Progress on Diagnosis of Tuberculous Meningitis

Using cerebrospinal fluid nanopore sequencing assay to diagnose tuberculous meningitis: a retrospective cohort study in China

OBJECTIVE

This study aimed to evaluate the efficiency of nanopore sequencing for the early diagnosis of tuberculous meningitis (TBM) using cerebrospinal fluid and compared it with acid-fast bacilli (AFB) smear, mycobacterial growth indicator tube culture and Xpert Mycobacterium tuberculosis (MTB)/rifampicin (RIF).

DESIGN

Single-centre retrospective study.

SETTING

The Tuberculosis Diagnosis and Treatment Center of Zhejiang Chinese and Western Medicine Integrated Hospital.

PARTICIPANTS

We enrolled 64 adult patients with presumptive TBM admitted to our hospital from August 2021 to August 2023.

METHODS

We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of AFB smear, culture, Xpert MTB/RIF and nanopore sequencing to evaluate their diagnostic efficacy compared with a composite reference standard for TBM.

RESULTS

Among these 64 patients, all tested negative for TBM by AFB smear. The sensitivity, specificity, PPV and NPV were 11.11%, 100%, 100% and 32.2% for culture, 13.33%, 100%, 100% and 2.76% for Xpert MTB/RIF, and 77.78%, 100%, 100% and 65.52% for nanopore sequencing, respectively.

CONCLUSION

The diagnostic accuracy of the nanopore sequencing test was significantly higher than that of conventional testing methods used to detect TBM.

Recent advances in microbiological and molecular biological detection techniques of tuberculous meningitis

Tuberculous meningitis (TBM) is the most common type of central nervous system tuberculosis (TB) and has the highest mortality and disability rate. Early diagnosis is key to improving the prognosis and survival rate of patients. However, laboratory diagnosis of TBM is often difficult due to its paucibacillary nature and sub optimal sensitivity of conventional microbiology and molecular tools which often fails to detect the pathogen. The gold standard for TBM diagnosis is the presence of MTB in the CSF. The recognised methods for the identification of MTB are acid-fast bacilli (AFB) detected under CSF smear microscopy, MTB cultured in CSF, and MTB detected by polymerase chain reaction (PCR). Currently, many studies consider that all diagnostic techniques for TBM are not perfect, and no single technique is considered simple, fast, cheap, and efficient. A definite diagnosis of TBM is still difficult in current clinical practice. In this review, we summarise the current state of microbiological and molecular biological diagnostics for TBM, the latest advances in research, and discuss the advantages of these techniques, as well as the issues and challenges faced in terms of diagnostic effectiveness, laboratory infrastructure, testing costs, and clinical expertise, for clinicians to select appropriate testing methods.

Knowledge domain and emerging trends in HIV-MTB co-infection from 2017 to 2022: A scientometric analysis based on VOSviewer and CiteSpace

Co-infection with Mycobacterium tuberculosis (MTB) in human immunodeficiency virus (HIV)-infected individuals is one of the leading causes of death. Also, research on HIV and MTB (HIV-MTB) co-infection was found to have a downward trend. In this work, we performed the knowledge domain analysis and visualized the current research progress and emerging trends in HIV-MTB co-infection between 2017 and 2022 by using VOSviewer and CiteSpace. The relevant literatures in this article were collected in the Web of Science (WoS) database. VOSviewer and CiteSpace bibliometric software were applied to perform the analysis and visualization of scientific productivity and frontier. Among all the countries, USA was dominant in the field, followed by South Africa, and England. Among all the institutions, the University of Cape Town (South Africa) had more extensive collaborations with other research institutions. The Int J Tuberc Lung Dis was regarded as the foremost productive journal. Survival and mortality analysis, pathogenesis, epidemiological studies, diagnostic methods, prognosis improvement of quality of life, clinical studies and multiple infections (especially co-infection with COVID-19) resulted in the knowledge bases for HIV-MTB co-infection. The clinical research on HIV-MTB co-infection has gradually shifted from randomized controlled trials to open-label trials, while the cognition of HIV-TB has gradually shifted from cytokines to genetic polymorphisms. This scientometric study used quantitative and qualitative methods to conduct a comprehensive review of research on HIV-MTB co-infection published over the past 5 years, providing some useful references to further the study of HIV-MTB co-infection.

Cerebrospinal fluid lactate as a predictive biomarker for tuberculous meningitis diagnosis

Objectives

The definitive diagnosis of tuberculous meningitis (TBM) is achieved by identifying Mycobacterium tuberculosis (MTb) in cerebrospinal fluid (CSF); however, diagnostic confirmation is difficult due to the inability of current tests for an effective diagnosis. Our objective was to retrospectively assess the characteristics of CSF lactate (CSF-LA) as an adjunct biomarker in the diagnosis of TBM.

Methods

608 CSF laboratory reports were assessed. Of these, 560 had clinically suspected TBM. These were classified as definite (n=36), probable (23), possible (278), or non-TBM (223) according to the international consensus TBM case definitions. An additional 48 CSF samples were negative controls with normal CSF.

Results

Against a reference standard of definite TBM, the cut-off value for CSF-LA was 4.0 mmol/L, the area under the ROC curve was 0.88 (95% CI, 0.82–0.94; p=0.0001), sensitivity was 69%, specificity 90%, negative predictive value 98%. These diagnostic parameters decreased when calculated against those of the other categories of TBM. CSF-LA exhibited high specificity, efficiency, negative predictive value, and clinical utility index in all the groups studied.

Conclusions

CSF-LA is a useful diagnostic marker to rule out TBM when associated with conventional microbiology tests, nucleic acid amplification assays, and clinical algorithms, particularly in endemic areas.

Current methods for microbiological diagnosis of acute central nervous system infections

The incidence of infections affecting the central nervous system has increased in recent years, making neuroinfections a current global health problem. The central nervous system is quite well protected from the external and internal environments, although it is susceptible to infection by a wide variety of pathogens. The etiological diversity further complicates the management of such infections because it is important to identify correctly the specific cause in order to choose the most appropriate antimicrobial therapy. Diagnosis is made not only based on clinical and epidemiological data but also on the results of clinical laboratory and microbiological examination of cerebrospinal fluid. This article aims to review current microbiological methods in the diagnosis of acute central nervous system infections and help healthcare providers to recognize their advantages and limitations in order to manage their patients appropriately.

Identification of protein biomarkers in host cerebrospinal fluid for differential diagnosis of tuberculous meningitis and other meningitis

Background and purpose

The diagnosis of tuberculous meningitis (TBM) is difficult due to the lack of sensitive methods. Identification of TBM-specific biomarkers in the cerebrospinal fluid (CSF) may help diagnose and improve our understanding of TBM pathogenesis.

Patients and methods

Of the 112 suspected patients with TBM prospectively enrolled in the study, 32 patients with inconclusive diagnosis, non-infectious meningitis, and long-term treatment with hormones and immunosuppressants were excluded. The expression of 8 proteins in the CSF was analyzed using ELISA in 22 patients with definite TBM, 18 patients with probable TBM, and 40 patients with non-TBM.

Results

Significant differences in the expression of 7 proteins were detected between the TBM and non-TBM groups (P < 0.01). Unsupervised hierarchical clustering (UHC) analysis revealed a disease-specific profile consisting of 7 differentially expressed proteins for TBM diagnosis, with an accuracy of 82.5% (66/80). Logistic regression with forward stepwise analysis indicated that a combination of 3 biomarkers (APOE_APOAI_S100A8) showed a better ability to discriminate TBM from patients with non-TBM [area under the curve (AUC) = 0.916 (95%CI: 0.857–0.976)], with a sensitivity of 95.0% (95%CI: 83.1–99.4%) and a specificity of 77.5% (95%CI: 61.5–89.2%).

Conclusion

Our results confirmed the potential ability of CSF proteins to distinguish TBM from patients with non-TBM and provided a useful panel for the diagnosis of TBM.

MRI-based radiomics signature for identification of invisible basal cisterns changes in tuberculous meningitis: a preliminary multicenter study

Objective

To develop and evaluate a radiomics signature based on magnetic resonance imaging (MRI) from multicenter datasets for identification of invisible basal cisterns changes in tuberculous meningitis (TBM) patients.

Methods

Our retrospective study enrolled 184 TBM patients and 187 non-TBM controls from 3 Chinese hospitals (training dataset, 158 TBM patients and 159 non-TBM controls; testing dataset, 26 TBM patients and 28 non-TBM controls). nnU-Net was used to segment basal cisterns in fluid-attenuated inversion recovery (FLAIR) images. Subsequently, radiomics features were extracted from segmented basal cisterns in FLAIR and T2-weighted (T2W) images. Feature selection was carried out in three steps. Support vector machine (SVM) and logistic regression (LR) classifiers were applied to construct the radiomics signature to directly identify basal cisterns changes in TBM patients. Finally, the diagnostic performance was evaluated by the receiver operating characteristic (ROC) curve analysis, calibration curve, and decision curve analysis (DCA).

Results

The segmentation model achieved the mean Dice coefficients of 0.920 and 0.727 in the training and testing datasets, respectively. The SVM model with 7 T2WI–based radiomics features achieved best discrimination capability for basal cisterns changes with an AUC of 0.796 (95% CI, 0.744–0.847) in the training dataset, and an AUC of 0.751 (95% CI, 0.617–0.886) with good calibration in the testing dataset. DCA confirmed its clinical usefulness.

Conclusion

The T2WI–based radiomics signature combined with deep learning segmentation could provide a fully automatic, non-invasive tool to identify invisible changes of basal cisterns, which has the potential to assist in the diagnosis of TBM.

Key Points

• The T2WI–based radiomics signature was useful for identifying invisible basal cistern changes in TBM.

• The nnU-Net model achieved acceptable results for the auto-segmentation of basal cisterns.

• Combining radiomics and deep learning segmentation provided an automatic, non-invasive approach to assist in the diagnosis of TBM.

Tuberculous meningitis in the elderly

OBJECTIVE

Although the elderly population remains at high risk for tuberculosis, studies addressing tuberculous meningitis (TBM) in this age group are scarce. The present study aimed to evaluate the spectrum and outcome of geriatric TBM and document differences between older and young patients.

METHODS

A prospective cohort study was conducted in the adult TBM patients admitted at PGIMER, Chandigarh (India). Consecutive older patients aged 60 years and above were enrolled from January 2019 to December 2020, and young adults aged 18-59 years were enrolled from July 2019 to December 2019.

RESULTS

Fifty-five older patients with a mean age of 66.6 years and 73 young patients with a mean age of 35.1 years were enrolled. At admission, older patients were more likely to have altered mental status (96.4% vs. 78.1%, P = 0.003) and advanced disease with British medical research council staging 2 or 3 (98.2% vs. 89.0%, P = 0.043); however, headache (38.2% vs. 67.1%, P = 0.001), vomiting (18.2% vs. 35.6%, P = 0.030) and fever (80.0% vs. 91.8%, P = 0.052) were less common. Cerebrospinal fluid (CSF) abnormalities were less marked in older patients, with a significant difference in median total cells (70 vs. 110/µl, P = 0.013). Hydrocephalous and infarct were common neuroimaging abnormalities in both groups; however, tuberculomas were significantly less in the elderly (15.1% vs. 35.2%, P = 0.012). Older patients had a significantly low survival rate (56.4% vs. 76.7%, P = 0.021).

CONCLUSION

Significant differences in clinical, CSF and radiological characteristics exist between elderly and young TBM patients, with survival remains dismal in the elderly.

Metagenomic Next-Generation Sequencing for Accurate Diagnosis of Acute HIV Infection with Aseptic Meningitis: A Case Report

Background

Although individuals infected with HIV for the first time manifest a series of acute syndromes, most patients show mild or no symptoms, which complicates the initial clinical diagnosis. Early diagnosis is important for effective prevention and management of patients. Metagenomic next-generation sequencing technology (mNGS) can rapidly detect a wide range of pathogenic microorganisms, even in atypical cases. However, to date, few studies have reported the application of mNGS to diagnose acute HIV infection with aseptic meningitis.

Case Presentation

A 38-year-old man was admitted to the Department of Infectious Diseases due to repeated fever, headache, and scattered rashes on his limbs. Routine blood analysis revealed elevated absolute lymphocytes and monocytes. Moreover, monocytes were found to be significantly increased following a lumbar puncture and cerebrospinal fluid detection. mNGS results revealed the presence of the human immunodeficiency virus (HIV-1), with HIV RNA of 910 copies/mL in his cerebrospinal fluid. The HIV antigen/antibody test was negative. According to a study by Fie Big et al, a clear diagnosis of acute HIV infection at Fiebig stage I. The patient’s condition improved after treatment, and he was prescribed antiretroviral therapy (ART) after discharge.

Conclusion

Aseptic meningitis is easily misdiagnosed during the initial stages of acute HIV infection. mNGS can be used to identify the pathogen early, rapidly, and accurately, thereby improving the treatment of acute HIV infections.

Efficacy of Xpert MTB/RIF Ultra in diagnosing tuberculosis meningitis: A systematic review and meta-analysis

BACKGROUND

This study aimed to assess whether Xpert MTB/RIF Ultra (Xpert Ultra) can effectively diagnose tuberculosis meningitis (TBM) and to simultaneously compare its effectiveness with Xpert in diagnosing TBM in the same population.

METHODS

On August 12, 2020, Wanfang Database, China National Knowledge Infrastructure, Embase, Cochrane Library, and PubMed were searched for studies evaluating the diagnostic accuracy of Xpert Ultra for TBM. Then, we assessed the efficacy of Xpert Ultra against a composite reference standard and culture. If applicable, we also examined the diagnostic efficacy of Xpert in the same population. Heterogeneity was then explored by meta-regression, subgroup, and sensitivity analyses.

RESULTS

Six studies containing 601 specimens reported the diagnostic efficacy of Xpert Ultra for TBM, with a composite reference standard. No study had compared the efficacy between Xpert Ultra and culture. The pooled sensitivity of Xpert Ultra was 64% (95% confidence interval [CI]: 45-80), and the I2 value was 86% (95% CI: 76-96); its specificity for TBM was consistently 100%. In the same population, 5 studies compared the diagnostic efficacy between Xpert Ultra and Xpert for TBM. The pooled sensitivity of Xpert Ultra and Xpert was 68% (95% CI: 46-84; I2 = 87%) and 37% (95% CI: 25-50; I2 = 72%), respectively. The studies were significantly heterogeneous in terms of sensitivity but not heterogeneous in specificity.

CONCLUSIONS

Xpert Ultra was more sensitive than Xpert, but both were specific (100%). Therefore, Xpert Ultra had an excellent diagnostic efficacy for TBM, and it could be the preferred initial test for TBM.

Comparative analysis between tuberculous meningitis and other forms of extrapulmonary tuberculosis

Introduction

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.

Methods

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.

Results

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).

Conclusions

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.

Paraplegia from spinal intramedullary tuberculosis: A case report

BACKGROUND

Tuberculosis (TB) mostly attacks the lungs, and extrapulmonary TB involving the central nervous system is uncommon; among these cases, spinal intramedullary TB is even more rare. The clinical manifestations of spinal intramedullary TB are similar to those of intramedullary spinal cord tumors. Therefore, it is necessary to make a careful differential diagnosis of spinal intramedullary lesions to achieve the appropriate treatment and favorable prognosis. We report a rare case of a young male patient with paraplegia due to spinal intramedullary TB, which is uncommon and regrettable.

CASE SUMMARY

A 23-year-old male presented with fever accompanied by nausea and vomiting lasting for 2 mo and was then diagnosed with tubercular meningitis. After anti-TB treatment, his symptoms were significantly improved. However, 2 mo after the diagnosis of tubercular meningitis, the patient felt numbness below the costal arch level, which lasted for 1 wk, and he paid no attention to this symptom. What followed was paraplegia and urine/fecal incontinence. Magnetic resonance imaging of the thoracic spine showed a ring-enhanced intramedullary cord lesion at T8-T9. Lesion exploration showed enlargement of the spinal cord at T8-T9, and the lesion could be observed by incision. The lesion was adhered to the peripheral tissue and was grayish-white and tough with a poor blood supply and a diameter of approximately 0.8 cm. The lesion was resected completely. The results of pathological examination by both hematoxylin-eosin staining and acid-fast bacilli staining confirmed TB, accompanied by acute and chronic suppurative inflammation and granulation tissue formation. The patient was instructed to continue anti-TB treatment after the operation, but he did not follow the medical advice. Follow-up continued for ten years, the patient had persistent paraplegia, the numbness disappeared and urine/fecal sensation recovered.

CONCLUSION

Although TB is a kind of benign disease, some cases progress rapidly. Moreover, spinal intramedullary TB may seriously endanger quality of life and still needs timely diagnosis and proper treatment.

A comparison of the accuracy of the CapitalBio Mycobacterium real-time polymerase chain reaction and the Xpert MTB/RIF assay for the diagnosis of tuberculous meningitis

OBJECTIVES

We aimed to compare the efficiency of the CapitalBioMycobacterium real-time polymerase chain reaction (PCR) detection test with the standard Xpert MTB/RIF assay for the diagnosis of tuberculous meningitis (TBM).

METHODS

We analyzed cerebrospinal fluid (CSF) from 163 patients with suspected TBM that were collected between January 1, 2018, and December 31, 2019. For both tests, we determined the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC). Next, we compared the diagnostic accuracy of the two techniques using clinical diagnosis as a reference standard.

RESULTS

The sensitivity, specificity, PPV, NPV, and AUC, of the CapitalBio Mycobacterium detection test were 48.5%, 100%, 100%, 29.6%, and 0.74, respectively, when used for the diagnosis of TBM. In comparison, the Xpert MTB/RIF assay returned values of 47.0%, 100%, 100%, 29.0%, and 0.74, respectively. Our analysis showed that the diagnostic accuracies of the CapitalBio Mycobacterium detection test and the Xpert MTB/RIF assay were very similar; the accuracy of both tests for detecting mycobacteria was significantly higher than that associated with acid-fast staining.

CONCLUSIONS

The CapitalBio Mycobacterium real-time PCR detection test has moderate sensitivity and very high specificity for TBM; results are very similar to those generated by the Xpert MTB/RIF assay. We recommend that the CapitalBio PCR test should be used as an initial screening method for TB.

Diagnostic Accuracy of T-SPOT.TB Assay for Tuberculous Meningitis: An Updated Meta-Analysis

Background: The role of T-SPOT.TB (T-SPOT) assay for tuberculous meningitis (TBM) diagnosis has not been fully assessed. Here, we conducted an updated meta-analysis to evaluate the diagnostic accuracy of peripheral blood (PB) T-SPOT and cerebrospinal fluid (CSF) T-SPOT for diagnosing TBM. Methods: Relevant studies in the PubMed database, EmBase database, Cochrane database, Scopus database, Google Scholar, China National Knowledge Internet, and Wan-Fang database were retrieved from August 1, 2005, to June 22, 2020. Statistical analysis was performed using Stata, Revman, and Meta-Disc software. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), summary receiver operating characteristic curves, and the area under the curve were determined and analyzed. Results: A total of 27 studies were eligible for inclusion within the meta-analysis. The pooled sensitivity and specificity of PB T-SPOT for TBM diagnosis were 0.78 (95% CI, 0.76-0.81) and 0.68 (95% CI, 0.66-0.71), respectively, whereas the pooled PLR, NLR, and DOR were 2.80 (95% CI, 2.29-3.42), 0.32 (95% CI, 0.27-0.38), and 10.08 (95% CI, 7.21-14.08), respectively. On the other hand, the pooled sensitivity and specificity of CSF T-SPOT on diagnosing TBM were 0.76 (95% CI, 0.72-0.80) and 0.88 (95% CI, 0.85-0.90), respectively, whereas the pooled PLR, NLR, and DOR were 5.92 (95% CI, 4.25-8.25), 0.28 (95% CI, 0.21-0.39), and 29.05 (95% CI, 16.40-51.45), respectively. The area under the summary receiver operating characteristic curve values of PB T-SPOT and CSF T-SPOT for TBM diagnosis were 0.83 (95% CI, 0.80-0.86) and 0.92 (95% CI, 0.89-0.94), respectively. Conclusions: CSF T-SPOT showed a higher specificity compared with PB T-SPOT for diagnosing TBM. Both two T-SPOT assays have considerable potential in improving the diagnosis of TBM. Furthermore, the standardization of the operating procedure is further needed when performing CSF T-SPOT.

Meningitis and encephalitis management in the ICU

PURPOSE OF REVIEW

Management of patients with meningitis and encephalitis oftentimes requires ICU level of care. This article is an update on management for meningitis and encephalitis with focus on clinical care in the ICU. Information provided is based on a review of recent studies with focus on studies since 2017.

RECENT FINDINGS

Advances in diagnostic and treatment approach for different pathogens are presented. Nosocomial meningitis now constitutes a major part of brain infections seen in ICUs in the developed world. Advances in ICU care of central nervous system (CNS) infections include application of newer diagnostic methods, improved understanding and delivery of antibiotics to the CNS, infection prevention for nosocomial infections, and application of neuromonitoring where indicated.

SUMMARY

Advances in diagnostics and therapeutic approach to CNS infections are continually made. For intensivists, focus on neuromonitoring and brain resuscitation in critically ill patients with CNS infections may present a path to enhance preservation of brain function and improve outcomes. VIDEO ABSTRACT: http://links.lww.com/COCC/A22.

Tubercular meningitis in patients with systemic lupus erythematosus: clinical characteristics, risk factors, and outcomes of 10 patients

Tubercular meningitis (TBM) is a rare condition in patients with systemic lupus erythematosus (SLE). The aim of this study is to describe the clinical characteristics, possible risk factors, and outcomes of SLE patients with TBM. We systematically reviewed medical records from10 SLE patients with TBM admitted to our hospital from December 2008 to December 2018. A total of 100 cases in the same period were randomly selected as controls from SLE inpatients without infection. In patients with TBM, the mean age at presentation was 35.2 years (range 19.8-45.2); the mean duration of SLE was 34.6 months (range 4-84 months). Patients with TBM had significantly longer SLE duration, higher ESR and CRP level, and lower CD4+ cell counts and albumin level than those without infections (p < 0.05 for all). There were no differences in prednisone dose at the time of symptom onset or cumulative dose over the preceding year between the two groups. Logistic regression analysis showed that patients with a lower CD4+ cell count were more likely to have TBM compared with controls (OR = 3.67, p = 0.020). TBM should be considered when SLE patients have central nervous system (CNS) symptoms with a longer duration, higher ESR and CRP level, and lower CD4+ cell counts and albumin level, even if the patients are receiving a low prednisone dose.Key Points• Patients with TBM have significantly longer SLE duration and lower CD4+ cell counts and albumin level than those without infections; lower CD4+ cell count was an independent risk factor to have TBM in patients with SLE.

A New Scoring System for the Differential Diagnosis between Tuberculous Meningitis and Viral Meningitis

BACKGROUND

Tuberculous meningitis (TBM) is associated with high mortality and morbidity despite administering anti-tuberculous chemotherapy to the patients. Differential diagnosis between TBM and viral meningitis (VM) is difficult in some clinical situations.

METHODS

We reviewed and analyzed records of adult patients who were admitted and diagnosed with TBM or VM at a tertiary hospital in Korea, between January 2006 and December 2015. Diagnostic criteria for TBM were categorized into three groups: definite, probable, and possible TBM. The VM group included patients with no evidence of other meningitis who achieved complete recovery with only conservative treatments. Clinical, laboratory and radiological findings, as well as outcomes, were compared between the TBM and VM groups.

RESULTS

Ninety-eight patients were enrolled. Among the study patients, 47 had TBM and 51 had VM. Based on univariate analysis and multivariate logistic regression, sodium < 135 mmol/L in serum (hyponatremia), lactate dehydrogenase > 70 (U/L) in cerebrospinal fluid (CSF), protein > 160 (mg/dL) in CSF, voiding difficulty, and symptoms of cranial nerve palsy were significant predictive factors for TBM in the final model. We constructed a weighted scoring system with predictive factors from multiple regression analyses. Receiver operating characteristic curve analyses and decision tree analyses were plotted to reveal an optimum cutoff point as 4 with this scoring system (range: 0-13).

CONCLUSION

For differential diagnosis between TBM and VM, we created a new weighted scoring system. This scoring system and decision tree analysis are simple and easy to apply in clinical practice to differentiate TBM from VM.