Optochiasmatic Arachnoiditis Research Articles

Optochiasmatic Tuberculoma and Arachnoiditis as a Paradoxical Reaction to Antituberculous Treatment.

Optochiasmatic Tuberculoma and Arachnoiditis as a Paradoxical Reaction to Antituberculous Treatment.

Paradoxical reactions in the form of Optochiasmatic arachnoiditis and stroke in An immunocompetent girl with tuberculous Meningitis- a case report

The paradoxical response is characterized by clinical or radiologic worsening of pre-existing lesions or the appearance of new lesions following initiation of treatment for tuberculosis (TB). The paradoxical response has raised questions about the accuracy of the diagnosis, the potential for treatment failure, and the presence of an underlying disease, making it an important topic of care for clinicians. In this case report, we present the paradox reaction of a 14 year old girl diagnosed and treated for TB meningitis. This healthy immune girl is successfully treated with steroids, and we discuss the importance of treating the paradox of tuberculosis progression despite the use of effective anti-TB drugs. Bangladesh J Medicine 2023; 34(3): 245-251

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.

Role of Thalidomide in the management of complicated Tuberculous Meningitis (S25.005)

<h3>Objective:</h3> The optimal management of TBM complications like opto-chiasmatic arachnoiditis, spinal arachnoiditis, vasculitic infarcts, tuberculomas (esp. paradoxical as well as persisting lesions), and hydrocephalus remains to be defined. These patients are managed by the continuation of ATT and administration of high-dose systemic corticosteroids. Some authors suggest more aggressive immunomodulation. <h3>Background:</h3> To study the role of Thalidomide in managing complications in patients of Tuberculous meningitis (TBM) despite being on the best medical therapy <h3>Design/Methods:</h3> The present study included 59 patients of Opto-chiasmatic arachnoiditis, 33 patients of spinal arachnoiditis with myelitis, and 27 patients with a paradoxical increase in the size of tuberculomas on follow-up despite being on full dose anti-tubercular drugs (ATT) and steroids. Imaging (Baseline MRI and follow-up MRI at 3 months and 1 year of treatment) was done in all patients. <h3>Results:</h3> The mean duration of appearance of vision loss despite being on treatment varied from 4 weeks to 9 months. The patients with spinal arachnoiditis with myelitis showed worsening from 2 weeks to 6 months, and a paradoxical response was observed as late as 8 months in a few patients. All these patients were treated with Thalidomide at the dose of 2–3 mg/ kg body weight (Range of 50–150 mg/ day), which was continued for an average of 6 months duration. Of 59 patients with vision loss, 39 patients showed clinical improvement in visual acuity, while 21 out of 33 patients with spinal arachnoiditis showed clinical improvement, and 18 out of 27 patients showed either reduction or healing of tuberculomas after starting this immunomodulation. Baseline MRI in most patients (&gt;95%) showed abnormalities in the form of arachnoiditis, tuberculomas, etc., which on 2–3-month follow-up Imaging showed worsening of radiological features and responded well after starting Thalidomide. <h3>Conclusions:</h3> Thalidomide is a promising immunomodulator, especially in complicated TBM cases due to worsening arachnoiditis and tuberculomas. <b>Disclosure:</b> Dr. Modi has nothing to disclose. Dr. Shree has nothing to disclose. Dr. Kakkar has nothing to disclose. Manoj Goyal has nothing to disclose. Kusum Sharma has nothing to disclose.

Tubercular Optochiasmatic Arachnoiditis: A Case Report with Current Therapeutics and Management

Central nervous system tuberculosis (CNS TB) involves the brain parenchyma, meninges, and spinal cord. The primary pathology in CNS TB includes thick basal exudates leading to intense meningeal inflammation, vasculitis, and hydrocephalus. When these exudates and inflammation predominantly involve the structure in and around suprasellar cistern region, it results in a condition called optochiasmatic arachnoiditis (OCA). OCA is one of the cataclysmal complications of CNS TB, leading to vision loss. A previously healthy young woman came to our center with the complaints of low-grade fever, headache, weight loss, and visual obscuration. For further evaluation, she underwent lumbar puncture, and based on cerebrospinal fluid analysis, she was a diagnosed with CNS TB and was promptly started on antitubercular therapy along with steroid. A contrast-enhanced magnetic resonance imaging of the brain and orbit showed OCA. For OCA, she was given pulse-dose dexamethasone along with intrathecal hyaluronidase with which there was marginal improvement in vision. Management of OCA can be very challenging with unsatisfactory response. Many agents such as pulse steroid, intrathecal hyaluronidase, thalidomide, tumor necrosis factor alpha inhibitors, and cyclophosphamide have been used with inconsistent results. We have also done a review of the literature for the current evidence and newer therapeutics available for the management of OCA.

Neuro-ophthalmic manifestations of central nervous system tuberculosis: Compilation of three diverse unique presentations

Tubercular meningitis is the most devastating form of tuberculosis. Neuro-ophthalmic involvement can manifest as cranial nerve palsies, pupil abnormalities, disc changes, like papillitis, papilloedema, or optic atrophy and choroidal tubercles. The rate and extent of recovery are strongly. Related to early diagnosis and treatment. Herein, we describe a constellation of three cases of central nervous system tuberculosis with aberrant regeneration of oculomotor nerve, optochiasmatic arachnoiditis presenting as bilateral primary optic atrophy and the last case of parietal lobe tuberculoma presenting as homonymous hemianopia, each one with its own characteristic ocular findings.

Intrathecal hyaluronidase for impending and symptomatic arachnoiditis in Tubercular Meningitis

CNS Tuberculosis, the most rampant infection of the developing world, clinicopathologically can occur alone or combined as Tubercular Meningitis, Tuberculomas (intracranial and/or spinal), Arachnoiditis (basal, optochaismatic, spinal) or Myelitis. The viscous exudates in basal cisterns cause Optochiasmatic arachnoiditis[1], and nodular, thickened, clumped nerve roots called Lumbosacral arachnoiditis.[2] We herein propose use of intrathecal hyaluronidase, as adjuvent for symptomatic as well as impending arachnoiditis.

Neurotuberculosis: an update.

Tuberculous (TB) meningitis (TBM), accounting for 70-80% of cases of neurotuberculosis, is one of the most severe forms of extrapulmonary tuberculosis. Two-thirds of new TB cases come from eight countries. Polymorphisms in toll-interleukin-1 receptor domain and in leukotriene A4 hydrolase (LTA4H) gene, affect the risk of inflammation in TBM. The common site of tuberculoma in children is cerebellum, and they may rarely develop tuberculous encephalopathy which has a high mortality. Young females with a high cerebrospinal fluid (CSF) protein have an increased predisposition to develop optochiasmatic arachnoiditis. Spinal TB meningitis may mimic transverse myelitis or Guillain-Barre syndrome. An extra-neural focus of TB should be sought clinically and radiologically as it may indicate safer and more accessible sites for diagnostic samplings. Cartridge-based nucleic acid amplification test (CBNAAT), also known as Genexpert test, is a polymerase chain reaction (PCR)-based method for detection of TB which also detects rifampicin resistance as it targets the rpob gene of mycobacteria. Line probe assays, based on PCR and reverse hybridization methods, identify mutations associated with drug resistance within a week. TBM being a paucibacillary disease, often evades a definite diagnosis and empirical treatment for a minimum of 9months is warranted based on clinical judgement. All TBM patients should receive adjunctive corticosteroids, even those with HIV infection. Drug resistance is strongly associated with previous treatment and bedaquiline as well as delamanid have received approvals for multidrug resistant (MDR) TB. The key principle of managing MDR TB is never to add a single drug to a failing regimen. Correct combination and duration of most effective second line drugs in MDR TB require further modifications. Early shunting should be considered in those with hydrocephalus failing medical management. The single most important determinant of outcome is the stage of TBM at which treatment has been started.

Thalidomide Use for Complicated Central Nervous System Tuberculosis in Children: Insights From an Observational Cohort.

Much of the neurological sequelae of central nervous system (CNS) tuberculosis (TB) is due to an excessive cytokine-driven host-inflammatory response. Adjunctive corticosteroids, which reduce cytokine production and thus dampen the inflammation, improve overall survival but do not prevent morbidity. This has prompted investigation of more targeted immunomodulatory agents, including thalidomide. We describe a retrospective cohort of 38 children consecutively treated with adjunctive thalidomide for CNS TB-related complications over a 10-year period. The most common presenting symptom was focal motor deficit (n = 16), followed by cranial nerve palsies and cerebellar dysfunction. Three of the 38 children presented with large dural-based lesions, manifesting as epilepsia partialis continua (EPC), 4 presented with blindness secondary to optochiasmatic arachnoiditis, and 2 children developed paraplegia due to spinal cord TB mass lesions. Duration of adjunctive thalidomide therapy (3-5 mg/kg/day) varied according to complication type. In children compromised by TB mass lesions, the median treatment duration was 3.9 months (interquartile range [IQR], 2.0-5.0 months), whereas in children with optic neuritis it was 2.0 months (IQR, 1.3-7.3 months) and in EPC it was 1.0 months (IQR, 1-2.5 months). Satisfactory clinical and radiological response was observed in 37 of the children. None of the children experienced rashes, hepatitis, or hematologic derangements or complained of leg cramps. This study is the largest cohort of adult or pediatric patients treated with adjunctive thalidomide for CNS TB-related complications. The drug has proved to be safe and well tolerated and appears to be clinically efficacious. The potential role of thalidomide or analogues in the treatment of other tuberculous meningitis-related complications requires further exploration.

Author response: Tuberculous optochiasmatic arachnoiditis and vision loss.

We thank Malhotra et al. for pointing out that our NeuroImage was of T1 postcontrast coronal images, not T2, and apologize for the error.1

Editors' Note

Editors' Note: In WriteClick this week, Kumfor et al. comment on the differences between brain reserve and cognitive reserve in reference to “Cognitive reserve in frontotemporal degeneration: Neuroanatomic and neuropsychological evidence.” Authors Placek et al. agree that more research is required to better characterize both mechanisms. Malhotra et al. correctly comment that in the NeuroImage “Tuberculous optochiasmatic arachnoiditis and vision loss,” T1-weighted postcontrast coronal images are shown rather than T2-weighted images, as labeled in the legend. A correction appears on page 1591. —Megan Alcauskas, MD, and Robert C. Griggs, MD Editors' Note: In WriteClick this week, Kumfor et al. comment on the differences between brain reserve and cognitive reserve in reference to “Cognitive reserve in frontotemporal degeneration: Neuroanatomic and neuropsychological evidence.” Authors Placek et al. agree that more research is required to better characterize both mechanisms.

Concurrent intramedullary spinal cord and multiple intracranial tuberculomas with tuberculous optic neuritis: A rare case report

Tuberculosis (TB) remains a worldwide burden, with a large majority of new active TB cases occurring in underdeveloped and developing countries. Tuberculous meningitis (TBM) is one of the common infections of central nervous system. Other manifestations include intracranial tuberculoma, tubercular brain abscess, spinal tuberculoma, and granulomatous arachnoiditis. Visual impairment in TBM may be due to optic neuritis, optochiasmatic arachnoiditis (OCA), tuberculoma in the chiasmatic region or in the optic pathways, chorioretinitis, secondary to hydrocephalus and increased intracranial pressure, and finally due to ethambutol toxicity. We report a case of young girl with concurrent spinal cord intramedullary tuberculoma and multiple intracranial tuberculomas with TBM and bilateral visual impairment due to tuberculous optic neuritis.

Paradoxical reaction in tuberculous meningitis: presentation, predictors and impact on prognosis.

BackgroundAwareness about paradoxical reactions in tuberculous meningitis is crucial as a paradoxical reaction may lead to certain wrong conclusions (for example, an erroneous diagnosis, and a possibility of treatment failure, mycobacterial drug-resistance, drug toxicity, or presence of a malignancy). The present study was planned to evaluate the incidence and predictive factors of paradoxical reactions in light of clinical, cerebrospinal fluid, and neuroimaging characteristics.MethodsIn this prospective cohort study, consecutive patients fulfilling the International Consensus criteria of tuberculous meningitis were included. Patients were subjected to clinical evaluation, cerebrospinal fluid evaluation, and neuroimaging. Patients were treated with anti-tuberculosis drugs along with corticosteroids. Patients were regularly followed up at 3 monthly intervals. At each follow up patients were evaluated clinically and repeat cerebrospinal fluid analysis was performed along with repeat neuroimaging. Disability assessment was done using Barthel index.ResultsWe enrolled 141 patients of tuberculous meningitis. Approximately one-third of patients (44/141; 31.2 %) developed a paradoxical reaction. Twenty-seven patients developed hydrocephalus, 26 developed tuberculomas, 12 developed optochiasmatic arachnoiditis and 4 patients had spinal arachnoiditis. In 41 patients (out of 44) cerebrospinal fluid paradoxically worsened (increase in cells and/or protein); 2 demonstrated a decrease in cells with polymorph predominance while in one it was normal. In 3 patients, paradoxical cerebrospinal fluid changes were not associated with neuroimaging changes. On multivariate analysis, predictors of paradoxical reaction were female gender (p = 0.013), HIV positivity (p = 0.01) and a shorter duration of illness (p = 0.049). Development of paradoxical reactions did not predict the disability status of the patients.ConclusionsParadoxical reaction occurs in approximately one-third of patients with tuberculous meningitis. Female gender, concomitant HIV infection, and a shorter duration of illness were significant predictors. Paradoxical reactions did not adversely affect the outcome.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-1625-9) contains supplementary material, which is available to authorized users.

Visual Impairment in HIV Negative Tuberculosis Meningitis

Objective: Visual impairment is a common problem in tuberculous meningitis (TBM). Present study has been conducted to evaluate the prevalence of visual impairment at presentation and at 3 months. Methods: Twenty seven consecutive HIV negative patients with TBM were included. Visual acuity, colour vision, field of vision, and visual evoked potentials (VEP) were recorded at baseline and at 3 months. The criteria for visual impairment were: visual acuity <6/12 and <N/10, defective color vision, and visual field abnormality either alone / in combination. Fundus was examined by a single examiner using slit lamp biomicroscopic examination with 90 D lens and by indirect ophthalmoscopy with 2.2D lens. Results: Twelve patients out of 27 had visual impairment at presentation and the causes were optochiasmatic arachnoiditis (n=6), optic atrophy (n=2), occipital infarct (n=1) and unremarkable (n=3). Three patients showed improvement in visual acuity, 6 patients had no change and 3 patients expired at 3 months. On multivariate analysis papilloedema, optic atophy, temporal disc pallor and hydrocephalus were predictors of visual impairment at 3months (p< 0.001 ). Conclusion: Visual impairment in TBM is observed in half the patients. It may be predicted by the presence of hydrocephalus on computerized tomography (CT)/ magnetic resonance imaging (MRI), while a simple bedside fundus examination can predict the visual impairment at three months. VEP helps in detecting sub-clinical visual impairment.

Delayed visual loss from optochiasmatic arachnoiditis after resection of craniopharyngioma

Visual loss following surgery for craniopharyngioma is usually the result of operative injury or tumor recurrence. The authors present the case of a 12-year-old boy who developed progressive visual field constriction 11 years after gross-total resection of a solid and cystic craniopharyngioma. No tumor recurrence was evident on multiple MRI studies, and it was only at surgical exploration that the diagnosis of optochiasmatic arachnoiditis was established. Lysis of the adhesions around the optic nerves and chiasm resulted in substantial and sustained visual improvement.

A Case of Tuberculous Optochiasmatic Arachnoiditis

결핵성 ì‹œì‹ ê²½êµì°¨ 거미막염은 결핵성 수막염의 드문 합병증으로 심각한 시각 ìž¥ì• ë¥¼ ìœ ë°œí• ìˆ˜ 있으나, í•­ê²°í•µì œë¥¼ ì‚¬ìš©í•˜ê³ ìžˆëŠ” 도중에도 ë°œìƒí• ìˆ˜ ìžˆê³ , í•­ê²°í•µì œì— 의한 ì•ˆë ì„± 증상과 í˜¼ëˆë ìˆ˜ 있다. ì €ìžë“¤ì€ 에탐부톨 ë ì„±ì— 의한 시각 ìž¥ì• ë¡œ 오인되었던 결핵성 ì‹œì‹ ê²½êµì°¨ 거미막염을 경험하였으므로 결핵성 수막염으로 í•­ê²°í•µì œ 치료를 ë°›ê³ ìžˆëŠ” 환자에서 시각 ìž¥ì• ì¦ìƒì„ 보일 경우, 결핵성 ì‹œì‹ ê²½êµì°¨ 거미막염의 가능성을 ê³ ë ¤í•˜ì—¬ 뇌 ìžê¸°ê³µëª ì˜ìƒ 및 ì•ˆê³¼ì  검사를 ì ê·¹ì ìœ¼ë¡œ 시행을 ê³ ë ¤í•´ì•¼ í• ê²ƒìœ¼ë¡œ 생각한다. 중심 단어: ì‹œì‹ ê²½êµì°¨ 거미막염; 결핵성 수막염; 시각 ìž¥ì• ; 에탐부톨 ì‹œì‹ ê²½ ë ì„±

Tuberculous optochiasmatic arachnoiditis: a devastating form of tuberculous meningitis

Tuberculous meningitis is primarily a disease of the meninges of brain and spinal cord along with adjacent brain parenchyma. The characteristic pathological changes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Tuberculous meningitis has a strong predilection for basal parts of the brain. Exudates, if dominantly present in the interpeduncular, suprasellar and Sylvian cisterns, result in optochiasmatic arachnoiditis and tuberculoma. Optochiasmatic arachnoiditis and tuberculoma are devastating forms of tuberculous meningitis and often associated with profound vision loss. This clinical entity more frequently affects young adults. In a recent study, on the multivariate logistic regression analysis, female sex, younger age and raised cerebrospinal fluid protein content were identified as predictors for developing optochiasmatic arachnoiditis. Frequently, optochiasmatic tuberculoma and optochiasmatic arachnoiditis develop paradoxically while a patient is being treated with anti-TB drugs. MRI reveals confluent enhancing lesions that are present in the interpeduncular fossa, pontine cistern, and the perimesencephalic and suprasellar cisterns. Management of tuberculous optochiasmatic arachnoiditis and optochiasmatic arachnoiditis tuberculoma has been variable. Treatment of optochiasmatic arachnoiditis continues to be a challenge and the response is generally unsatisfactory. In isolated case reports and in small series, corticosteroids, methyl prednisolone, thalidomide and hyaluronidase have been used with variable success. The benefit from neurosurgery is controversial and deterioration may follow the initial temporary improvement. Management of paradoxical optochiasmatic arachnoiditis is also controversial. Some patients regain vision following treatment with anti-TB drugs and continued usage of corticosteroids. Neurosurgery may be considered in the patients with either treatment failure or when diagnosis is in doubt. In conclusion, presence of optochiasmatic arachnoiditis or tuberculoma has important therapeutic and prognostic implications for patients of tuberculous meningitis.

Incidence, predictors and prognostic value of cranial nerve involvement in patients with tuberculous meningitis: A retrospective evaluation

Background Cranial nerve involvement is commonly observed in patients with tuberculous meningitis. The present study evaluated the incidence, predictors and prognostic significance of cranial nerve involvement in tuberculous meningitis. Materials and method One hundred-fifty-eight adult patients with tuberculous meningitis were retrospectively evaluated and followed up for 9 months. A detailed clinical evaluation and cranial magnetic resonance imaging were done in every patient. Result At inclusion, 60 (38%) patients had cranial neuropathy. Sixteen patients were having involvement of two or more cranial nerves. Abducent nerve was the most frequently (32.3%) affected cranial nerve. Predictors of cranial nerve involvement were age > 25 years, history of vomiting, altered sensorium, hemiparesis, diplopia, papilledema, signs of meningeal irritation, severe functional disability, cerebrospinal fluid protein > 2.5 g/L and cerebrospinal fluid cell count > 100/mm 3. The presence of optochiasmatic arachnoiditis and hydrocephalus was also a significant predictor of cranial neuropathy. Presence of cranial neuropathy was significantly associated with poor outcome. Conclusion Cranial nerve involvement occurred in more than one third of patients with tuberculous meningitis. The presence of cranial neuropathy was associated with poor outcome.

Predictors of stroke in patients of tuberculous meningitis and its effect on the outcome

Stroke is a devastating complication of tuberculous meningitis and is an important determinant of its outcome. To prospectively evaluate the predictive factors for stroke in patients with tuberculous meningitis and to assess the impact of stroke on the overall prognosis and outcome. We evaluated and followed 100 patients of tuberculous meningitis for 6 months. Magnetic resonance imaging was performed at inclusion and after 6 months. We evaluated the predictors of stroke and also assessed the effect of stroke on the outcome. Outcome was defined with the help of modified Rankin scale. Of the 100 patients, 6 lost to follow-up. Thirty patients had stroke, 27 of them had stroke at inclusion. Three patients developed stroke during follow-up. In most of the patients, stroke was a manifestation of advanced stages of tuberculous meningitis. Internal capsule/basal ganglia were the most frequently involved sites. Infarcts commonly involved the middle cerebral arterial territory. On univariate analysis, predictors of stroke were aged >25 years (P < 0.001), cranial nerve involvement (P < 0.001), sylvian fissure exudates (P = 0.026), posterior fossa exudates (P = 0.016), optic chiasmal exudates (P = 0.04) and vision impairment (P = 0.004). Stage III tuberculous meningitis (P < 0.001) was also a predictor of stroke. On multivariate analysis aged >25 years was found a significant predictor of stroke. Strokes in patients with tuberculous meningitis were associated with poor prognosis. Stroke occurred in 30% of cases with tuberculous meningitis. Advanced stage of tuberculous meningitis, basal exudates, optochiasmatic arachnoiditis and vision impairment were significant predictors of stroke. Stroke independently predicted the poor outcome of tuberculous meningitis.

Tuberculous Meningitis-Related Optic Neuritis: Recovery of Vision With Thalidomide in 4 Consecutive Cases

Blindness is an uncommon but devastating complication of tuberculosis meningitis. The main causes are chronically raised intracranial pressure (hydrocephalus and/or tuberculomas) or direct involvement of the optic chiasm or optic nerves by the basal arachnoiditis (inflammation and/or compression). Antituberculosis therapy combined with corticosteroids and control of intracranial pressure constitutes the mainstay of therapy for tuberculous meningitis. Despite these treatment measures, some patients develop blindness, mainly as a result of progressive optochiasmatic arachnoiditis. This led us to explore the role of adjuvant thalidomide therapy, and we describe the dramatic recovery of vision in 4 consecutive cases. Clinical recovery was accompanied by marked radiological improvement on magnetic resonance imaging (MRI) of the brain.