Tuberculous Meningits and CNS Whippel’s Disease

Today, we discussed a case of an elderly woman presenting with recurrent, cryptogenic stroke. We had an interesting discussion on approach to recurrent strokes, and discussed the diagnosis of tuberculous meningitis.

Top Pearls from Today:
A. Serial LP’s are often necessary to confirm diagnosis of various CNS infections, including tuberculous meningitis. CNS AFB yield increases from 37% (with 1 LP) to 89% (with 4 LP’s)!

B. If clinical suspicion is high for tuberculous meningitis and AFB staining is negative, send nucleic acid testing of CSF!______________________________________________________

Interested in more details?

Tuberculous Meningitis

  • 1% of all cases of TB and 5% of all extrapulmonary disease in immunocompetent individuals
  • Three discernible phases of TB meningitis 1) prodromal phase (2-3 weeks): malaise, headache, low-grade fever 2) meningitic phase: meningismus, headache, vomiting, lethargy, confusion, cranial nerve involvement 3) paralytic phase: stupor, coma, seizures, hemiparesis. If untreated, death ensues.
  • Diagnosis – can be quite difficult! – CSF: Characteristic CSF findings of low glucose, elevated protein, mononuclear pleocytosis (however, early in the course of illness, cellular reaction is often atypical. Needs serial CSF examinations, which may show a change to a lymphocytic cellular pattern!) – AFB smear and culture: in general, a minimum of 3 serial LPs should be performed, as diagnostic yield can increase from 37% on LP#1 to 89% on LP #4! – Nucleic acid tests: Xpert MTB/RIF assay should be submitted in the setting of high clinical suspicion and negative AFB staining.

CNS Disease in Whipple’s

  • Whipple’s Disease is a rare entity that may be a mimicker of many different illnesses!
  • When to suspect Whipple’s? – Think about 4 cardinal manifestations: arthralgias, diarrhea, abdominal pain, weight loss – other clinical syndromes that raise suspicion include: FUO, chronic serositis, progressive CNS disease or early onset cognitive deficits, myoclonus or ophthalmoplegia, generalized lymphadenopathy!
  • Neurologic involvement has been reported in 10-40% of cases with Whippel’s disease (isolated CNS infection with T. whipplei can rarely occur).
  • Most commonly, CNS involvement  is asymptomatic – diagnosed usually by PCR detection of T. whipplei in the CSF!
  • Various clinical syndromes may occur with primary Whipple’s disease of the brain 1) Multifarious neurologic symptoms and signs: seizures, ataxia, eye movement disorders, amnesic syndrome, SIADH, meningoencephalitis, dementia 2) Focal neurologic symptoms secondary to a solitary mass lesion

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