Uganda

Yes, TB Meningitis can be treated in Uganda, and better still it can be prevented

Back to Home
Yes, TB Meningitis can be treated in Uganda, and better still it can be prevented

By Sabrina.B.Kitaka

Case Presentation:

T.O (not his initials) was a 2 year old boy who was the 1st born to both his parents. He presented to the emergency unit of the Mulago National Referral Hospital on 18th January 2016 with a history of fever and refusal to feed for 2 days. He had abnormal movements and excessive vomiting. He was found to be febrile with a temperature of 39 degrees centigrade and had moderate pallor of the mucous membranes.Significantly,he was semi-conscious and scored low on the modified Glasgow Coma Scale, a total of 11/15.His neck was stiff, but his pupils were normal. A lumbar puncture test done revealed a marked rise in his cells.He was not HIV infected or exposed.He was treated for acute bacterial meningitis as per standard operating procedure with intravenous ceftriaxone for 10 days and seemed to improve.

 

Unfortunately, on Day 10 of his treatment, his fevers recurred and he had a generalized tonic clonic seizure which lasted more than 30 minutes. The ward team was concerned that probably he had acquired malaria while on the ward, so we ran a battery of tests to exclude malaria. On his torso, he had a few moluscum lesions, so a viral encephalitis was suspected, but not confirmed. A more detailed review of his history was taken, and our key findings included that he had never been vaccinated in his entire life!! His mother had left him in the care of his grand aunt when he was only 2 days old. She had to attend a course in Europe and had only returned a month prior to his illness.

 

Further tests were done including a repeat lumbar puncture, and a CT scan of his brain. We confirmed one of our biggest fears.T.O had tuberculous meningitis! The parents were devastated but we were hopeful, and gave them counseling and encouragement. On Day 14 of the TB treatment, T.O showed signs of recovery, his coma scale improved from 6/15, to 12/15.There was jubilation for us as the paediatrics team, and the parents too showed some glimmer of hope. Before long, we were able to remove his feeding tube, and start him on physiotherapy.

 

I saw T.O a week ago, 2 months after his initiation of treatment, and he was completely well. He ran up to me and gave me the biggest hug his little arms could master; and said very proudly:’ I am now much better!! And I want to become a doctor when I grow up!’

 

Discussion:

Tuberculous meningitis is also known as TB meningitis or tubercular meningitis. Tuberculous meningitis is Mycobacterium tuberculosis infection of the meninges—the system of membranes which envelop the central nervous system. Tuberculosis (TB) is a contagious airborne disease that typically affects the lungs. (1) TB is caused by a bacterium called Mycobacterium tuberculosis. The bacterium can travel through the bloodstream if the TB infection is not treated quickly. It can infect other organs and tissues in the body. Sometimes, the bacterium will travel to the membranes surrounding the brain and spinal cord (the meninges). Infection of the meninges can result in the development of a life-threatening condition known as meningeal tuberculosis. Meningeal tuberculosis is also known as tubercular meningitis or TB meningitis.(2) Symptoms of TB meningitis typically appear slowly at first. They become more severe over a period of weeks. During the early stages of the infection, symptoms typically include: fatigue, malaise, and low-grade fever. As the disease progresses, the symptoms will become more serious. Classic symptoms of meningitis (e.g., stiff neck, headache, light sensitivity) are not always present. Instead, one may experience the following symptoms: fever; changes in mental status (confusion); nausea and vomiting; lethargy; irritability; unconsciousness.(3)

 

Diagnosis of TB Meningitis is complicated because of its non-specific clinical presentation which may be acute, sub-acute or chronic. It may present with with or without fever.(2).The diagnosis can be further confirmed by: biopsy (taking a small piece) of the meninges; blood culture; chest X-ray; CT scan of the head; and skin test for tuberculosis (PPD).

 

Early diagnosis and prompt treatment are vital in effective treatment.(2).The treatment consists of multiple anti-microbial agents given over a period of one year. Bacillus Calmette-Guerin (BCG) vaccine is still the only vaccine approved for the prevention of tuberculosis (TB), and is widely used in highly endemic countries, where all newborns receive a single injection in the skin immediately after birth. (4)Prevention of TB meningitis in children is possible with provision of BCG vaccination in the first 6 weeks of life.

 

REFERENCES:

1.         Donald PR. Chemotherapy for Tuberculous Meningitis. The New England journal of medicine. 2016;374(2):179-81.

2.         Nabukeera-Barungi N, Wilmshurst J, Rudzani M, Nuttall J. Presentation and outcome of tuberculous meningitis among children: experiences from a tertiary children's hospital. African Health Sciences. 2014;14(1):143-9.

3.         Beneri CA, Aaron L, Kim S, Jean-Philippe P, Madhi S, Violari A, et al. Understanding NIH clinical case definitions for pediatric intrathoracic TB by applying them to a clinical trial. The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease. 2016;20(1):93-100.

4.         Montagnani C, Esposito S, Galli L, Chiappini E, Principi N, de Martino M. Recommendations for pediatric tuberculosis vaccination in Italy. Human vaccines & immunotherapeutics. 2015:0.

2 comments
Level 1 (XP: 100)
Juvenal,thanks for your comment,BCG vaccination is usually given at Day 0 in Uganda,but can be given before the age of 6 weeks.The bacille Calmette-Guérin (BCG) vaccine has existed for 80 years and is one of the most widely used of all current vaccines, reading ]80%of neonates and infants in countries where it is part of the national childhood immunization programme. BCG vaccine has a documented protective effect against meningitis and disseminated TB in children. It does not prevent primary infection and, more importantly, does not prevent reactivation of latent pulmonary infection, the principal source of bacillary spread in the community.
Level 1 (XP: 0)
Thanks for the nice read Dr. Sabrina. Is there hope for a child who has missed BCG vaccination in the first six weeks of life?

Recent Posts

Popular Posts

Category