A novel scoring system has been developed to predict neurologic sequelae (NS) in children with tuberculous meningitis, in a retrospective study of 20 cases treated during 1991-2001 at the University of California and Children’s Hospital, San Diego, CA. Seven children developed severe NS and I child died during hospitalization. Tuberculous meningitis acute neurologic (TBAN) scores (range, 0-8) were based on weighted scores for the following: 1) mental status; 2) seizure; 3) cranial nerve abnormalities; 4) focal motor abnormalities; 5) increased muscle tone. Patients were assigned a TBAN score on day 0 and on day 3 of hospitalization. Those who had developed severe NS at 1 year follow-up had a higher score on day 0, and the difference became statistically significant by day 3 of hospitalization (5.5 versus 0.0, P=0.02). Sensitivity and specificity of the TBAN score (>4) on day 0 (75 and 92%) and day 3 (88 and 100%) were superior to the traditional clinical staging system (Lincoln et al, 1960) on day 0 (63 and 58%), to predict severe NS. [1]

COMMENT. A novel scoring system (TBAN) employing neurologic symptoms and clinical signs, and not relying on radiologic and laboratory findings, provides an objective marker for early response to therapy and predicting severe neurologic sequelae in children with tuberculous meningitis.

The problems concerning diagnosis and treatment of TM are reviewed by researchers at the Centre for Tropical Medicine, Oxford University, UK; and Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam [2]. Subtle behavioral changes can herald the onset of TM in some children; in others, the disease presents as pyogenic bacterial meningitis, with sudden onset and polymorphonuclear cell predominance in the CSF. Basal meningeal enhancement on MRI, tuberculoma, or both, are 89% sensitive and 100% specific for the diagnosis of TM. A bacteriologic diagnosis is made in about 80% of cases, and molecular techniques (nucleic-acid-amplification assays) have added little to the diagnosis. Treatment lacks proof by controlled trials; isoniazid, rifampicin, pyrazinamide and either streptomycin or ethambutol are used in the first 2 months; isoniazid and rifampicin in the next 7-10 months; and in patients not suffering from HIV, dexamethasone is advised. Steroids improve survival but may not prevent disability. M tuberculosis resistant to antituberculosis drugs is an increasingly common clinical problem, and the use of WHO recommended alternative treatment with fluoroquinolones is restricted to case reports.

Of interest regarding the increasing importance of infectious disease in neurology, during 2004 one quarter of the case reports in The Lancet were patients with neurological infections. [3]