Abstract
Objectives:
To summarize the incidence and spectrum of spinal cord-related complications in patients of tuberculous meningitis.
Setting:
Reports from multiple countries were included.
Methods:
An extensive review of the literature, published in English, was carried out using Scopus, PubMed and Google Scholar databases.
Results:
Tuberculous meningitis frequently affects the spinal cord and nerve roots. Initial evidence of spinal cord involvement came from post-mortem examination. Subsequent advancement in neuroimaging like conventional lumbar myelography, computed tomographic myelography and gadolinium-enhanced magnetic resonance-myelography have contributed immensely. Spinal involvement manifests in several forms, like tuberculous radiculomyelitis, spinal tuberculoma, myelitis, syringomyelia, vertebral tuberculosis and very rarely spinal tuberculous abscess. Frequently, tuberculous spinal arachnoiditis develops paradoxically. Infrequently, spinal cord involvement may even be asymptomatic. Spinal cord and spinal nerve involvement is demonstrated by diffuse enhancement of cord parenchyma, nerve roots and meninges on contrast-enhanced magnetic resonance imaging. High cerebrospinal fluid protein content is often a risk factor for arachnoiditis. The most important differential diagnosis of tuberculous arachnoiditis is meningeal carcinomatosis. Anti-tuberculosis therapy is the main stay of treatment for tuberculous meningitis. Higher doses of corticosteroids have been found effective. Surgery should be considered only when pathological confirmation is needed or there is significant spinal cord compression. The outcome in these patients has been unpredictable. Some reports observed excellent recovery and some reported unfavorable outcomes after surgical decompression and debridement.
Conclusions:
Tuberculous meningitis is frequently associated with disabling spinal cord and radicular complications. Available treatment options are far from satisfactory.
Similar content being viewed by others
Log in or create a free account to read this content
Gain free access to this article, as well as selected content from this journal and more on nature.com
or
References
Horsley V . Chronic spinal meningitis: its differential diagnosis and surgical treatment. Br Med J 1909; 1: 513–517.
Cameron HC . Section from a case of tuberculous meningitis of the spinal cord simulating anterior poliomyelitis. Proc R Soc Med 1919; 12 (Sect Study Dis Child) 23–24.
Ransome GA, Montiero ES . A rare form of tuberculous meningitis. Br Med J 1947; 1: 413.
World Health Organization. Global tuberculosis report 2014. Downloaded from: http://www.who.int/tb/publications/global_report/gtbr14_main_text.pdf?ua=1.
Sandgren A, Hollo V, van der Werf MJ . Extrapulmonary tuberculosis in the European Union and European Economic Area, 2002 to 2011. Euro Surveill 2013; 18: 20431.
Ducomble T, Tolksdorf K, Karagiannis I, Hauer B, Brodhun B, Haas W et al. The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009. Euro Surveill 2013; 18: 20436.
Peto HM, Pratt RH, Harrington TA, LoBue PA, Armstrong LR . Epidemiology of extrapulmonary tuberculosis in the United States, 1993-2006. Clin Infect Dis 2009; 49: 1350–1357.
Anderson NE, Somaratne J, Mason DF, Holland D, Thomas MG . Neurological and systemic complications of tuberculous meningitis and its treatment at Auckland City Hospital, New Zealand. J Clin Neurosci 2010; 17: 1114–1118.
van Well GT, Paes BF, Terwee CB, Springer P, Roord JJ, Donald PR et al. Twenty years of pediatric tuberculous meningitis: a retrospective cohort study in the western cape of South Africa. Pediatrics 2009; 123: e1–e8.
Candy S, Chang G, Andronikou S . Acute myelopathy or cauda equina syndrome in HIV-positive adults in a tuberculosis endemic setting: MRI, clinical, and pathologic findings. AJNR Am J Neuroradiol 2014; 35: 1634–1641.
Rich AR, McCordock HA . The pathogenesis of Tuberculous Meningitis. Bull Johns Hopkins Hosp 1933; 52: 2–33.
Dastur DK, Manghani DK, Udani PM . Pathology and pathogenetic mechanisms in neurotuberculosis. Radiol Clin North Am 1995; 33: 733–752.
Dastur DK, Lalitha VS, Udani PM, Parekh U . The brain and meninges in tuberculous meningitis-gross pathology in 100 cases and pathogenesis. Neurol India 1970; 18: 86–100.
Dastur D, Wadia NH . Spinal meningitides with radiculo-myelopathy. 2. Pathology and pathogenesis. J Neurol Sci 1969; 8: 261–297.
Wadia NH, Dastur DK . Spinal meningitides with radiculo-myelopathy. 1. Clinical and radiological features. J Neurol Sci 1969; 8: 239–260.
Dastur HM . A tuberculoma review with some personal experiences. II. Spinal cord and its coverings. Neurol India 1972; 20: 127–131.
Dastur DK . The pathology and pathogenesis of tuberculous encephalopathy and myeloradiculopathy: a comparison with allergic encephalomyelitis. Childs Nerv Syst 1986; 2: 13–19.
Fehling MG, Bernstein M . Syringomyelia as a complication of tuberculous meningitis. Can J Neurol Sci 1992; 19: 84–87.
Caplan LR, Norohna AB, Amico LL . Syringomyelia and arachnoiditis. J Neurol Neurosurg Psychiatry 1990; 53: 106–113.
Ahuja GK, Venkataraman S, Roy S, Viramani V . Tuberculous radiculomyelopathy. Neurol India 1978; 26: 135–139.
Freilich D, Swash M . Diagnosis and management of tuberculous paraplegia with special reference to tuberculous radiculomyelitis. J Neurol Neurosurg Psychiatry 1979; 42: 12–18.
Hernández-Albújar S, Arribas JR, Royo A, González-GarcÃa JJ, Peña JM, Vázquez JJ et al. Tuberculous radiculomyelitis complicating tuberculous meningitis: case report and review. Clin Infect Dis 2000; 30: 915–921.
Srivastava T, Kochar DK . Asymptomatic spinal arachnoiditis in patients with tuberculous meningitis. Neuroradiology 2003; 45: 727–729.
Kozlowski K . Late spinal blocks after tuberculous meningitis. AJR Am J Radiol 1963; 90: 1220–1226.
Chang KH, Han MH, Choi YW, Kim IO, Han MC, Kim CW et al. Tuberculous arachnoiditis of the spine: findings on myelography, CT, and MR imaging. AJNR Am J Neuroradiol 1989; 10: 1255–1262.
Trebst C, Raab P, Voss EV, Rommer P, Abu-Mugheisib M, Zettl UK et al. Longitudinal extensive transverse myelitis—it's not all neuromyelitis optica. Nat Rev Neurol 2011; 7: 688–698.
Sahu SK, Giri S, Gupta N . Longitudinal extensive transverse myelitis due to tuberculosis: a report of four cases. J Postgrad Med 2014; 60: 409–412.
Skendros P, Kamaria F, Kontopoulos V, Tsitouridis I, Sidiropoulos L . Intradural extramedullary tuberculoma of the spinal cord as a complication of tuberculous meningitis. Infection 2003; 31: 115–117.
Garg RK, Karak B, Misra S . Acute paraparesis with tuberculous meningitis. Postgrad Med J 1998; 74: 269–271.
Shaharao VB, Pawar M, Agarwal R, Bavdekar SB . Intra-medullary tuberculoma occurring during treatment of tuberculous meningitis. Indian J Pediatr 2004; 71: 107–108.
Tacconi L, Arulampalam T, Johnston FG, Thomas DG . Intramedullary spinal cord abscess: case report. Neurosurgery 1995; 37: 817–819.
Ozates M, Ozkan U, Kemaloglu S, Hosoglu S, Sari I . Spinal subdural tuberculous abscess. Spinal Cord 2000; 38: 56–58.
Tanriverdi T, Kizilkilic O, Hanci M, Kaynar MY, Unalan H, Oz B et al. Atypical intradural spinal tuberculosis: report of three cases. Spinal cord 2003; 41: 403–409.
Schon F, Bowler JV . Syringomyelia and syringobulbia following tuberculous meningitis. J Neurol 1990; 237: 122–123.
Daif AKal Rajeh S, Ogunniyi A, al Boukai A, al Tahan A . Syringomyelia developing as an acute complication of tuberculous meningitis. Can J Neurol Sci 1997; 24: 73–76.
Lolge S, Chawla A, Shah J, Patkar D, Seth M . MRI of spinal intradural arachnoid cyst formation following tuberculous meningitis. Br J Radiol 2004; 77: 681–684.
Thwaites GE, Tran TH . Tuberculous meningitis: many questions, too few answers. Lancet Neurol 2005; 4: 160–170.
Asselman V, Thienemann F, Pepper DJ, Boulle A, Wilkinson RJ, Meintjes G et al. Central nervous system disorders after starting antiretroviral therapy in South Africa. AIDS 2010; 24: 2871–2876.
Pepper DJ, Marais S, Maartens G, Rebe K, Morroni C, Rangaka MX et al. Neurologic manifestations of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome: a case series. Clin Infect Dis 2009; 48: e96–107.
Marais S, Meintjes G, Pepper DJ, Dodd LE, Schutz C, Ismail Z et al. Frequency, severity, and prediction of tuberculous meningitis immune reconstitution inflammatory syndrome. Clin Infect Dis 2013; 56: 450–460.
Shen WC, Cheng TY, Lee SK, Ho YJ, Lee KR . Disseminated tuberculomas in spinal cord and brain demonstrated by MRI with gadolinium-DTPA. Neuroradiology 1993; 35: 213–215.
Garg RK, Sharma R, Kar AM, Kushwaha RA, Singh MK, Shukla R et al. Neurological complications of miliary tuberculosis. Clin Neurol Neurosurg 2010; 112: 188–192.
Garg RK, Jain A, Malhotra HS, Agrawal A, Garg R . Drug-resistant tuberculous meningitis. Expert Rev Anti Infect Ther 2013; 11: 605–621.
Patel VB, Padayatchi N, Bhigjee AI, Allen J, Bhagwan B, Moodley AA et al. Multidrug-resistant tuberculous meningitis in KwaZulu-Natal, South Africa. Clin Infect Dis 2004; 38: 851–856.
Borges MA, Carmo MI, Sambo MR, Borges FC, Araújo CM, Campos MJ et al. Intramedullary tuberculoma in a patient with human immunodeficiency virus infection and disseminated multidrug-resistant tuberculosis: case report. Int J Infect Dis 1998; 2: 164–167.
Agrawal R, Addison P, Saihan Z, Pefkianaki M, Pavesio C . Optic neuropathy secondary to linezolid for multidrug-resistant mycobacterial spinal tuberculosis. Ocul Immunol Inflamm 2014; 23: 90–92.
Lin SK, Wu T, Wai YY . Intramedullary spinal tuberculomas during treatment of tuberculous meningitis. Clin Neurol Neurosurg 1994; 96: 71–78.
Muthukumar N, Sureshkumar V, Ramesh VG . En plaque intradural extramedullary spinal tuberculoma and concurrent intracranial tuberculomas: paradoxical response to antituberculous therapy. Case report. J Neurosurg Spine 2007; 6: 169–173.
Malhotra HS, Garg RK, Lalla R, Gupta A . Paradoxical extensive thoracolumbosacral arachnoiditis in a treated patient of tuberculous meningitis. BMJ Case Rep 2012; 2012 pii: bcr2012006262. doi:10.1136/bcr-2012-006262.
Garg RK, Malhotra HS, Kumar N . Paradoxical reaction in HIV negative tuberculous meningitis. J Neurol Sci 2014; 340: 26–36.
Vlcek B, Burchiel KJ, Gordon T . Tuberculous meningitis presenting as an obstructive myelopathy. Case report. J Neurosurg 1984; 60: 196–199.
Bernaerts A, Vanhoenacker FM, Parizel PM, Van Goethem JW, Van Altena R, Laridon A et al. Tuberculosis of the central nervous system: overview of neuroradiological findings. Eur Radiol 2003; 13: 1876–1890.
Phadke RV, Kohli A, Jain VK, Gupta RK, Kumar S, Gujral RB et al. Tuberculous radiculomyelitis (arachnoiditis): myelographic (and CT myelographic) appearances. Australas Radiol 1994; 38: 10–16.
Schon F, Brown G, Britton J . Tuberculous myelopathy: a serial MRI study. J Neurol Neurosurg Psychiatry 1995; 58: 259–260.
Wasay M, Arif H, Khealani B, Ahsan H . Neuroimaging of tuberculous myelitis: analysis of ten cases and review of literature. J Neuroimaging 2006; 16: 197–205.
Hristea A, Constantinescu RV, Exergian F, Arama V, Besleaga M, Tanasescu R et al. Paraplegia due to non-osseous spinal tuberculosis: report of three cases and review of the literature. Int J Infect Dis 2008; 12: 425–429.
Ozek E, Iplkcioglu AC, Erdal M . Intradural extramedullary tuberculoma mimicking en plaque meningioma. Neurol India 2009; 57: 211–212.
Gupta RK, Gupta S, Kumar S, Kohli A, Misra UK, Gujral RB et al. MRI in intraspinal tuberculosis. Neuroradiology 1994; 36: 39–43.
Gupta A, Garg RK, Singh MK, Verma R, Malhotra HS, Sankhwar SN et al. Bladder dysfunction and urodynamic study in tuberculous meningitis. J Neurol Sci 2013; 327: 46–54.
Hughes IE, Adams JH, Ilbert RC . Invasion of the leptomeninges by tumour: the differential diagnosis from tuberculous meningitis. J Neurol Neurosurg Psychiatry 1963; 26: 83–89.
Heijink DS, Urgun K, Sav A, Seker A, Konya D . A case of primary diffuse leptomeningeal gliomatosis predominantly involving the cervical spinal cord and mimicking chronic meningitis. Turk Neurosurg 2012; 22: 90–94.
Kon T, Funamizu Y, Miki Y, Tomiyama M, Baba M, Kurotaki H et al. An autopsy case of meningeal carcinomatosis with parenchymal invasion through the cranial and spinal nerve roots. Neuropathology 2014; 34: 499–503.
Louapre C, Desestret V, Mokhtari K, Lubetzki C . Primary diffuse leptomeningeal gliomatosis diagnosed on CSF cytology: perseverance pays off. Pract Neurol. 2014; 15: 138–140.
Mohit AA, Santiago P, Rostomily R . Intramedullary tuberculoma mimicking primary CNS lymphoma. J Neurol Neurosurg Psychiatry 2004; 75: 1636–1638.
World Health Organization. Treatment of tuberculosis: guidelines – 4th edn (WHO/HTM/TB/2009.420) World Health Organization 2010 (http://whqlibdoc.who.int/publications/2010/9789241547833_eng.pdf (assessed on 6 April 2010).
Thwaites GE, Nguyen DB, Nguyen HD, Hoang TQ, Do TT, Nguyen TC et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med 2004; 351: 1741–1751.
Gourie-Devi M, Padmini R, Satish P . Use of intrathecal hyaluronidase in spinal arachnoiditis complicating tuberculous meningitis. Indian J Med Res 1980; 71: 581–593.
Hanci M, Sarioglu AC, Uzan M, Islak C, Kaynar MY, Oz B et al. Intramedullary tuberculous abscess: a case report. Spine 1996; 21: 766–769.
Kaynar MY, Koçer N, Gençosmanoglu BE, Hanci M . Syringomyelia—as a late complication of tuberculous meningitis. Acta Neurochir (Wien) 2000; 142: 935–938.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The authors declare no conflict of interest.
Additional information
Supplementary Information accompanies this paper on the Spinal Cord website
Supplementary information
Rights and permissions
About this article
Cite this article
Garg, R., Malhotra, H. & Gupta, R. Spinal cord involvement in tuberculous meningitis. Spinal Cord 53, 649–657 (2015). https://doi.org/10.1038/sc.2015.58
Received:
Revised:
Accepted:
Published:
Issue date:
DOI: https://doi.org/10.1038/sc.2015.58
This article is cited by
-
Surgical treatment for recurrent thoracic ventral intradural arachnoid cyst secondary to tuberculous meningitis: a case report
Spinal Cord Series and Cases (2024)
-
Multi-level tuberculosis of the spine identified by 18Â F-FDG-PET/CT and concomitant urogenital tuberculosis: a case report from the spinal TB X cohort
Infection (2024)
-
Radiological approach to non-compressive myelopathies
Egyptian Journal of Radiology and Nuclear Medicine (2022)
-
Pelvic and central nervous system tuberculosis complicated by a paradoxical response manifesting as a spinal tuberculoma: a case report
BMC Infectious Diseases (2022)
-
Tuberculous myelitis: a prospective follow-up study
Neurological Sciences (2022)
