Diagnosis of cerebral tuberculosis

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

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

• positive Pandy and None-Apelt reactions;
• cell count (cytosis) 100-400 in 1 ml and higher, mainly lymphocytes;
• glucose content is reduced to 1.1-1.65 mmol/l (with the norm being 2.2-3.9 mmol/l).

When the cerebrospinal fluid stands for 12-24 hours, a delicate web-like film falls out, in which, as in the centrifugate, MBC is detected.

Blood tests reveal a decrease in hemoglobin concentration, a decrease in the number of platelets to 80.0-100.0x10 ⁹ /l, moderate leukocytosis, and a moderate increase in ESR.

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

• Anamnesis (information about contact with patients with tuberculosis).
• The nature of tuberculin tests, timing of revaccination (considering that if the child’s condition is severe, tuberculin tests may be negative).
• Clinical picture (nature of onset and development of meningitis, state of consciousness, severity of meningeal symptoms).
• Chest X-ray: detection of active tuberculosis or residual changes of previous tuberculosis (at the same time, their absence does not allow to exclude tuberculous etiology).
• Lumbar puncture with examination of cerebrospinal fluid is a decisive moment in determining the etiology of meningitis.
• Fundus examination: detection of tuberculous tubercles on the retina undoubtedly indicates tuberculous etiology of meningitis. Congested optic discs reflect increased intracranial pressure. It should be taken into account that with pronounced congestion in the fundus, axial dislocation is possible during lumbar puncture. In this case, the cerebrospinal fluid should be released without removing the mandrin from the needle.
• Bacteriological examination of cerebrospinal fluid: detection of MBT is indisputable proof of the tuberculous nature of meningitis.

Differential diagnostics

In pneumonia, flu, dysentery, viral hepatitis A and other diseases in children, irritation of the meninges is possible, caused by a quickly passing edema without true signs of inflammation. In such cases, children may complain of headache, vomiting, positive meningeal symptoms appear (rigidity of the occipital muscles, Kernig's symptom, Brudzinski's symptom). Cerebrospinal fluid during lumbar puncture flows out under increased pressure, but its composition does not change. This condition is called "meningism". With the improvement of the general condition of the child, the phenomena of meningism also disappear. However, in such cases, meningitis can be excluded only after examining the cerebrospinal fluid. Differential diagnostics in young children is carried out primarily with intestinal infections, since increased frequency of stool, vomiting, increased body temperature, convulsions occur in both cases. However, with tuberculosis meningitis, exsicosis is absent. Particular attention should be paid to the tension and bulging of the fontanelle (in dyspepsia it sinks in), which is sometimes the only leading symptom.

The second disease that must be remembered in a serious condition of the baby is purulent meningitis. Common symptoms include acute onset, vomiting, increased body temperature, convulsions, refusal to eat, presence of meningeal symptoms, severity of the condition. To make a correct diagnosis, a cerebrospinal fluid test is necessary.

Serous meningitis is polyetiological. The viral origin of most acute serous meningitis has been established. Their pathomorphological basis is 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 occurs as meningoencephalitis.

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

• Acute onset and vivid clinical picture.
• An increase in body temperature to high levels at the onset of the disease.
• Severity of meningeal syndrome from the very beginning of the disease.
• Disruption of the condition during the acute period and its rapid recovery.
• Significantly increased lymphocytic cytosis in the cerebrospinal fluid with normal (sometimes increased) glucose levels and moderately increased protein levels. Film rarely falls out.
• Symptoms of cranial nerve damage tend to rapidly and completely reverse.
• There are no exacerbations or relapses.
• Typical epidemiological history and the presence of other signs of pathology (for example, enlarged parotid lymph nodes, etc.).

In most cases, purulent inflammation of the meninges is caused by meningococci and streptococci. Meningitis of mixed etiology is possible. The absence of the pathogen in the cultures is associated with the early use of antibiotics. The pathogen penetrates the meninges most often hematogenously, contact penetration of the infection is possible (with otitis, mastoiditis, brain abscess, cranial trauma).

In differential diagnosis, the following differences must be taken into account:

• epidemiological situation;
• acute, sometimes lightning-fast onset of the disease;
• no cranial nerve damage;
• pronounced inflammatory nature of the peripheral blood;
• purulent nature of cerebrospinal fluid;
• detection of the pathogen in the cerebrospinal fluid;
• rapid positive dynamics against the background of non-specific antibacterial therapy (10-14th day).

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