DGI:ZNS-Infektionen/Tuberkulose Meningitis/Diagnostik: Difference between revisions

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==<span class="mw-headline" id="Diagnose" style="box-sizing: inherit;">Diagnose</span>==
====Anamnese====


====<span class="mw-headline" id="Anamnese" style="box-sizing: inherit;">Anamnese</span>====
*Chronischer Husten? Gewichtsverlust? B-Symptomatik?
<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span>Chronischer <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Husten? Gewichtsverlust? B-Symptomatik?</span>
*Reiseanamnese
*Herkunftsland
*Frühere Tbc-Diagnose oder Therapie, Tbc-Fall im sozialen Umfeld?


<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Reiseanamnese</span>
*Risikofaktoren:
**Malnutrition
**Immunsuppression
**Andere Infektionen, v.a. HIV (Bei Erstdiagnose Tbc immer HIV Test)
**Chronischer Alkoholabusus


<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Herkunftsland</span>
======Radiologie:======


<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Frühere Tbc-Diagnose oder Therapie, Tbc-Fall im sozialen Umfeld?</span>
*Röntgen-Thorax
*Sensitivität MRT > CT für pathogene Tbc-Assoziation
*Ggf. SPECT, PET


<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Risikofaktoren:</span>
======Mikrobiologie:======
 
Liquor
*Malnutrition
{| class="wikitable "
*Immunsuppression
*Andere Infektionen, v.a. HIV (Bei Erstdiagnose Tbc immer HIV Test)
*Chronischer Alkoholabusus
 
======<span class="mw-headline" id="Radiologie:" style="box-sizing: inherit;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Radiologie''':'''</span></span>======
<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Röntgen-Thorax</span>
 
<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Sensitivität MRT > CT für pathogene Tbc-Assoziation</span>
 
<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}" style="box-sizing: inherit; font-family: Symbol;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">· <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;">       </span></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Ggf. SPECT, PET</span>
 
======<span class="mw-headline" id="Mikrobiologie:" style="box-sizing: inherit;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Mikrobiologie''':'''</span></span>======
<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Liquor</span>
{| class="wikitable  
|+
|+
!-
|+Tabelle 1: Differentialdiagnostische Liquoranalyse
!
!Normal
!Normal
!Virale Meningitis
!Virale Meningitis
Line 35: Line 30:
|-
|-
!Aspekt
!Aspekt
|klar
|Klar
|klar
|Klar
|trüb
|Trüb
|klar-trüb
|Klar-trüb
|-
|-
!Druck (cm H<sub>2</sub>O)
!Druck (cm H2O)
|5-12
|5-12
|Normal oder  
|Normal oder (Pfeil nach oben)
<span style="font-size:12.0pt;font-family:Symbol;
mso-ascii-font-family:Arial;mso-fareast-font-family:Calibri;mso-fareast-theme-font:
minor-latin;mso-hansi-font-family:Arial;mso-bidi-font-family:Arial;mso-ansi-language:
DE;mso-fareast-language:EN-US;mso-bidi-language:AR-SA;mso-char-type:symbol;
mso-symbol-font-family:Symbol"><span style="mso-char-type:symbol;mso-symbol-font-family:
Symbol">­</span></span>
|>20
|>20
|Normal oder  
|Normal oder (Pfeil nach oben)
<span style="font-size:12.0pt;font-family:Symbol;
mso-ascii-font-family:Arial;mso-fareast-font-family:Calibri;mso-fareast-theme-font:
minor-latin;mso-hansi-font-family:Arial;mso-bidi-font-family:Arial;mso-ansi-language:
DE;mso-fareast-language:EN-US;mso-bidi-language:AR-SA;mso-char-type:symbol;
mso-symbol-font-family:Symbol"><span style="mso-char-type:symbol;mso-symbol-font-family:
Symbol">­</span></span>
|-
|-
!Leukozyten(x 10<sup>6</sup>/l)
!Leukozyten (x 106/l)
|1-4
|1-4
|< 1000 Lymphozyten
|< 1000 Lymphozyten
Line 72: Line 55:
|< 40%
|< 40%
|-
|-
!Eiweiß (mg(l)
!Eiweiß (mg/l)
|150-500
|150-500
|Normal oder  
|Normal oder (Pfeil nach oben)
<span style="font-size:12.0pt;font-family:Symbol;
mso-ascii-font-family:Arial;mso-fareast-font-family:Calibri;mso-fareast-theme-font:
minor-latin;mso-hansi-font-family:Arial;mso-bidi-font-family:Arial;mso-ansi-language:
DE;mso-fareast-language:EN-US;mso-bidi-language:AR-SA;mso-char-type:symbol;
mso-symbol-font-family:Symbol"><span style="mso-char-type:symbol;mso-symbol-font-family:
Symbol">­</span></span>
|>> 500
|>> 500
|>> 500|
| 500 > |
|-
|-
!Laktat (mmol/l)
!Laktat (mmol/l)
Line 96: Line 73:
|35% positiv
|35% positiv
|}
|}
<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Tabelle 1: Differentialdiagnostische Liquoranalyse</span>


<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Goldstandard: Kultur auf Tbc (sensitiver als Mikroskopie, ist in bis zu 50-70% positiv). Dauer der Kultur bis 8 (-12) Wochen <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">[8</span></span><ref><span style="font-size:12.0pt;line-height:107%;
font-family:&quot;Times New Roman&quot;,serif;mso-fareast-font-family:&quot;Times New Roman&quot;;
mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">8.        Schaberg T, et al., Tuberculosis Guideline for Adults - Guideline for Diagnosis and Treatment of Tuberculosis including LTBI Testing and Treatment of the German Central Committee (DZK) and the German Respiratory Society (DGP). Pneumologie 2017; '''71'''(6): 325-397</span></ref><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
mso-fareast-font-family:&quot;Times New Roman&quot;">9.        Wilkinson RJ, et al., Tuberculous meningitis''.'' Nat Rev Neurol, 2017; '''13'''(10): 581-598</span></ref><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
mso-fareast-font-family:&quot;Times New Roman&quot;">10.        Ducomble T, et al., The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009. Euro Surveill, 2013; '''18'''(12)</span></ref><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
mso-fareast-font-family:&quot;Times New Roman&quot;">11.         in Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. 2011; London</span></ref><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
mso-fareast-font-family:&quot;Times New Roman&quot;">12.        Thwaites G, et al., British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect, 2009; '''59'''(3): 167-87</span></ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">-12</span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">, 14</span></span><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
mso-fareast-font-family:&quot;Times New Roman&quot;">14.         Chin JH, Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract, 2014; '''4'''(3):199-205</span></ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">, 15</span></span><ref><span style="font-size:12.0pt;font-family:&quot;Times New Roman&quot;,serif;
mso-fareast-font-family:&quot;Times New Roman&quot;">15.        Marais S, et al., Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis, 2010; '''10'''(11): 803-12</span></ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">]</span>.</span>


<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Xpert MTB/Rif, PCR zur Bestimmung von Tbc sowie Rifampicin-Resistenz, welches ein Hinweis für eine MDR-Tbc ist. Die Verlässlichkeit eines resistenten Ergebnisses (positiv prädiktiver Wert) ist abhängig von der Häufigkeit der Resistenz in der untersuchten Bevölkerung. Liegt die MDR-Rate, wie in Deutschland, unter 5%, sinkt der positiv prädiktive Wert auf unter 70% <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">[1</span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;">]</span>.</span>
Goldstandard: Kultur auf Tbc (sensitiver als Mikroskopie, ist in bis zu 50-70% positiv). Dauer der Kultur bis 8 (-12) Wochen <span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"></span></span><ref name=":0">Schaberg T, Bauer T, Brinkmann F, et al. [Tuberculosis Guideline for Adults - Guideline for Diagnosis and Treatment of Tuberculosis including LTBI Testing and Treatment of the German Central Committee (DZK) and the German Respiratory Society (DGP)]. Pneumologie. 2017;71(6):325-397. doi:10.1055/s-0043-105954</ref><ref>Wilkinson RJ, Rohlwink U, Misra UK, et al. Tuberculous meningitis. Nat Rev Neurol. 2017;13(10):581-598. doi:10.1038/nrneurol.2017.120</ref><ref>Ducomble T, Tolksdorf K, Karagiannis I, et al. The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009. Euro Surveill. 2013;18(12):20436.</ref><ref>National Collaborating Centre for Chronic Conditions (UK), Centre for Clinical Practice at NICE (UK). Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. National Institute for Health and Clinical Excellence (UK); 2011. Accessed August 9, 2021. <nowiki>http://www.ncbi.nlm.nih.gov/books/NBK97852/</nowiki></ref><ref>Thwaites G, Fisher M, Hemingway C, et al. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect. 2009;59(3):167-187. doi:10.1016/j.jinf.2009.06.011</ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"></span></span><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"></span></span><ref>Chin JH. Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract. 2014;4(3):199-205. doi:10.1212/CPJ.0000000000000023</ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"></span></span><ref>Marais S, Thwaites G, Schoeman JF, et al. Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis. 2010;10(11):803-812. doi:10.1016/S1473-3099(10)70138-9</ref><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}" style="box-sizing: inherit;"></span></span>.
 
Es sollte eine kulturelle Resistenzbestimmung für die Medikamente der Standardtherapie erfolgen sowie zusätzlich eine molekularbiologische Analyse hinsichtlich der Genabschnitte mit einer Isoniazid- und Rifampicinresistenz. Die Verlässlichkeit eines resistenten Ergebnisses (positiv prädiktiver Wert) ist abhängig von der Häufigkeit der Resistenz in der untersuchten Bevölkerung. Liegt die MDR-Rate, wie in Deutschland, unter 5%, sinkt der positiv prädiktive Wert auf unter 70% <ref name=":0" />


===<span class="mw-headline" id="Differentialdiagnose" style="box-sizing: inherit;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Differentialdiagnose</span></span>===
===<span class="mw-headline" id="Differentialdiagnose" style="box-sizing: inherit;"><span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Differentialdiagnose</span></span>===


*Andere bakterielle Meningitiden (Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, Streptococcus, agalactiae), Neuroborreliose
*Andere bakterielle Meningitiden (''Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, Streptococcus, agalactiae''), Neuroborreliose
*<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Pilze: Candida spp., Aspergillus spp., Kryptokokkus spp.</span>
*Pilze: ''Candida'' spp., ''Aspergillus'' spp., ''Kryptokokkus'' spp.
*<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Parasiten: Echinokokkus spp., Toxoplasma</span>
*Parasiten: ''Echinokokkus'' spp., Toxoplasma
*<span class="ve-pasteProtect" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Nicht-infektiös: Sarkoidose, tumorös (Meningiosis carcinomatosa)</span>
*Nicht-infektiös: Sarkoidose, tumorös (Meningiosis carcinomatosa)
<references />

Latest revision as of 09:04, 17 March 2026

Anamnese

  • Chronischer Husten? Gewichtsverlust? B-Symptomatik?
  • Reiseanamnese
  • Herkunftsland
  • Frühere Tbc-Diagnose oder Therapie, Tbc-Fall im sozialen Umfeld?
  • Risikofaktoren:
    • Malnutrition
    • Immunsuppression
    • Andere Infektionen, v.a. HIV (Bei Erstdiagnose Tbc immer HIV Test)
    • Chronischer Alkoholabusus
Radiologie:
  • Röntgen-Thorax
  • Sensitivität MRT > CT für pathogene Tbc-Assoziation
  • Ggf. SPECT, PET
Mikrobiologie:

Liquor

Tabelle 1: Differentialdiagnostische Liquoranalyse
Normal Virale Meningitis Bakterielle Meningitis Tuberkulöse Meningitis
Aspekt Klar Klar Trüb Klar-trüb
Druck (cm H2O) 5-12 Normal oder (Pfeil nach oben) >20 Normal oder (Pfeil nach oben)
Leukozyten (x 106/l) 1-4 < 1000 Lymphozyten > 1000

(> 70% Neutrophile)

< 1000

(Mono- und Lymphozyten)

Glukose (% des Serumwertes) 50-80% 50-80% < 40% < 40%
Eiweiß (mg/l) 150-500 Normal oder (Pfeil nach oben) >> 500
Laktat (mmol/l) < 1,6 < 1,6 > 3,5 > 1,6
Direktpräparat Negativ Negativ 80% positiv 35% positiv


Goldstandard: Kultur auf Tbc (sensitiver als Mikroskopie, ist in bis zu 50-70% positiv). Dauer der Kultur bis 8 (-12) Wochen [1][2][3][4][5][6][7].

Es sollte eine kulturelle Resistenzbestimmung für die Medikamente der Standardtherapie erfolgen sowie zusätzlich eine molekularbiologische Analyse hinsichtlich der Genabschnitte mit einer Isoniazid- und Rifampicinresistenz. Die Verlässlichkeit eines resistenten Ergebnisses (positiv prädiktiver Wert) ist abhängig von der Häufigkeit der Resistenz in der untersuchten Bevölkerung. Liegt die MDR-Rate, wie in Deutschland, unter 5%, sinkt der positiv prädiktive Wert auf unter 70% [1]

Differentialdiagnose

  • Andere bakterielle Meningitiden (Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, Streptococcus, agalactiae), Neuroborreliose
  • Pilze: Candida spp., Aspergillus spp., Kryptokokkus spp.
  • Parasiten: Echinokokkus spp., Toxoplasma
  • Nicht-infektiös: Sarkoidose, tumorös (Meningiosis carcinomatosa)
  1. ↑ 1.0 1.1 Schaberg T, Bauer T, Brinkmann F, et al. [Tuberculosis Guideline for Adults - Guideline for Diagnosis and Treatment of Tuberculosis including LTBI Testing and Treatment of the German Central Committee (DZK) and the German Respiratory Society (DGP)]. Pneumologie. 2017;71(6):325-397. doi:10.1055/s-0043-105954
  2. ↑ Wilkinson RJ, Rohlwink U, Misra UK, et al. Tuberculous meningitis. Nat Rev Neurol. 2017;13(10):581-598. doi:10.1038/nrneurol.2017.120
  3. ↑ Ducomble T, Tolksdorf K, Karagiannis I, et al. The burden of extrapulmonary and meningitis tuberculosis: an investigation of national surveillance data, Germany, 2002 to 2009. Euro Surveill. 2013;18(12):20436.
  4. ↑ National Collaborating Centre for Chronic Conditions (UK), Centre for Clinical Practice at NICE (UK). Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. National Institute for Health and Clinical Excellence (UK); 2011. Accessed August 9, 2021. http://www.ncbi.nlm.nih.gov/books/NBK97852/
  5. ↑ Thwaites G, Fisher M, Hemingway C, et al. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect. 2009;59(3):167-187. doi:10.1016/j.jinf.2009.06.011
  6. ↑ Chin JH. Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract. 2014;4(3):199-205. doi:10.1212/CPJ.0000000000000023
  7. ↑ Marais S, Thwaites G, Schoeman JF, et al. Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis. 2010;10(11):803-812. doi:10.1016/S1473-3099(10)70138-9
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