Diagnosis of tuberculosis of the meninges

If suspected of meningitis, that is, in the presence of fever, persistent, intensifying headaches, meningeal syndrome and miliary dissemination in the lungs, a lumbar puncture is indicated.

The character of the cerebrospinal fluid in tuberculosis of meninges in children is as follows:

• positive reactions of Pandi and Non-Apelt;
• number of cells (cytosis) 100-400 in 1 ml and above, mainly lymphocytes;
• the glucose content was reduced to 1,1-1,65 mmol / l (at a rate of 2,2-3,9 mmol / l).

When the liquor is standing for 12-24 hours, a gentle cobweb-like film falls out, in which, like in a centrifuge, MBC is detected.

In the blood test, a decrease in the concentration of hemoglobin, a decrease in the number of platelets to 80.0-100.0 × ^{10 9} / L, moderate leukocytosis, a moderate increase in ESR.

Diagnosis of tuberculous meningitis is necessary before the 7-10th day of the disease, even during the exudative phase of inflammation. In these cases, you can hope for a complete cure. It is important to take into account the following data, which are discussed in more detail above.

• Anamnesis (information on contact with tuberculosis patients).
• The nature of tuberculin samples, the timing of revaccination (given that in case of a severe condition of the child, tuberculin samples may be negative).
• The clinical picture (the nature of the onset and development of meningitis, the state of consciousness, the severity of meningeal symptoms).
• X-ray examination of the chest: the detection of active tuberculosis or residual changes of the transferred tuberculosis (at the same time, their absence does not allow to reject the tuberculosis etiology).
• Lumbar puncture with the study of cerebrospinal fluid is the decisive moment in elucidating the etiology of meningitis.
• Investigation of the fundus: the detection of tubercular tubercles on the retina indicates with certainty the tubercleous etiology of meningitis. Stagnant discs of the optic nerves reflect an increase in intracranial pressure. It should be borne in mind that with a pronounced stagnation in the fundus, an axial dislocation is possible with lumbar puncture. In this case, the cerebrospinal fluid should be discharged without removing the mandrel from the needle.
• Bacteriological study of cerebrospinal fluid: detection of MW is an indisputable proof of the tubercular nature of meningitis.

Differential diagnostics

With pneumonia, influenza, dysentery, viral hepatitis A and other diseases in children, irritation of the meninges can occur, due to fast edema without the true signs of inflammation. In such cases, children may complain of headache, vomiting, positive meningeal symptoms appear (stiff neck, Kernig symptom, Brudziński). Likvor with lumbar puncture follows under increased pressure, but its composition does not change. This condition is called the term "meningism". With the improvement of the general state of the child, the phenomena of meningism also disappear. However, in such cases, it is possible to exclude meningitis only after investigation of the CSF. Differential diagnosis in young children is primarily carried out with intestinal infections, since frequent stools, vomiting, fever, convulsions are met in both cases. However, with tuberculosis of meningitis there is no exsicosis. Particular attention should be paid to the intensity and swelling of the fontanelle (with dyspepsia it sinks), which sometimes is the only leading symptom.

The second disease, which must be remembered in the severe condition of the baby, is purulent meningitis. Common symptoms include acute onset, vomiting, fever, cramps, refusal to eat, the presence of meningeal symptoms, and the severity of the condition. For the correct diagnosis, it is necessary to study the cerebrospinal fluid.

Serous meningitis is polyethiologic. The viral origin of most acute serous meningitis has been established. Pathomorphological their basis are hyperemia and edema of the soft meninges, lymphocytic infiltration and pronounced changes in the vascular plexuses of the ventricles. When the inflammatory process spreads to the cortex, the disease proceeds like meningoencephalitis.

Serous meningitis includes acute serous lymphocytic meningitis. Meningitis caused by enteroviruses, adenoviruses, mumps virus, tick-borne encephalitis, poliomyelitis, measles, chickenpox, etc. Meningitis is also serous in some bacterial infections: pneumonia, typhoid fever, scarlet fever. When conducting a differential diagnosis with tuberculous meningitis, the following features of serous meningitis can be considered the most typical.

• An acute onset and a vivid clinical picture.
• Increase in body temperature to high numbers at the onset of the disease.
• Severity of meningeal syndrome from the very beginning of the disease.
• Violation of the state in the acute period and its rapid recovery.
• Significantly increased lymphocytic cytosis in cerebrospinal fluid with a normal (sometimes elevated) amount of glucose with a moderately increased amount of protein. The film is rare.
• Symptoms of the defeat of the cranial nerves tend to a rapid and complete reverse development.
• There are no exacerbations and relapses.
• A typical epidemiological anamnesis and the presence of other signs of pathology (eg, parotid lymph nodes, etc.).

In most cases, purulent inflammation of the meninges cause meningococci and streptococci. Meningitis of mixed etiology is possible. The absence of a causative agent in the crops is associated with the early use of antibiotics. The causative agent penetrates the meninges most often through hematogenous pathways, contact penetration of the infection is possible (with otitis, mastoiditis, brain abscess, trauma of the skull).

For differential diagnosis, the following differences should be considered:

• epidemiological situation;
• acute, sometimes lightning-fast onset of the disease;
• absence of cranial nerve damage;
• pronounced inflammatory nature of peripheral blood;
• purulent character of the cerebrospinal fluid;
• detection of the pathogen in the cerebrospinal fluid;
• rapid positive dynamics on the background of nonspecific antibiotic therapy (10-14 day).

[1], [2], [3], [4], [5], [6], [7], [8], [9],