In Korea, tuberculosis is still common disease. Central nervous system tuberculosis can manifest in a variety of forms, including tuberculous meningitis, tuberculous cerebritis, tuberculoma, tuberculous abscess, and miliary tuberculosis. Although intra-axial tuberculomas are the more common type of CNS tuberculosis, extra-axial lesions are rarely encountered. En plaque tuberculoma is an extremely rare presentation of intracranial tuberculosis with mimicking primary or secondary meningeal neoplasia. We describe a rare case of an en plaque tuberculoma accompanied by tuberculous meningitis and tuberculomas.
Abscess ; Korea ; Magnetic Resonance Imaging ; Tuberculoma* ; Tuberculosis ; Tuberculosis, Central Nervous System ; Tuberculosis, Meningeal ; Tuberculosis, Miliary

As a cause of spinal cord compression, intramedullary spinal tuberculoma with central nervous system (CNS) involvement is rare. Aurthors report a 66-year-old female presented with multiple CNS tuberculomas including spinal intramedullary tuberculoma manifesting paraparesis and urinary dysfunction. We review the clinical menifestation and experiences of previous reported literature.
Aged ; Central Nervous System ; Female ; Humans ; Paraparesis ; Spinal Cord Compression ; Tuberculoma ; Tuberculoma, Intracranial ; Tuberculosis

The incidence of tuberculosis (TB) infection in multiple organs outside the lungs is of particular concern. We present the case of a 48-year-old woman with a history of pulmonary TB who had a gradual loss of consciousness in one day, worsening shortness of breath, and a cough with green phlegm two weeks before admission. She had been undergoing five days of TB treatment with the drug-sensitive TB treatment regimen. The genital examination revealed a whitish mass in the paraurethral area, which impaired her urination. Blood gas analysis showed respiratory acidosis, and a chest X-ray suggested pulmonary TB and concurrent community-acquired pneumonia. She was diagnosed with extrapulmonary tuberculosis (EPTB) in the central nervous systems and urogenital sites. To treat her lifethreatening EPTB, she received crystalloid infusions, oxygen supplementation, ampicillin-sulbactam (converted to meropenem the next day), an oral fixed-dose combination antituberculosis therapy, pyridoxine, N-acetylcysteine, ursodeoxycholic acid, Curcuma, bisoprolol, proton pump inhibitor, and antiemetics. Additionally, she was inserted with a urethral catheter and a nasogastric tube to assist her urination and nutritional intake. Our facility was a subdistrict hospital and had a limited capacity for diagnosing and treating EPTB due to a lack of advanced intensive care units, blood and sputum cultures, and laboratory panels. After her two-day hospital admission to ICU for stabilisation, she was referred to a higher-level hospital with more advanced pulmonary treatment overseen by a multidisciplinary team. Our resource limitations highlight the importance of being well-informed about evidencebased primary EPTB management strategies.
Tuberculosis, Central Nervous System

Infectious diseases of the central nervous system (CNS) cause inflammatory processes within the brain and spinal cord that can lead to morbidity and mortality in a high proportion of patients. Pharmacological strategies to dampen inflammation have been investigated, and steroids are one of the adjunctive treatments for bacterial meningitis, tuberculous meningitis, and herpes simplex virus encephalitis. In this paper, we review the recent literature that provides guidelines for the use of steroids in combination with appropriate antimicrobial therapy, and we discuss how systemic steroid treatment is an important aspect of treatment regimens for CNS infectious diseases.
Brain ; Central Nervous System Infections ; Central Nervous System ; Communicable Diseases ; Encephalitis ; Humans ; Inflammation ; Meningitis, Bacterial ; Mortality ; Simplexvirus ; Spinal Cord ; Steroids ; Tuberculosis ; Tuberculosis, Meningeal

PURPOSE: To compare the effect of different etiologies in children with central nervous system (CNS) infections on the incidence of initial and hospital-acquired hyponatremia (IH and HAH) (plasma sodium concentration, PNa <135 mEq/L). METHODS: Children with CNS infections during the period between 2011 and 2012 were evaluated retrospectively. Patients were classified into 4 groups: group A, aseptic meningitis; group B, viral meningoencephalitis; group C, bacterial meningitis; group D, tuberculous meningitis. All patients had measured the initial PNa and were retested serially. By the sodium concentration of IV fluid, children were divided into 2 groups: group-I of <0.45% saline in dextrose, and group-II of > or =0.45% saline in dextrose. RESULTS: Of 244 children with CNS infections (group A: 185, group B: 33, group C: 23, and group D: 3), 55 patients (22.5%) revealed IH- or HAH-hyponatremia. IH and HAH was found in 13.1% (32/244) and 9.4% (23/244), respectively. The incidence of IH was significantly higher in group-C (30.4%, P=0.010) than in group-A (9.2%) or group-B (21.2%). HAH was more frequent in group-B (27.3%, P<0.001) and in group-D (66.7%, P=0.001) than in group-A (4.9%) or in group-C (13.0%). Of the patients in group-I, 28.6% (8/28) developed more common HAH compared with 6.9% (15/216) of children in group-II (P<0.001). CONCLUSION: IH and HAH were relatively common in children with CNS infections and their incidences were distinctly different among patients from different etiologies. It seems that the administration of hypertonic saline can help to reduce the incidence of HAH among children with CNS infections. election.
Central Nervous System Infections* ; Central Nervous System* ; Child* ; Glucose ; Humans ; Hyponatremia* ; Incidence ; Meningitis ; Meningitis, Aseptic ; Meningitis, Bacterial ; Meningoencephalitis ; Retrospective Studies ; Sodium ; Tuberculosis, Meningeal

The authors present a retrospective analysis of central nervous system(CNS) tuberculoma, describing the clinical manifestations, radiological findings, diagnosis, treatment, and prognosis. Between February 1984 to December 1996, 22 cases of CNS tuberculoma presenting as intracranial space occupying lesions were managed at Seoul National University Hospital. The age of patients ranged from two to 47 (mean, 28) years and the male-to-female ratio was 6 to 16. The diagnosis of CNS tuberculoma was pathologically confirmed in 18 cases, while the remaining four were diagnosed on the basis of clinical manifestations and radiological findings. The duration of follow-up ranged from 10 months to 7 years(median, 2 years). The results of treatment and prognosis were defined according to the status of patients on their final visit to the Outpatients' clinic. The symptoms of CNS tuberculoma were seizure(45% of cases), headache(36%), visual disturbance(18%), and hemiparesis(18%), and in 12 patients(55%), the presence of related pulmonary tuberculosis was noted. The most commom site of CNS tuberculoma was the frontal lobe; multiple lesions were present in five cases, and brain stem lesions in three. In 13 cases, CNS tuberculoma was seen as low signal intensity on T2 weighted magnetic resonance images(MRI). Gadolinium-enhanced T1 weighted MRI showed strong rim enhancement in ten cases and nodular enhancement in five, as well as characteristic grape-like conglomerated lesions in six cases. Surgical removal was performed in 13 cases, stereotactic biopsy in two, and biopsy via craniotomy in three. Although microbiologic study was negative in all 18 cases, diagnosis of CNS tuberculoma was possible on histological examination. After clinical or surgical diagnosis, a course of anti-tuberculosis medication was started in all patients. In 18 cases, intracranial lesions disappeared completely after anti-tuberculosis medication, and during the follow-up period, there was no evidence of recurrence. In three cases the lesions became smaller during treatment and symptoms improved. One patient died in spite of medication and decompressive surgery. Between the group of 13 patients who underwent decompressive surgery or lesionectomy via craniotomy, and the other group of nine, the outcome of treatment was not different(p=1.000, Fisher's exact test). In conclusion, the MRI findings of intracranial CNS tuberculoma are characteristic MRI findings. In cases of CNS tuberculoma, the treatment of choice is anti-tuberculous medication after histologic confirmation, though if sufficient clinical data support this diagnosis, then diagnostic and therapeutic medication without histologic confirmation is recommanded. Stereotactic biopsy is an ideal method for confirming a pathologic diagnosis of intracranial CNS tuberculoma, except in the cases in which intracranial pressure is high.
Biopsy ; Brain Stem ; Central Nervous System* ; Craniotomy ; Diagnosis ; Follow-Up Studies ; Frontal Lobe ; Humans ; Intracranial Pressure ; Magnetic Resonance Imaging ; Prognosis ; Recurrence ; Retrospective Studies ; Seoul ; Tuberculoma* ; Tuberculosis ; Tuberculosis, Pulmonary

The Immunological diagnosis of tuberculous meningitis (TBM) requires the presence of de novo synthesis of immunoglobulin in the central nervous system. We investigated the CNS IgG synthetic rate and IgG antibody titers against lipoarabinomanan (LAM) and PPD antigens in the serum and CSF by using ELISA in patients with TBM and patients with only pulmonary tuberculosis (PTB). The CNS IgG synthetic rate was markedly increased in all 11 patients with TB with PTB (56.42+l886 mg/day vs 7.47+435 mg/day). On the other hand, abnormally elevated IgG titers in the CSF against either LAM or PPD antigen were present in all 7 patients with TBM and in 4 of 11 patients with PTB tested. The 4 patients with the false positivity showed markedly elevated IgG antibody titers in the sera suggesting the passive diffusion of IgG antibodies through the intact blood brain barrier from the sera to the CSF. It is likely that the simultaneous measurement of CNS IgG sythesis is an useful addition to the ELISA of IgG antibody titration against the antigens of M. tuberculare in the CSF for the accurate diagnosis of TBM, especially in the endemic area of tuberculosis.
Antibodies ; Blood-Brain Barrier ; Central Nervous System ; Diagnosis ; Diffusion ; Enzyme-Linked Immunosorbent Assay ; Hand ; Humans ; Immunity, Humoral* ; Immunoglobulin G* ; Immunoglobulins* ; Immunologic Tests ; Tuberculosis ; Tuberculosis, Meningeal* ; Tuberculosis, Pulmonary

Hyponatremia in patients with central nervous system disorders is suggestive of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), and volume restriction is recommended for its correction. However, if volume depletion is present in a situation otherwise compatible with SIADH, cerebral salt wasting syndrome (CSWS) should be considered as the cause of the hyponatremia to avoid hypovolemic shock that may be induced by the standard management of SIADH, i.e. volume restriction. We present a case of a 17-year-old male patient with CSWS associated with tuberculous meningitis. The clinical feature of the patient comprised hyponatremia, excessive natriuresis, polyuria, and hypovolemia. Following the administration of saline and fludrocortisone, natriuresis and polyuria were decreased, and the hyponatremia improved
Adolescent ; Central Nervous System Diseases ; Fludrocortisone ; Humans ; Hyponatremia ; Hypovolemia ; Inappropriate ADH Syndrome ; Male ; Natriuresis ; Polyuria ; Shock ; Tuberculosis, Meningeal* ; Wasting Syndrome*

Hyponatremia which is due to excessive sodium loss in the urine and decrease in extracellular fluid volume following an acute or chronic central nervous system injury, has been conjunctively described as cerebral salt wasting syndrome (CSWS). This syndrome is often confused with dilutional hyponatremia due to inappropriate secretion of antidiuretic hormone. Accurate diagnosis and management are mandatory for improvement of the course of the disease. This report describes a case of a 31-year-old male patient with CSWS associated with tuberculous meningitis. The patient exhibited hyponatremia, polyuria, excessive natriuresis, volume depletion, and hypotension. He was diagnosed to manifest CSWS and was treated by administration of fluids, salt, and fludrocortisone. After the respective treatments, symptoms of polyuria and hypotension were gradually resolved and hyponatremia was corrected.
Adult ; Central Nervous System ; Diagnosis ; Extracellular Fluid ; Fludrocortisone ; Humans ; Hyponatremia ; Hypotension ; Male ; Natriuresis ; Polyuria ; Sodium ; Tuberculosis, Meningeal* ; Wasting Syndrome*

BACKGROUND/AIMS: Tuberculous meningitis is a common, occasionally fatal infectious disease of the central nervous system. We evaluated the diagnostic validity of weighted diagnostic index scores (WDIS), which have been suggested to aid in the diagnosis of adult patients with tuberculous meningitis, on the basis of simple clinical and laboratory findings. METHODS: The microbiological and clinical data of adult patients with either tuberculous or bacterial meningitis were reviewed retrospectively. Diagnostic validity and WDIS cut-off values were evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 77 cases were included: 47 with tuberculous meningitis and 30 with bacterial meningitis. For the diagnosis of tuberculous meningitis, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of WDIS suggested by Thwaites (cut-off value of < or =4) were 100, 90, 94 and 100%, respectively. Based on ROC curve analysis (area under ROC curve=0.993), a cut-off value of < or =3 was most appropriate for the diagnosis of tuberculous meningitis. The sensitivity and specificity of WDIS with a cut-off value of < or =3 were 100 and 93.3%, respectively. CONCLUSIONS: Our study demonstrated that WDIS are highly predictable and acceptable for the early diagnosis of tuberculous meningitis in Korea, based on our analysis of clinical and laboratory findings. A cut-off value of < or =3 showed the best diagnostic validity.
Adult ; Central Nervous System ; Communicable Diseases ; Early Diagnosis ; Humans ; Korea ; Meningitis, Bacterial ; Retrospective Studies ; ROC Curve ; Sensitivity and Specificity ; Tuberculosis, Meningeal