Neurologic Complications of Tuberculosis

Deanna Saylor, MD, MHS Neuroinfectious Disease p. 992-1017 August 2021, Vol.27, No.4 doi: 10.1212/CON.0000000000001005
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PURPOSE OF REVIEW This article describes the current epidemiology, common clinical characteristics, and up-to-date evidence-based approaches to the diagnosis and management of the most common neurologic complications of tuberculosis (TB): tuberculous meningitis, intracranial tuberculoma, and spinal TB.

RECENT FINDINGS Central nervous system (CNS) TB remains common and associated with significant mortality and neurologic sequelae worldwide. Human immunodeficiency virus (HIV) co-infection is strongly associated with both the development of and mortality due to CNS TB. Strongyloides co-infection is associated with reduced CNS inflammation and improved outcomes in the setting of tuberculous meningitis. Stroke remains a common complication of tuberculous meningitis, and emerging evidence suggests aspirin may be used in this context. Although a recent nucleic acid amplification test has demonstrated suboptimal sensitivity in the diagnosis of CNS TB, emerging diagnostic techniques include cell-free DNA, peripheral blood microRNA, metagenomic next-generation sequencing, and advanced imaging techniques, but these are not yet well validated. CNS TB is associated with high mortality even with current treatment regimens, although novel, promising strategies for treatment are under investigation, including a combination of IV isoniazid and ethambutol and high-dose rifampicin.

SUMMARY TB can affect the nervous system in various ways and is associated with high mortality. Diagnosis remains challenging in endemic settings, with empiric treatment often initiated without a definitive diagnosis. Furthermore, optimal treatment regimens remain uncertain because current treatment for all forms of CNS TB is extrapolated from trials of tuberculous meningitis whereas the role of steroids in people with HIV and tuberculous meningitis remains controversial.

Address correspondence to Dr Deanna Saylor, Meyer 6-113, 600 N Wolfe St, Baltimore, MD 21287, [email protected].

RELATIONSHIP DISCLOSURE: Dr Saylor has received research/grant support from the American Academy of Neurology, National Institute of Aging (R01 AG059504-01A), National Institute of Mental Health (R01 MH120693-01, P30 MH075673), National Institute of Neurological Disorders and Stroke (R01 NS094037-05S1, R21 NS118543-01), and National Multiple Sclerosis Society.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Saylor discusses the unlabeled/investigational use of thalidomide and nonstandard doses and/or nonstandard formulations of ethambutol, isoniazid, and rifampin for the treatment of central nervous system tuberculosis.

© 2021 American Academy of Neurology.