Tuberculosis of the central nervous system in children: a 20-year survey.

OBJECTIVE

To review our experience of central nervous system (CNS) tuberculosis at a major British paediatric tertiary referral centre, following the introduction of CT Scan facilities.

METHODS

This was a retrospective case survey (prospective in nine patients) of patients admitted to Great Ormond Street over a 20-year period (1977-1997), who fulfilled criteria for a diagnosis of CNS tuberculosis. Data were collected with regard to the clinical, laboratory and demographic characteristics of patients, as well as results of radiological investigations and data on clinical outcome.

RESULTS

We identified 38 children with CNS tuberculosis: 23 with tuberculous meningitis (TBM), 10 with tuberculous meningitis and associated tuberculomas and five with tuberculomas alone. The mean age of this group was 3.7 years, ranging from 8 months to 16 years. Only 14 (37%) were of Caucasian origin. A contact source was identified in 18 patients (47%). Previous BCG had only been given to six (16%). The main clinical symptoms and signs present on admission were alteration in consciousness in 30 patients (79%), focal neurological signs in 25 (66%) and fever in 25 (66%). Seizures were observed in 20 patients (53%) and meningism in 18 (47%). Mycobacterium tuberculosis was either cultured or identified by acid-fast stain from CSF or brain tissue from 24 patients (63%). The Mantoux reaction was positive in 17/33 (51%); abnormalities of the chest X-ray were found in 15 (40%). Cranial CT scans of the patients presenting with TBM showed hydrocephalus in 31 patients (94%), and basilar enhancement in 27 (93%) out of the 29 patients who received intravenous contrast. Anti-tuberculous therapy administered varied according to current recommendations of the period; concurrent steroids were given to 31 patients (82%). Neurosurgical procedures were required in the majority of patients with TBM, 25 (76%). In five patients with TBM, new tuberculoma developed during treatment. The overall mortality for our group of patients was 13%, whilst permanent neurological sequelae were seen in 47% of the patients. None of the patients who received BCG either died or had severe sequelae. Mortality and morbidity rates were higher in the first 10 years of the study and amongst those patients admitted in Stage III disease.

CONCLUSIONS

CNS tuberculosis continues to be a condition which carries significant morbidity and mortality. Early diagnosis and prompt initiation of treatment are essential to improve the poor outcome.