CNS Tuberculosis Research Articles

An Unusual Case of CNS Tuberculoma in a 19-Year-Old Man

Background: Tuberculosis (TB) is ranked as one of the top 10 causes of death. Mycobacterium tuberculosis (M. TB) infection, the causative organism for TB affects approximately a quarter of the global population placing a burden on the healthcare system. Central nervous system tuberculosis (CNS TB) is seen in 5 to 10% of extrapulmonary TB cases and has the highest mortality. CNS tuberculoma is one of its manifestation. Clinical presentation of CNS tuberculoma depends on its location within the CNS and commonly include headache, seizures, and focal neurological deficits, due to the presence of a space occupying lesion, although patients can be asymptomatic. We report the case of a 19yr old man who had an unusual presentation of CNS tuberculoma, highlighting its clinical presentation, diagnosis and treatment. Case Presentation: Index patient is a 19-year-old male college student who resides in a city. He presented with 15 days history of fever, headache, vomiting, vertigo, ataxia, and inability to concentrate. He received antimalarial, anti typhoid and body booster medications but had no improvement and had a history of weight loss despite no dietary change. He had never been diagnosed with TB and had all his childhood vaccinations given. Plain Magnetic Resonance Imaging (MRI) brain scan done revealed a posterior fossa mass lesion with perilesional edema. Futher, a contrast MRI brain scan showed multiple ring-enhancing conglomerates of lesion around the tentorium on the posterior fossa with intense contrast enhancement. The largest of this mass measured 4.5 cm x 2.5 cm x 2.5 cm in the right superior cerebellum compressing the 4th ventricle and with effacement of the cerebellopontine angle. Lastly, an MRI spectrometry revealed elevated lipid lactate peak. His chest x-ray was unremarkable. Other blood parameters were essentially within range with the exception of Erythrocyte ESR and mantoux test. He received antitubercular drug (Isoniazid, Rifampin, Pyrazinamide, Ethambutol, Levoflox and Streptomycin) for 18th months with complete remission. Conclusion: CNS tuberculomas are tuberculous masses that can be located anywhere from the brain to spinal cord. Advanced diagnostic modalities may guide clinicians towards making it's diagnosis. Treatment maybe medical (use of antitubercular drugs) or surgical excision with medical therapy being first choice. While the index patient had no obvious risk factors for his disease, his BCG vaccination pose a possible source of his exposure to TB infection. More research is needed on this however.

Area Postrema Syndrome as the Initial Presentation of CNS Tuberculosis.

Area Postrema Syndrome as the Initial Presentation of CNS Tuberculosis.

Case Report: A rare case of Intracranial tuberculous granuloma (tuberculoma) in a 19-year -old male

A tuberculoma is a clinical sign of tuberculosis that combines tubercles into a solid mass and can resemble several forms of malignant tumors on imaging. They frequently develop in people whose original tuberculosis infection is not well controlled. When they develop intracranially, tuberculomas are symptoms of CNS tuberculosis Meningitis, radiculomyelitis, bony spinal disease, and tuberculoma/tuberculous abscess are some of the symptoms of neurological tuberculosis (TB) that can also arise intracranially or in the spinal canal. comparable to other neurological TB symptoms. The majority of the time, the diagnosis of cerebral tuberculoma is presumptive and is based on radiological findings, additional supportive TB evidence from other areas, and treatment response. However, despite adequate TB treatment and concomitant corticosteroid therapy, lesions may persist for many years, as the therapeutic response of tuberculomas is unpredictable. A 19-year-old male patient admitted to the hospital for medical treatment complained of abdominal pain, constipation, nausea and vomiting, generalized weakness, fever, and chills. According to the patient’s complaints, my patient has a history of tonic-clonic seizures dating back a month, as well as a history of typhoid fever and sickle cell disease AS pattern, both of which he had been receiving treatment at a civil hospital. At the time of admission, he had undergone a number of invasive and non-invasive investigations, including a CT brain plane and an MRI brain with contrast. Brain computed tomography (CT) revealed a persistent lacunar infarct in the left corona radiata. Acute infarct in the right corona radiata, abnormal meningeal enhancement on post-contrast with meningitis, multiple ring-enhancing lesions in the bilateral cerebral hemisphere, cerebellum, corpus callosum, and intracranial tuberculous granuloma are all revealed by MRI with contrast. left corona radiata chronic infarction.

The etiological spectrum of miliary brain lesions: A systematic review of published cases and case series.

This systematic review aimed to evaluate the published cases with miliary brain lesions and their etiological factors, clinical manifestations, diagnostic procedures, and outcomes. A comprehensive search of PubMed, Scopus, Embase, and Google Scholar was conducted using the specified search strategy. Eligibility criteria included cases with miliary lesions in the brain confirmed through neuroimaging and various diagnostic procedures. The PRISMA guidelines were followed, and the PROSPERO registration number for the protocol is CRD42023445849. Data from 130 records provided details of 140 patients. Tuberculosis was the primary cause in 93 cases (66.4%), malignancies in 36 cases (25.7%), and other causes accounted for the remaining 11% cases. Tuberculosis patients averaged 35.7years old, while those with malignancies averaged 55.44years. Tuberculosis symptoms primarily included fever, headache, and altered sensorium, whereas malignant cases often exhibited progressive encephalopathy, headache, and specific neurological deficits. Distinctive indicators for CNS tuberculosis were choroidal tubercles and paradoxical reactions. Additionally, 63 tuberculosis patients showed miliary lung shadows and 49 had abnormal CSF findings. For the malignancy group, 13 exhibited miliary lung lesions, and 8 had CSF abnormalities. Regarding outcomes, a significant mortality disparity was observed, with 58.3% in the malignancy group, compared to 10.8% in the tuberculosis group and 27.3% in other cases. Miliary brain lesions are a crucial imaging abnormality that necessitates prompt work up. In an immunocompromised state, diagnostic possibilities of miliary brain lesions are more varied and often pose a bigger challenge.

Neuroimaging of tuberculosis- modalities, imaging protocols and radiomics: a review

Background and Objective:
 A large number of review and research articles exists in literature which describe the radiological appearance of various manifestations of nervous system tuberculosis, however there is paucity of text which describes the application of each and every imaging modality in the workup of the entire spectrum of this pathology. The intent of this article is to review the existing literature on the role of different radiological modalities in the stepwise work up of CNS TB. The article focuses on the role of plain radiograph, fluoroscopy, computed tomography, magnetic resonance imaging along with its advanced sequences and nuclear medicine in imaging of the many faces of tuberculosis in CNS. The article also aims to review the existing literature on the role of MR based textural analysis (Radiomics) as a problem-solving tool in various nervous system pathologies.
 Methods:
 We searched PubMed central databases for articles published in English from January 1 2000 to February 28 2021 along with references from the relevant articles. The search terms included “imaging in central nervous system tuberculosis” “Radiomics in tuberculosis “, “Radomics in central nervous system ”. In total 95 articles including case reports, case series, original articles and review articles were included in this review.
 Results:
 Conventional imaging modalities including radiograph and fluoroscopy are becoming extinct in work up of tuberculosis in the nervous system itself, however a plain radiograph still holds a key position in screening the chest for presence of subclinical respiratory tract infection in patients presenting with brain tuberculosis. In addition, it is a sensitive tool as baseline investigation in workup of spinal tuberculosis (T.B). Fluoroscopy is a useful tool in image guided procedures for collection of samples for histopathology and CSF analysis.
 Cross sectional imaging modalities including computed tomography and magnetic resonance imaging have revolutionized imaging of central nervous system pathologies in particular tuberculosis. Computed tomography acts as a screening tool to identify the presence of intracranial tuberculosis and recognize its complications. In addition it is an important tool to determine the extent of spinal T.B. Magnetic Resonance Imaging (MRI) along with its advanced sequences including spectroscopy, Magnetization transfer T1 sequence (MT T1), perfusion imaging, and magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) is an ideal imaging method to work up CNS TB. It can identify numerous manifestations of tuberculosis in the brain, work up its associated complication, and explain the extent of neurological symptoms. Moreover, it has the capability to differentiate TB from other nervous system infections. Furthermore, it can differentiate neoplastic and inflammatory brain disorders from CNS TB. Radiomics, particularly the textural features based on MR imaging is the future of neuroimaging. Its role is getting established in the work up of several intracranial pathologies including brain tumors and neurodegenerative disorders. Certainly, it has significant potential in the imaging work up of CNS tuberculosis, which is underexplored and therefore requires the central attention of upcoming researchers focusing on this topic.
 Conclusion:
 Cross sectional imaging is the mainstay of imaging workup. Nuclear imaging is becoming an essential adjuvant to determine the burden of the disease. Role of radiomics is evolving in intracranial pathologies and certainly needs the central attention of future researches to establish its role in CNS TB imaging.

Surgery for Central Nervous System Tuberculosis in Children.

Tuberculosis (TB) is the second most common cause of death due to a single infectious agent worldwide after COVID-19. Central nervous system tuberculosis is widely prevalent in the world, especially in the developing countries and continues to be a socioeconomic problem. It is highly devastating form of tuberculosis leading to unacceptable levels of morbidity and mortality despite appropriate antitubercular therapy. The clinical symptoms are varied and nonspecific. They can be easily overlooked. Tuberculous meningitis is the most common presentation and its sequelae viz. vasculitis, infarction and hydrocephalus can be devastating. The ensuing cognitive, intellectual, and endocrinological outcome can be a significant source of morbidity and mortality, especially in resource constrained countries. Early diagnosis and treatment of tuberculous meningitis and institution of treatment is helpful in limiting the course of disease process. The diagnosis of CNS tuberculosis remains a formidable diagnostic challenge. The microbiological methods alone cannot be relied upon. CSF diversion procedures need to be performed at the appropriate time in order to achieve good outcomes. Tuberculous pachymeningitis and arachnoiditis are morbid sequelae of tuberculous meningitis. Tuberculomas present as mass lesions in the craniospinal axis. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Tuberculosis of the spinal cord is seen similar to intracranial tuberculosis in pathogenesis but with its own unique clinical manifestations and management. Multidrug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. Heightened clinical suspicion is paramount to ensure prompt investigation. Early diagnosis and treatment are essential to a gratifying outcome and prevent complications.

Predictors of drug induced hepatitis in patients of CNS tuberculosis

Predictors of drug induced hepatitis in patients of CNS tuberculosis

Multiple Intracranial Tuberculomas In Immunocompetent Patient: An Uncommon Primary Manifestation Of Central Nervous System Tuberculosis (CNS TB)

Tuberculosis (TB) is a serious yet potentially-curable health issue among most developing countries including Pakistan. We report the case of an immunocompetent patient having multiple intracranial tuberculomas without evidence of meningitis which is an uncommon manifestation of CNS tuberculosis. A 50-year old man presented with 5 episodes of tonic-clonic generalized fits for 1 day, right sided body weakness for 2 weeks, generalized headaches and intermittent low-grade fever for 1 month. No contact or past history of tuberculosis was reported. On neurologic examination, there was hypertonia, exaggerated deep tendon reflexes and power of 3/5 in both right upper limb and right lower limb with a right plantar extensor response. CT scan (Brain) showed hyperdense areas in left frontal and temporal lobes with surrounding vasogenic edema. ESR was raised at 86 mm/hour. CSF analysis demonstratedRBC 0 cells/uL, WBC 783 cells/uL with 100% lymphocytes, Glucose 39 mg/dl andProtein 81 mg/dl with negative organism microscopy onAFB and Giemsa staining. However, CSF was positive for GeneXpert-PCR-MTB but drug resistance was not detected to rifampicin. Brain MRI with FLAIR demonstrated multiple disseminated, rim enhancing lesions with perilesional edema in bilateral cerebral hemispheres, thalami, left basal ganglia, medulla oblangata and cerebellum having no meningeal enhancement. Workup for immune-suppression was normal. A diagnosis of multiple intracranial tuberculomas was established and Anti-tubercular therapy was commenced. He was asymptomatic and taking ATT with good compliance having no adverse affects by 6-week follow up.

Sociodemographic and Clinical Profile of Tubercular Meningitis Patients without Pulmonary Signs and Symptoms

Background: Among the different forms of CNS tuberculosis, tubercular meningitis (TBM) is the most frequent one. Early diagnosis and treatment of tubercular meningitis (TBM) can give an excellent outcome with minimal residual morbidity. Sociodemographic and clinical findings of patients with or without pulmonary signs and symptoms may be useful for the early diagnosis and treatment of suspected TBM patients. Aim of the study: This study aimed to make a sociodemographic and clinical profile of tubercular meningitis patients without pulmonary signs and symptoms. Methods: This was a cross-sectional study that was conducted in the Department of Medicine, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh, from September 2020 to August 2021. A total of 77 diagnosed cases of tubercular meningitis without pulmonary signs and symptoms admitted to the mentioned hospital were included in this study as the study population. In sample selection, a purposive sampling technic was used. Along with the sociodemographic as well as clinical findings, all relevant information was recorded in a data collection sheet. After completion, data analysis was done by SPSS 23.0. Results: The mean age of our respondents was 37.93±11.8 years; 53.2% of them were male and 46.8% were female. The majority of the respondents were service holders (32.5%) and the majority (57.1%) of the patients had middle-family income. In this study, 61% of the study population had a family history of TB. As for the clinical features of TBM, we observed that all of the study subjects had a fever, 80.5% had a headache, 68.8% had altered sensation, 62.3% had anorexia and nausea, 55.8% had vomiting, 19.5% had convulsions and 15.6% had neck stiffness. The majority (46.8%) of the respondents had TBM Grade II. In total, 58.4% of the respondents had Mantoux test positive and 41.6%, whereas 36.4% showed chest X-ray positive for TB. Conclusion: The prevalence of tubercular meningitis without pulmonary signs and ........

Clinical and Diagnostic Findings Among Tubercular Meningitis Patients without Pulmonary Signs and Symptoms

Background: Tubercular meningitis (TBM) is the most frequent one among the different forms of CNS tuberculosis. Early diagnosis, as well as treatment of tubercular meningitis (TBM), can give an excellent outcome with minimal residual morbidity. Clinical and diagnostic findings of patients without pulmonary signs and symptoms may be useful for the treatment of suspected tubercular meningitis patients. Aim of the study: This study aimed to make a patient profile on the clinical and diagnostic findings of tubercular meningitis patients without pulmonary signs and symptoms. Methods: This cross-sectional study was conducted in the Department of Medicine, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh, from September 2020 to August 2021. A total of 77 confirmed cases of tubercular meningitis without pulmonary signs and symptoms admitted to the mentioned hospital were enrolled in this study as the study population. A purposive sampling technic was used in sample selection. Along with the clinical and diagnostic findings, all relevant information was recorded in a data collection sheet. Results: In this study, 61% of the study population had a family history of TB. Among all the patients, all had fever, 80.5% had headache, 68.8% had altered sensation, 62.3% had anorexia and nausea, 55.8% had vomiting, 19.5% had a convulsion and 15.6% had neck stiffness. In our settings, the majority (46.8%) of the respondents had TBM Grade II. The mean WBC count was 134.80±34.59 106/L, Lymphocyte (%) was 79.49±11.77, Glucose was 26.49±5.43 mg/dl, Protein was 142.8±72.5 and ADA level was 12.08±1.29 U/L. In our settings, 58.4% of the respondents had Mantoux test and 36.4% showed chest X-ray positive. In this study, 22.1% of the respondents had CT scan or MRI findings normal. Conclusion: A family history of tuberculosis may be a potential factor for TBM. Fever, headache, altered sensation, anorexia/nausea and vomiting are very common clinical features in such patients. Chest X-ray ..

Effectiveness of Adjunctive High-Dose Infliximab Therapy to Improve Disability-Free Survival Among Patients With Severe Central Nervous System Tuberculosis: A Matched Retrospective Cohort Study.

Few treatment options exist for patients with severe central nervous system (CNS) tuberculosis (TB) worsening due to inflammatory lesions, despite optimal antitubercular therapy (ATT) and steroids. Data regarding the efficacy and safety of infliximab in these patients are sparse. We performed a matched retrospective cohort study based on Medical Research Council (MRC) grading system and modified Rankin Scale (mRS) scores comparing 2 groups of adults with CNS TB. Cohort A received at least 1 dose of infliximab after optimal ATT and steroids between March 2019 and July 2022. Cohort B received only ATT and steroids. Disability-free survival (mRS score ≤2) at 6 months was the primary outcome. Baseline MRC grades and mRS scores were similar between the cohorts. Median duration before initiation of infliximab therapy from start of ATT and steroids was 6 (IQR: 3.7-13) months and for neurological deficits was 4 (IQR: 2-6.2) months. Indications for infliximab were symptomatic tuberculomas (20/30; 66.7%), spinal cord involvement with paraparesis (8/30; 26.7%), and optochiasmatic arachnoiditis (3/30; 10%), worsening despite adequate ATT and steroids. Severe disability (5/30 [16.7%] and 21/60 [35%]) and all-cause mortality (2/30 [6.7%] and 13/60 [21.7%]) at 6 months were lower in cohort A versus cohort B, respectively. In the combined study population, only exposure to infliximab was positively associated (aRR: 6.2; 95% CI: 2.18-17.83; P = .001) with disability-free survival at 6 months. There were no clear infliximab-related side effects noted. Infliximab may be an effective and safe adjunctive strategy among severely disabled patients with CNS TB not improving despite optimal ATT and steroids. Adequately powered phase 3 clinical trials are required to confirm these early findings.

Bilateral vocal cord palsy as complication of CNS tuberculosis

BackgroundTuberculous meningitis, a rare but severe form of extrapulmonary tuberculosis, frequently affects cranial nerves. While nerves III, VI and VII are commonly involved, involvement of caudal cranial nerves is rarely described. Here, we report a rare case of bilateral vocal cord palsy secondary to caudal cranial nerve involvement in tuberculous meningoencephalitis, that occurred in Germany, a country with low tuberculosis incidence.Case presentationA 71-year-old woman was transferred for further treatment of hydrocephalus as a complication of presumed bacterial meningitis with unknown pathogen at that time. Because of decreased consciousness, intubation was performed and an empiric antibiotic therapy with ampicillin, ceftriaxone and acyclovir was initiated. Upon admission to our hospital, an external ventricular drainage was placed. Cerebrospinal fluid analysis revealed Mycobacterium tuberculosis as the causative pathogen, and antitubercular treatment was initiated. Extubation was possible one week after admission. Eleven days later, the patient developed inspiratory stridor that worsened within a few hours. Flexible endoscopic evaluation of swallowing (FEES) revealed new-onset bilateral vocal cord palsy as the cause of respiratory distress, which required re-intubation and tracheostomy. The bilateral vocal cord palsy persisted despite continued antitubercular therapy on the follow-up examination.ConclusionConsidering the aetiology of infectious meningitis, cranial nerve palsies may be suggestive for tuberculous meningitis as underlying disease given their rarity in other bacterial forms of meningitis. Nevertheless, intracranial involvement of inferior cranial nerves is rare even in this specific entity, as only extracranial lesions of inferior cranial nerves have been reported in tuberculosis. With this report of a rare case of bilateral vocal cord palsy due to intracranial involvement of the vagal nerves, we emphasize the importance of timely initiation of treatment for tuberculous meningitis. This may help to prevent serious complications and associated poor outcome since the response to anti-tuberculosis therapy may be limited.

Asymptomatic severe hypercalcaemia and renal impairment following vitamin-D replacement in a patient with miliary and CNS tuberculosis

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Clinical and Radiological Features and Outcome of Hospitalized Patients with CNS Tuberculosis : A Prospective Observational Study in A Tertiary Care Centre, Mumbai

Clinical and Radiological Features and Outcome of Hospitalized Patients with CNS Tuberculosis : A Prospective Observational Study in A Tertiary Care Centre, Mumbai

Giant Intracranial Tuberculoma Resembling a Brain Tumor: A Diagnostic Challenge

Despite being potentially remediable, central nervous system tuberculosis continues to be a major cause of morbidity and mortality in developing countries. Intracranial tuberculoma is one of the many presentations of CNS tuberculosis that can occur as solitary or multiple lesions. When tuberculomas are solitary and extremely large, they may cause increased intracranial pressure, compressive focal neurological deficits, or epileptic seizures mimicking a malignant lesion. Even using magnetic resonance imaging and spectrography, giant tuberculoma and brain tumors could be mistaken for one another, which warrants consideration of an infectious etiology as a diagnostic differential for prompt diagnosis and appropriate treatment plan. This case study demonstrates a 22-year-old woman who presented with headache, nausea and vomiting ,blurring of vision , weakness of the right side of the body, and features of frontal lobe syndrome with no particular clinical features of TB, and underwent craniotomy who had a preoperative diagnosis of brain tumor. Histopathology later revealed it to be a tuberculoma. J Shaheed Suhrawardy Med Coll 2021; 13(2): 177-182

Clinical Profile Analysis of Tuberculosis Patients Attended in a Tertiary Care Hospital in Bangladesh

Background: Despite noteworthy socio-economic development and advances in medical science, tuberculosis (TB) remains a major public health problem. Although it is a curable disease, still millions of people suffer and a large number of patients die from this infectious disease. Now a day, the prevalence and nature of tuberculosis are not in a consistent stage. So we need more current information regarding this issue. Aim of the study: The aim of this study was to assess the clinical profile of tuberculosis patients attended in a tertiary care hospital in Bangladesh. Methods: This was a prospective, observational study which was conducted in the department of Medicine, North Bengal Medical College, Sirajgonj, Bangladesh during the period from January 2020 to June 2022. In total 87 diagnosed patients with tuberculosis, treated in the mentioned hospital were selected as the study subjects. Before data collection, proper written consents were taken from all the participants. For data collection a predesigned questionnaire was used in data collection. Collected data were processed, analyzed and disseminated by using MS Excel and SPSS version 23.0 program as per necessity. Results: In this study, the male-female ratio of the participants was 1.7:1. The highest number of participants were from the 41-50 years’ age group which was 27.59%. BMI (Kg/m2) was found ≥18.5 in 61% and < 18.5 was found in 39% of patients. Majority (56%) of the cases were ‘non- smoker’. As the types of TB, pulmonary Koch’s, CNS tuberculosis, abdominal Koch’s, and TB lymphadenitis were found in 43% 21%, 14%, and 13% of participants respectively which was noticeable. In this study, among all the participants, cough and fever were found as two most frequent symptoms which were found in 93% and 84% of patients respectively. Conclusion: Fever and cough are the two most frequent symptoms in tuberculosis patients. Although the death rate among TB patients is not alarming, the treatment success rate of the first treatment attempt is not satisfactory among tuberculosis patients.

Pediatric Neurotuberculosis: A cases series and review of the literature.

Neurotuberculosis or central nervous system tuberculosis is a form of tuberculous infection that affects any part of the nervous system. Although it is more frequent in adults, pediatric cases have been reported in endemic countries and it is potentially a deadly affection. Therefore, any unusual neurological manifestation in a formerly healthy child, independently of their vaccination status, must bring suspicion of CNS tuberculosis among other diagnoses. We report four cases of pediatric neurotuberculosis with various clinical presentations and outcome and a brief review of the litterature. We conclude that clinical manifestations of pediatric neurotuberculosis are extremely variable and could be misleading. Extra-neurological sites are a key element for diagnosis especially in the pediatric population. A diagnosis and clinical outcome score, especially designed for children might help personalize the therapeutic approach and outcome measures.

Subdural Tubercular Empyema in an Immunocompetent Patient: A Rare Primary Presentation of CNS Tuberculosis

Tuberculosis (TB) remains a potentially-curable serious health problem in most of the developing world including Pakistan. Subdural Tubercular Empyema is a very rare presentation of CNS tuberculosis. A 25-year-old gentleman presented with a 25-day history of low-grade intermittent fever and generalized headache. On examination, he had a temperature of 99.6oF with equally round and reactive to light pupils with normal extraocular muscle movements. However, there were signs of papilledema on fundoscopic examination. Signs' of neck rigidity (Kernig and Brudzinski) were negative. There was no focal neurological deficit. CSF analysis showed TLC 660 cells/uL with 100% lymphocytes, RBC 0 cells/uL, Protein 73 mg/dl, and Glucose 43 mg/dl with no organisms on Giemsa staining but positive AFB stain microscopy. GeneXpert-PCR for MTB was also positive on CSF with no drug resistance to rifampicin detected. His brain MRI scan showed left subdural empyema. Workup for the immunosuppressive condition was negative. He was diagnosed as having Subdural Tubercular Empyema and started on Anti-tubercular therapy. On follow-up at 4 weeks, he was asymptomatic and tolerating ATT without any adverse effects.

P144 The uncommon meets the common: Invasive Aspergillosis and tuberculosis co-infection in non-neutropenic patients— arare association

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMBackground and ObjectiveInvasive aspergillosis (IA) is known to occur in immunocompromised patients including neutropenic patients. But, recently increasing cases have been reported in patients with non-classical risk factors and non-neutropenic patients like diabetes mellitus, chronic lung disease, HIV infection, critically ill patients, etc. According to ISHAM these non-classical risk factors should be included in EORTC/MSG host criteria for diagnosis of invasive aspergillosis.India has a high tuberculosis (TB) burden, and this is always considered as the first differential for any patient with fever, cough, hemoptysis, and weight loss. Post-tubercular chronic pulmonary aspergillosis common reported condition. However, co-infection of active TB and invasive aspergillosis is less reported. This co-infection could be one of the contributors of high morbidity and mortality in cases with tuberculosis.We hereby present a series of five cases of TB concomitant with invasive aspergillosis in non-neutropenic patients.MethodsThis is a prospective observational study, all patients admitted with molecular diagnosis (GeneXpert) of tuberculosis and with at least one non-classical risk factor for invasive aspergillosis were subjected to further evaluation. Diagnosis of invasive aspergillosis was considered in patients who had at least one clinical and one mycological EORTC criteria. Galactomannan level in different samples was measured via PlateliaTM ELISA. The efficacy of different antifungals and outcomes were analyzed.ResultsTotal 57 patients with TB underwent for evaluation of invasive aspergillosis. Among them, five patients were diagnosed to have concomitant TB and invasive aspergillosis, of which three cases of CNS TB and CNS aspergillosis and two had concomitant pulmonary infections. The average age was 31 ± 12 years with a female preponderance (4/5). Two patients were HIV positive, while among non-HIV patients, one had CD4 cytopenia (CD4-171). One patient had no known predisposing factor. Radiologically, most common pulmonary lesions were patchy consolidation with centrilobular nodules with tree in bud appearance, while CNS lesions showed multiple ring-enhancing lesions. All the patients had CBNAAT positive, two from BAL sample, 1 from CSF, and 1 from the lymph node. Rifampicin was sensitive in all, except one who had rifampicin resistance indeterminate. Of these patients, four were probable invasive aspergillosis satisfying the host, mycological and clinical factors as per the EORTC/MSGERC 2021 guidelines. The treatment of coinfection is challenging due to the interaction of rifampicin with voriconazole, which is the drug of choice for invasive aspergillosis. Here, 3 patients were treated with Inj amphotericin B, while the other 2 patients were started on voriconazole with rifampicin sparing regimen for TB. Of the 5 patients, 4 patients survived with excellent response to the treatment, with one fatality.ConclusionThe possibility of concurrent TB and invasive aspergillosis in non-neutropenic hosts should be considered to avoid devastating outcomes. The lack of clinical suspicion may result in misdiagnosis, and most importantly, the chronicity of the infection makes it indistinguishable from TB. Moreover, the co-administration of antifungal and anti-TB medications presents significant therapeutic challenges necessitating thorough evaluation and monitoring.

Peculiarities of the detection and course of the pediatric extrapulmonary tuberculosis taking into account drug resistance

Abstract Pediatric tuberculosis is a health problem of special significance because it is a marker for current transmission of tuberculosis in society. The research aimed at analyzing the peculiarities of detection and course of pediatric extrapulmonary tuberculosis (EPTB) taking into account the profile of drug resistance. A retrospective study of medical charts of children with EPTB (n = 47; 1st group) and pulmonary tuberculosis (PTB) (n = 49; 2nd group) aged 0-15 for 2013-2020 has been conducted. 2 subgroups with EPTB were identified separately: resistant (EPRTB) (n = 23) and sensitive (EPSTB) (n = 24). Results and discussion. The frequency of EPTB was 9.8%. Tuberculosis of peripheral LN (40.5%), CNS (27.7%), bones and joints (23.4%) was significantly more often diagnosed, than other lesions. Almost half of children with EPTB had a miliary distribution. In 44.7% of children with EPTB contact with a patient with tuberculosis was not established. EPRTB was significantly more common among children under 1 and up to 3 years of age than EPSTB. The resistance to combination of HR (73.6%) was found more often than to HRES (10.5%), HRS, H and Z (5.3% each; p<0.01). In 73.9% of children with EPRTB was detected when seeking medical care, in 13.0% the time to diagnosing lasted 6 months. Among children with EPRTB, gradual course was more frequent and in 47.8% intoxication syndrome was dominating. 78.3% of children with EPRTB were not vaccinated. Conclusion. The above indicates the need to intensify preventive measures against tuberculosis among children, especially at risk groups, make monitoring of contacts and their treatment.