Blood-brain-barrier and intrathecal immunoglobulin changes in tuberculous meningitis and demyelinating disorders: a preliminary report from a south Indian hospital

Tuberculous meningitis: protracted course and clinical response to interferon-gamma

A 12-year-old girl with protracted tuberculous meningitis received standard chemotherapy and dexamethasone and had a progressive cerebrospinal fluid neutrophilia, raised protein and depressed glucose levels. Her temperature was raised for 5 months until a second course of dexamethasone was given. At week 15, multiple tuberculomas and hydrocephalus were detected followed by acute hydrocephalus (week 58), which required a ventricular-peritoneal shunt. Tuberculomas resolved after a second course of dexamethasone but recurred 15 months later. Immunological investigations were normal including integrity of the type 1 cytokine pathway. From month 24, interferon-gamma was given subcutaneously (initially 50 microg/m(2)) and continued for 19 months. Within 2 weeks she responded clinically followed by a reduction in inflammatory signs on magnetic resonance imaging scan (but not in the tuberculomas). At month 44, when chemotherapy was stopped, the cerebrospinal fluid/serum albumin quotient was 57x10(-3) (normal <6.0x10(-3)), which supports continuing major impairment of the blood-brain barrier. Gene expression in peripheral blood mononuclear cells before and during treatment with interferon-gamma, assessed by gene array analysis, showed reduction in a number of cytokine and chemokine genes. The response to interferon-gamma might have been secondary to downregulation of certain cytokine and chemokine genes.

The cerebrospinal fluid in the diagnosis of tuberculous meningoencephalitis: review of the literature

We review the literature on the biochemical, cytological and immunological changes in the cerebrospinal fluid (CSF) in tuberculous meningoencephalitis, emphasizing the inconsistency and low specificity of the CSF findings described in classic accounts of this disease. We consider separately the possible causes of yellow or bloody fluid. The development of accurate techniques of analysis does not diminish the importance of the clinical findings and history in the early diagnosis of this disease.