Hydrocephalus in tuberculous meningitis
Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai, India.

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056, India.

Clinical Problem :
A 4 years old girl was referred as she had been on antituberculous therapy {ATT} for past 2 years 8 months. At age of 1 year 4 months, she was diagnosed as tuberculous meningitis {TBM} with hydrocephalus and was started on ATT and underwent ventriculoperitoneal {VP} shunt insertion. She was alright was next 6 months and at 2 years she developed drowsiness with right sided hemiparesis. A CT brain showed large granuloma anterior to brain stem causing upper cervical cord compression. She was thus restarted on steroids which was given for 2 months. At 2 years 4 months, she developed an encysted collection of fluid 16.4 x 13.9 cm underneath the anterior abdominal wall that required excision. At 2 years 7 months of age she developed a peritoneal pseudocyst and hence VP shunt was removed and a ventriculo-atrial {VA shunt} was put. Abdominal lymphnode biopsy was done at the same time where mycobacterium tuberculosis was isolated and 2 drugs ATT consisting of Isoniazid {H}, Rifampicin {R} was continued. At 3 years 4 months of age, MRI brain was done which showed substantial regression of confluent granulomas in retroclivum region. At 3 years 10 months of age, she had headache and a fall following which VA shunt broke and again a VP shunt was reinserted. CT brain now showed disappearance of granuloma. At 4 years of age, at the time of referral, the child was asymptomatic, had normal milestones and no focal neurological deficit. Her weight was 14 kg, height was 84.5 cm, head circumference was 46 cm. Her hearing assessment, ophthalmological assessment was normal and EEG was also normal. Her ATT was thus stopped and she was advised regular follow up.

Question :
Do all patients with TBM and hydrocephalus require a VP shunt_?

Expert Opinion :
Hydrocephalus is the most common complication of TBM seen in up to 87 percent of patients. Early shunting with drugs therapy may offer the best therapeutic outcome. Shunt surgery does not alter the prognosis of stage III TBM as these patients usually have high mortality or are left with major disability like mental retardation, hemiparesis or blindness. Shunt surgery is indicated in patients who have failure of medical management, or have TBM with hydrocephalus and uncontrolled raised intracranial pressure. Shunt prevents the development of subsequent visual deterioration. VP shunt is preferred as it can be done in presence of active disease and early shunting with anti-TB therapy improves outcome.
The criteria for performing VP Shunt are CSF polymorphs less than 5 cells, cumm, CSF protein less than 100 mg, dl with evidence of hydrocephalus on CT scan irrespective of the number of CSF lymphocytes. In patients with Grade 1 and 2 based on Palur Grading system {1} {Table 1}, in presence of periventricular edema on CT scan, shunt surgery may be required. For patients in Grade III, surgery may be performed either if external ventricular drainage causes an improvement in sensorium or without selection. As per Palur et al, all patients in Grade IV should undergo external ventricular drainage and only those who show a significant change in their neurological status within 24 to 48 hours of drainage, should have shunt surgery. {1} However, recent studies have depicted that there may be improvement in patients with Grade 4 also when VP shunt is inserted. {2,3}

1. Palur R, Rajshekhar V, Chandy MJ, Joseph T, Abraham J. Shunt surgery for hydrocephalous in tubercular meningitis: A long-term follow up study. J Neurosurg 1991` 74: 64-69.
2. Srikantha U, Morab JV, Sastry S, Abraham R, Balasubramaniam A, Somanna S, et al. Outcome of ventriculoperitoneal shunt placement in Grade IV tubercular meningitis with hydrocephalus: a retrospective analysis in 95 patients. Clinical article. J Neurosurg Pediatr. 2009`4{2}:176-83.
3. Peng J, Deng X, He F, Omran A, Zhang C, Yin F, et al. Role of ventriculoperitoneal shunt surgery in grade IV tubercular meningitis with hydrocephalus. Childs Nerv Syst. 2012`28:209-215

Correct Answers :  yes 86%
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