650 Cells per 1 ml, neutrophils — 85%, lymphocytes — 15%, glucose — 3.1 mmol/L, chlorides — 115 mmol/L. Your diagnosis is:

A. Serous meningitis

B. Tuberculous

C. Meningococcal

D. Secondary purulent meningitis

E. Meningism

2. The optimal combination of anti-mycobacterial drugs in the treatment of tuberculous meningoencephalitis:

A. Isoniazid + rifampicin + ethambutol

B. Isoniazid + rifampicin + streptomycin + pyrazinamide

C. Isoniazid + streptomycin + pyrazinamide + ethambutol

D. Isoniazid + rifampicin + kanamycin + ethionamide

E. Pyrazinamide + ethionamide + thioacetazone + streptomycin

3. The most frequent onset of tuberculous meningoencephalitis.

A. Gradual

B. Acute

C. Asymptomatic

D. Recurrent

E. Sudden

4. The frequency of primary tuberculous meningitis (isolated meningeal involvement).

A. 2 %

B. 5 %

C. 20 %

D. 40 %

E. 50 %

5. The results of which study are most informative for confirming tuberculous meningitis?

A. Mantoux test

B. Koch's test

C. Complete Blood count

D. Cerebrospinal fluid analysis

E. Study of serum protein fractions

6. Which pairs of Cranial Nerves are most commonly affected in tuberculous meningitis?

A. III, VI, VII, XII

B. I, II, III

C. I, II, X, XII

D. V, VI, X

E. II, III, VII

7. Average duration of the prodromal period in patients with tuberculous meningitis.

A. 1-7 days

B. 5-10 days

C. 1 to 4 weeks

D. 2-3 months

E. 4-6 months

8. What is the most likely glucose level in the cerebrospinal fluid of a patient with tuberculous meningitis?

A. 1,5 mmol/L

B. 2,4 mmol/L

C. ,9 mmol/L

D. 5,5 mmol/L

Е. 6,5 mmol/L

9. In severe cases of tuberculous meningitis, In addition to isoniazid, rifampicin, pyrazinamide, and streptomycin sulfate, the treatment includes:

A. ATP, cocarboxylase, inhalations with 2% solutison solution

B. endolumbar administration of streptomycin calcium chloride complex, glucocorticosteroids, dehydration therapy,

C. intrarectal administration of isoniazid, Vitamins B1, B₆ and C,

D. 10% mannitol solution, albumin, dibazole,

E. sibazone, 25% magnesium sulfate solution, neostigmine.

10. A 45-year-old patient is diagnosed with tuberculous meningitis for the first time. General condition is severe, meningeal symptoms are pronounced, consciousness is clouded. What is the total duration of treatment for this patient?

A. 1 month

B. 3 months

C. 5 months

D. 7 months

E. 12 months

11. Patient M., 19 years old, developed an insidious onset of illness: generalized weakness, headache, dizziness, diplopia, vomiting, body Temperature up to 37 °C. She had a history of contact with a patient suffering from pulmonary tuberculosis. Tuberculous meningitis is suspected. Indicate which of the present symptoms is not characteristic of tuberculous meningitis.

A. Diplopia (double Vision)

B. Headache

C. Insidious onset of the disease

D. Normal body temperature

E. Vomiting

12. A patient with tuberculous meningoencephalitis presents with right-sided ptosis, mydriasis, and divergent strabismus. Which cranial nerve is affected?

A. III

B. IV

C. VI

D. VII

E. X

PROBLEMS

1. Physician's management strategy in cases where the Etiology of meningitis cannot be determined:

1... 2...

2. A 35-year-old patient Z. developed a fever up to 39.2 °C and a severe headache. Anti-inflammatory therapy and analgesics showed no positive effect. Chest X-ray reveals diffuse miliary dissemination in both Lungs. Blood test: WBC 10.0×10⁹/L, ESR - 15 mm/h.

a) Formulate a provisional diagnosis.

b) Examination plan.

c) Treatment.

3. Patient P., aged 36, has been diagnosed with tuberculous meningoencephalitis accompanied by persistent vomiting and severe headache.

What treatment regimen would you prescribe?