I. Diagnostic points.
1, acute or subacute onset, chronic course, may have a history of tuberculosis or tuberculosis contact history.
2, early fever, headache, vomiting, lasting 1 to 2 weeks; if not treated in time, symptoms of brain parenchymal damage often appear in 4 to 8 weeks.
3, Meningeal irritation signs: cervical tonicity, Kernig sign (+).
4, increased intracranial pressure: early mild to moderate increase, due to inflammatory response, increased cerebrospinal fluid production, decreased absorption of arachnoid particles, the formation of traffic hydrocephalus. In the late stage, intracranial pressure increases significantly, and the arachnoid membrane and choroid plexus are adherent, showing incomplete or complete obstructive hydrocephalus. It shows headache, vomiting, optic papillary edema, and in severe cases, de-cephalic tonic seizure or de-cortical state.
5, brain parenchymal damage symptoms: mental symptoms (depression, apathy, delirium or delusions), seizures, impaired consciousness (drowsiness, coma), limb paralysis (two types: ① stroke-like paralysis: mostly due to tuberculous cerebral arteritis, can be hemiplegia, crossed paralysis, quadriplegia, or paraplegia; ② chronic paralysis: similar to tumor, caused by tuberculoma or cerebrospinal meningitis).
6. Cerebral nerve damage: more common. Motility, abduction, facial, and optic nerves are most likely to be involved, due to irritation, adhesions, and compression of inflammatory exudates from the skull base.
7, Characteristics of TBM in the elderly: less headache and vomiting, low incidence of increased intracranial pressure, atypical cerebrospinal fluid, and more incidences of tuberculous endarteritis causing cerebral infarction.
8. Cerebrospinal fluid: increased pressure, up to 400 mmH2O or more; yellow appearance, with film formation after resting; mild to moderate elevation of WBC, usually ≯500×106/L, with lymphocytes predominating; elevated protein, 1~2 g/L; decreased sugar and chloride. Antacid bacillus stain (+); bacterial culture (+), the gold standard for diagnosis.
9, brain CT: basal pool and meningeal contrast enhancement, hydrocephalus, etc.
II. Treatment.
1, treatment principles: early administration, rational drug selection, combination of drugs, systemic treatment. As long as clinical signs and symptoms and cerebrospinal fluid examination suggest the disease, even if the cerebrospinal fluid antacid smear (-) should be immediately anti-TB treatment.
It is currently believed that
1. Isoniazid (INH, 10-20 mg/kg/day; 600 mg in adults, qd; 1 to 2 years).
2.Rifampicin (RFP, 10-20mg/kg/day; 600mg in adults, oral qd; 6-12 months), and
3, pyrazinamide (PZA; 20-30mg/kg/day; adults 500mg, oral tid; 2-3 months) or
4. Ethambutol (EMB, 15-20mg/kg/day ;adult 750mg, oral qd; 2-3 months), and
5, Streptomycin (SM, 20-30mg/kg/day ;adult 750mg, intramuscular, qd ;3-6 months) is the most effective combination drug regimen.
2, according to the WHO recommendation, at least three drugs should be combined, commonly used INH, RFP, PZA. three months after the mild case can stop PZA, and then followed by INH, RFP for 7 months. For resistant strains, SM or EMB should be added. 9 months of total treatment is required for non-resistant RFP, and 18-24 months of continuous treatment is required for resistant RFP. INH can be increased to 600-1200 mg/day in adult patients (Chinese are fast metabolizers of INH). Pay attention to side effects: RFP, INH and PZA cause liver function damage, INH causes polyneuropathy and seizures, EMB optic neurotoxic effects in children, EMB auditory nerve effects in pregnant women are not used as much as possible.
3, glucocorticoids: severe disease, intracranial pressure or brain hernia formation, spinal canal obstruction, anti-TB treatment aggravation and combined tuberculoma need to be added. For adults, prednisone 1mg/kg/d or flumethasone 10-20mg/d; for children, prednisone 1-4mg/kg/d or flumethasone 8mg/d (0.3-0.6mg/kg/d). Reduce the dosage after 3-6 weeks of application, and then taper off for 2-3 weeks.
4.Intrathecal injection: the efficacy can be improved in severe cases. Flumethasone 5-10mg, α-chymotrypsin 4000u, hyaluronidase 1500u; once in 2-3 days, twice a week after the symptoms disappear, once in 1-2 weeks after the signs disappear, until the cerebrospinal fluid is normal. Use with caution if the cerebrospinal fluid pressure is too high.
5.Cranial pressure lowering treatment: 20% mannitol, glycerol saline, glycerol fructose, etc. Pay attention to replenish fluids and electrolytes, protect the kidneys, and detect plasma osmolality.