Abstract

Tuberculosis (TB) is one of the greatest threats to global public health, with 9.2 million new cases in 20061 and has become increasingly common in the UK. Central nervous system (CNS) infection with Mycobacterium tuberculosis (MTB) is relatively rare but is associated with a serious risk of neurological morbidity or death. Delays in diagnosis worsen prognosis and even with anti-tuberculous therapy up to 30% of tuberculous meningitis (TBM) patients may die.2 TBM and tuberculomas can mimic other CNS pathologies. Careful analysis of the clinical features, CSF examination and pragmatic use of diagnostic tests can aid the diagnosis. Prolonged anti-tuberculous treatment is required and presumptive treatment should not be delayed for microbiological confirmation of the disease.
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References

1. WHO. Global tuberculosis control-surveillance, planning, financing. 2008; Available from: http://www.who.int/tb/publications/global_report/2008/ en/
2. Thwaites GE, Chau TT, Stepniewska K, et al; Diagnosis of adult tuberculous meningitis by use of clinical and laboratory features. Lancet 2002; 360: 1287–92.
3. HPA. Available from: http://www.hpa.org.uk/webw/HPAweb&HPAweb Standard/HPAweb_C/1225354113418?p=1204186170287.
4. Rose AM, Watson JM, Graham C, et al; Tuberculosis at the end of the 20th century in England and Wales: results of a national survey in 1998. Thorax 2001; 56: 173–9.
5. Martineau AR, Lowey H, Tocque K, et al; Decreasing tuberculosis case fatality in England and Wales, 1988–2001. Int J Tuberc Lung Dis 2004; 8: 737–42.
6. Dinnes J, Deeks J, Kunst H, et al; A systematic review of rapid diagnostic tests for the detection of tuberculosis infection. Health Technol Assess 2007; 11: 1–196.
7. NICE. Clinical diagnosis and managment of tuberculosis and measures for its prevention and control. NICE; Available from: http://www.nice.org. uk:80/nicemedia/pdf/CG033FullGuideline.pdf.
8. Ormerod P: Non-respiratory tuberculosis, Davies PDO, Barnes PF, Gordon SB, editors: Clinical Tuberculosis. London, 2008, Hodder Arnold; Chapter. 10, p. 163.
9. Pagnoux C, Genereau T, Lafitte F, et al; Brain tuberculomas. Ann Med Interne (Paris) 2000; 151: 448–55.
10. Schwander SK, Ellner JJ: Human immune response to M. tuberculosis, Davies PDO, Barnes PF, Gordon SB, editors: Clinical Tuberculosis, 2008, Hodder Arnold; Chapter 8, p. 121.
11. Lucas SB: Histopathology, Davies PDO, Barnes PF, et al, editors: Clinical Tuberculosis. London, 2008, Hodder Arnold; Chapter 7, p. 105.
12. Tufariello JM, Chan J, Flynn JL; Latent tuberculosis: mechanisms of host and bacillus that contribute to persistent infection. Lancet Infect Dis 2003; 3: 578–90.
13. Horsburgh CR, Jr.; Priorities for the treatment of latent tuberculosis infection in the United States. N Engl J Med 2004; 350: 2060–7.
14. Sharma SK, Mohan A, Sharma A, et al; Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis 2005; 5: 415–30.
15. Vidal JE, Hernandez AV, Oliveira AC, et al; Cerebral tuberculomas in AIDS patients: a forgotten diagnosis? Arq Neuropsiquiatr 2004; 62: 793–6.
16. Unal A, Sutlas PN; Clinical and radiological features of symptomatic central nervous system tuberculomas. Eur J Neurol 2005; 12: 797–804.
17. Kim TK, Chang KH, Kim CJ, et al; Intracranial tuberculoma: comparison of MR with pathologic findings. AJNR Am J Neuroradiol 1995; 16: 1903–8.
18. Brandli O; The clinical presentation of tuberculosis. Respiration 1998; 65: 97–105.
19. Thwaites GE, Duc Bang N, Huy Dung N, et al; The influence of HIV infection on clinical presentation, response to treatment, and outcome in adults with Tuberculous meningitis. J Infect Dis 2005; 192: 2134–41.
20. Lu CH, Chang WN, Chang HW; The prognostic factors of adult tuberculous meningitis. Infection 2001; 29: 299–304.
21. Schutte CM; Clinical, cerebrospinal fluid and pathological findings and outcomes in HIV-positive and HIV-negative patients with tuberculous meningitis. Infection 2001; 29:213–7.
22. Koh SB, Kim BJ, Park MH, et al; Clinical and laboratory characteristics of cerebral infarction in tuberculous meningitis: a comparative study. J Clin Neurosci 2007; 14: 1073–7.
23. Kinirons P, Baily C, De Gascun C, et al; Lymphocytic meningitis: incidence, causes and outcomes over five years. Ir Med J 2005; 98:238–40.
24. Tunkel AR, Glaser CA, Bloch KC, et al; The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2008; 47: 303–27.
25. Bicanic T, Harrison TS; Cryptococcal meningitis. Br Med Bull 2004; 72: 99–118.
26. Oncul O, Baylan O, Mutlu H, et al; Tuberculous meningitis with multiple intracranial tuberculomas mimicking neurocysticercosis clinical and radiological findings. Jpn J Infect Dis 2005; 58: 387–9.
27. Hoitsma E, Faber CG, Drent M, et al; Neurosarcoidosis: a clinical dilemma. Lancet Neurol 2004; 3: 397–407.
28. Pai M, Riley LW, Colford JM, Jr.; Interferon-gamma assays in the immunodiagnosis of tuberculosis: a systematic review. Lancet Infect Dis 2004; 4: 761–76.
29. Karstaedt AS, Valtchanova S, Barriere R, et al; Tuberculous meningitis in South African urban adults. QJM 1998; 91: 743–7.
30. Wasay M, Kheleani BA, Moolani MK, et al; Brain CT and MRI findings in 100 consecutive patients with intracranial tuberculoma. J Neuroimaging 2003; 13: 240–7.
31. Thomas MM, Hinks TS, Raghuraman S, et al; Rapid diagnosis of Mycobacterium tuberculosis meningitis by enumeration of cerebrospinal fluid antigen-specific T-cells. Int J Tuberc Lung Dis 2008; 12: 651–7.
32. Quan C, Lu CZ, Qiao J, et al; Comparative evaluation of early diagnosis of tuberculous meningitis by different assays. J Clin Microbiol 2006; 44: 3160–6.
33. Bouchama A, al-Kawi MZ, Kanaan I, et al; Brain biopsy in tuberculoma: the risks and benefits. Neurosurgery 1991; 28: 405–9.
34. Field M, Witham TF, Flickinger JC, et al; Comprehensive assessment of hemorrhage risks and outcomes after stereotactic brain biopsy. J Neurosurg 2001; 94: 545–51.
35. McGirt MJ, Woodworth GF, Coon AL, et al; Independent predictors of morbidity after image-guided stereotactic brain biopsy: a risk assessment of 270 cases. J Neurosurg 2005; 102: 897–901.
36. Dammers R, Haitsma IK, Schouten JW, et al; Safety and efficacy of frameless and frame-based intracranial biopsy techniques. Acta Neurochir (Wien) 2008; 150: 23–9.
37. Woodworth GF, McGirt MJ, Samdani A, et al; Frameless image-guided stereotactic brain biopsy procedure: diagnostic yield, surgical morbidity, and comparison with the frame-based technique. J Neurosurg 2006; 104: 233–7.
38. Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Joint Tuberculosis Committee of the British Thoracic Society. Thorax 1998; 53: 536–48.
39. Ormerod LP, Skinner C, Wales J; Hepatotoxicity of antituberculosis drugs. Thorax 1996; 51: 111–3.
40. Breen RA, Miller RF, Gorsuch T, et al; Adverse events and treatment interruption in tuberculosis patients with and without HIV co-infection. Thorax 2006; 61: 791–4.
41. Ungo JR, Jones D, Ashkin D, et al; Antituberculosis drug-induced hepatotoxicity. The role of hepatitis C virus and the human immunodeficiency virus. Am J Respir Crit Care Med 1998; 157: 1871–6.
42. Thwaites GE, Nguyen DB, Nguyen HD, et al; Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med 2004; 351: 1741–51.
43. Hachad H, Ragueneau-Majlessi I, Levy RH; New antiepileptic drugs: review on drug interactions. Ther Drug Monit 2002; 24: 91–103.
44. Thwaites GE, Simmons CP, Than Ha Quyen N, et al; Pathophysiology and prognosis in vietnamese adults with tuberculous meningitis. J Infect Dis 2003; 188: 1105–15.
45. AbdulJabbar M; Paradoxical response to chemotherapy for intracranial tuberculoma: two case reports from Saudi Arabia. J Trop Med Hyg 1991; 94: 374–6.
46. Reiser M, Fatkenheuer G, Diehl V; Paradoxical expansion of intracranial tuberculomas during chemotherapy. J Infect 1997; 35: 88–90.
47. Dautremer J, Pacanowski J, Girard PM, et al; A new presentation of immune reconstitution inflammatory syndrome followed by a severe paradoxical reaction in an HIV-1-infected patient with tuberculous meningitis. AIDS 2007; 21: 381–2.
48. Lee CH, Lui CC, Liu JW; Immune reconstitution syndrome in a patient with AIDS with paradoxically deteriorating brain tuberculoma. AIDS Patient Care STDS 2007; 21: 234–9.
49. Rao GP, Nadh BR, Hemaratnan A, et al; Paradoxical progression of tuberculous lesions during chemotherapy of central nervous system tuberculosis. Report of four cases. J Neurosurg 1995; 83: 359–62.
50. Jha DK, Mishra V, Choudhary A, et al; Factors affecting the outcome of neuroendoscopy in patients with tuberculous meningitis hydrocephalus: a preliminary study. Surg Neurol 2007; 68: 35–41; discussion -2.
51. Rotbart HA; Viral meningitis. Semin Neurol 2000; 20: 277–92.
52. Kosters K, Nau R, Bossink A, et al; Rapid Diagnosis of CNS Tuberculosis by a T-Cell Interferon-gamma Release Assay on Cerebrospinal Fluid Mononuclear Cells. Infection 2008.