Tuberculous meningitis in the southwest United States: a community-based study

This community-based study analyzed 54 patients with definite or probable tuberculous meningitis (TBM) in New Mexico from 1970 through 1990. Patients ranged in age from 4 months to 86 years. The highest age-specific incidence occurred in the elderly, but 22% of patients were less than 10 years old. Native American patients were overrepresented. Patients were as likely to live in small towns as in large urban cities. Symptoms were present for a median of 13 days before admission. The majority of patients had fevers, headache, stiff neck, and mental changes, such as confusion or lethargy. No patient was admitted comatose. Focal neurologic signs were present in 33%. Laboratory testing found hyponatremia in 79%, pulmonary infiltrates on chest x-ray in 40%, ventricular dilatation on CT or MRI in 52%, and tuberculomas in 16%. PPD skin tests were positive in 64%. CSF cultures grew Mycobacterium tuberculosis in 50%, but colony counts were always lower than 10(2)/ml. As a consequence, acid-fast stains of CSF sediment were reported as positive in only 4%. Six patients were not diagnosed during the hospitalization and died of complications. Twenty-three percent of patients who were appropriately treated also died of complications during the initial hospitalization. Tuberculous meningitis continues to be an important disease in small communities, and affects all ages and ethnic and socioeconomic backgrounds.

Improved detection of mycobacterial antigens in clinical specimens by combined enzyme-linked immunosorbent assay

Three types of antibodies against cellular and secretory-excretory protein antigens were simultaneously used for the direct detection of mycobacterial antigens in sputum and cerebrospinal fluid (CSF) specimens, using enzyme-linked immunosorbent assay (ELISA). The antibodies consisted of in-house raised and prepared anti-whole-cell, heat-killed, and sonicated Mycobacterium tuberculosis, anti-secretory-excretory protein extract of bacilli Calmette-Guerin (BCG) strain, and commercially available anti-BCG. Sputum specimens comprised 24 smear positive, culture positive, and 47 smear-negative, culture positive (SNCP), from patients with pulmonary tuberculosis, as well as 45 smear-negative, culture-negative (SNCN) control samples. The CSF specimens included 18 SNCPs from patients with tuberculous meningitis and 18 SNCN controls. The sensitivity of the individual tests for sputum and CSF specimens ranged from 70% to 79% and 72% to 89%, respectively, whereas in the combined tests it reached 86%-96% for sputum specimens and 100% for CSF specimens. The specificity of ELISAs for sputum specimens was lower in the combined (73%-87%) than in the individual (87%-98%) tests, whereas for CSF specimens it was 100% in all tests. Thus, the combined ELISA approach for mycobacterial antigen detection provides a rapid and reliable laboratory adjunct in the diagnosis of patients with tuberculosis.

Nontuberculous mycobacterial infection of the central nervous system in patients with AIDS

Infections due to nontuberculous mycobacteria (NTM) are especially common in patients with AIDS. Meningitis due to NTM, however, is rare. A search for CSF cultures positive for NTM over the past 11 years at our hospital yielded 16 cases. Of these, 15 were caused by Mycobacterium avium-intracellular (MAI), and one was caused by M fortuitum. All patients with MAI infection had widespread dissemination and at least one risk factor for AIDS. Clinical features included weight loss, altered mentation, and seizures. Analysis of cerebrospinal fluid revealed a mildly elevated leukocyte count with lymphocyte predominance and normal protein and glucose values. All direct smears were negative for acid-fast bacilli. In-hospital mortality was 67%. The patient with infection due to M fortuitum had a preexisting diagnosis of AIDS and had a right upper lobe pneumonia and headaches. Cranial CT showed an enlarged infundibulum of the pituitary gland. Results of CSF analysis were essentially normal, and direct smears were negative. He left the hospital against medical advice. Our study indicates that the finding of MAI in the CSF in patients with AIDS is associated with an in-house mortality of 67% indicating a very poor prognosis.

[The diagnosis of tuberculous meningitis using polymerase chain reaction]

The PCR system can detect 10 pg of DNA and 10-50 cfu of M. tuberculosis. The sensitivity and specificity rate of our PCR system about 80 cases of tuberculosis meningitis and 63 cases of nontuberculous meningitis is 85% and 98.4%, respectively. Comparing with the routine mycobacterial examination in 61 cases of tuberculous meningitis, the positive rate of PCR is 86.9%, while the positive rate of routine mycobacterial examination (smear and/or culture) is only 13.1%. In the 53 negative cases of routine mycobacterial examination, the positive rate of PCR can reach 86.8%. The whole detection can be finished within 2 days.

[Evaluation of detection of M. tuberculosis in clinical specimens of tuberculosis by DNA amplification]

The sensitivity of detection of M. tuberculosis genomic DNA were 1pg or 10-100 bacterial cell by PCR. Only M. tuberculosis, M. bovis and BCG were positive with 165 b.p band, but all other 14 mycobacterium and 10 bacteria of non-mycobacterial tested, were negative. Of 75 sputum specimens of pulmonary tuberculosis, the positive rate of PCR were 53.3%, culture method showed only 21.3%, fast-acid staining were 25.3%. 17 non-tuberculosis lung disease were negative in three methods. Of 58 tuberculosis meningitis, the positive rate of PCR, the fast-acid staining and culture in cerebrospinal fluid were 51.7%, 8.6%, 1.7% respectively. 30 non-tuberculosis meningitis were negative in three methods. The results showed that DNA amplification is a superior method with high degree of sensitivity and specificity for rapid diagnosis of pulmonary tuberculosis and tuberculosis meningitis.

Evidence of transmission of tuberculosis by DNA fingerprinting

OBJECTIVE

To determine whether a subject who had died of tuberculous meningitis had been infected by a neighbour.

DESIGN

Retrospective comparison of isolates of Mycobacterium tuberculosis from the two cases and from 10 controls by DNA fingerprinting.

SETTING

Public Health Service Reference Laboratory for Mycobacteria and bacterial molecular genetics unit of the London School of Hygiene and Tropical Medicine.

SUBJECTS

Deceased and neighbour; 10 controls from the same city, from whom isolates had been collected over three months before the subject's death.

MAIN OUTCOME MEASURES

Identity and similarity values (SAB) between fingerprint patterns from different isolates obtained by hybridisation of restriction fragments produced by PvuII with a probe from the insertion element IS6110/986, present in multiple copies throughout the genome of M tuberculosis.

RESULTS

Isolates from the two cases under investigation had identical fingerprints whereas those from the controls were all distinct. Two clusters of isolates with a similarity coefficient > 0.25 were identified: in one, four out of five patients were born in the midlands (the birth place of the fifth was not known) and in the other all three patients were born in the Indian subcontinent.

CONCLUSIONS

The data are consistent with, but do not prove, transmission of tuberculosis from the neighbour to the deceased. Geographical separation of the pools of infection may have led to the evolution of distinct clusters of fingerprint patterns. DNA fingerprinting of M tuberculosis is a powerful new tool for study of the epidemiology and pathogenesis of tuberculosis.

Tuberculous meningitis in patients infected with the human immunodeficiency virus

BACKGROUND AND METHODS

Tuberculosis is a frequent complication of human immunodeficiency virus (HIV) infection. We describe the clinical manifestations and outcomes of tuberculous meningitis in patients with HIV infection, and compare them with those in non-HIV-infected patients. We reviewed the records from 1985 through 1990 at two large referral hospitals in Madrid for patients who had Mycobacterium tuberculosis isolated from cerebrospinal fluid.

RESULTS

Of 2205 patients with tuberculosis, 455 (21 percent) also had HIV infection, of whom 45 had M. tuberculosis isolated from the cerebrospinal fluid. Of the 37 HIV-infected patients with tuberculous meningitis for whom records were available, 24 (65 percent) had clinical or radiologic evidence of extrameningeal tuberculosis at the time of admission. In 18 of 26 patients (69 percent), a CT scan of the head was abnormal. In most patients, analysis of cerebrospinal fluid showed pleocytosis (median white-cell count, 0.234 x 10(9) per liter) and hypoglycorrhachia (median glucose level, 1.3 mmol per liter), but in 43 percent (15 of 35), the level of protein in cerebrospinal fluid was normal. In four patients with HIV infection, tuberculosis was only discovered after their deaths. Of the 33 patients who received antituberculous treatment, 7 died (in-hospital mortality, 21 percent). Illness lasting more than 14 days before admission and a CD4+ cell count of less than 0.2 x 10(9) per liter (200 per cubic millimeter) were associated with a poor prognosis. Comparison with tuberculous meningitis in patients without HIV infection showed that the presentation, clinical manifestations, cerebrospinal fluid findings, and mortality were generally similar in the two groups. However, of the 1750 patients without HIV infection, only 2 percent (38 patients) had tuberculous meningitis, as compared with 10 percent of the HIV-infected patients (P less than 0.001).

CONCLUSIONS

HIV-infected patients with tuberculosis are at increased risk for meningitis, but infection with HIV does not appear to change the clinical manifestations or the outcome of tuberculous meningitis.

Correlation between culture of Mycobacterium tuberculosis and antimycobacterial antibody in lumbar, ventricular and cisternal cerebrospinal fluids of patients with tuberculous meningitis

In this study positive culture for M. tuberculosis were obtained, 20% in lumbar cerebrospinal fluid (CSF), 75% in ventricular CSF and 87.5% in cisternal CSFs of patients with tuberculous meningitis. Low culture positivity in lumbar CSF is due to the low density of circulating tubercle bacilli in lumbar CSF than in cisternal or ventricular CSFs. However antimycobacterial antibody in lumbar, cisternal and ventricular CSFs circulate in significant titres and are not statistically different from one another. Since specimens of CSF can not be obtained from cisternal or ventricular routes for the routine bacteriological investigations in patients with tuberculous meningitis, detection of antimycobacterial antibody of M. tuberculosis antigen 5 in lumbar CSF by an indirect ELISA may be considered as an aid for the diagnosis of tuberculous meningitis, particularly when repeated CSF cultures are negative for M. tuberculosis.

Rapid diagnosis of tuberculous meningitis by polymerase chain reaction

The polymerase chain reaction (PCR) in cerebrospinal fluid was compared with conventional bacteriology and an enzyme-linked immunosorbent assay (ELISA) for cerebrospinal fluid antibodies in the diagnosis of tuberculous meningitis (TBM). PCR was the most sensitive technique; it detected 15 (75%) of 20 cases of highly probable TBM (based on clinical features), 4 (57%) of 7 probable cases, and 3 (43%) of 7 possible cases. ELISA detected 11 (55%) of the highly probable cases and 2 each of the probable and possible cases. Culture was positive in only 4 of the highly probable cases. Among the controls (14 pyogenic meningitis, 3 aseptic meningitis, 34 other neurological disorders), 6 subjects tested early in the study (2 pyogenic meningitis, 4 other disorders) were PCR positive. Second DNA preparations from their stored cerebrospinal fluid samples were all PCR negative, suggesting that the false-positive results were due to cross-contamination. 18 PCR-positive TBM samples retested were all still PCR positive. The antibody ELISA was positive in 3 controls despite the use of a high cutoff value.

Enzyme-linked immunosorbent assay to detect Mycobacterium tuberculosis antigen 5 and antimycobacterial antibody in cerebrospinal fluid of patients with tuberculous meningitis

Inhibition ELISA and indirect ELISA was standardised to detect Mycobacterium tuberculosis antigen 5 and antimycobacterial antibody in cerebrospinal fluid (CSF) specimens of 75 patients with tuberculous meningitis, (TBM) and 75 patients with non-tuberculous neurological diseases (control group). In both ELISAs, no false-negative results were observed in 15 culture proven patients with TBM. Detection of M. tuberculosis antigen 5 is more sensitive than detection of antimycobacterial antibody. However, both ELISAs showed 100% specificity for tuberculous aetiology in culture-negative patients with TBM. ELISA should be considered as one of the approaches in the laboratory diagnosis of TBM, particularly when standard bacteriological methods are unable to demonstrate M. tuberculosis in CSF specimens of patients with TBM.

Intracranial tuberculosis in children: CT appearance and clinical outcome

We retrospectively evaluated the CT studies of 9 children who presented with intracranial tuberculosis during 1981-1987, and compared their radiographic appearance with the clinical outcome. The most common radiographic findings were: 1) ventriculomegaly (7/9) ,2) tuberculoma formation (6/9), and 3) infarction (4/9). Of 7 patients with ventriculomegaly, 3 required a ventricular shunt and 2 had spontaneous resolution of ventricular dilatation. Four children with ventriculomegaly were moderately or severely retarded, one had cognitive dysfunction, and one was neurologically normal. Four of six children with tuberculoma also had infarction and/or ventriculomegaly; of these four children, three were moderately or severely retarded. Two patients with tuberculoma as the only intracranial abnormality had complete resolution of the granuloma with normal neurologic outcome following antituberculous therapy. The four children with large vessel infarction also had ventriculomegaly; three had poor clinical outcome. The presence of tuberculoma alone is not necessarily predictive of poor neurologic outcome; age less than 20 months, infarct, and/or ventriculomegaly are usually associated with sequelae.

Rapid diagnosis of tuberculous meningitis by polymerase chain reaction (PCR)

Using a rapid and highly sensitive method for the diagnosis of tuberculous meningitis by polymerase chain reaction (PCR), we detected the Mycobacterium tuberculosis genome in CSF of 5 of 6 patients with clinically diagnosed tuberculous meningitis. The genome was not present in CSF from 10 patients with other types of meningitis and 10 normal controls.

Drug resistant tuberculous meningitis in the Philippines: report of a case

A fatal case of tuberculous meningitis caused by a multiply-resistant tubercle bacillus is described, the first such case from Southeast Asia. Increased efforts to isolate Mycobacterium tuberculosis from the cerebrospinal fluid and determine the extent and pattern of drug resistance are necessary if the high mortality from this disease is to be reduced.

A competition ELISA for the detection of mycobacterial antigen in tuberculosis exudates

An enzyme-linked immunosorbent assay (ELISA) was designed to detect the inhibition of BCG-anti-BCG reactions by soluble antigens of Mycobacterium tuberculosis. Eighty-four samples were tested of which 59 were of cerebrospinal fluid (CSF) (25 control, 10 bacterial, 14 viral and 10 tuberculous meningitis); and twenty-five were of pleural or ascitic fluid (15 tuberculous exudates and 10 non-tuberculous samples). A statistically significant difference (p less than 0.01) was found between the tuberculous and control groups. The sensitivity and specificity of this test was almost 100%--no false negatives and only one false positive result occurred among the samples of CSF tested.

Tuberculous meningitis due to BCG in two previously healthy children

Tuberculous meningitis with favourable outcome has been observed in two immunocompetent previously healthy children. The mycobacteria isolated from the cerebrospinal fluid of both patients proved to be Mycobacterium bovis BCG. The patients had been inoculated with BCG, one 5 and the other 6 months before onset of the disease.

Virulence of tubercle bacilli isolated from patients with tuberculosis in Bangalore, India

This is a study of the virulence of cultures of Mycobacterium tuberculosis isolated from pulmonary and extrapulmonary forms of tuberculosis in patients living in or near Bangalore, India. The findings are as follows: 1. The percentage of cultures recovered from cases of pulmonary tuberculosis in Bangalore classified as being of low, moderate, and high virulence, was the same as that reported by Mitchison et al., in 1960 for isolates obtained from patients in Madras, India. 2. The distribution of the root index of virulence (RIV) of isolates from patients living in the city of Bangalore was significantly different (p less than 0.05) from that of isolates from patients living in rural Bangalore. 3. Even though the number of cultures classified as high virulent was significantly greater in isolates from patients with tuberculosis meningitis compared with those from patients with pulmonary tuberculosis, the data show that 36% of the isolates from the meningitis group were classified as low virulent.

Tuberculous meningitis--clinical and laboratory review of 100 patients

In developing countries tuberculous meningitis is a difficult infection to differentiate from other central nervous system (CNS) infections. This paper presents the history, physical findings, laboratory data, and clinical course of 100 patients who were admitted to a special ward and had CSF cultures positive for Mycobacterium tuberculosis. Fifty-four patients were comatose when admitted and 76 had meningeal signs. Mean admission CSF values were WBC 531, glucose 23 mg/dl, and protein 166 mg/dl. Only two CSF AFB smears were positive. Sixty-one percent of the chest X-rays taken were consistent with pulmonary tuberculous and 39% were normal. Twenty-four patients died within the first week after admission, before the clinical diagnosis was made and anti-tuberculous therapy could be started. Fifty-three of 76 patients given antituberculous therapy died. Neurologic sequelae developed in 48% of the survivors. The high mortality and morbidity rates in this patient-group were due to the severity of illness on admission and the predominance of children (54%).