Paraplegia due to non-osseous spinal tuberculosis: report of three cases and review of the literature

Tuberculous Paraplegia: Outcome of Operative Intervention

BACKGROUND

Tuberculosis of the spine, a common manifestation of extra-pulmonary tuberculosis is characterized by vertebral destruction, paradiscal involvement, abscess collection and varying degrees of neurologic affectation. The primary disease caused by mycobacterium tuberculosis complex infects the lungs, lymph nodes of the mediastinum and gastrointestinal tract/ viscera with spinal involvement being secondary and caused by haematogenous spread. Tuberculous paraplegia arises as a complication of spinal involvement.

AIM

To determine the outcome of operative intervention in tuberculous paraplegia. Methodology: This was a retrospective study involving 10 patients with tuberculous spinal involvement with varying degrees of neurological deficit as defined by both Tuli and ASIA grading. The VAS score, ESR, ASIA grade (both pre-op and post op), Tuli's grade (pre-op and post op) were used to analyze the therapeutic effects of the surgery.

RESULTS

The mean pre-operative VAS score was 5.9 ±1.8, which significantly decreased to 2.2 ±1.3 six weeks post operatively. The mean pre-operative ESR and CRP was 78.9 ± 11.3mm/hr and 83 ± 13.5 respectively; which both showed a statistically significant decrease post-operatively, p<0.05. All cases achieved an increase of more than one ASIA grade post-operatively.

CONCLUSION

Early surgical intervention is beneficial in patients with tuberculous spinal disease with neurologic involvement.

Non-osseous intradural tuberculoma of the thoracic spine with compressive myelopathy

Key Clinical Message

An uncommon form of CNS tuberculosis called non-osseous IDEM tuberculoma frequently results from paradoxical drug interactions. It should be considered one of the differentials when patients receiving ATT experience acute neurological impairment.

Abstract

Tuberculoma affecting the spinal cord is a rare condition in modern times. The occurrence of non-osseous intradural tuberculosis, specifically in the spine, is even more exceptional. In fact, it is uncommon to encounter an intradural extramedullary tuberculous granuloma that lacks radiological indications of vertebral involvement, especially within the thoracic region. We present a case of a patient with a neurological deficit caused by a non-osseous intradural tuberculoma in the thoracic region, without any associated bone involvement. The patient experienced a gradual deterioration of neurological function. An MRI of the thoracic spine revealed the presence of a tuberculoma located intradurally, extramedullary, and juxtamedullary of the T5 vertebra. The compression of the spinal cord resulted in paraparesis which was worsening to paraplegia. A D4-D6 laminectomy and microsurgical excision were performed under intraoperative neurophysiological monitoring (IONM), and the patient showed clinical recovery. Excellent clinical outcomes were achieved. However, it is crucial to consider the possibility of a non-osseous intradural tuberculoma as a rare condition when encountering a SOL, particularly in patients with a history of tuberculosis and spinal cord compression. In cases where a progressing neurological deficit is present, a combination of surgical intervention and anti-tuberculous treatment should be considered as the optimal approach.

Tuberculous meningitis initially manifesting as acute areflexic paraparesis: A case report

Key Clinical Message

TBM has a very high rate of adverse sequelae if not treated immediately. Diagnosing can be challenging due to overlapping symptoms with other disease processes, and diagnostic tests are often inconclusive.

Abstract

A 20-year-old man experienced progressive paraplegia and urinary retention. After extensive laboratory and imaging evaluation for tuberculous meningitis and alternative diagnoses, spinal MRI showed features suggestive of arachnoiditis. He was treated empirically with anti-tuberculosis drugs and corticosteroids. This led to significant improvement and eventual recovery.

A predictive model for early clinical diagnosis of spinal tuberculosis based on conventional laboratory indices: A multicenter real-world study

Background

Early diagnosis of spinal tuberculosis (STB) remains challenging. The aim of this study was to develop a predictive model for the early diagnosis of STB based on conventional laboratory indicators.

Method

The clinical data of patients with suspected STB in four hospitals were included, and variables were screened by Lasso regression. Eighty-five percent of the cases in the dataset were randomly selected as the training set, and the other 15% were selected as the validation set. The diagnostic prediction model was established by logistic regression in the training set, and the nomogram was drawn. The diagnostic performance of the model was verified in the validation set.

Result

A total of 206 patients were included in the study, including 105 patients with STB and 101 patients with NSTB. Twelve variables were screened by Lasso regression and modeled by logistic regression, and seven variables (TB.antibody, IGRAs, RBC, Mono%, RDW, AST, BUN) were finally included in the model. AUC of 0.9468 and 0.9188 in the training and validation cohort, respectively.

Conclusion

In this study, we developed a prediction model for the early diagnosis of STB which consisted of seven routine laboratory indicators.

Recovery of Long Standing Neurological Deficit in Pediatric Dorsal Spinal Tuberculosis: A Single Center Experience of 13 Cases

STUDY DESIGN

Retrospective analysis of case series.

OBJECTIVE

The aim is to study the recovery of neurological deficit in pediatric spinal tuberculosis cases presenting to us more than 6 months after onset of motor weakness in lower limbs.

METHODS

This is a retrospective analysis of 13 consecutive patients of pediatric spinal tuberculosis presenting to us at least 6 months after the onset of neurologic deficit. All these patients underwent surgical intervention at our center and their neurological recovery was noted in terms of improvement in Frankel grading and spasticity improvement by modified Ashworth scale. All the patients were followed up to at least 18 months post op and final neurologic status was assessed at that time.

RESULTS

The mean age of the patients at presentation was 8.5 years. The mean duration of neurologic deficit at the time of presentation was 10.23 months (6-24 months). Seven patients had a Frankel grade B at presentation out of which 6 improved to Frankel grade D and one improved to Frankel C at final follow up. Out of the other 3 patients with Frankel A at presentation, 2 improved to Frankel grade D and 1 to Frankel grade C. The remaining 3 patients presented with Frankel grade C at presentation, 2 improved to Frankel D and one improved to Frankel E at the time of final follow up.

CONCLUSION

Neurologic recovery in patients with neurological deficit is possible even in cases of long standing deficit more than 6 months and in some cases upto 24 months as shown in our study.

Pulse corticosteroids for the management of extensive CNS tuberculosis presenting with acute-onset quadriparesis

Myelopathy in central nervous system tuberculosis is notorious for poor outcomes, determined by the severity of inflammation and cord level involved. Acute-onset quadriplegia or paraplegia in these cases represents a neuro-emergency. We report a young female with disseminated tuberculosis who presented with acute onset flaccid quadriparesis with loss of bladder and bowel function. Imaging helped identify the extensive involvement of the neuraxis. We propose that, in addition to anti-tubercular therapy, high-dose corticosteroids such as pulse methylprednisolone may result in a meaningful improvement and show greater rapidity of response in cases of severe central nervous system inflammation such as arachnoiditis or myelopathy.

MRI findings in tubercular radiculomyelitis

This article aims to familiarize the reader with the MR imaging findings of tubercular radiculomyelitis (TBRM) and to identify the sources of infection. We evaluated 29 patients on a 1.5 T GE MRI in a cross-sectional study. MRI of the spine with contrast and lumbar puncture were performed in all patients. MRI brain was performed for 13 patients. The typical and atypical manifestations enlisted in this article, will enable early detection of TBRM when the clinical history is ambiguous, as TBRM can present with low backache in both retrovirus positive and negative patients.

Early surgical intervention for active thoracic spinal tuberculosis patients with paraparesis and paraplegia

Background

To explore the therapeutic effect of early surgical intervention for active thoracic spinal tuberculosis (TB) patients with paraparesis and paraplegia.

Methods

Data on 118 active thoracic spinal TB patients with paraparesis and paraplegia who had undergone surgery at an early stage (within three weeks of paraparesis and paraplegia) from January 2008 to December 2014 were retrospectively analyzed. The operation duration, blood loss, perioperative complication rate, VAS score, ASIA grade and NASCIS score of neurological status rating, Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP), kyphotic Cobb’s angle, and duration of bone graft fusion were analyzed to evaluate the therapeutic effects of surgery.

Results

The mean operating time was 194.2 minutes, and the mean blood loss was 871.2 ml. The perioperative complication rate was 5.9 %. The mean preoperative VAS score was 5.3, which significantly decreased to 3.2 after the operation and continued decreasing to 1.1 at follow up (P<0.05). All cases achieved an increase of at least one ASIA grade after operation. The rate of full neurological recovery for paraplegia (ASIA grade A and B) was 18.0 % and was significantly lower than the rate (100 %) for paraparesis (ASIA grade C and D) (P<0.05). On the NASCIS scale, the difference in the neurological improvement rate between paraplegia (22.2 % ± 14.1 % in sensation and 52.2 % ± 25.8 % in movement) and paraparesis (26.7 % ± 7.5 % in sensation and 59.4 % ± 7.3 % in movement) was remarkable (P<0.05). Mean preoperative ESR and CRP were 73.1 mm /h and 82.4 mg/L, respectively, which showed a significant increase after operation (P>0.05), then gradually decreased to 11.5 ± 1.8 mm/h and 2.6 ± 0.82 mg/L, respectively, at final follow up (P<0.05). The mean preoperative kyphotic Cobb’s angle was 21.9º, which significantly decreased to 6.5º after operation (P<0.05) while kyphotic correction was not lost during follow up (P>0.05). The mean duration of bone graft fusion was 8.6 ± 1.3 months.

Conclusions

Early surgical intervention may be beneficial for active thoracic spinal TB patients with paraparesis and paraplegia, with surgical intervention being more beneficial for recovery from paraparesis than paraplegia.

Spinal Tuberculosis Treatment: An Enduring Bone of Contention

Spinal tuberculosis is the most common form of extrapulmonary tuberculosis. It is of great importance to neurologists because of the potentially devastating complication of paraplegia, which may set in during active disease or the healed phase. Due to the deep-seated nature of the disease, definitive diagnosis is often challenging. There is no clear consensus on the appropriate duration of therapy for spinal tuberculosis, with various guidelines recommending treatment from as short as 6 months to up to 18 months. In this article, we present a critical appraisal of the evidence on the same. In our opinion, the duration of antitubercular therapy needs to be individualized and the decision to terminate therapy should be multifactorial (clinical, radiological, pathological/microbiological where possible) rather than being enmeshed within any particular guideline.

Severe Pott's Kyphosis in a 19-Month-Old Child: Case Report and Review of Literature

BACKGROUND

Spinal osseous tuberculosis, or Pott's spine, although very common in endemic countries, has a lower incidence in very young children. However, the infection has the propensity to cause greater vertebral destruction in this age group, leading to severe structural kyphotic deformity and associated neurologic deficits. We report the case of a 19-month-old child with severe tubercular kyphotic deformity of the upper thoracic spine managed with posterior vertebral column resection (VCR) and nonfusion posterior pedicle screw instrumentation.

CASE DESCRIPTION

This 19-month-old boy presented with 1-month history of spontaneous-onset, progressive, painful rigid kyphotic deformity of the upper back associated with spastic paraparesis with bowel and bladder incontinence. Magnetic resonance imaging showed severe destruction of bodies of D4-D7 vertebrae with cord edema and draping of the spinal cord over the internal gibbus at D4-D7. Surgery was performed with a restricted anterior fusion via single-stage posterior VCR at D4-D7 with nonfusion pedicle screw instrumentation from D1 to D9, with subsequent extension of instrumentation to D10 after 4 months.

CONCLUSIONS

Multilevel posterior VCR with a restricted fusion and nonfusion pedicle screw instrumentation beyond the resection site can be safely done in young children (age <3 years) requiring rigid tubercular kyphotic deformity correction. However, these patients require regular follow-up and may need multiple surgeries.

A rare neurological complication of tuberculosis: Transverse myelitis

Acute transverse myelitis is a rare inflammatory demyelinating disorder characterized by relatively acute onset of motor, sensory, and autonomic dysfunction. Mycobacterium tuberculosis is a very rare cause of transverse myelitis. We present a patient with tuberculosis presenting with meningitis and transverse myelitis who had marked clinical improvement and neurologic recovery after treatment of tuberculosis and intravenous steroid pulses.

Spinal Intramedullary Tuberculosis with Concurrent Supra- and Infratentorial Intracranial Disease in a 9-Month-Old Boy: Case Report and Comprehensive Review of the Literature

BACKGROUND

Tuberculous involvement of the spinal cord parenchyma is an exceedingly rare clinical entity; even more so is concurrent intracranial tuberculosis (TB). Spinal intramedullary TB presents with a characteristic subacute myelopathy, with slowly progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction. Diagnosis is strongly suspected with a clinical history of known TB in conjunction with characteristic findings on magnetic resonance imaging. Management involves multiagent antitubercular chemotherapy without or with operative intervention.

CASE DESCRIPTION

We present a case of a 9-month-old boy with a retrospectively recognized history of pulmonary TB presenting with fever and back tenderness found to have lower-extremity hypertonia and clonus. Imaging revealed concurrent intracranial and spinal intramedullary tuberculomas. The patient was treated for hydrocephalus with external ventricular drainage followed by T8-T10 laminectomy, drainage of abscess, and duraplasty. Parietal lobe biopsies proved the tuberculous etiology of intracranial lesions.

CONCLUSION

Etiopathogenesis, diagnosis, and management considerations of spinal intramedullary tuberculosis are reviewed and discussed.

A Rare Complication of Tuberculosis: Acute Paraplegia

Background

Tuberculous radiculomyelitis(TBRM) is one of the complications of neurological tuberculosis and includes cases of arachnoiditis, intradural spinal tuberculoma or granuloma, and spinal cord complications of tuberculous meningitis (TBM). Here, we report a case of TBRM which presented with acute paraplegia.

Case Details

Neurological examination on admission revealed flaccid paralysis, bilateral extensor plantar responses, and exaggerated deep tendon reflexes. Cerebrospinal fluid analysis showed xanthochromic fluid that contained 600 cells/mm3, 98% lymphocytes, protein 318 mg/dl and glucose 51 mg/dl (blood glucose 118 mg/dl). On thorax CT, calcified lymph nodes that were sequelae of primary tuberculosis infection was detected. Antituberculosis and intravenous corticosteroids treatment was started. Seven weeks from the onset, on-control spinal MRI myelomalacia was determined, and there was no leptomeningeal enhancement. After six weeks of rehabilitation, lower limb total motor score was increased from 0/50 to 15/50.

Conclusions

Tuberculous radiculomyelitis is a complication of TBM. It is rarely seen.

An Imaging-Based Approach to Spinal Cord Infection

Infections of the spinal cord, nerve roots, and surrounding meninges are uncommon, but highly significant given their potential for severe morbidity and even mortality. Prompt diagnosis can be lifesaving, as many spinal infections are treatable. Advances in imaging technology have now firmly established magnetic resonance imaging (MRI) as the gold standard for spinal cord imaging evaluation, enabling the depiction of infectious myelopathies with exquisite detail and contrast. In this article, we aim to provide an overview of MRI findings for spinal cord infections with special focus on imaging patterns of infection that are primarily confined to the spinal cord, spinal meninges, and spinal nerve roots. In this context, we describe and organize this review around 5 distinct patterns of transverse spinal abnormality that may be detected with MRI as follows: (1) extramedullary, (2) centromedullary, (3) eccentric, (4) frontal horn, and (5) irregular. We seek to classify the most common presentations for a wide variety of infectious agents within this image-based framework while realizing that significant overlap and variation exists, including some infections that remain occult with conventional imaging techniques.

Intramedullary Tuberculoma Combined with Abscess: Case Report and Literature Review

BACKGROUND

Intramedullary spinal tuberculoma combined with abscess has low incidence and could easily be misdiagnosed. Given the rarity of spinal intramedullary tuberculoma, there is no standardized treatment protocol for this condition. We reported the case of a 28-year-old male who was diagnosed with intramedullary tuberculoma combined with abscess and treated with antituberculosis therapy followed by surgery.

CASE DESCRIPTION

A 28-year-old male was admitted to our hospital with lower back pain and lower limb sensory and motor dysfunction. The radiographic results indicated tuberculosis (TB). The patient was suggested to undergo anti-TB therapy and was later transferred to Tuberculosis Hospital for systemic treatment for 20 days. He was readmitted to our hospital because of aggravating syndromes including impaired superficial sensation below the T11 level, spastic paresis with muscle strength of 0/5 in both lower extremities, and exaggerated bilateral tendon reflexes. To alleviate the neurologic dysfunction, surgery was undertaken. The postoperative diagnosis was thoracic intramedullary TB combined with abscess. He reported marked improvement in lower limb motor and sensory function the day after surgery, and his muscle strength recovered to 3/5.

CONCLUSIONS

Although intramedullary TB combined with abscess is clinically rare, it should be taken into consideration when patients present with intramedullary space-occupying lesions with TB lesions elsewhere. Most patients respond well to the anti-TB therapy, but for those with severe spinal cord compression or those irresponsive to the drug therapy, surgical intervention could facilitate neurologic recovery and improve the prognosis.

[A case of tuberculous myeloradiculitis with abdominal lymphadenitis presenting with symptoms of radiculomyelopathy]

A 30-year old man was admitted with right hip pain and gait disturbances. Neurological findings revealed muscular weakness in the lower limbs, hyporeflexia, dysesthesia in the sacral region, and bowel and bladder disturbances. Cerebrospinal fluid (CSF) examination indicated a white blood cell count of 371/μl (lymphocyte:polymorphonuclear leukocyte = 97:3), protein levels of 463 mg/dl and sugar of 20 mg/dl. Although CSF culture was negative, tuberculous infection was presumed. Magnetic resonance imaging revealed areas of enhancement in the intramedullary region surrounding the spinal cord and cauda equina. Enhanced computed tomography (CT) of the abdomen revealed lymph node swelling around the head of the pancreas. Biopsy of the lymph node swelling was culture-positive for Mycobacterium tuberculosis. Hence, assuming a diagnosis of tuberculous lymphadenitis of the abdomen, antitubercular drugs were started. Since antitubercular therapy had beneficial effects on the neurological symptoms and CSF findings, we diagnosed the patient with tuberculous myeloradiculitis. Systematic examinations including lymph node biopsy and cultures were useful for the diagnosis of tuberculous myeloradiculitis.

Spinal cord involvement in tuberculous meningitis

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.

Abdominal pain and swelling as an initial presentation of spinal tuberculosis

Spinal tuberculosis (Pott's disease) is one of the common extra-pulmonary presentations of tuberculosis. Spinal tuberculosis commonly presents with back pain, fever and night sweats. In this report, we present a case of spinal tuberculosis complicated by bilateral large psoas abscesses. The patient presented with bilateral flank pain and swellings rather than the classic presentation of back pain. The aim of this report is to draw the attention of physicians to this uncommon presentation of spinal tuberculosis, as an early recognition of such condition may expedite diagnosis and treatment, thereby preventing future complications of the disease.

Pulmonary tuberculosis presenting acutely as paraplegia: an unusual presentation

Extrapulmonary tuberculosis most commonly involves the bones and the spine. The present case is that of a young boy who presented with acute onset paraplegia without any pre-existant complaints of cough with sputum, fever, night sweats or weight loss.

Infectious myelopathies

Every genus of microorganism, as well as prions, has been associated with disease of the spinal cord. The spectrum of pathogens resulting in myelopathy varies with the population. Myelopathy is uniquely associated with certain retroviruses, particularly HIV type 1 and human T-cell lymphotropic virus type I, but the myelopathies that occur with these viruses are chiefly limited to "at risk" populations. In the immunocompromised population, a diverse array of pathogens may cause spinal cord disease, especially viruses from the Herpesviridae family, most notably cytomegalovirus and varicella-zoster virus. The prototypical myelopathy resulting from bacterial infection is tabes dorsalis, but this disorder is vanishingly rare in the modern era. In developing countries, Mycobacterium tuberculosis and schistosomiasis remain significant causes of myelopathy.

Spinal tuberculosis: a review

Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a 'cold' abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.

British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children

SUMMARY AND KEY RECOMMENDATIONS: The aim of these guidelines is to describe a practical but evidence-based approach to the diagnosis and treatment of central nervous system tuberculosis in children and adults. We have presented guidance on tuberculous meningitis (TBM), intra-cerebral tuberculoma without meningitis, and tuberculosis affecting the spinal cord. Our key recommendations are as follows: 1. TBM is a medical emergency. Treatment delay is strongly associated with death and empirical anti-tuberculosis therapy should be started promptly in all patients in whom the diagnosis of TBM is suspected. Do not wait for microbiological or molecular diagnostic confirmation. 2. The diagnosis of TBM is best made with lumbar puncture and examination of the cerebrospinal fluid (CSF). Suspect TBM if there is a CSF leucocytosis (predominantly lymphocytes), the CSF protein is raised, and the CSF:plasma glucose is <50%. The diagnostic yield of CSF microscopy and culture for Mycobacterium tuberculosis increases with the volume of CSF submitted; repeat the lumbar puncture if the diagnosis remains uncertain. 3. Imaging is essential for the diagnosis of cerebral tuberculoma and tuberculosis involving the spinal cord, although the radiological appearances do not confirm the diagnosis. A tissue diagnosis (by histopathology and mycobacterial culture) should be attempted whenever possible, either by biopsy of the lesion itself, or through diagnostic sampling from extra-neural sites of disease e.g. lung, gastric fluid, lymph nodes, liver, bone marrow. 4. Treatment for all forms of CNS tuberculosis should consist of 4 drugs (isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months followed by 2 drugs (isoniazid, rifampicin) for at least 10 months. Adjunctive corticosteroids (either dexamethasone or prednisolone) should be given to all patients with TBM, regardless of disease severity. 5. Children with CNS tuberculosis should ideally be managed by a paediatrician with familiarity and expertise in paediatric tuberculosis or otherwise with input from a paediatric infectious diseases unit. The Children's HIV Association of UK and Ireland (CHIVA) provide further guidance on the management of HIV-infected children (www.chiva.org.uk). 6. All patients with suspected or proven tuberculosis should be offered testing for HIV infection. The principles of CNS tuberculosis diagnosis and treatment are the same for HIV infected and uninfected individuals, although HIV infection broadens the differential diagnosis and anti-retroviral treatment complicates management. Tuberculosis in HIV infected patients should be managed either within specialist units by physicians with expertise in both HIV and tuberculosis, or in a combined approach between HIV and tuberculosis experts. The co-administration of anti-retroviral and anti-tuberculosis drugs should follow guidance issued by the British HIV association (www.bhiva.org).