These foci located in the subpial or subependymal surface of the brain, meninges and bacilli remain in a dormant state for a prolonged duration. Initially, small tuberculous lesions known as 'Rich foci' form around the bacteria that are deposited in the brain during bacteraemia of primary TB. CNS is involved following primary infection of the lungs through haematogenous spread to the brain.
Global as well as country-wise disease burden of TBM in children is largely unavailable and understudied.Īrnold Rich and Howard McCordock showed the presence of a caseating focus in the brain parenchyma or meninges on autopsy in patients with TBM 9. Most reports describing TBM in children had been hospital based, and very few were from systematic surveillance. It is unclear whether geographic differences exist for the risk of TBM among TB-exposed children related to differences in circulating strains, demographics, genetics or other factors. A hospital-based study in Beijing showed that among 1212 children admitted for TB treatment between 20, almost half of them had EPTB and around 39 per cent had TBM 8. In one hospital in Greece, 43 children were diagnosed with TBM between 19, with a declining trend over the years 7. According to surveillance data from Germany, of the total paediatric TB patients, TBM occurred in 3.9 per cent of the children in less than five-year age group, 2.2 per cent in 5 to 9 yr of age and 1.3 per cent in 10 to 14 yr of age 6. However, there are isolated reports from different countries regarding local TBM burden. There is a paucity of data about global burden of different types of EPTB in children, including TBM. Here we discuss the clinical presentation, investigations, management and outcome of TBM in children.ĭespite advancements in technology for Mtb detection, TB diagnosis, especially EPTB in children is a major challenge. Most of the available information regarding paediatric TBM is from retrospective studies, as only a few prospective studies have been conducted. TBM is diagnosed based on clinical findings, demonstration of Mtb in the cerebrospinal fluid (CSF) by smear microscopy, culture, DNA amplification testing, aided by imaging techniques 5. Early diagnosis and management of TBM is important, as delay in diagnosis leads to poor outcomes such as death, neurological sequelae and neurocognitive disorders. TBM frequently presents with non-specific symptoms in the early stages and is diagnosed in the later stages of the illness when brain damage has already occurred. TBM has a poor prognosis, and survivors often have severe disabilities 4. Even though TBM constitutes a small proportion of the total reported TB cases (around 1%), it causes a disproportionate amount of suffering with higher rates of mortality and morbidity, especially in young children 3.
The most common manifestation of Mycobacterium tuberculosis (Mtb) infection in the central nervous system (CNS) is meningitis. Infants, young and HIV-infected children are often affected with severe forms such as disseminated TB or tuberculous meningitis (TBM). Mathematical modelling has shown that more than 58 per cent cases of paediatric TB occur in children less than five years and one-fourth of them have EPTB 2. Almost 10-20 per cent of the children with TB live in high TB burden countries 1. Globally, almost half a million children become sick with tuberculosis (TB) every year, 20-30 per cent being affected by extrapulmonary TB (EPTB). This review describes the clinical presentation, investigations, management and outcome of TBM in children and also discusses various studies conducted among children with TBM. Further studies are needed to identify appropriate regimens with adequate dosing of ATT for the management of paediatric TBM to improve treatment outcomes.
There are studies reporting low concentrations of ATT, especially of rifampicin and ethambutol in cerebrospinal fluid (CSF), and very young children are at higher risk of low ATT drug concentrations. Children diagnosed with TBM should be managed with antituberculosis therapy (ATT) and steroids. Hence, a high degree of suspicion and a combined battery of tests including clinical, bacteriological and neuroimaging help in diagnosis of TBM. Early diagnosis and management of the disease, though difficult, is essential to avoid death or neurologic disability. Bacteriological confirmation of diagnosis is ideal but is often difficult because of its paucibacillary nature as well as decreased sensitivity and specificity of diagnostic tests. Confirmation of diagnosis is often difficult, and other infectious causes such as bacterial, viral and fungal causes must be ruled out. The peak incidence of TBM occurs in younger children who are less than five years of age, and most children present with late-stage disease. Although the occurrence of tuberculous meningitis (TBM) in children is relatively rare, but it is associated with higher rates of mortality and severe morbidity.
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