Cases Of Tubercular Meningitis Research Articles

Clinical characteristics, radiological pointers and outcomes of central nervous system tuberculosis

BackgroundCentral nervous system tuberculosis (CNS-TB) is a severe and aggressive form of tuberculosis with a high mortality. With early identification and appropriate therapy, it carries a good outcome. Aim: To identify the clinical characteristics, radiological pointers, and outcomes of central nervous system tuberculosis. MethodsSingle-center retrospective study was conducted from January 01, 2018 to December 31, 2022 on patients diagnosed with CNS-TB.Adult patients with at least nine months of follow-up were included. Those seropositive for HIV or lost to follow-up before treatment completion were excluded. Variables were expressed as mean with standard deviation, median, and range. Chi-square and student's t-test for qualitative and quantitative variables were used. Results158 records were reviewed, and 56 were excluded. 102 patients were included with 90(88.23 %) cases of tubercular meningitis(TBM) and 12 (11.76 %) cases of isolated tuberculoma. There were 22(24.44 %) and 63(70.00%) cases of definite and probable tuberculous meningitis. Leptomeningeal enhancement (79.41%)and hydrocephalus (42.22%)were noted commonly. All cases of TBM and tuberculoma completed 9–12 months of anti-tubercular treatment. Dexamethasone was given to all patients with TBM for 6–12 weeks. One patient with biopsy-proven isolated tuberculoma received up to 24 months of ATT. Nine patients with TBM died(9/102,8.82 %). Grade III TBM, age >60 years, hydrocephalus,drug-induced hepatitis, and extra-neural tuberculosis were significant in the expired versus survivors comparison (p < 0.05). ConclusionsEarly identification, appropriate ATT regimen, and duration of treatment are associated with a good outcome in this fatal and disabling disease.

Tubercular Meningitis Presenting as Section Multiple Cranial Nerve Palsy

Tubercular Meningitis (TBM) is caused due to the seeding of meninges with mycobacterium tuberculosis and about one-third of the world’s population is infected with it. The risk of contracting the infectionincreases in immunocompromised states which includes diabetes mellitus, chronic use of steroids, chronic alcoholism and Human Immunodeficiency Virus (HIV) co-infection. Here, a case of 47-year-old female has been presented, who reported to the Department of Medicine with complaints of weakness overthe leftside of the face associated with diminished hearing and tinnitus in the left ear and subjective vertigo since 20 days. Initially, all the above involvement was attributed to bell’s palsy but no improvement was seen with its treatment. Incidentally, she was found to be HIV positive and lumbar puncture was done and eventually, she was diagnosed as a case of TBM. The patient was successfully treated with antitubercular medications and supportive measures and she responded well. She was discharged with antitubercular medications with regular follow-up in view of starting antiretroviral therapy after 6 weeks.

Efficacy of CBNAAT versus Adenosine Deaminase in Fluids in Extrapulmonary Tuberculosis

Introduction: Tuberculosis though primarily, is a pulmonary disease, it may manifest as Extrapulmonary Tuberculosis (EPTB). The gold standard method for the diagnosis of extrapulmonary tuberculosis is blood culture. Increased activity of Adenosine Deaminase (ADA) is observed in tuberculosis. Cartridge-based Nucleic Acid Amplification Test (CBNAAT) or Gene Xpert Mycobacterium tuberculosis/ rifampicin (MTB/RIF) is based on Real-Time Polymerase Chain Reaction (RTPCR). Extrapulmonary tuberculosis may present with varied features, may mimic malignancy, and pose a diagnostic challenge. Aim: To assess and compare the efficacy of Cartridge-based Nucleic Acid Amplification Test (CBNAAT) and Adenosine Deaminase (ADA) in cases with extrapulmonary tuberculosis. Materials and Methods: This cross-sectional study was conducted on presumptive cases of extrapulmonary tuberculosis presenting in Department of Medicine at People’s Hospital, Bhopal, Madhya Pradesh, India, from November 2019 to August 2021. All the patients were subjected to detailed history and clinical examination including series of blood and radiological investigations. Apart from this, ADA analysis and CBNAAT was done in all the cases and were treated accordingly. The two tests were compared using Chi-square test. The p-value &lt;0.05 were considered statistically significant. Results: Male predominance was observed and with no statistical difference in age (p-value=0.09) and gender (p-value=0.21). Out of 19 cases of Tubercular Meningitis (TBM) from total 125, ADA was raised in 10 (52.6%) cases, whereas out of 42 Tubercular Pleural Effusion (TBPE) and 24 Tubercular Peritonitis (TBP) cases, ADA was raised in 26 (61.9%) and 4 (16.7%) cases, respectively. Out of 19 cases of TBM, CBNAAT was positive in 4 (21.1%) cases, whereas out of 42 TBPE and 24 TBP cases, CBNAAT positivity was documented in 8 (19%) and 2 (8.3%) cases, respectively. Overall, the sensitivity of ADA was higher for detection of TBM and TBPE as compared to CBNAAT but the specificity of CBNAAT was higher for all the extrapulmonary tuberculosis. Overall diagnostic accuracy of ADA was higher (61.6%) as compared to CBNAAT (43.2%) for detection of extrapulmonary tuberculosis. Conclusion: Extrapulmonary tuberculosis poses diagnostic challenge and thus for diagnosis, evaluation of each component i.e., history, physical examination, blood investigations, fluid analysis, ADA estimation, and CBNAAT is important. Relying solely on single diagnostic modality may be associated with low diagnostic yield, and thus each step of patient assessment must be given equal preference so as to improve the diagnostic yield.

MR vessel wall imaging in tubercular meningitis.

Tubercular meningitis (TBM) has the propensity to cause secondary vasculitis through various mechanisms leading to development of cerebrovascular complications. These vascular involvements can be detected by vessel wall imaging (VWI). In this study, we aimed to study detailed findings of vessel wall imaging in cases of tubercular meningitis. All consecutive patients of suspected tubercular meningitis in whom diagnosis of TBM could be made according to diagnostic criteria given by Ahuja et al. were included in thestudy. High-resolution MR VWI and time of flight (TOF) magnetic resonance angiography (MRA) were done along with routine MRI sequences. Arteries up to second-order branches were studied, and statistical analyses were done with respect to stage of tubercular meningitis, infarctions and TOF MRA findings. Out of all 101 cases of TBM, infarctions were found in 49 cases (48.5%), and vessel wall enhancement was seen in 67 cases (66.3%). With increasing severity of disease, more severe vascular involvement was seen on VWI. There was significant association between enhancement of individual arteries and infarctions in their territories. VWI had better sensitivity than the MRA, while MRA had better specificity than VWI for detection of vascular complications. Tubercular vasculitis can be detected by VWI in the form of nodular or smooth segmental enhancement of vessel wall with or without stenosis. Incorporation of VWI in routine MR imaging can play a greater role in early detection and management of cerebrovascular complications which can help to improve prognosis of the disease.

Technical Nuances of Ventriculoatrial Shunt Using Seldinger Technique for Percutaneous Insertion of Distal Shunt Catheter

Abstract Introduction One of the most seen neurosurgical complications is the ventriculoperitoneal (VP) shunt failure. The cause can be often due to peritoneal malabsorption of cerebrospinal fluid. The next safer alternative is to place a ventriculoatrial (VA) shunt. Various methods of access to the right atrium had been described. The percutaneous method of insertion of distal catheter using Seldinger technique is a safer alternative to open method. We describe the percutaneous insertion of distal catheter using Seldinger technique, modifications in the method, and specific tools required for the insertion. Clinical History The patient is a 22-year-old male who is a known case of tubercular meningitis with recurrent failure of VP shunt due to malabsorption at peritoneal end of catheter. During the last hospital visit, he presented with altered sensorium and computed tomography scan brain showed ventriculomegaly. He was planned for VA shunt placement. Surgical Technique The insertion of ventricular end of the catheter is similar to any other shunt placement. The internal jugular vein (IJV) was punctured using introducer needle and guide wire was placed in the IJV at the level of T6-T7 and the serial dilators passed on the guide wire for creating a track for passage of shunt catheter. The shunt catheter was passed over the guide wire to the desired vertebral level and distal shunt catheter is connected proximally to the shunt catheter in the neck. Conclusion The percutaneous insertion of distal catheter with serial dilators using Seldinger technique is a safe and effective method for VA shunt placement.

Adenosine deaminase, an aid in the diagnosis of tubercular meningitis – hospital based study

Introduction: Tubercular meningitis (TBM) is the most prevalent and most grave form of extrapulmonary tuberculosis. It is associated with high mortality rate. The confounding factor for this is the delay in diagnosing the disease and initiation of treatment. The present study aims to look for the diagnostic utility of ADA estimations in Tubercular meningitis patients. Materials and Methods: For this study the patients with the signs and symptoms of meningitis and attending our hospital within a st ipulated period of one year approximately, were taken as subjects. As per the accepted criteria, the patients were segregated into two broad groups: tubercular meningitis cases and nontubercular meningitis cases. CSF specimens were collected and ADA levels were estimated on semiautoanalyser in the laboratory. Results: Out of 31 patients of tubercular meningitis, 27 showed ADA levels above 10 U/L while 2 showed lower values. On the other hand 32 cases of non- tubercular meningitis showed ADA levels below 10 U/L and 4 showed higher values, thereby supporting the fact that ADA evaluation in CSF is of substantial value in diagnosing TBM. It also illustrious that if CSF ADA value of 10 U/L is taken as bench mark then the sensitivity for diagnosing TBM is 93.10% and specificity is 88.87% which is fairly good. Conclusion: Therefore, just by evaluating CSF ADA levels we can diagnose the TBM cases with respectably good sensitivity and high specificity and consuming least time and resources. Therefore, ADA estimation is a valuable adjunct to routine investigations in diagnosis of TBM. Keywords: Tubercular Meningitis (TBM), Cerebrospinal fluid (CSF), Adenosine Deaminase (ADA).

Pattern of HIV infected meningitis patient investigated in a tertiary care institute of eastern India

Background: This study was started in the aim of determining the pattern of meningitis and their clinico-laboratorial presentation among HIV infected patients.Methods: This secondary data based cross-sectional study was conducted on 2010 in a tertiary care institute of eastern India among HIV infected meningitis patients. From June 2009 to May 2010, 92 patients were included in our study. Bed head tickets, laboratory reports and registers were used for data collection. Chi square test was applied for the test of significance.Results: 70.7% cryptococcal and 29.3% tubercular meningitis cases were found. Mean CD4 cell count, CSF protein, CSF glucose, WBC cell count of TB and cryptococcal meningitis patients were 143 cells/cumm, 546.1 mg/dl, 26.8 mg/dl, 550 cells/ cumm and 175 cells/ cumm, 189.1 mg/dl, 30.1 mg/dl, 36 cells/ cumm respectively. 29.2% patients of Cryptococcal meningitis were presented with mental change, confusion or psychological disorders, but these symptoms were not observed among TB meningitis patients.Conclusions: This study provided a baseline data about epidemiology and clino-laboratorial features of HIV meningitis patients of eastern India and will help for further investigation in this field.

Pediatric Tubercular Meningitis: A Review.

Childhood tuberculosis (TB) has a high incidence and prevalence in developing countries like India with tubercular meningitis (TBM) being the most common cause of death. Most cases of TBM are diagnosed late when despite adequate therapy; morbidity and mortality continue to remain high. This review aims to provide a pragmatic approach at dealing with cases of tubercular meningitis in children including clinical features, laboratory and radiological criteria, treatment options and prognostic implications. The objective of this review is to assist in early identification, proper investigation and timely treatment of TBM in children in order to reduce neurological morbidity and mortality associated with it.

GeneXpert for Diagnosis of Tubercular Meningitis.

Diagnosis of tubercular meningitis (TBM) is difficult in children. The GeneXpert MTB/RIF assay has been recommended by WHO in 2013 to be used in children and in extra pulmonary clinical specimens. The present study was designed to assess the diagnostic utility of GeneXpert in detecting Mycobacterium tuberculosis in cerebrospinal fluid (CSF) in TBM cases and to compare the results with liquid culture BACTEC 460. Thirty four subjects <15y were diagnosed as TBM based on clinical, CSF and imaging details. Sensitivity of GeneXpert in CSF was 38.24% as compared to Bactec culture which was only 14.71% (p 0.0279). To conclude, GeneXpert MTB/RIF test is able to rapidly confirm diagnosis of TBM with higher sensitivity as compared to conventional methods and liquid culture.

Comparison of recoveries of Mycobacterium tuberculosis using the Automated BACTEC MGIT 960 System and Lowenstein-Jensen Medium in clinically suspected cases of tubercular meningitis in children

Background: Tubercular meningitis (TBM) remains a major complication in children with a considerable mortality and morbidity. Inconsistent and variable clinical features coupled with lack of rapid, sensitive and specific tests poses a diagnostic challenge to the clinical acumen. This study was carried out to diagnose TBM by a combination of direct microscopy by Ziehl-Neelsen (ZN) staining, culture by conventional Lowenstein Jensen (LJ) media and Bactec MGIT 960 system in clinically suspected cases TBM and compare the utility of these diagnostic modalities in the diagnosis of paediatric TBM. Methods: A total of 50 cerebrospinal fluid (CSF) samples from suspected cases of TBM in children aged 0-12 years of age were processed for direct acid fast bacilli (AFB) smear examination, and culture on LJ media and automated Bactec MGIT 960 system. Results: The study comprised of 32 male and 18 female patients in the age group of 0-12 years with a male to female ratio of 1.77: 1. 1 (2%) out of 50 samples was positive for AFB by ZN staining. Overall culture was positive in 15 cases (30%). Culture by LJ media was positive in 4 (8%) of the cases while culture by Bactec MGIT 960 system was positive in 14 cases (28%). The mean time of detection of Mycobacterium tuberculosis in LJ media and MGIT were 13.2 days and 32.4 days, respectively. Conclusion: Automated Bactec MGIT 960 system increases the sensitivity of diagnosing TBM in comparison to conventional microscopy and culture and reduces the mean time to diagnosis.

Have we made any headway in the diagnosis of neurotuberculosis? Place of real time PCR or real time PCR

The diagnosis of Central Nervous System tuberculosis (CNS TB) had been always an enigma as yield of Mycobacterium tuberculosis in cerebrospinal fluid (CSF) is very low and diagnosis mainly rested on combination of clinical, CSF analysis and radiological findings. We attempted to find whether 16s rRNA primer based real time Polymerase chain reaction (PCR) aids in diagnosis of tubercular meningitis (TBM) and tuberculoma. Literature is flooded with newer techniques for the diagnosis of neuro-tuberculosis by real time PCR. But no clear cut guidelines are available about their role. 40 cases of tubercular meningitis, diagnosed on basis of Modified Ahuja Criteria and 40 controls were included in this prospective study. All patients were evaluated clinically and investigated in detail including cerebrospinal fluid analysis, Acid Fast Bacilli staining, culture for TB by Bac T Alert 3-D system,16s rRNA real time PCR assay, chest X ray, computed tomography scans of head, contact survey using chest X-ray, Mantoux test and hemogram. Comparative analysis of real time PCR were done in control group vs. cases of TBM diagnosed on the basis of Modified Ahuja criteria. Results: CSF for tuberculosis by real time PCR was positive in 26/40 cases (65%) of TBM, as against 2/40 controls. Keeping the CSF culture as the gold standard its sensitivity is 62.50 (95% confidence intervals- 54.7, 85.2), specificity is 77.40 (95% confidence intervals- 54.7, 85.2), positive predictive value is 46.15 and negative predictive value is 88.89. Modified Ahuja criteria can serve as useful tool in diagnosis. CSF analysis by real time PCR has shown better sensitivity and quicker results than culture. However, it cannot be recommended alone as it was negative in about a third of cases. But its significance is underlined in early diagnosis and as an adjunct to culture.

Multi drug resistant (MDR) tuberculous meningitis with hydrocephalus treated with ventriculo-peritoneal shunting: a review

Introduction: Tubercular meningitis (TBM) is one of the severe manifestations of extra pulmonary tuberculosis. Prognosis of cases of multidrug resistance TBM is even worse. We present report of three cases of MDR tuberculous meningitis with hydrocephalus to highlight the challenges in the management of these patients.Materials and Methods: The present study was done was done at IHBAS, a tertiary care neuropsychiatry hospital in Delhi, India. Three patients of MDR CNS TB treated at neurosurgery department were included in this study. Study design was a descriptive case series.Results: All three cases were treated with second line ATT and ventrriculoperitoneal shunting. After a regular follow up with clinical and neuroimaging vigil and with laboratory testing, these patients showed improvement.Conclusion: The decision to start second line ATT to treat resistant cases of CNS TB is often delayed and increases the morbidity and mortality. Prompt and precise decision is possible with vigilant clinical observation, lab tests and neuroimaging. Close follow-up is mandatory for detecting any adverse drug effect and therapeutic response in patients of MDR-CNS TB.

Surgery in hydrocephalus of tubercular origin: challenges and management

Hydrocephalus of tubercular origin is one of the most dreaded and difficult to manage complications of brain tuberculosis. Traditionally, the management has been ventriculoperitoneal shunting, but in recent years emerging interest is in endoscopic ventriculostomy. In this article, we discuss the management protocol of hydrocephalus in various stages of disease. A total of 424 cases of tubercular origin hydrocephalus were managed between years 2000 and 2009. Initially the cases were managed by ventriculoperitoneal shunting, which was followed by use of endoscopic third ventriculostomy. Drug-resistant cases were also encountered and managed according to drug sensitivity. The results provided through evaluation of retrospective data showed a high mortality in cases of hydrocephalus of acute origin if endoscopic third ventriculostomy was performed. The cerebrospinal fluid protein level and neurological status of the patient determined the success or failure of the procedure. For better management, patients were divided into six groups and their management underlined. The cases of tubercular meningitis with aqueductal stenosis presenting in early stages should be given a trial of endoscopic third ventriculostomy where chronic burnt-out cases or cases with communicating hydrocephalus should be managed by ventriculoperitoneal shunting.

Ocular Manifestations of Meningitis in Children

Introduction: Meningitis is the most common central nervous system disease affecting children leading to focal neurological deficits and various oculovisual anomalies including blindness in children. The objective of this study was to evaluate the oculovisual anomalies occurring in Nepalese children suffering from different types of bacterial meningitis. Materials and Methods: A Prospective, study was undertaken for 18 months at B.P.Koirala Lion’s Center for ophthalmic studies, TU Teaching Hospital to study the children suffering from bacterial meningitis admitted at Kanti Children’s Hospital for ocular involvement. A through history, anterior and posterior segment ocular examination and investigations like blood, CSF and CT scan were done. Results: A total of 182 cases of bacterial meningitis were screened. Tubercular meningitis cases were 40 (21.97%) and Pyogenic were 142 (78.02%). Oculovisual anomalies were seen in 70 (38.46%) cases. The ocular abnormalities included pupillary changes (34.28%), Cranial Nerve Palsy (22.86%), Fundus changes (35.72%), Cortical Blindness (4.28%), Panophthalmitis and Proptosis (1.43%). Third nerve involvement was seen in 17.14% cases, sixth nerve in 4.29% cases, Papilledema in 11.43 % and Optic atrophy in 22.86 %. Risk factors included late presentation; hydrocephalous and increased CSF cell count and protein level. Conclusion: Oculovisual anomalies formed an important group of clinical manifestations of bacterial meningitis. Incidence of oculovisual anomalies was more frequently seen in Tubercular meningitis (55%).Children with early presentation and intervention had better prognosis. Hence, timely intervention and health education is important. J. Nepal Paediatr. Soc. 32(2) 2012 136-141 doi: http://dx.doi.org/10.3126/jnps.v32i2.5534

Role of Cerebrospinal Fluid - Adenosine Deaminase Level in Early diagnosis of Various Etiologies of Meningitis in children

Background: Determination of cerebrospinal fluid-adenosine deaminase (CSF-ADA) activity is a reliable means to differentiate tubercular from non- tubercular meningitis. This study was carried out to see the range with mean CSF-ADA levels in meningitis of various etiologies and to see if early diagnosis is possible based on these levels. Methods: A prospective study of 140 children admitted in Manipal Teaching Hospital, from July 2009 – June 2011. Diagnosis was established by clinical findings and relevant investigations and patients were divided in different groups as pyogenic meningitis (PM), partially treated meningitis (PPM), tubercular meningitis (TBM), viral meningitis (VM) and controls. CSF-ADA estimation was done by using spectrophotometer. Results: Out of total 140 patients, 103 were cases of meningitis and 37 were controls. There were 32 cases of PM, 27 cases of PPM, 34 cases of VM and 10 cases of TBM. The mean±SD with range of CSF-ADA was respectively 48±20.37 IU/L (20-70 IU/L), 14.57±6.48 IU/L (2-28 IU/L), 6.40±2.17 IU/L (3-9 IU/L), 8.29±10 IU/L (3-11 IU/L) and 5.27±2.69 IU/L (2-7 IU/L) in TBM, PM, PPM, VM and controls and the value was highest in TBM. The specificity, sensitivity, positive predictive value and negative predictive value of CSF-ADA for TBM were 94.6%, 100 %, 83.3% and 100%. Conclusion: Estimation of ADA activity in CSF can be of great value in early diagnosis of tubercular meningitis. Furthermore it is a simple, reliable, relatively inexpensive test with easy procedure. DOI: http://dx.doi.org/10.3126/njms.v1i2.6608 Nepal Journal of Medical Sciences. 2012;1(2): 97-102

Diagnostic efficacy of adenosine deaminase levels in cerebrospinal fluid in patients of tubercular meningitis: A comparison with PCR for Mycobacterium Tuberculosis.

The rapid diagnosis of Tubercular meningitis (TBM) is fundamental to clinical outcome. The key to diagnosis lies in Cerebrospinal fluid (CSF) analysis and radiological investigations. There are numerous lacunae in the confirmation of diagnosis of TBM from CSF. The aim of present study was to compare the efficacy of CSF adenosine deaminase (ADA) level assays and Polymerase chain reaction (PCR) for Mycobacterium tuberculosis (M. tuberculosis) in the diagnosis of TBM. Fifty four adult patients with suspected TBM and 37 controls were included in the study and CSF analyzed for ADA and PCR for M. tuberculosis. The cases were subdivided into definite (5), highly probable (22), probable (22) and possible TBM (5) as per previously validated criteria. The first two were grouped as "most likely" TBM (27) and last two as "unconfirmed" TBM (27). The mean ADA of the "most likely" TBM was 29±24, "unconfirmed" TBM was 21 ± 15 and controls were 4.8±2.2 U/L. The ADA levels correlated with CSF proteins, absolute lymphocyte count and the staging of the disease. Using a cut off level of >L10 U/L, CSF ADA had a sensitivity of 92.5% and specificity of 97%. PCR for M. tuberculosis was positive in 12 out of 27 "most likely" TBM cases, 5 out of 27 "unconfirmed" TBM cases and 3 out of 37 controls. PCR for M. tuberculosis had a sensitivity of 44.5% and specificity of 92% in the "most likely" TBM cases. ADA is a rapid, inexpensive and sensitive test in the diagnosis of TBM. It is more sensitive than AFB smear and culture. PCR is another rapid test in the diagnosis of TBM with a good specificity, even in those patients already on presumptive anti-tuberculous treatment. However, despite the sensitivity and specificity of CSF ADA, it should be corroborated with AFB smear and CSF PCR.

Outcome of ventriculoperitoneal shunt placement in Grade IV tubercular meningitis with hydrocephalus: a retrospective analysis in 95 patients

Hydrocephalus is the most common complication of tubercular meningitis (TBM). Relieving hydrocephalus by ventriculoperitoneal (VP) shunt placement has been considered beneficial in patients in Palur Grade II or III. The role of VP shunt placement in those of Grade IV is controversial and the general tendency is to avoid its use. Some authors have suggested that patients in Grade IV should receive a shunt only if their condition improves with a trial placement of an external ventricular drain (EVD). In the present study, the authors assessed the outcome of VP shunt placement in patients in Grade IV TBM with hydrocephalus to examine the factors predicting outcome and to determine whether a trial with an EVD is absolutely necessary prior to shunt placement. Ninety-five consecutive cases of TBM with hydrocephalus in which the patients underwent VP shunt placement were retrospectively analyzed, and direct VP shunts were placed whenever possible. An EVD was placed first only in the presence of deranged blood parameters. Outcomes were assessed both in the short and long term. The mean patient age was 17.5 years (range 1-55 years). Fifty-two patients underwent direct VP shunt placement, and the remaining 43 received EVDs first. Overall, 33 and 45% of patients had favorable short- and long-term outcomes, respectively. Age older than 3 years and duration of altered sensorium < or = 3 days were predictive of a favorable short-term outcome. Glasgow Coma Scale score at presentation was predictive of long-term outcome. Of the patients who did not improve with placement of an EVD prior to VP shunt insertion, 24 and 18% had favorable short- and long-term outcomes, respectively; this was not significantly different from the outcome in the patients who underwent direct VP shunt placement. Direct VP shunt placement is an effective option in patients with Grade IV TBM with hydrocephalus. Age and duration of altered sensorium are predictive of short-term outcome, while Glasgow Coma Scale score at presentation predicts long-term outcome. Ventriculoperitoneal shunts should be considered even in patients who do not improve with an EVD.

Dissemination of tubercular bacilli by shunt placement

A unique case of tubercular meningitis, developing shunt complication is being reported. We present a pediatric patient with tubercular ulcer formation at abdominal shunt insertion site, marking a grotesque form of tuberculosis. The final outcome of the child was satisfactory after complete course of chemotherapy. doi : 10.5214/ans.0972.7531.2009.160211 Competing interests: None. Source of Funding: None Received Date: 07 April 2009 Revised Date: 29 April 2009 Accepted Date: 09 May 2009

Vascular endothelial growth factor as a marker of disease activity in neurotuberculosis

Vascular endothelial growth factor (VEGF) is a potent angiogenesis mediator. Scant reports are available defining the role of VEGF in active and inactive tubercular meningitis (TBM) with no studies on brain tuberculoma. We quantified VEGF levels by enzyme linked immunoassay (ELISA) in cerebrospinal fluid (CSF) and serum in 20 cases each with active and inactive TBM as well as 22 cases of intraparenchymal tuberculoma. VEGF expression and microvessel angiogenesis quantification was done in 7 cases where tuberculomas were excised. Significantly increased VEGF levels in CSF were found in active TBM cases (106.0+/-50.0 pg/ml) compared to inactive TBM cases (14.7+/-10.0 pg/ml) (p<0.001). Mean serum VEGF levels in active TBM, inactive TBM and tuberculoma were 694.93+/-820.66 pg/ml, 499.61+/-238.33 pg/ml and 541.0+/-389.0 pg/ml, respectively. Immunohistochemical staining of excised tuberculoma demonstrated high expression of VEGF in granulomatous areas with intense positivity in inflammatory mononuclear cells, Langhan's giant cells as well as reactive astrocytes and fibrocytes. A strong positive correlation was observed between microvessel density and VEGF expression. Serial decrease in serum VEGF levels was observed with increasing duration of therapy in tuberculoma. We conclude that increased CSF and serum VEGF levels are a measure of activity of the disease in neurotuberculosis and its gradual decrease over a period of time is probably an indicator of therapeutic response.

Childhood bacterial meningitis and usefulness of C-reactive protein

Background: C-reactive protein raises rapidly in the first 24–48 hours of occurrence of bacterial meningitis and in large incremental increases thereafter. This prospective study was undertaken in a tertiary care hospital of Armed Forces to ascertain the usefulness of C-reactive protein in early diagnosis of bacterial meningitis. Methods: All children admitted during the period of study, with clinical suspicion of meningitis were clinically, biochemically, cytologically and bacteriologically investigated to clinch the diagnosis. Blood and CSF were also sent for C-reactive protein assay by latex agglutination test. CSF gram staining, culture and biochemical results were taken as gold standard. CSF and serum CRP were then evaluated against this gold standard. Statistical analysis was done by Epiinfo 6. Results: There were 63 cases of meningitis admitted in the hospital. By gold standard, there were 38 cases of bacterial, 21 cases of tubercular and 4 cases of viral meningitis. H. influenza was the predominant organism grown. CSF C-reactive protein was raised in 33 cases of bacterial and 2 cases of tubercular meningitis. Serum C-reactive protein was raised in 29 cases of bacterial, and eight cases of tubercular meningitis. These tests were negative in all cases of viral meningitis. The sensitivity and specificity of serum and CSF C-reactive protein was 96% and 100%. Conclusion: Quantitative and qualitative assay of C-reactive protein is a simple bedside test. It can be completed in 10 minutes and requires only 0.2 ml of blood. This will significantly reduce unnecessary antibiotics to children.