Coordinating Care in the Specialist Setting: Tuberculous Meningitis - Essay Example

?TOPIC: Coordinating Care in the Specialist Setting – Tuberculosis Meningitis History of the Patient: This is the case of a 48 year old, female patient named MJ, who presented with complaints of three month history of headache, tiredness, and fever. MJ was self – medicating with Paracetamol 500 mg on as needed basis for fever and Mefenamic Acid 500 mg for body malaise and headache. However, despite of taking the abovementioned medication, her complaints were not alleviated but had progressed gradually instead. The patient is now presenting with complaints of altered levels of consciousness, which bring her to seek for hospital admission. Background: Tuberculosis meningitis is an infection caused by Mycobacterium tuberculosis that initially starts as an infection in the lungs, and progressively develops in the bloodstream once the bacteria have multiplied. In TB meningitis, Mycobacterium tuberculosis eventually spread through the meninges of the brain or the spinal cord (Meningitis UK, 2009). It is the most destructive form of meningitis, and the key to its management lies on its prompt diagnosis (Haldar, et al., 2009). Meningitis UK (2009) stated that TB meningitis is formed when small abscesses called tubercles bursts in the meninges. This condition is considered as fatal when treatment is delayed. Tuberculosis is the severest form of Mycobacterium tuberculosis and is the leading cause of fatality around the world. Mycobacterium tuberculosis starts as a solitary communicable agent that commonly affects the lungs, even though almost every organ in the body is involved (Newton, 1994, Thwaites, et al. 2004, and WebHealthCentre, 2009). Looking back, tuberculosis had already existed even before the Neolithic period. The only treatment available till the early 20th century was to rest in the open air in a place known as specialised sanitoria (WebHealthCentre, 2009). At present, about one third of the total population around the world is infected with Mycobacterium tuberculosis and this attributes to about three million cases of fatality per year (WebHealthCentre, 2009). The crowded conditions of living that favours highly the transmission of airborne microorganisms attributes well to the rapid spread of tuberculosis in the human beings. In 1980s, a steady decline of cases was observed among developed countries; however, this was reversed due to the combination of several factors that includes social, economical, and historic. All of which were responsible for urban homelessness, intravenous abuse of drugs, a rising neglect of control programs on tuberculosis, and recently, epidemic of AIDS (WebHealthCentre, 2009). According to Thwaites, et al., (2004), in spite of being treated with antituberculosis chemotherapy, tuberculous meningitis oftentimes results to death or severe neurologic deficits. Although uncommon in the developed countries like the United Kingdom (UK), there are still about 300 cases of TB meningitis that has been reported in the year 2007 (Meningitis UK, 2009). And despite of optimal treatment, Nardell (2009) stated that TB meningitis is possibly fatal in about 25 percent of cases. Assessment: Based on the history and presenting signs and symptoms, MJ is suspected to have a Tuberculous Meningitis. MJ presented with complaints typical for Tuberculous Meningitis during its early stage of development, which is called the prodromal period. MJ’s complaints of headache, tiredness, and fever and later on, altered levels of consciousness are typical for Tuberculous Meningitis. Ramachandran (2011) stated in his article, that nonspecific symptoms for tuberculous meningitis during the prodromal period include fatigue, malaise, myalgia, and fever. Ramachandran added that in the elderly, more common symptoms of TB meningitis presents in the form of headache and changes in the mental status and all of the symptoms mentioned by Ramachandran are presented by the patient, MJ at the time of admission. Identifications and Investigations: In managing TB meningitis, arriving at a rapid and accurate diagnosis and early treatment are the critical issues that a specialist has to consider because of its high rate of morbidity and mortality, and because of the fact that it is considered as a life threatening form of tuberculosis (Humphries, 1992 and Thwaites, undated). Thwaites (undated) and Thwaites, et al. (2004) added that since it is difficult to diagnose TB meningitis, death is often associated with delayed treatment. This leads one to suggest that to prevent death and severe sequelae of TB meningitis, empiric treatment must be instituted prior to coming up with definitive diagnosis (Thwaites, undated). For this reason, it is highly recommended that a good fact finding investigation of the history of the patient is a very good tool in diagnosing TB meningitis (Thwaites, undated). A high index of suspicion for TB meningitis when patients have risk factors for AIDS, excessive use of alcohol, pulmonary tuberculosis, and weak immune system accompanied with the following presenting signs and symptoms for TB meningitis: fever and chills, changes in the mental status, nausea and vomiting, sensitivity to light or photophobia, severe headache, stiff neck, agitation, bulging of the fontanelles, decreased consciousness, poor feeding, irritability in children, and unusual posture presented as opisthotonos (Dugdale, 2010). Additionally, according to the NICE guidelines in managing TB meningitis (2006), even with negative rapid diagnostic tests, treatment must be started right away with the presence of clinical signs and other laboratory findings consistent with TB meningitis. Dugdale (2010) stated that on physical examination, a specialist may notice that patients with TB meningitis usually presents with increase in heart rate and temperature, changes in the mental state, and stiff neck. Essential facts in diagnosing TB meningitis include: increase in cerebrospinal fluid (CSF) pressure to about 50 percent and chest x-ray suggestive of pulmonary tuberculosis in about 50 percent of cases, basal meningeal enhancement in about 80 percent, hydrocephalous in about 70 percent, tuberculomas in about 20 percent and infarcts in about 10 percent (Thwaites, undated). Other diagnostic features for TB meningitis include Pott’s spine, radiculo – myelitis, and tuberculoma (Thwaites, undated). Dugdale (2010) added that a health care provider must perform lumbar puncture to patients who are highly suspicious for TB meningitis to collect spinal fluids needed for the diagnosis. Dugdale enumerated that other diagnostic tests for TB meningitis include brain or meningeal biopsy, blood culture, chest x – ray, examination of CSF for cell count, glucose, and protein. Dugdale (2006) added that CT scan of the head, skin test for tuberculosis (PPD) as well as gram stain and CSF culture and polymerase reaction chain must be performed in order to arrive to a definitive diagnosis for TB meningitis. NICE (2006) stated that when pulmonary tuberculosis is suggested in chest x – ray, other tests must be arranged for further diagnosis. These include the following: (1) Three spontaneously produced samples of sputum obtained early in the morning must be sent for culture and microscopy (2) If no spontaneous sputum is produced, induction of sputum through bronchoscopy and lavage in adults and gastric washing in the children must be done to obtain sputum for sample. NICE (2006) noted that these samples must be taken prior to commencement of treatment. It is also important to note that treatment regimen must be started even before the result of the culture is released. On the other hand, even with a negative culture result, treatment regimen must be completed to avoid relapse or development of multi – drug resistance. For non – pulmonary tuberculosis, NICE (2006) stated that the advantages and disadvantages of doing the fine needle biopsy must be discussed with the patient. In cases of non respiratory tuberculosis, biopsy of the lymph node and from pus aspirated from lymph nodes must be sent for TB culture. Also, samples of the following must be placed in a dry pot and be sent to the laboratory for culture: (1) Pleural biopsy (2) For routine culture, samples from any radiological or surgical procedure must be sent (3) Samples from histology, aspiration, and autopsy must also be sent to the laboratory for TB culture. NICE (2006) noted that even without TB culture result, treatment regimen must be started in cases of positive clinical history of TB and histology. Patients must be advised also to continue with the treatment regimen even if the TB culture result would come out as negative. Among patients with non respiratory TB, coexisting respiratory TB must be checked by obtaining a chest x ray. Lastly, patients who presents with multi – drug resistance (MDR) in his evaluation must be assessed further for rapid diagnostic tests for resistance to Rifampicin, and while waiting for the result, MDR measures and treatment must be started right away for infection control (NICE, 2006). Investigations/Research to Support the Management of TB Meningitis: A study by Marais, et al (2010) suggested that to have a better understanding on the pathogenesis of tuberculous meningitis, more research study is urgently needed to improve its clinical management and outcome because of its high mortality and morbidity rate among children and adults. Marais, et al. (2010) added that the absence of standardised diagnostic criteria became a major stumbling block in this study, and a variety of limitations presented in various study include difficulty in comparing research findings, prevention of the best use of data that are existing already, and disease management limitation. Marais, et al. presented that a three – day workshop in tuberculous meningitis attended by 41 international participants was done in Cape Town, South Africa to address the abovementioned problem. These participants were experienced in tuberculous meningitis management or research. Diagnostic criteria were assessed and discussed during the workshop, and for the future use in the clinical research, a writing committee was selected to settle a consensus case on tuberculous meningitis definition that is applicable regardless of the age of the patient, status on HIV infection, or resources available. Together with the rationale following the recommendations, a consensus was presented. Marias, et al. (2010) concluded that comparison of studies, improve scientific communication, and improved care can be aided by consistent use of proposed definition of case. In another research study to support the diagnosis of TB meningitis, Komolafe, et al. (2008) reported a case study of a patient in Nigeria who presented with a three week history of weakness of both upper and lower extremities, six hour history of failure to speak and irrational behavior. The past medical history of the patient was unremarkable; however, on the physical examination, it revealed an increase in temperature and altered level of consciousness with a 7/15 Glasgow come scale. Komolafe, et al. (2008) stated that the patient presented also with signs of irritation in the meninges such as anisocoria as well as right – sided spastic paralysis. On laboratory investigations, it revealed an “elevated erythrocyte sedimentation rate, normal cerebrospinal fluid protein and reduced glucose.” Features that indicate obstructive hydrocephalus was shown in brain computed tomography scanning. As a result of the aforementioned diagnostic findings, antituberculous drugs, intravenous steroids, and mannitol were started immediately following the diagnoses. Consequently, Komolafe, et al. (2008) reported that a remarkable clinical recovery was noted following the course of treatment, and the patient was eventually discharged six weeks subsequent to her admission. Another investigation presented by Komolafe, et al. (2008) during their study was a case of a 40 year old man with presenting complaints of headaches and fever for six weeks and a history of alteration of levels of consciousness for two weeks. The patient presented no neck pain, stiffness, nausea, or vomiting in the history and the past medical history was unremarkable as well. It was indicated in the history that the patient was placed on various intravenous antibiotics prior to his admission; however, no clinical improvement was noted in the patient’s condition. On physical examination, the patient was in coma with a Glasgow coma scale of only 4 over 15 and increased in temperature of 38.5 degrees Celsius. Komolafe, et al. (2008) reported that no signs of meningeal irritation were noted; however, there was an impairment of the reflexes of the brain stem and spastic quadriparesis were also noted during the physical assessment. Features in keeping the presentation of meningeal irritation and elevated erythrocyte sedimentation rate were revealed during cerebrospinal fluid analysis. Also, features of obstructive hydrocephalous were shown in brain computed tomography scan. The patient died six days following his admission despite of being placed on an antituberculous medication and intravenous steroids. Komolafe, et al. (2008) concluded in their study that this report was intended for the awareness of the physician on the extraordinary presentation of tuberculous meningitis in the clinical practice. Komolafe, et al. (2008) also stated that suspicions of TB meningitis must be made when the patient will show symptoms of fever, headaches, recurrent seizures that lasts longer than 2 to 3 weeks, and poor conventional antibiotic medication response. Signs and symptoms of meningeal irritation such as hemiplegia, aphasia, and multiple cranial nerve palsies should make a clinician to suspect the occurrence of TB meningitis. And most importantly, to prevent death of the patient, a high index of suspicion for TB meningitis must be accounted for even though the patient is presenting atypical findings in the CSF but with the symptoms of obstructive hydrocephalous. Another study was made on the effect of Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults by Thwaites, et al (2004). Findings of the study revealed that the adverse events and outcomes caused by the changes of antituberculosis drug or regimen such as severe hypersensitivity reactions to drug are improved by Dexamethasone treatment. Although these effects were undocumented in this study, no further corticosteroid related adverse effects are reported at the end of the study. Thwaites, et al (2004) noted that data obtained from their study suggested that dexamethasone is safe to use and is beneficial to the group of patients in this research study. Thwaites, et al (2004) concluded in their study that although severe disability among the survivors were not prevented; the survival rates among patients’ ages more than 14 years old had improved with early dexamethasone and antituberculosis drug treatment. Even though this study is a little bit remote, an informative detail was reported by Thwaites, et al. (2000) on Tuberculous Meningitis. In their study, Thwaites, et al. (2000) noted that to achieve a better clinical outcome, rapid diagnosis of TB meningitis must be made. Laboratory methods to date were reportedly insensitive and slow to allow accurate diagnosis for TB meningitis. Hence, newer methods in assessing TB meningitis such as amplification of bacterial DNA by polymerase chain reaction and comparable systems are yet suitable for widespread use especially in developing countries. As a result, the most effective rapid diagnostic tests considered to date remained as careful and repeated search for the presence of acid fast bacilli by using a special stain called Ziehl – Neelsen stain. The conventional diagnostic tool used in diagnosing patients with TB meningitis cannot be disregarded, and this includes the use of history of recent contact with a person suffering from tuberculosis. Although some studies still suggest the usefulness of tuberculin testing among children, tuberculin testing, which was previously used in diagnosing TB meningitis is already considered as of limited value at present (Thwaites, et al., 2000). Thwaites, et al. (2000) also added that diagnosis for TB meningitis remained to be dependent on lumbar puncture and examination of the CSF. Thwaites, et al. also stated that the most crucial part in investigating TB meningitis is through searching for acid fast bacilli since on microscopy, the detection limit is 100 mycobacteria per ml. Diagnostic yield can be assisted by the clinicians by sending large CSF volume and once there is a high suspicion for diagnosis, a repeat in lumbar puncture is highly appreciated. Thwaites, et al. (2000) noted that the sample quality and volume sent for examination as well as the technician skills and persistence of acid fast bacilli examination are among the factors that has to be considered in a successful test for TB meningitis. An insensitive and slow gold standard used in diagnosing M. Tuberculosis is with the use of culture from the CSF. However, an eight week of waiting for the M. Tuberculosis employed in a solid media such as Lowenstein – Jensen is considered. As we progress, the culture time was reduced with the use of Bactec 450 and automated continuously monitoring system from semiautomated radiometric culture systems. Since TB meningitis is a deadly and serious disease, the decision to treat the patient must not take this long even though the culture time to wait for the exact diagnosis has already been reduced. Thwaites, et al. noted that an insight that provides information on the prognosis and diagnostic information on the progression of the disease has been provided with the advent of CT scanning and Magnetic Resonance Imaging (MRI). Hydrocephalus, basilar meningeal thickening, infarcts, oedema, and tuberculomas were all disclosed with the use of both CT and MRI of the brain. Thwaites, et al. further stated that although they lack specificity in the diagnosis, changes brought by TB meningitis such as the hydrocephalus and basal meningeal exudates are exhibited by both CT and MRI. Monitoring and Management: TB meningitis was considered to be almost universally fatal prior to the introduction of chemotherapeutic treatment; however, repeated prolonged treatment also leads to another condition called multi-drug resistance that causes repeated infections (Thwaites, et al. 2000 and Dugdale, 2010). Ramachandran (2011) stated that to prevent TB meningitis from being transmitted in the United States, legal constraints that include quarantine, vaccination, and exclusion from immigration has to be followed by the patients. Ramachandran (2011) added that to protect the public from acquiring this transmissible disease, patients must be quarantined. Additionally, directly observing the treatment (DOT) of the patient must be practiced as well to prevent the disease from spreading (Ramachandran, 2011). According to Iype (2010), the principles behind the management of TB management is the same as with the pulmonary tuberculosis. For this reason, patients diagnosed with TB meningitis must be referred to a physician who is well trained and experienced in treating patients (NICE, 2006). Diagnosis and treatment of TB meningitis must be immediate because of the sequelae of death with delayed treatment (Ramachandran, 2011). During the intensive phase, the first line of treatment for TB meningitis is the administration of Isoniazid, Rifampicin, Pyrazinamide, Streptomycin, Ethambutol, and Ethionamide (Ramachandran, 2011 and Iype, 2010). With the presence of inflammation of the meninges, the aforementioned antibiotic drugs can pass readily in the cerebrospinal fluid, although ethambutol is considered to be less effective than other drugs, but when used with high doses, it increases its efficacy. In treating patients, it is important to know the basic characteristic of the antibiotic drugs used during the course of treatment. Hence, a brief review of these drugs is made. Isoniazid freely passes the CSF and during the first two weeks of treatment, it kills most of the rapidly replicating bacilli (Ramachandran, 2011 and Iype, 2010). Rifampicin is an antibiotic designed to kills those organisms that are slow and are none replicating. On the other hand, Pyrazinamide is a drug that kills those organisms in sites that are hostile to other drugs’ penetration and action. Streptomycin and Ethambutol has a unique property since it penetrates well with the presence of inflammation in the blood brain barrier. Ethionamide can penetrate both the healthy and inflamed meninges (Ramachandran, 2011 and Iype, 2010). Iype (2010) noted that Ethambutol must be replaced with Streptomycin when treating TB meningitis. In the United Kingdom (UK), NICE (2006) suggested that during the twelve month of therapy, the initial standard regimen recommended for the patients is the combination of Isoniazid and Rifampicin together with Ethambutol and Pyrazinamide on its first two months of treatment, and on the remaining ten months, only the combination of Isoniazid and Rifampicin is prescribed to the patient. The first three drugs, Isoniazid, Rifampizin, and Pyrazinamide are all bactericidal; however, there is a conflicting ideas as to the evidence of treatment duration is concerned (Ramachandran, 2011). Other investigators recommend a 6 – 9 month therapy while others will go as far as 24 months of therapy. High doses of anti TB agents can be safely given to children with TB meningitis without the fear of having hepatotoxicity and high changes of relapse. Although a conservative estimate is recommendable that combination of antibiotic therapy and adjunctive corticosteroid must be given to the children for duration of twelve months (Ramachandran, 2011). Adjuvant corticosteroid treatment is given to reduce the harmful inflammatory defects of antibiotics as it acts in killing the microorganisms; however, in adults, its usage remains controversial because it reduces the CNS penetration of anti – tuberculous drugs. Corticosteroid also reportedly causes bleeding of the gastrointestinal tract; increase the chances of having a disabled survivor although it saves lives, and increase the chances of acquiring hyperglycemia (Iype, 2010). Although the use of corticosteroids is controversial, they are still indicated in treating cases of increased intracranial pressure, altered consciousness, focal neurological findings, spinal block, and tuberculous encephalopathy (Ramachandran, 2011). NICE (2006) noted that in active TB meningitis, patients must be offered initially with a combo treatment comprising of Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol in the first two months followed by the combination of Isoniazid and Rifampicin for the remaining ten months of therapy. At a normal dosage range, glucocorticoid is given in adults at 20 to 40 mg when given with Rifampicin or 10 to 20 mg when given alone. In children, glucocorticoid is given 1 – 2 mg per kilogram with a maximum dosage of 40 mg. Starting within the first 2 to 3 weeks of initial administration, gradual withdrawal of glucocorticoid is considered in the children (NICE, 2006). On the other hand, a vaccination in the neonates in the form of BCG is administered to infants who have high risks of acquiring tuberculosis. Also, a compulsory vaccination among the neonates is recommended in the Primary Care Organisations of neonates with high incidence of acquiring tuberculosis (NICE, 2006). NICE (2006) suggested that to promote compliance, patients must get involved in decisions of treatment. The importance of compliance and the consequence of failing to take their medication must be given importance by the patients. NICE (2006) emphasised that if the patient failed in his treatment, counselling for health education, patient – based interview and provision of booklet that emphasise on health education, provision of home visits and diary of the patient, random tests of urine and other monitoring, and information on how to secure help in paying for prescription are among the recommended intervention designed for patients. Discussion: Based from the various supporting literature reviewed, it is essential that understanding the diagnosis and diagnostic tool for TB meningitis is necessary and recommended to all practising specialist in order to come up to a positive outcome of the patient treatment and to avoid mortality. A concise and complete history of illness and physical examination is necessary in providing prompt treatment to the patient before the result of other laboratory will come out, and to some extent, before the patient dies while waiting for the result to come out from the laboratory. It is also important that the practising specialist must learn the proper way of approaching the patient, and knows how to handle objections along the way. Also, a practising specialist must equip himself to lecture the patient on the consequences of non compliance of drug intake. Hence, in managing patients with TB meningitis, a holistic approach is expected from the specialist himself. There are various schools of thoughts in managing patients with TB meningitis, but the most important thing that is seen from this study is that, compliance of drug intake remains to be the most important factor in the success of treating the patient to avoid future problems of reinfection and multi-drug resistance. D’Souza, et al. (2002) noted that an increase in the incidence of TB meningitis, which is associated with increasing rate of morbidity and mortality, is attributed to improved notification cases, increase in the population of the elderly, high rates of TB among the immigrants, increasing poverty level, and epidemic of HIV. As noted previously, D’Souza, et al. (2002) stated that to minimise the complications of TB meningitis and decrease the rate of mortality, early diagnosis and prompt treatment remains to be important in managing tuberculosis. D’Souza, et al. (2002) added that TB meningitis is often treated as a great challenge in the diagnosis with a resultant good prognosis with early recognition and prompt treatment. Conclusion: From various studies reviewed, it was found out that managing TB meningitis is a broad scope of disease entity that involves not only the young ones but also the older generations alike. However, there was no existing study that suggests that a better prognosis in children and older age group exist. Overall, it was found out that a better outcome of the disease process and treatments were reported from various studies with early diagnosis and prompt treatment of TB meningitis. References: 1. D’Souza, R., Franklin, D., Simpson, J., and Kerr, F., 2002. Atypical Presentation of Tuberculos Meningitis. [Online] Available at: < http://www.smj.org.uk/0202/atypical_presentation_of_TB.htm> [Accessed 13 December 2011]. 2. Dugdale, D., 2010. Tubercular Meningitis. [Online] Available at: [Accessed 13 December 2011]. 3. Figaji, A., Sandler, S., Fieggen, A., Le Roux P., Peter J., and Argent, A., 2008. Continuous Monitoring and Intervention for Cerebral Ischemia in Tuberculosis. Pediatric Critical Care in Medicine, 9(4): 25-30. 4. Gotera, N., Dominguez, A., and San Miguel, M., 2005. Tuberculosis. [Online] Available at: < http://www.finlay.sld.cu/publicaciones/tuber/booktuber.pdf > [Accessed 14 December 2011]. 5. Haldar, S., Sharma, N., Gupta, V., and Tyagi, G., 2009. Efficient diagnosis of tuberculous meningitis by detection of Mycobacterium tuberculosis DNA in cerebrospinal fluid filtrates using PCR. Journal of Medical Microbiology, 58(5): 616-624. 6. Humphries, M., 1992. The Management of Tuberculos Meningitis. Thorax, 47(1992): 577 – 581. 7. Iype, T., 2010. Management of Tuberculous Meningitis. [Online] Available at: < http://kankerala.org/admin/downloads/TBM%20Management.pdf> [Accessed: 13 December 2011]. 8. Kashyap, R., Kainthla, R., Agarwal, N., Chandak, N., Purohit, H., Taori, G., and Daginawala, H., 2004. Differential Diagnosis of Tuberculous Meningitis from Partially – Treated Pyogenic Meningitis by cell ELISA. BMC Neurology, 4(1): 16 9. Komolafe, M., Sunmonu, T., and Esan, O. (2008). Tuberculous meningitis presenting with unusual clinical features in Nigerians: Two case reports. Cases Journal, 1(2008): 180 10. Marais, S., Thwaites, G., Schoeman, J., Torok, S., and Misra, U. , 2010. Tuberculous meningitis: a uniform case definition for use in clinical research 11. MeningitisUK, 2009. Tuberculos Meningitis. [Online] Available at: [Accessed 13 December 2011]. 12. Nardel, E., 2009. Tuberculosis. [Online] Available at: < http://www.merckmanuals.com/professional/infectious_diseases/mycobacteria/tuberculosis_tb.html > [Accessed: 14 December 2011]. 13. National Institutes of Health, 2010. Meningitis Tuberculos. [Online] Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000650.htm [Accessed 13 December 2011]. 14. Newton, R., 1994. Tuberculous meningitis. [Online] Avalable at: [Accesssed 13 December 2011]. 15. NICE Guidelines, 2006. Tuberculosis. [Online] Available at: [Accessed 13 December 2011]. 16. Ramachandran, T., 2011. Tuberculous Meningitis. [Online] Available at: [Accessed 13 December 2011]. 17. Thwaites, G., Duc Bang, N., and Dung, N., 2004. Dexamethasone for the Treatment of Tuberculous Meningitis in Adolescents and Adults. The New England Journal of Medicine, 351(2004): 1741-1751. 18. Thwaites, G., undated. The Diagnosis and Management of Tuberculose Meningitis. [Online] Available at: [Accessed 12 December 2011]. 19. Thwaites, G., Chau, T., Mai, N., Drobniewski, F., McAdam, K., and Farrar, J., 2000. Tuberculous Meningitis. Journal of Neurology, Neurosurgery, and Psychiatry with Practical Neurology, 68(3): 289 – 299. 20. Thwaites, G., Chau, T., and Farrar, J., 2004. Improving the Bacteriological Diagnosis of Tuberculus Meningitis. Journal of Clinical Microbiology, 42(1): 378-379. 21. WebHealthCentre, 2009. Tuberculosis. [Online] Available at: [Accessed 14 December 2011]. 22. Woodfield, J., 2008. Evidence behind the WHO Guidelines: Hospital Care for Children: What is the Most Appropriate Anti-microbial Treatment for Tuberculous Meningitis? Journal of Tropical Pediatrics, 54(4): 220 -224. Read More