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Laboratory Studies Again, the most important is the lumbar puncture, which preferably should be performed before the administration of antibiotics The CSF is usually under increased pressure and contains between 50 and 500 white cells per cubic millimeter, rarely more Early in the disease there may be a more or less equal number of polymorphonuclear leukocytes and lymphocytes; but after several days, lymphocytes predominate in the majority of cases In some cases, however, M tuberculosis causes a persistent polymorphonuclear pleocytosis, the other usual causes of this CSF formula being Nocardia, Aspergillus, and Actinomyces (Peacock) One of our patients, a museum guard who spent all his time among Egyptian artifacts, manifested a persistent polymorphonuclear response due to M fortuitum The protein content of the CSF is always elevated, between 100 to 200 mg/dL in most cases, but much higher if the ow of CSF is blocked around the spinal cord Glucose is reduced to levels below 40 mg/dL but rarely to the very low values observed in pyogenic meningitis; the glucose falls slowly and a reduction may become manifest only several days after the patient has been admitted to the hospital The serum sodium and chloride and CSF chloride are often reduced, in most instances because of inappropriate ADH secretion or an addisonian state due to tuberculosis of the adrenals Most children with tuberculous meningitis have positive tuberculin skin tests (85 percent), but the rate is far lower in adults with or without AIDS: 40 to 60 percent in most series The conventional methods of demonstrating tubercle bacilli in the spinal uid are inconsistent and often too slow for immediate therapeutic decisions Success with the traditional identi cation of tubercle bacilli in smears of CSF sediment stained by the ZiehlNeelsen method is a function not only of their number but also of the persistence with which they are sought There are effective means of culturing the tubercle bacilli; but since their quantity is usually small, attention must be paid to proper technique The amount of CSF submitted to the laboratory is critical; the more that is cultured, the greater the chances of recovering the organism Unless one of the newer techniques is utilized, growth in culture media is not seen for 3 to 4 weeks PCR, by DNA ampli cation, permits the detection of small amounts of tubercle bacilli and is now widely available for clinical use There is also a rapid culture technique that allows identi cation of the organisms in less than 1 week However, even these new diagnostic methods may give uncertain results or take several days to demonstrate the organism, and they cannot be counted on to exclude the diagnosis For these reasons, if a presumptive diagnosis of tuberculous meningitis has been made and cryptococcosis and other fungal infections and meningeal neoplasia have been excluded, treatment should be instituted immediately, without waiting for the results of bacteriologic study Other diagnostic procedures (CT, MRI) may be necessary in patients who present with or develop raised intracranial pressure, hydrocephalus, or focal neurologic de cits One or more tuberculomas may also be visualized (see below) MR angiography may demonstrate vascular occlusive disease from granulomatous in ltration of the walls of arteries of the circle of Willis and their primary branches
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content, and normal glucose levels Headache, lethargy, and confusion are present in some cases and there are mild meningeal signs Lincoln, who was the rst to call attention to this syndrome, believed it to be a meningeal reaction to an adjacent tuberculous focus that did not progress to a frank meningitis This form of meningitis is not always self-limited Tuberculomas These are tumor-like masses of tuberculous granulation tissue, most often multiple but also occurring singly, that form in the parenchyma of the brain and range from 2 to 12 mm in diameter (Fig 32-3) The larger ones may produce symptoms of a space-occupying lesion and periventricular ones may cause obstructive hydrocephalus, but many are unaccompanied by symptoms of focal cerebral disease In the United States tuberculomas are rarities; but in developing countries they constitute from 5 to 30 percent of all intracranial mass lesions In some tropical countries, cerebellar tuberculomas are the most frequent intracranial tumors in children Because of their proximity to the meninges, the CSF often contains a small number of lymphocytes and increased protein (serous meningitis), but the glucose level is not reduced True tuberculous abscesses of the brain are rare except in AIDS patients In two of our patients who presented with a brainstem tuberculoma, there was a serous meningitis that progressed to a fatal generalized tuberculous meningitis Myeloradiculitis The spinal cord may be affected in a number of ways in the course of tuberculous infection In addition to compressing spinal roots and cord, causing spinal block, the in ammatory meningeal exudate may invade the underlying parenchyma, producing signs of posterior and lateral column and spinal root disease Spinal cord symptoms may also accompany tuberculous osteomyelitis of the spine with compression of the cord by an epidural abscess, a mass of granulation tissue (Pott paraplegia), or, less frequently, by the mechanical effects of angulation of the ver-
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