PE27.2 | Tuberculous Meningitis — Summary & Reflection

KEY TAKEAWAYS

Tuberculous Meningitis — Key Points

• Causative organism: Mycobacterium tuberculosis; pathogenesis = Rich focus rupture → basal exudate + vasculitis + hydrocephalus
• Presentation: subacute onset over 1–6 weeks; prodrome (fever, headache, irritability) → meningism, cranial nerve palsies (CN VI commonest), raised ICP
• MRC staging: Stage I (alert, no deficit) → Stage II (confused/drowsy OR focal deficit) → Stage III (coma/dense deficit); stage determines prognosis
• CSF in TBM: clear/faintly turbid, ↑opening pressure, lymphocytic pleocytosis, markedly ↑protein, ↓glucose, cobweb clot — distinct from bacterial (neutrophilic)
• Key diagnostic tests: GeneXpert on CSF (first-line rapid test), ZN stain (low sensitivity), Mantoux (positive supports but negative in 30–50%), CT (basal enhancement + hydrocephalus)
• ATT regimen (NTEP): 2HRZE + 10HR = 12 months total (NOT 6 months)
• Dexamethasone: 0.4 mg/kg/day, taper over 4–6 weeks; mandatory in all stages
• Complications: hydrocephalus, vasculitic stroke, cranial nerve palsies, SIADH, paradoxical reaction, long-term cognitive/motor deficits
• Prevention: BCG at birth (60–80% protection against TBM/miliary TB); IPT (isoniazid 6 months) for contacts <5 years of sputum-positive cases

REFLECT

Consider this scenario: You are posted at a rural PHC. A grandmother brings a 5-year-old child with a 3-week history of headache, low fever, and irritability. The father was recently diagnosed with pulmonary TB at the district hospital. The child looks unwell but can carry a conversation. You have no LP tray and the nearest district hospital is 60 km away. What steps would you take right now, and what would you communicate to the family? Reflect on the tension between the urgency of early treatment and the logistical barriers in the Indian primary care setting. What systems-level changes might reduce the diagnostic delay for TBM in resource-limited environments?