Tuberculosis Meningitis, overview,TBM is the most serious type in children with tuberculosis TBM is an early primary complications in Primary tuberculosis the incidence is significantly decreased after BCG vaccination, Epidemiology,Age of Onset：More common in 1 5 year-old 1180 TBM in Beijing Childrens Hospital 3y 56.7%，1y 48.5% (half the number) Onset in Season ： common in Winter or spring, Pathogenesis,Hematogenous dissemination： blood-CSF path main Brain , meningeal tuberculosis rupture secondly Tuberculosis in nearly organize direct spread occasionally, Pathology,Extensive lesions Lesions in the bases of skull “basilar meningitis” (most obvious) 病变以脑底部最明显 “脑底脑膜炎” leptomeningeal hyperemia, edema, Inflammatory exudate The inflammatory exudate is accumulated in the subarachnoid（ cistern in pavimentum cerebri ） cranial nerve lesion cerebrovascular disorder Pyocephalus and Hydrocephalus。 Tuberculoma, Clinical manifestation,Most typical cases -slow onset,General symptom,Tuberculosis toxic symptom,meningeal irritation sign cranial nerve lesion irritative or destructive symptoms of encephalon intracranial hypertension spinal cord disorder symptom,nervous system symptom,prodromal period （prophase）,meningeal irritation period （metaphase）,coma period （advanced stage）,Tuberculosis toxic symptom Headache vomiting Personality change,intracranial hypertension meningeal irritation sign cranial nerve lesion irritative or destructive symptoms of encephalon pyramid sign;pyramidal sign convulsion,symptom increased go into coma spinal cord dysfunction,Clinical manifestation, Diagnoses,()History： Age, Seasons, History of exposure and BCG vaccination, History of infectious diseases ()clinical feature：,() CSF Examination ： 1、routine： Appearance：Like ground-glass ， floccule or membrane High pressure Cell count（Lymphocytes）：50500106/L 2、biochemistry： Protein 、glucose and chloride 3、film preparation： precipitum acid-fast stain positive 30%,() CSF Examination ： 3、Others 1）tubercle bacillus antigen detection 2）anti-tuberculosis antibody （one of the early diagnosis evidence） 3）adenosine deaminase （ADA）activity TBM：ADA 9/L 4）immunoglobulin：IgG 5）detect DNA fragment 6）tubercle bacillus culture film preparation and cultivation - may be have a clear diagnosis,() X-ray examination Chest X-ray: About 85% have tuberculose focus ()CT or MRI early: normal progression：Shadow of the basal ganglia enhanced, cistern density , fuzzy, calcification, ventricular dilatation, cerebral edema or infarct foci () PPD-Test,a. Transverse T1W image after contrast administration reveals ringlike enhancement in occipital region and abnormal enhancement of the ependymal of the ventricles,b. coronal T1W image of same patient （同一病人的冠状面T1W）,枕区环形强化灶,侧脑室室管膜异常增强,侧脑室明显扩大, Differential Diagnosis,1、purulent meningitis 2、Viral Encephalitis 3、Cryptococcus neoformans meningitis 4、cerebral abscess, treatment,（）General treatment bed rest Nutrition Nursing Care Coma Patients：nasogastric feeding、 pressure sore prevention attention Water-Electrolyte Balance,（）Anti-tuberculosis therapy Principle：Early , Complete,Intensification treatment,INH+RFP（早、中期） INH+RFP+SM INH+RFP+SM+PZA,34M,INH 1525mg/kg.d RFP 1020mg/kg.d SM 1520mg/kg.d PZA 2030mg/kg.d, treatment,Consolidation treatment,INH+RFP,course of treatment12M or when CSF normal, continue treatment 6M,（）Anti-tuberculosis therapy,（）decrease intracranial hypertension CSF secretion：lateral ventricles choroid（占70%） Ependyma、encephalon -TBM， Inflammatory stimulation, secretion absorption：arachnoid granulations - TBM， absorb disturbance circulation： - TBM, inflammatory in base of skull, pathway blocked, treatment,（）decrease intracranial hypertension 1、dehydrant 20%mannitol：0.51.0(2.0)g/kg.次 iv q4hq6h 2、adrenocortical hormone Dx 0.20.4mg/kg.d 3、lateral ventricular puncture 4、lumbar puncture decompression, intrathecal injections： INH、Dx 5、Surgery： Ventriculoperitoneal shunt or external drainage,（）adrenocortical hormone therapy Dx 0.20.4mg/kg.d Prednison 12mg/kg.d （ 4 weeks after decreasing，course：812 weeks ） （）others 1、Control convulsions、Antipyretic 2、Water-Electrolyte Balance disturbances Hyponatremia（dilutional, Cerebral ） Hypokalemia （）follow observation at least 35years,criterion of cure Symptoms disappeared CSF normal No recurrence (2 years After the end of Treatment), Prognosis (Relevant factors),age Time of therapy- early or late The degree of brain damage Therapeutic method- correct？ Tubercle bacillus- resistance？,