Features Of Tuberculous Meningitis Research Articles

Comparative analysis between tuberculous meningitis and other forms of extrapulmonary tuberculosis.

Tuberculosis is a multisystem disease that may affect any organ or tissue. Tuberculous meningitis (TBM) is the most severe form of tuberculosis and commonly affects the brain. We aimed to study the epidemiological, clinical, therapeutic and evolutionary features of TBM among adults and to compare them with other forms of extrapulmonary tuberculosis. We conducted a retrospective study including all patients hospitalized for extrapulmonary tuberculosis in the infectious disease department in Sfax, Tunisia between 1993 and 2018. We specified the particularities of TBM cases, and we compared them with other extrapulmonary tuberculosis cases. We encountered 78 patients diagnosed with TBM, among 519 patients with extrapulmonary tuberculosis (15%). The median age was 36 years (23-50) years. There were 44 females (56.4%). In comparison with other forms of extrapulmonary tuberculosis, fever [odds ratio (OR)=4.4; p<0.001], asthenia (OR=3.4; p<0.001) and anorexia (OR=2.3; p=0.001) were significantly more frequent in TBM patients. Adverse effects of antitubercular therapy were more frequent among TBM patients (OR=3.1; p<0.001). The mean duration of antitubercular therapy was 15 (12-20) months. Recovery occurred in 66 cases (84.6%), complications in 44 cases (56.4%) and death in 7 cases (9%). Comparison of the disease evolution showed that complications (OR=7.4; p<0.001) and mortality rates (OR=10.7; p<0.001) were significantly more frequent in TBM patients, while recovery was significantly more frequent in other sites of extrapulmonary tuberculosis patients (OR=0.5; p=0.02). In our country, TBM remains a disabling disease. Despite antitubercular therapy, the prognosis was more severe with the occurrence of not only complications but also a high mortality rate in comparison with other forms of extrapulmonary tuberculosis. When clinical and laboratory features suggest the diagnosis of TBM, clinicians should look for tuberculosis elsewhere in the body.

Predictors Modifying the Outcome of Tuberculous Meningitis (TBM) in Adults: A Hospital Based Study in Bangladesh

Background: Outcome of TBM can be modified by several predictors.&#x0D; Objective: This study was undertaken to evaluate the predictors of outcome of tuberculous meningitis (TBM) at 6 and 9 months.&#x0D; Methodology: This hospital based prospective cohort study was carried out from October, 2016 to September, 2017 (1 year) in the in-patient Department of Neurology at the National Institute of Neurosciences &amp; Hospital (NINS &amp; H), Dhaka, Bangladesh. All the patients with age 18 years or more of both sexes with features of TBM fulfilling the case definition criteria was included as the study population. The outcome was measured at 6 and 9 months by modified Rankin Scale (mRS) with no disability (score=0-1), mild disability (score = 2), moderate disability (score=3-4), severe disability (score=5) and dead (score=6). For statistical analysis outcome was classified as death and survival group. A number of clinical, laboratory and radiological parameters were evaluated initially by univariate and finally multiple regression analysis.&#x0D; Results: A total 54 TBM patients were included in this study. Over 70% of the patients were adolescent or young adult (&lt; 30 years) with mean age of 28.2 ± 12.3 years and 63% were female. Staging of the TBM showed that nearly half (48.1%) were at stage II and 37% cases were in stage III disease. Baseline imaging (CT-scan and MRI) showed basal meningeal enhancement in 40.7% cases, hydrocephalus in 40.7%, infarction 46.3% and tuberculoma in 29.6% cases. Final diagnosis was established as definite TBM in 3(5.6%) cases, probable TBM 30(55.6%) and possible TBM in 21(38.9%) cases. In terms of 6-months outcome, 16(29.6%) cases died and 10(18.5%) had recovered without any neurological sequelae; however, mild, moderate and severe disability were in11.1%, 27.8% and 13% cases respectively. At the 9 months of evaluation 13 (24.0%) had complete recovery without any neurological sequelae, 22 (40.9%) patients survived with various degree of disabilities like visual impairment, hemi or paraplegia, cognitive impairment, rests died giving a total mortality of 19(35.1%). In univariate analysis, age &gt;50 years (p=0.019), duration of illness before initiation of treatment (&gt;45 d) (p = 0.041), convulsion (p = 0.010), altered sensorium (p&lt;0.001), delayed initiation of treatment &gt;1 month (p=0.041) and stage III TBM (p&lt;0.001) were significantly associated with mortality. In multivariate analyses stage III TBM (p=0.004), altered sensorium (p=0.036), delayed initiation of treatment &gt;1 month (p=0.043) emerged as independent predictors of mortality.&#x0D; Conclusions: In conclusion stage III TBM, altered sensorium and delayed initiation of treatment more than 1 month are the independent predictors of mortality in TBM patients.&#x0D; Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 14-19

A Study of CT Findings in children with neurotuberculosis

Objectives: To study the computed tomography (CT) features of tuberculous meningitis in children. Methods: A total of 45 patients diagnosed with neurotuberculosis were included. Cranial CT scans were done in these patients with and without IV contrast. The CT results were evaluated. Results: CT findings were abnormal in 41 (91.11%) and normal in 4 (8.89%). Basal exudate was the most common finding, seen in 25 (55.55%) cases followed by hydrocephalus in 15 (33.33%) cases. Infarcts were seen in 8 (17.77%), tuberculoma in 6 (13.33%), cerebral oedema in 3 (6.66%) children, cerebral atrophy and cerebral abscess were 1 (2.22%) each. Conclusion: CT is abnormal in the great majority of patients with neurotuberculosis and can aid in the diagnosis. Basal enhancement was the most common finding in our study.

The cerebrospinal fluid cytological features of tuberculous meningitis in children

Background Tuberculous meningitis (TBM) is a common central nervous system (CNS) infectious disease,and is a serious threat to people's health. Due to its diverse clinical manifestations, especially atypical in infants and young children, it is easy to be misdiagnosed and can lead to high disablility rate and mortality rate. At present, cerebrospinal fluid (CSF) cytology still plays an important role in the etiological diagnosis of CNS infectious diseases. Based on the observation of CSF cytological changes of children with TBM, this study is to further understand the performance and evolution characteristics of this disease, so as to improve the ability of early diagnosis and judgment on the treatment effect. Methods Fresh CSF was collected to make smears by using cytological slide centrifugation, and apply May-Grunwald-Giemsa (MGG) staining for morphological classification. Results CSF cytology of all patients were abnormal. The average leukocyte count of children with TBM was (310.19 ± 156.26) × 106/L, and was significantly different from that of children with purulent meningitis ( P = 0.000). Lymphocyte proportion of TBM group was (66.56 ± 14.08)% , and there were significant differences among different groups ( P = 0.037, 0.000). Compared to children with purulent meningitis, higher proportion of monocytes ( P = 0.000, 0.020) and plasma cells ( P = 0.001, 0.004) were found in children with TBM and viral meningitis. The positive detection rate of plasma cells in children with TBM was higher than that in children with purulent meningitis ( P = 0.001). Conclusion The CSF cytology changing characteristics of children with TBM are revealed. In the beginning the lymphocyte proportion is dominant in CSF cytology, and then different extents of mixed cellular response appear as disease develops. For children with effective treatment, the proportion of neutrophils decreases rapidly and turns to lymphocyte reaction gradually, with monocytes and plasma cells, lasting for a long time. Long-term mixed cellular response will happen in children with ineffective treatment. All in all, the CSF cytology changing characteristics are significant in clinical diagnosis and differential diagnosis of TBM in children.

Delayed diagnosis of tuberculous meningitis in a pregnant Nigerian: A case report.

Tuberculous meningitis (TBM) is the most severe form of tuberculosis and is commoner in those with immunsuppression. Diagnosis continues to be difficult particularly in resource limited settings, and this may be truer in the setting of pregnancy. We report the case of a pregnant Nigerian who was diagnosed late with atypical features of TBM complicated by cerebral infarction. High index of suspicion and early administration of anti-tuberculous medications as daily therapy according to the national treatment guidelines: 600mg Rifampicin, 300mg Isoniazid, 1.2g Pyrazinamide and 800mg Ethambutol plus 50mg pyridoxine and 0.4mg/kg body weight/day dexamethasone which was tapered weekly led to a slow but sustained clinical improvement. The relationship between pregnancy, susceptibility to TBM and presenting features of TBM requires further exploration. Clinicians should also be aware of atypical presentation of TBM in pregnancy, and the suspicion of TBM may be sufficient grounds to initiate empirical anti-tuberculous therapy.

The clinical and cerebrospinal fluid cytological features of tuberculous meningitis

Objective To analyze the clinical and cerebrospinal fluid (CSF) cytological features of patients with tuberculous meningitis (TBM), to improve early diagnostic accuracy and treatment of TBM. Methods Clinical presentations, etiology and biochemical and cytological features of CSF were analyzed retrospectively among 60 adult cases with TBM hospitalized at Neurology Department of General Hospital of Ningxia Medical University from January 2005 to May 2011. Results Most patients (58/60, 96.67%) had fever and headache at onset. In some patients, disturbance of consciousness (9/60, 15.00%), seizure (5/60, 8.33%) occurred in 1 week and focal neurological signs developed during the course. Forty⁃four patients (73.33%) had pulmonary tuberculosis history. In CSF examination, acid⁃fast bacillus positive was found in 8 patients. Positive acid ⁃ fast myobacterium tuberculous culture was detected in 5 patients and positive myobacterium tuberculosis DNA were seen in 5 patients. The main changes of CSF were intracranial hypertension, increase of protein, and decrease of glucose. CSF presented mixed cellular response with predominace in the increasing of leucocytes. During early stage the mean percentage of neutrophil in CSF was less than 40%. After short term (as long as 2 months) of regular antituberculotic therapy no significant changes in total cell count and the proportion of neutrophils were seen. In 60 patients, 44 patients were ameliorated, 11 were not healed or were discharged or transferred to other hospital and 5 were dead. Prognosis of patients treated within 3 weeks after onsets was superiorly to those treated at more than 3 weeks after onset. Conclusion There are no specific clinical features in TBM and it is hard to perform early diagnosis for TBM, particularly, existing of low efficiency in pathogenic detection, but pulmonary tuberculosis is of accessary value to diagnose TBM. Whereas mixed cellular response may complementarily provide the diagnosis of TBM in early stage. Cytologic changes of CSF can be very slow even after therapy. Therefore persistent mixed cellular response in CSF cannot exclude TBM. The time of treatment will determine the therapeutic effectiveness in a great degree. DOI：10.3969/j.issn.1672⁃6731.2012.02.021

Extra-adrenal Paraganglioma: An Uncommon Cause of Secondary Hypertension in a Young Subject

An 8 year boy was admitted with features of tuberculous meningitis. He was detected to have hypertension. Further investigations revealed an extra-adrenal paraganglioma. Tuberculous meningitis and paraganglioma could be chance associations. Paraganglioma is a rare and potentially lethal cause of secondary hypertension, very uncommon at this age. If left untreated it leads to complications arising from unrelenting hypertension. We report a case report on this very rare disease of paraganglioma presenting in an unexpected way. Key words: Paraganglioma; Tuberculous meningitis; Secondary hypertension DOI: http://dx.doi.org/10.3126/jnps.v31i3.4965 J Nep Paedtr Soc 2011;31(3): 238-240

MRI findings in children with tuberculous meningitis: a comparison of HIV-infected and non-infected patients

Radiological studies on HIV infection in tuberculous meningitis (TBM) in children are limited to small, retrospective studies using CT features. They report that HIV-infected children are less likely to display meningovascular enhancement, tuberculoma formation and obstructive hydrocephalus. No similar MRI-based studies were found in the literature. The purpose of this study is to compare the MRI features of TBM in HIV-infected and uninfected children. Retrospective descriptive study comparing clinical, laboratory and MRI features of 8 HIV-infected and 19 HIV-uninfected children with TBM. Intense basal meningeal enhancement occurred less frequently (p = 0.31) in HIV-infected children whilst cerebral atrophy was more commonly encountered (p = 0.06) Neither finding was however of statistical significance. All HIV-infected children had visible meningeal nodules on MR imaging compared to 72% in HIV-uninfected children with TBM. No differences were noted regarding number or location of infarcts and presence of hydrocephalus. Hydrocephalus in HIV-infected children was exclusively of communicating nature. The MRI criteria for diagnosis of TBM apply to HIV-infected children. The presence of nodular meningeal disease in all HIV-infected children has not previously been reported and requires further investigation.

Secondary hypertension: A rare cause

A 13-year-old, previously asymptomatic girl was admitted with features of tuberculous meningitis. She was found to be hypertensive and further investigations revealed an extra-adrenal paraganglioma. Tuberculous meningitis and paraganglioma could be chance associations. Paraganglioma is a very rare and potentially lethal cause of secondary hypertension. We are reporting a very rare disease, which has come to light in a most unexpected manner.

Value of early follow-up CT in paediatric tuberculous meningitis

The value of CT in the diagnosis of tuberculous meningitis (TBM) in children is well reported. Follow-up CT scanning for these patients is, however, not well described and, in particular, the value of early follow-up CT has not been addressed for children with TBM. To assess the value of early follow-up CT in children with TBM in identifying diagnostic, prognostic and therapeutically relevant features of TBM. A retrospective 4-year review of CT scans performed within 1 week and 1 month of initial CT in children with proven (CSF culture-positive) and probable TBM (CSF profile-positive but culture-negative) and comparison with initial CT for the diagnostic, prognostic and therapeutic CT features of TBM. The CT scans of 50 children were included (19 "definite" TBM; 31 "probable" TBM). Of these, 30 had CT scans performed within 1 week of the initial CT. On initial CT, 44 patients had basal enhancement. Only 24 patients had contrast medium-enhanced follow-up scans. Important findings include: 8 of 29 patients (who were not shunted) developed new hydrocephalus. New infarcts developed in 24 patients; 45% of those who did not have infarction initially developed new infarcts. Three of the six patients who did not show basal enhancement on initial scans developed this on the follow-up scans, while in seven patients with pre-existing basal enhancement this became more pronounced. Two patients developed hyperdensity in the cisterns on non-contrast medium scans. Eight patients developed a diagnostic triad of features. Three patients developed CT features of TBM where there was none on the initial scans. Early follow-up CT is useful in making a diagnosis of TBM by demonstrating features that were not present initially and by demonstrating more sensitive, obvious or additional features of TBM. In addition, follow-up CT is valuable as a prognostic indicator as it demonstrates additional infarcts which may have developed or become more visible since the initial study. Lastly, follow-up CT has therapeutic value in demonstrating hydrocephalus, which may develop over time and may require drainage. We advise routine follow-up CT in patients with suspected TBM within the first week of initial CT and optionally at 1 month.

Magnetic resonance features of intracranial tuberculosis in children

Intracranial tuberculosis in children is seen as either parenchymal tuberculous lesions or tuberculous meningitis (TBM). This article demonstrates the MR features of TBM and the two varieties of tuberculous (TB) granulomata. Gummatous granulomata (tuberculomata) comprise 90% of presenting intracranial TB lesions. They have a characteristic low signal on T2-weighted sequences that differentiates them from other commonly encountered ring-enhancing lesions such as neurocysticerci. TB abscesses are very rare and have the same features as pyogenic abscesses. Features of TBM include hydrocephalus, basal meningeal enhancement and basal ganglia infarctions.

The clinical, radiological and pathological profile of tuberculous meningitis in patients with and without human immunodeficiency virus infection

Background: As human immunodeficiency virus (HIV) infection primarily impairs cellular immunity, the immune responses of HIV-infected individuals to tuberculous bacilli may be inadequate. The features of pulmonary and abdominal tuberculosis evident in HIV-positive (HIV-P) patients with severe immunosuppression are markedly different from those seen in HIV-negative (HIV-N) patients. However, such differences have not been reported in tuberculous meningitis (TBM). Here, we therefore compared the clinical, radiological and pathological features of TBM in patients with and without HIV infection. Methods and results: Twenty-two HIV-P patients with TBM, seen over 5 years, were studied and compared with 31 HIV-N patients with TBM. Although clinical features were similar, cognitive dysfunction was more common amongst the HIV-P group. Pathological features were markedly different in the HIV-P group reflecting severely reduced and atypical inflammatory response, and extensive vasculopathy. This manifested as absence or minimal meningeal enhancement and absence of communicating hydrocephalus on CT scan in HIV-P patients. Mortality was higher within the HIV-P group and depressed levels of consciousness and hemiplegia were associated with poor prognosis. Conclusion: The clinical, radiological and pathological features of TBM in HIV-P patients are distinctly different from those without HIV infection; a finding previously unreported.

The potential contribution of the polymerase chain reaction to the diagnosis of tuberculous meningitis.

To examine diagnostic utility of polymerase chain reaction (PCR) on cerebrospinal fluid (CSF) in tuberculous meningitis (TBM). Comparison study. Referral center for tuberculosis diagnosis and treatment in Ho Chi Minh City, Vietnam, and research laboratory in Amsterdam, the Netherlands. One hundred thirty-six consecutive patients, aged 4 months to 85 years, with features compatible with TBM seen during a 12-month period. Clinical examination; cytology; Gram, india ink, and Ziehl-Neelsen staining; culture of CSF for bacteria, mycobacteria, fungi, and viruses; and CSF chloride, protein, and glucose. All these tests were performed in Vietnam. The PCR on CSF was performed in the Netherlands. Patients were managed in Vietnam without knowledge of PCR results. Based on clinical grounds and the results of initial CSF microscopy, antituberculous treatment was given to 104 patients, 66 of whom had evidence of extraneural tuberculosis. Among the 39 patients with confirmed TBM (ie, positive Ziehl-Neelsen staining or culture or PCR results for Mycobacterium tuberculosis), PCR detected 32 patients (82%), 1 case was proven positive through microscopy and 17 (44%) had positive culture results. There were no false-positive PCR results. In 99 patients with a final diagnosis of confirmed or probable TBM (ie, clinical features of TBM and response to antituberculous treatment), PCR had a sensitivity of 32%; culture, 17% and microscopy, 1%. Many patients who respond to treatment for TBM do not have M tuberculosis in the CSF identifiable by microscopy, PCR, or culture. Polymerase chain reaction on CSF is the best method for the laboratory diagnosis of TBM. Polymerase chain reaction is especially useful for the early diagnosis of TBM in those without active extraneural tuberculosis.