DGI:ZNS-Infektionen/Tuberkulose Meningitis/Diagnostik: Difference between revisions
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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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" style="box-sizing: inherit;"></span></span><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" style="box-sizing: inherit;"></span></span><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;"><span class="ve-pasteProtect" data-ve-attributes="{"style":"box-sizing: inherit;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" 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="{"style":"box-sizing: inherit; font-family: Arial, sans-serif;"}" style="box-sizing: inherit; font-family: Arial, sans-serif;">Differentialdiagnose</span></span>=== | ||
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
| 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)
- ↑ 1.0 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
- ↑ Wilkinson RJ, Rohlwink U, Misra UK, et al. Tuberculous meningitis. Nat Rev Neurol. 2017;13(10):581-598. doi:10.1038/nrneurol.2017.120
- ↑ 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.
- ↑ 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/
- ↑ 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
- ↑ Chin JH. Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract. 2014;4(3):199-205. doi:10.1212/CPJ.0000000000000023
- ↑ 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