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

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<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;">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="color: rgb(51, 51, 51)">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;</span> '''71'''<span style="color: rgb(51, 51, 51)">(6): 325-397</span><br /></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><ref> <span style="color: rgb(51, 51, 51)">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;</span> '''59'''<span style="color: rgb(51, 51, 51)">(3): 167-87</span><br /></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;">, 14</span></span><ref><span style="color: rgb(51, 51, 51)">Chin JH, Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract, 2014;</span> '''4'''<span style="color: rgb(51, 51, 51)">(3):199-205</span><br /></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="color: rgb(51, 51, 51)">Marais S, et al., Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis, 2010;</span> '''10'''<span style="color: rgb(51, 51, 51)">(11): 803-12</span><br /></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;">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><ref><span style="color: rgb(51, 51, 51)">Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K, EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009; 2;302(21):2323-9</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>


===<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>===
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*<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>
*<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>
*<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>
*<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>
<references />

Revision as of 12:34, 25 May 2021

Diagnose

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 ­ > 20 Normal oder ­
Leukozytenzahl

(x 106/l)

1-4 < 1000

Lymphozyten

> 1000

(> 70% Neutrophile)

< 1000

(Mono- und Lymphozyten)

Glukosegehalt

(% des Serumwertes)

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

Tabelle 1: Differentialdiagnostische Liquoranalyse

Goldstandard: Kultur auf Tbc (sensitiver als Mikroskopie, ist in bis zu 50-70% positiv). Dauer der Kultur bis 8 (-12) Wochen [8[1][2][3][4][5]-12, 14[6], 15[7]].

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% [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. ↑ 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
  2. ↑ 9.        Wilkinson RJ, et al., Tuberculous meningitis. Nat Rev Neurol, 2017; 13(10): 581-598
  3. ↑ 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)
  4. ↑ 11.         in Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for Its Prevention and Control. 2011; London
  5. ↑ 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
  6. ↑ 14.         Chin JH, Tuberculous meningitis: Diagnostic and therapeutic challenges. Neurol Clin Pract, 2014; 4(3):199-205
  7. ↑ 15.        Marais S, et al., Tuberculous meningitis: a uniform case definition for use in clinical research. Lancet Infect Dis, 2010; 10(11): 803-12
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