Tuberculous meningitis during infancy: 26 cases in South Turkey among 20 years

Due to the lack of a standard case definifion and the diffuculty in estabilishing a definitive diagnsos, TB in children needs increasing attention by physicians caring for pediatric patients. Tuberculous meningitis (TBM) is the most serious form of extrapulmonary tuberculosis that is associated with significant morbidity and mortality rate in the pediatric age group, especially in infants. This descriptive study was conducted in an University hospital, at the South of Turkey, from May 1999 to May 2019.

The hospital records of 26 TBM infant that was diagnosed at our hospital were retrospectively evaluated. The epidemiological findings (age, gender, family history of TB, tuberculin skin test results, status of BCG scaring), stage of TBM at admission and clinical, laboratory and radiological features were collected.

Of the 26 infants, 61.5% were male and mean age of the patients was 7,65±2,6 (range, 3-12 months). The history of close contact with an infected adult was encountered in 73.1% (19 infant) of the cases. Only 69.2% of the patients (18 case) had a BCG scar. The prodromal stage (period between the onset of symptoms to hospital admission) ranged from 4 days to 180 days (39±51.3). 2 cases were defined as stage I, 10 cases as stage II and 14 cases as stage III TBM. Only two patients were initially positive for PPD test. While no neurological findings were found in 2 patients (diagnosed as stage I), neurologic findings at the time of admission included increased intracranial pressure; alteration in consciousness (92.3%), seizures (88.4%), vomiting (61.5%) cranial nerve palsy (23%), irritability 19.2%, hemiplegia 15.3% and meningeal signs (7%, only 2 patients). The presence of hepatomegaly 26.9 % and/or splenomegaly 11.5 % and/or extrapulmonary lymphadenopathy 3.8 % in nearly half of the cases suggested that totally 42,2% of cases had disseminated of tuberculosis. On admission, 46.1% of the patients were noted to have hyponatremia. Microbiologic confirmation was established in eleven (42.3%) of the 26 infant. A positive CSF culture for Mtb and/or smear for AFB and/or PCR was obtained in only 5 (19.2%) patients, whereas 3 of the cases had accompaining gastric aspirate examination positivity. Pulmonary consolidation in 14 (53.8%) patients, miliary patern in 10 (41.6%) and pulmonary hilar lymphadenopathy in only 5 (20.8%) patients. 23 (88.4 %) had hydrocephalus, 15 (57.6 %) infarction, 10 (38.4 %) basilar meningitis and 9 (34.6%) tuberculomas. Empiric anti-tuberculosis treatment was instituted in all, at a median of 3 days (range 1-15 days) following admission. 8 (30.7%) died, 3 (11.5%) recovered completely, and 15 (57.6%) recovered with sequelae. 12 case (2 died) of the infants had required ventriculoperitoneal shunting.

As early diagnosis and specific treatment appears to prevent serious complications and reduce mortality, a high index of suspicion among pediatricians is especially required in an infant with an atypical picture suggestive of tuberculosis infection.