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Review
. 2021 Jun 1;34(3):396-402.
doi: 10.1097/WCO.0000000000000920.

Central nervous system tuberculosis

Sofiati Dian  1   2 , Ahmad Rizal Ganiem  1   2 , Arjan van Laarhoven  3
Affiliations
Review

Central nervous system tuberculosis

Sofiati Dian et al. Curr Opin Neurol. .

Abstract

Purpose of review: Central nervous system (CNS) tuberculosis is the most devastating form of tuberculosis (TB), with mortality and or neurological sequelae in over half of individuals. We reviewed original research and systematic reviews published since 1 January 2019 for new developments in CNS TB pathophysiology, diagnosis, management and prognosis.

Recent findings: Insight in the pathophysiology is increasing steadily since the landmark studies in 1933, focussing on granuloma type classification, the relevance of the M. tuberculosis bacterial burden and the wide range of immunological responses. Although Xpert/RIF has been recommended by the WHO for extrapulmonary TB diagnosis, culture is still needed to increase the sensitivity of TB meningitis diagnosis. Sequential MRIs can improve understanding of neurological deficits at baseline and during treatment. Pharmacokinetic/pharmacodynamic modelling suggests that higher doses of rifampicin and isoniazid in TB meningitis could improve survival.

Summary: Recent studies in the field of CNS-TB have largely focussed on TB meningitis. The outcome may improve by optimizing treatment dosing. This needs to be confirmed in clinical trials. Due to the important role of inflammation, these trials should be used as the platform to study the inflammatory and metabolomic responses. This could improve understanding of the biology of this disease and improve patient outlook by enabling individualised host-directed therapy.

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Conflict of interest statement

Conflict of interest

None

Figures

Figure.1
Figure.1. Tuberculous meningitis imaging
Axial spin-echo T2 weighted MR image shows meningeal enhancement at suprasellar and both middle cerebral artery cistern. Enlargement of lateral ventricles indicating a hydrocephalus.
Figure.2
Figure.2. Spinal tuberculosis/ Pott’s Disease
Sagittal spin-echo T2-weighted MR image shows tuberculous spondylitis of T6-T9 with wedge shaped bone deformity (black arrows) of vertebral body T6-T8 causing occlusion of spinal canal (white arrows) at level T7-T8 with pus collection (paravertebral abscess) at vertebral T6-T9 and leptomeningeal abscess at level T6-9.
See this image and copyright information in PMC

References

    1. WHO. Global Tuberculosis Report 2020.
    1. Zaharie SD, Franken DJ, van der Kuip M, van Elsland S, de Bakker BS, Hagoort J, et al. The immunological architecture of granulomatous inflammation in central nervous system tuberculosis. Tuberculosis (Edinb). 2020;125:102016. - PubMed

    2. This article presents the new possible mechanism of granuloma formation in TBM by performing a sophisticated immunohistochemistry technique in a large number of brain specimens (439 post-mortem and 24 biopsy-derived brain) from cohort of 84 patients. Study on the brain specimens is not largely available in some countries where TBM cases mostly present due to the ethical matter.

    1. Rock RB, Olin M, Baker CA, Molitor TW, Peterson PK. Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin Microbiol Rev. 2008;21(2):243–61, table of contents. - PMC - PubMed
    1. Thwaites G, Fisher M, Hemingway C, Scott G, Solomon T, Innes J. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect. 2009;59(3):167–87. - PubMed
    1. Koeken VACM, Ganiem AR, Dian S, Ruslami R, Chaidir L, Netea MG, et al. Cerebrospinal fluid IL-1β is elevated in tuberculous meningitis patients but not associated with mortality. Tuberculosis (Edinb). 2020;126:102019. - PubMed

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