Manifestasi dan Tatalaksana TB pada Sistem Saraf Rivan Danuaji Staff Bagian Neurologi RSUD Dr Moewardi / FK UNS Outline Introduction Pathogenesis of TB of The Nervous System Clinical Features Diagnosis Treatment Conclusion 2
Introduction Tuberculosis remains a major global problem and a public health issue of considerable magnitude, not mention in Indonesia Several risk factors have been observed for this serious phenomenon. The increasing prevalence of HIV infection, over-crowding in the urban population and in abnormal communities (such as prisons, concentration camps, refugee colonies), poor nutritional status, appearance of drug-resistant strains of tuberculosis, ineffective tuberculosis control programmes, and an increase in migration from countries where tuberculosis is prevalent to the developed world. 3
Introduction The incidence of tuberculosis varies from 9 cases per 100 000 population per year in the US; to 110165 cases per 100 000 population in the developing countries of Asia and Africa. In Indonesia there were 156.733 new cases (Ministry of Health, 2017) Tuberculous involvement of the central nervous system (CNS) is an important and serious type of extra-pulmonary involvement. It has been estimated that approximately 10% of all patients with tuberculosis have CNS involvement (Wood M, Anderson M, 1998). 4 Statistic of TB in Indonesia
New cases: 156.733 (2017) Case Detection Rate: 60,59% Success rate : 75,4% CNS TB: 15.000 cases 5 Introduction CNS Tuberculosis has a good result if treated carefully, but it will be fatal, both
mortality or serious sequels, for bad management. 6 Pathogenesis of CNS Tuberculosis 7 Pathogenesis of CNS Tuberculosis Most tuberculous infections of the CNS
are caused by Mycobacterium tuberculosis. Less frequently, other mycobacteria may be involved. It is believed that the bacilli reach the CNS by the haematogenous route secondary to disease elsewhere in the body 8 Pathogenesis of CNS Tuberculosis CNS tuberculosis develops in two stages: Initially small tuberculous lesions (Richs foci) develop in the CNS,
either during the stage of bacteremia of the primary tuberculous infection or shortly afterwards. These initial tuberculous lesions may be in the meninges, the sub-pial or sub-ependymal surface of the brain or the spinal cord, and may remain dormant for years after initial infection Later, rupture or growth of one or more of these small tuberculous lesions produces development of various types of CNS tuberculosis. The specific stimulus for rupture or growth of Richs foci is not known, although immunological mechanisms are believed to play an important role. Rupture into the subarachnoid space or into the ventricular system results in meningitis. 9 Pathogenesis of CNS
Tuberculosis The type and extent of lesions that result from the discharge of tuberculous bacilli into the cerebrospinal fluid (CSF), depend upon the number and virulence of the bacilli, and the immune response of the host The pathogenesis of localized brain lesions is also thought to involve haematogenous spread from a primary focus in the lung (which is visible on the chest radiograph in only 30% of cases) Classification of CNS tuberculosis: Intracranial
Tuberculous meningitis (TBM) TBM with miliary tuberculosis Tuberculous encephalopathy Tuberculous vasculopathy Space-occupying lesions: tuberculoma (single or multiple); multiple small tuberculoma with miliary tuberculosis; tuberculous abscess Spinal Potts spine and Potts paraplegia Tuberculous arachnoiditis (myeloradiculopathy) Non-osseous spinal tuberculoma
Spinal meningitis 10 Risk factors Age (children> adults) HIV-coinfection, Malnutrition, Recent measles in children, Alcoholism, Malignancies, The use of immunosuppressive agents in adults and disease prevalence in the community 11 Clinical Features
12 Clinical features These nonspecific symptoms include malaise, anorexia,
fatigue, fever, myalgias, and headache. Adults with tuberculous meningitis (TBM) can often present with the classic meningitis symptoms: fever, headache and stiff neck along with focal neurological deficits, behavioral changes, and alterations in consciousness
Cerebrovascular complications of tuberculous meningitis that occur typically as multiple or bilateral lesions in the territories of the middle cerebral artery perforating vessels are termed as tuberculous vasculopathy 13 Clinical features Children with TBM often present: fever,
stiff neck, seizures, and abdominal symptoms such as nausea and vomiting Headache occurs less often than in adults neurological symptoms range from lethargy and agitation to coma TBM in children develops most often within 3 months of primary tuberculosis infection Contemporary criterion for staging TBM Modified MRC criteria Stage
1 2 3 Criteria Alert and oriented without focal neurological deficits Glasgow coma score of 14-11 or 15 with focal neurological deficits Glasgow coma score of 10 or less, with or without focal neurological deficits Thwaites, G. E., T. H. Tran. Tuberculous meningitis: many questions, too few answers. Lancet Neurol. 2005;4:16070. 14
Staging of TBM TBM is classified into 3 stages according to the British Medical Research Council (MRC) criteria Stage I: Prodromal phase with no definite neurologic symptoms. Stage II: Signs of meningeal irritation with slight or no clouding of sensorium and minor (cranial nerve palsy) or no neurological deficit. Stage III: Severe clouding of sensorium, convulsions, focal neurological deficit and involuntary movements.
Tuberculous meningitis Clinical fever and headache (for more than 14 days) Vomiting altered sensorium or focal neurological deficit CSF pleocytosis (more than 20 cells, more than 60% lymphocytes) increased proteins (more than 100 mg/dl) low sugar (less than 60% of corresponding blood sugar)
India ink studies and microscopy for malignant cells should be negative Imaging exudates in basal cisterns or in sylvian fissure hydrocephalus infarcts (basal ganglionic) gyral enhancement tuberculoma formation Evidence of tuberculosis elsewhere Adapted 16
Tuberculous meningitis Clinical manifestations of tuberculoma or tuberculous brain abscess depend largely on their location, and patients often present with headache, seizures, papilledema, or other signs of increased intracranial pressure. The presentation of brain abscess is more sub acute (1 week to 3 months) than tuberculoma but slower in onset than pyogenic brain abscesses 17 Tuberculous meningitis TB Bacillemia (primary or late reactivation) subependymal tubercles rupture into the subarachnoid space meningitis
Tuberculous Meningitis. Donald and Shoerman, 18 NEJM. 351:17. 10/21/2004 Tuberculous Encephalopathy (TBE) TBE is a rare outcome usually more common in younger population and is characterized by diffuse brain edema and demyelination, which usually is extensive Clinical features: Impaired consciousness, seizures, disseminated intravascular coagulation, signs and symptoms of meningitis with or without spinal fluid changes characterize this syndrome. This syndrome may be one of the leading causes of neurologic devastation and death in CNS TB patients
19 Spinal tuberculosis Involvement of the spine occurs in less than 1% of TB patients and it can be secondary to Potts spine or as non-osseous spinal cord tuberculosis or spinal tuberculous meningitis. It is a leading cause of paraplegia Spinal cord compression in Potts spine is mainly caused by pressure from a paraspinal abscess. Neurological deficits may also result from dural invasion by granulation tissue and compression from the debris of sequestrated bone, a destroyed intervertebral disc, or a dislocated vertebra Neurological involvement can occur at any stage of Potts spine and even years later, when there has been apparent healing, because of
stretching of the cord in the deformed spinal canal. 20 Spinal tuberculosis Typically, there is a history of local pain, tenderness over the affected spine or even overlying bony deformity in the form of gibbus. Paravertebral abscess may be palpated on the back of a number of patients. These patients usually have acute or subacute, progressive, spastic type of sensorimotor paraparesis. The incidence of paraparesis in patients with Potts spine varies from 27% to 47%. Non-osseous spinal cord tuberculosis canoccur in the form of tuberculomas:
Spinal tuberculosis The acute form presents with: fever, headache, and radiating root pains, accompanied by myelopathy The chronic form: usually localised to a few segments,
presents with progressive spinal cord compression and may suggest a spinal cord tumour. Tuberculous CSF exudate 23 Diagnosis 24 Investigation CSF Analysis
Definitive diagnosis of tuberculous meningitis depends upon the detection of the tubercle bacilli in the CSF, either by smear examination or by bacterial culture. Rates of CSF culture positivity for clinically diagnosed cases range from 25% to 70% Once anti-tuberculosis medication is commenced, the sensitivity of smear and culture falls rapidly Molecular and Biochemical Analysis:
nucleic acid amplification (NAA) polymerase chain reaction (PCR) antibody detection, antigen detection, or chemical assays such as adenosine deaminase (ADA) and tuberculostearic acid measurements 25
Tuberculin skin test (TST) The diagnostic utility of skin testing being positive for CNS tuberculosis varies from 10-20% to 50%. The performance of the tuberculin skin test for the diagnosis of tuberculosis varies according to: TST provide indication of
previous tuberculosis infection; neither is sufficiently sensitive nor specific to diagnose active disease age, vaccination with BCG, nutritional status, HIV infection, and technique of administration 26 Radiological Evaluation Every patient with TBM should preferably be evaluated with contrast
enhanced CT imaging before the start or within the first 48 hours of treatment MRI shows diffuse, thick, meningeal enhancement Contrast enhanced MRI is generally considered as the modality of choice. It is useful for assessment of the location of lesions and their margins, as well as ventriculitis, meningitis and spinal involvement (sensitivity 86%, specificity 90%) All patients should have a chestX-ray as part of the diagnostic assessment. Serial transcranial doppler
ultrasonography (TCD) with blood flow velocity (Vm) and pulsatility index (PI) measurments, can be efficiently utilized to prognosticate outcome in tuberculous meningitis- related vasculopathy 27 Radiological Evaluation MENINGITIS TB 28 Radiological Evaluation
SPINAL TUBERCULOSIS 32 Treatment of CNS TB 33 Treatment of CNS TB Rationale use of steroids in CNS TB: All patients with TBM may receive adjunctive corticosteroids regardless of disease severity at presentation Adults (>14 years) should start
treatment with dexamethasone 0.4 mg/kg/24 hours with a tapering course over 6 to 8 weeks Children (d14 years) should be given prednisolone 4mg/ kg/24 hrs (or equivalent dose dexamethasone: 0.6 mg/kg/24 hrs) for 4 weeks, followed by a tapering course over 4 weeks 34 Prognosis and sequelae The single most important determinant of outcome, for both survival and sequelae, is the stage of tuberculous
meningitis at which treatment has been started. If treatment is started in stage I, mortality and morbidity is very low, while in stage III almost 50% of patients die, and those who recover may have some form of neurological deficit 36 Conclusion Early recognition and timely treatment of CNS TB is critical if the
considerable mortality and morbidity associated with the condition is to be prevented A minimum of 10 month-treatment is warranted, and the single most important determinant of outcome is the stage of tuberculous meningitis at which treatment has been started 37 AKU TELAH MEMBERIKAN OBAT YANG AKU KENAL TERHADAP PENYAKIT YANG AKU PAHAMI KEPADA PASIEN YANG SEBAGIAN BESAR TIDAK
TAHU APA-APA (Lucas Meliala, 2009) 38 Come and Joint us at SUNSHINE 2018 Visite our website: www.soloneuro. org
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