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Basu A, Saini AG, Mishra S, Bhatia V. Inverted starfish sign in tuberculous meningitis. BMJ Case Rep 2023; 16:e255564. [PMID: 37907308 PMCID: PMC10618996 DOI: 10.1136/bcr-2023-255564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
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Mahomed N, Kilborn T, Smit EJ, Chu WCW, Young CYM, Koranteng N, Kasznia-Brown J, Winant AJ, Lee EY, Sodhi KS. Tuberculosis revisted: classic imaging findings in childhood. Pediatr Radiol 2023; 53:1799-1828. [PMID: 37217783 PMCID: PMC10421797 DOI: 10.1007/s00247-023-05648-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 05/24/2023]
Abstract
Tuberculosis (TB) remains one of the major public health threats worldwide, despite improved diagnostic and therapeutic methods. Tuberculosis is one of the main causes of infectious disease in the chest and is associated with substantial morbidity and mortality in paediatric populations, particularly in low- and middle-income countries. Due to the difficulty in obtaining microbiological confirmation of pulmonary TB in children, diagnosis often relies on a combination of clinical and radiological findings. The early diagnosis of central nervous system TB is challenging with presumptive diagnosis heavily reliant on imaging. Brain infection can present as a diffuse exudative basal leptomeningitis or as localised disease (tuberculoma, abscess, cerebritis). Spinal TB may present as radiculomyelitis, spinal tuberculoma or abscess or epidural phlegmon. Musculoskeletal manifestation accounts for 10% of extrapulmonary presentations but is easily overlooked with its insidious clinical course and non-specific imaging findings. Common musculoskeletal manifestations of TB include spondylitis, arthritis and osteomyelitis, while tenosynovitis and bursitis are less common. Abdominal TB presents with a triad of pain, fever and weight loss. Abdominal TB may occur in various forms, as tuberculous lymphadenopathy or peritoneal, gastrointestinal or visceral TB. Chest radiographs should be performed, as approximately 15% to 25% of children with abdominal TB have concomitant pulmonary infection. Urogenital TB is rare in children. This article will review the classic radiological findings in childhood TB in each of the major systems in order of clinical prevalence, namely chest, central nervous system, spine, musculoskeletal, abdomen and genitourinary system.
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Affiliation(s)
- Nasreen Mahomed
- University of Witwatersrand, 7 York Road Parktown, Johannesburg, 2193, South Africa.
| | - Tracy Kilborn
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Elsabe Jacoba Smit
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Winnie Chiu Wing Chu
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Catherine Yee Man Young
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Nonceba Koranteng
- University of Witwatersrand, 7 York Road Parktown, Johannesburg, 2193, South Africa
| | | | - Abbey J Winant
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, USA
| | - Kushaljit Singh Sodhi
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
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Chen J, Wu J, Luo Y, Huang N. NELL2 as a potential marker of outcome in the cerebrospinal fluid of patients with tuberculous meningitis: preliminary results from a single-center observational study. Eur J Med Res 2022; 27:281. [PMID: 36494747 PMCID: PMC9733264 DOI: 10.1186/s40001-022-00921-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To detect the changes in Nel-like 2 (NELL2) in cerebrospinal fluid (CSF) in the outcome of tuberculous meningitis (TBM) patients and to initially evaluate its potential as a marker. METHODS We collected the clinical data of patients with suspected TBM in the First People's Hospital of Zunyi from November 2017 to January 2021 and retained their CSF. According to the selection and exclusion criteria, the TBM group (11 cases) and the control group (18 cases) were obtained. Western blotting (WB) was used to detect the level of NELL2 in the CSF of the two groups, especially the change in NELL2 before and after treatment in TBM patients. RESULTS The level of NELL2 in the TBM group was lower than that in the control group (P < 0.05), and the level of NELL2 showed an increasing trend after anti-tuberculosis treatment in the TBM group. CONCLUSIONS NELL2 in the CSF of TBM patients decreased significantly. Anti-tuberculosis treatment can improve the level of NELL2, which may become one of the potential markers of outcome in the cerebrospinal fluid of patients with tuberculous meningitis.
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Affiliation(s)
- Jianhua Chen
- grid.452884.7Department of Neurology, Third Affiliated Hospital of Zunyi Medical University, (The First People’s Hospital of Zunyi), Zunyi, 563000 China
| | - Jie Wu
- grid.452884.7Scientific Research Center, Third Affiliated Hospital of Zunyi Medical University, (The First People’s Hospital of Zunyi), Zunyi, 563000 China
| | - Yong Luo
- grid.452884.7Department of Neurology, Third Affiliated Hospital of Zunyi Medical University, (The First People’s Hospital of Zunyi), Zunyi, 563000 China
| | - Nanqu Huang
- grid.452884.7National Drug Clinical Trial Institution, Third Affiliated Hospital of Zunyi Medical University, (The First People’s Hospital of Zunyi), Zunyi, 563000 China
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Fatema K, Rahman MM, Akhter S, Akter N, Paul BC, Begum S, Begum F. Clinicoradiologic Profile and Outcome of Children With Tubercular Meningitis in a Tertiary Care Hospital in Bangladesh. J Child Neurol 2020; 35:195-201. [PMID: 31726924 DOI: 10.1177/0883073819884169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Children are most vulnerable to tubercular meningitis. Neuroimaging is an important initial investigation in tubercular meningitis. OBJECTIVE This study was done to describe the clinical profile, neuroimaging changes, and clinical outcome in children with tubercular meningitis. METHODOLOGY This was an observational cohort study on children with tubercular meningitis, between January 2012 and June 2018. Tubercular meningitis was diagnosed on the basis of clinical criteria, cerebrospinal fluid analysis, neuroimaging, and response to antitubercular drug treatment. Preferably magnetic resonance imaging (MRI) with contrast was done. RESULT Out of 79 pediatric patients, 17 patients were lost during follow-up; thus, a total of 62 patients were studied. Mean age at presentation was 7.040 (±3.99 SD) year, 51.6% children were male. Rural children were more affected. Twenty eight (45.2 patients had contact with a person with tuberculosis. Only 3 (4.8%) patients presented within 10 days of duration of illness. Most of the cases (67.7%) were in stage 2 at the time of diagnosis. The most common clinical feature was fever, seizure, and signs of meningeal irritation (all present in 12.9%). In neuroimaging most common findings were tuberculoma (50%), hydrocephalus (54.8%), and basal meningeal enhancement (33.8%). Regarding outcome, 6 (9.67%) patients expired and 47 (75%) patients had sequelae. The most common complications were hydrocephalus (30.64%) and intellectual disability (12.9 ). Hydrocephalus was the most common neuroimaging finding among the patients who expired (33%). CONCLUSION Hydrocephalus is the most common neuroimaging finding. Normal neuroimaging is associated with good outcome whereas all the patients who died had abnormal neuroimaging.
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Affiliation(s)
- Kanij Fatema
- Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Md Mizanur Rahman
- Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Shaheen Akhter
- Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Naznin Akter
- Department of Pediatrics, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Bikush Chandra Paul
- Medical Officer, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Suraiya Begum
- Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Fahmida Begum
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2020. [PMID: 31984242 DOI: 10.12688/wellcomeopenres.15512.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.,Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2019; 4:163. [PMID: 31984242 PMCID: PMC6964359 DOI: 10.12688/wellcomeopenres.15512.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/21/2022] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K. Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W. Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Division of Pediatric Critical Care, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A. Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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Evaluation of cases of pediatric extrapulmonary tuberculosis: a single center experience. Turk Arch Pediatr 2019; 54:86-92. [PMID: 31384143 PMCID: PMC6666364 DOI: 10.14744/turkpediatriars.2019.33239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 03/11/2019] [Indexed: 12/01/2022]
Abstract
Aim: Extrapulmonary tuberculosis is observed more frequently and leads to complications with a higher rate in children compared with adults because the risk of lymphohematogen spread is higher. In this study, the clinical, laboratory, and radiologic findings and treatment outcomes were evaluated in pediatric patients who were followed up in our clinic with a diagnosis of extrapulmonary tuberculosis. Material and Methods: Seventy patients aged 0–18 years who were followed up with a diagnosis of extrapulmonary tuberculosis between 2008 and 2017 in the Division of Pediatric Infectious Diseases in our hospital were examined retrospectively. Results: The median age of the patients was 8,8 (range, 0,4–17) years and 47.1% were female (n=33). Twenty-seven patients (38.6%) were aged 0–4 years, 15 (21.4%) were aged 5–9 years, and 28 patients (40%) were aged 10–18 years. Forty-four patients (62.9%) were diagnosed as having extrapulmonary tuberculosis and 26 (37.1%) had pulmonary + extrapulmonary tuberculosis. The most common form of extrapulmonary tuberculosis was extrathoracic lymphadenopathy, which was found in 22 patients (31.4%). The other patients were diagnosed as having musculoskeletal system tuberculosis (n=10, 14.3%), gastrointestinal system tuberculosis (n=9, 12.9%), miliary tuberculosis (n=8, 11.4%), intrathoracic lymphadenopathy (n=7, 10%), renal tuberculosis (n=6, 8.6%), central nervous system tuberculosis (n=5, 7.1%), and pleural tuberculosis (n=3, 4.3%). Among a total of 58 patients in whom tuberculin skin test and interferon gamma release tests were studied together, tuberculin skin test positivity (n=37, 63.8%) was found with a higher rate compared with interferon gamma release test positivity (n=32, 55.2%), but the difference was not statistically significant (p=0.35). The median treatment period was 12 (range, 6–24) months. Among the patients whose treatments were terminated, improvement was observed in 52 patients (74.2%) and the development of sequela was observed in six patients (8.5%). Two patients who were diagnosed as having central nervous system tuberculosis (2.8%) died. Conclusion: Clinical, laboratory, and radiologic data should be evaluated together when making a diagnosis of extrapulmonary tuberculosis in children. Interferon gamma release tests alone are not superior to tuberculin skin test, but should be considered to be used in combination in the diagnosis.
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Abstract
Prevention and management of opportunistic infections in children is particularly relevant in an era demonstrating an increased prevalence of immunocompromising conditions. The presence of an unusual organism which results in serious infection in a child should therefore always raise the consideration of immune compromise. The more common opportunistic infections have become easier to recognize in recent times due to improved awareness and more refined diagnostic testing. Targeted treatment is usually followed by long-term prophylactic medication. The impact of these conditions on patient outcome is of clear significance and certainly warrants further discussion.
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Wilkinson RJ, Rohlwink U, Misra UK, van Crevel R, Mai NTH, Dooley KE, Caws M, Figaji A, Savic R, Solomons R, Thwaites GE. Tuberculous meningitis. Nat Rev Neurol 2017; 13:581-598. [PMID: 28884751 DOI: 10.1038/nrneurol.2017.120] [Citation(s) in RCA: 285] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tuberculosis remains a global health problem, with an estimated 10.4 million cases and 1.8 million deaths resulting from the disease in 2015. The most lethal and disabling form of tuberculosis is tuberculous meningitis (TBM), for which more than 100,000 new cases are estimated to occur per year. In patients who are co-infected with HIV-1, TBM has a mortality approaching 50%. Study of TBM pathogenesis is hampered by a lack of experimental models that recapitulate all the features of the human disease. Diagnosis of TBM is often delayed by the insensitive and lengthy culture technique required for disease confirmation. Antibiotic regimens for TBM are based on those used to treat pulmonary tuberculosis, which probably results in suboptimal drug levels in the cerebrospinal fluid, owing to poor blood-brain barrier penetrance. The role of adjunctive anti-inflammatory, host-directed therapies - including corticosteroids, aspirin and thalidomide - has not been extensively explored. To address this deficit, two expert meetings were held in 2009 and 2015 to share findings and define research priorities. This Review summarizes historical and current research into TBM and identifies important gaps in our knowledge. We will discuss advances in the understanding of inflammation in TBM and its potential modulation; vascular and hypoxia-mediated tissue injury; the role of intensified antibiotic treatment; and the importance of rapid and accurate diagnostics and supportive care in TBM.
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Affiliation(s)
- Robert J Wilkinson
- Department of Medicine, Imperial College London, Norfolk Place, London W2 1PG, UK
- The Francis Crick Institute, Midland Road, London NW1 2AT, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Republic of South Africa
| | - Ursula Rohlwink
- Division of Neurosurgery, University of Cape Town, Anzio Road, Observatory 7925, Republic of South Africa
| | - Usha Kant Misra
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Reinout van Crevel
- Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, Maryland 21287, USA
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Anthony Figaji
- Division of Neurosurgery, University of Cape Town, Anzio Road, Observatory 7925, Republic of South Africa
| | - Rada Savic
- UCSF School of Pharmacy, Department, Bioengineering, 1700 4th Street, San Francisco, California 94158, UA
| | - Regan Solomons
- Faculty of Health Sciences, Stellenbosch University, Tygerberg Hospital, Francie van Zijl Drive, Tygerberg 7505, Cape Town, Republic of South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road, Oxford OX3 9FZ, UK
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Kritsaneepaiboon S, Andres MM, Tatco VR, Lim CCQ, Concepcion NDP. Extrapulmonary involvement in pediatric tuberculosis. Pediatr Radiol 2017; 47:1249-1259. [PMID: 29052770 DOI: 10.1007/s00247-017-3867-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Revised: 02/23/2017] [Accepted: 04/09/2017] [Indexed: 12/17/2022]
Abstract
Tuberculosis in childhood is clinically challenging, but it is a preventable and treatable disease. Risk factors depend on age and immunity status. The most common form of pediatric tuberculosis is pulmonary disease, which comprises more than half of the cases. Other forms make up the extrapulmonary tuberculosis that involves infection of the lymph nodes, central nervous system, gastrointestinal system, hepatobiliary tree, and renal and musculoskeletal systems. Knowledge of the imaging characteristics of pediatric tuberculosis provides clues to diagnosis. This article aims to review the imaging characteristics of common sites for extrapulmonary tuberculous involvement in children.
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Affiliation(s)
- Supika Kritsaneepaiboon
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, 90110, Thailand.
| | - Mariaem M Andres
- Institute of Radiology, St. Luke's Medical Center, 32nd Avenue corner 5th Street, Bonifacio Global City, 1634, Taguig City, Philippines
| | - Vincent R Tatco
- Institute of Radiology, St. Luke's Medical Center, 32nd Avenue corner 5th Street, Bonifacio Global City, 1634, Taguig City, Philippines
| | - Cielo Consuelo Q Lim
- Institute of Radiology, St. Luke's Medical Center, 279 E. Rodriquez Sr. Boulevard, 1102, Quezon City, Philippines
| | - Nathan David P Concepcion
- Institute of Radiology, St. Luke's Medical Center, 32nd Avenue corner 5th Street, Bonifacio Global City, 1634, Taguig City, Philippines
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Rohlwink UK, Kilborn T, Wieselthaler N, Banderker E, Zwane E, Figaji AA. Imaging Features of the Brain, Cerebral Vessels and Spine in Pediatric Tuberculous Meningitis With Associated Hydrocephalus. Pediatr Infect Dis J 2016; 35:e301-10. [PMID: 27213261 PMCID: PMC5024759 DOI: 10.1097/inf.0000000000001236] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric tuberculous meningitis (TBM) leads to high rates of mortality and morbidity. Prompt diagnosis and initiation of treatment are challenging; imaging findings play a key role in establishing the presumptive diagnosis. General brain imaging findings are well reported; however, specific data on cerebral vascular and spinal involvement in children are sparse. METHODS This prospective cohort study examined admission and followed up computed tomography brain scans and magnetic resonance imaging scans of the brain, cerebral vessels (magnetic resonance angiogram) and spine at 3 weeks in children treated for TBM with hydrocephalus (HCP; inclusion criteria). Exclusion criteria were no HCP on admission, treatment of HCP or commencement of antituberculosis treatment before study enrollment. Imaging findings were examined in association with outcome at 6 months. RESULTS Forty-four patients (median age 3.3 [0.3-13.1] years) with definite (54%) or probable TBM were enrolled. Good clinical outcome was reported in 72%; the mortality rate was 16%. Infarcts were reported in 66% of patients and were predictive of poor outcome. Magnetic resonance angiogram abnormalities were reported in 55% of patients. Delayed tuberculomas developed in 11% of patients (after starting treatment). Spinal pathology was more common than expected, occurring in 76% of patients. Exudate in the spinal canal increased the difficulty of lumbar puncture and correlated with high cerebrospinal fluid protein content. CONCLUSION TBM involves extensive pathology in the central nervous system. Severe infarction was predictive of poor outcome although this was not the case for angiographic abnormalities. Spinal disease occurs commonly and has important implications for diagnosis and treatment. Comprehensive imaging of the brain, spine and cerebral vessels adds insight into disease pathophysiology.
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Affiliation(s)
- Ursula K Rohlwink
- From the *Division of Neurosurgery, Pediatric Neurosurgery, †Division of Pediatric Radiology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; and ‡University of Swaziland, Kwaluseni, Swaziland
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Affiliation(s)
| | - Ira Shah
- a Department of Pediatrics , Bai Jerbai Wadia Hospital for Children , Parel , Mumbai , India
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Sharma D, Shah I, Patel S. Late onset hydrocephalus in children with tuberculous meningitis. J Family Med Prim Care 2016; 5:873-874. [PMID: 28349011 PMCID: PMC5353834 DOI: 10.4103/2249-4863.201145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Hydrocephalus is a known complication of tuberculous meningitis (TBM). It is almost always present in patients who have had the disease for four to six weeks. However, hydrocephalus can also develop later in the disease course as seen in our 3 patients. All 3 patients had multi-drug resistant (MDR) tuberculosis (TB) and developed hydrocephalus after variable time after starting second line anti-tuberculous therapy (ATT). A 7 years old girl had hydrocephalus at onset of TBM and was shunted but the hydrocephalus increased in size after 6 months of being on second line ATT in spite of a patent ventricular peritoneal (VP) shunt. Hydrocephalus responded to oral acetazolamide. Other 2 patients, a 2 years old girl and 3½ years old boy developed hydrocephalus after being on treatment for 14 months. Both required insertion of VP shunt. Thus, in patients with MDR-TB, hydrocephalus may develop as late onset phenomenon and a neurological examination would be essential in each visit to the hospital.
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Affiliation(s)
- Disha Sharma
- Pediatrics TB Clinic, B.J. Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Ira Shah
- Pediatrics TB Clinic, B.J. Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Sharad Patel
- Pediatrics TB Clinic, B.J. Wadia Hospital for Children, Mumbai, Maharashtra, India
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Mullanfiroze K, Shah I. Hydrocephalus in tuberculous meningitis--how fast does it develop? ACTA ACUST UNITED AC 2014; 46:475-7. [PMID: 24702689 DOI: 10.3109/00365548.2014.896034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ramzan A, Nayil K, Asimi R, Wani A, Makhdoomi R, Jain A. Childhood tubercular meningitis: an institutional experience and analysis of predictors of outcome. Pediatr Neurol 2013; 48:30-5. [PMID: 23290017 DOI: 10.1016/j.pediatrneurol.2012.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 09/04/2012] [Indexed: 10/27/2022]
Abstract
Tubercular meningitis constitutes an important cause of morbidity and mortality in developing countries, and various factors determine its outcome. We studied demographic and clinical profiles of childhood tubercular meningitis, and identified predictors of outcome. This prospective study was performed in 65 children aged ≤ 18 years, hospitalized with a diagnosis of tubercular meningitis. Boys outnumbered girls. Most patients presented with a poor clinical grade. Headache and vomiting comprised common features. Cerebrospinal fluid was characterized by predominant lymphocytosis. Many patients were diagnosed for Mycobacterium tuberculosis via polymerase chain reaction. Hydrocephalus comprises a common finding via computed tomography. Low Glasgow Coma Scores, seizures, basal exudates, and infarcts predict outcomes. Children with headaches, fevers, and altered sensorium should be investigated promptly for tubercular meningitis. Timely intervention may lead to early diagnoses and reductions in morbidity and mortality.
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Affiliation(s)
- Altaf Ramzan
- Department of Neurosurgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
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16
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Nogueira Delfino L, Fariello G, Lancella L, Marabotto C, Menchini L, Devito R, Errante Y, Quattrocchi CC, Longo D. Central nervous system tuberculosis in non-HIV-positive children: a single-center, 6 year experience. Radiol Med 2011; 117:669-78. [PMID: 22095412 DOI: 10.1007/s11547-011-0743-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 04/07/2011] [Indexed: 12/21/2022]
Abstract
PURPOSE The aim of this paper is to describe the imaging features of central nervous system (CNS) tuberculosis on computed tomography (CT) and magnetic resonance imaging (MRI) studies in non-HIV-positive children. MATERIALS AND METHODS A retrospective descriptive evaluation was conducted on imaging studies obtained from ten children admitted to our hospital over a 6-year period who fulfilled criteria for a diagnosis of CNS tuberculosis. Data were collected with regard to patients' clinical, laboratory and demographic characteristics, as well as results of radiological investigation. RESULTS We studied ten children, of whom five were boys and five were girls and whose mean age was 4 (range 7 months to 16) years. Neuroradiological findings on the first imaging study were basal meningeal enhancement (100%), hydrocephalus (70%), infarcts (90%), tuberculomas (40%) and cranial nerve involvement (20%). Follow-up studies revealed basal meningeal enhancement, hydrocephalus, and infarcts in all patients, tuberculomas in 70% and cranial nerve involvement in 50%. Only one patient showed a pattern of miliary tuberculosis. CONCLUSIONS CNS tuberculosis is still an important cause of childhood morbidity and mortality even in nonimmunosuppressed children. Because prompt diagnosis results in earlier treatment, it is crucial to be aware of tuberculous meningitis and its complications at imaging, especially because of the impact on patients' prognosis.
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Affiliation(s)
- L Nogueira Delfino
- Department of Radiology, IRCCS, Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio 4, 00100, Rome, Italy.
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17
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Dekker G, Andronikou S, van Toorn R, Scheepers S, Brandt A, Ackermann C. MRI findings in children with tuberculous meningitis: a comparison of HIV-infected and non-infected patients. Childs Nerv Syst 2011; 27:1943-9. [PMID: 21494882 DOI: 10.1007/s00381-011-1451-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 04/04/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND 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. PURPOSE The purpose of this study is to compare the MRI features of TBM in HIV-infected and uninfected children. METHODS Retrospective descriptive study comparing clinical, laboratory and MRI features of 8 HIV-infected and 19 HIV-uninfected children with TBM. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Gerrit Dekker
- Department of Radiology, Stellenbosch University, Stellenbosch, South Africa
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18
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Abstract
Tuberculous meningitis is a severe form of extrapulmonary tuberculosis. The exact incidence and prevalence are not known. In countries with high burden of pulmonary tuberculosis, the incidence is expected to be proportionately high. Children are much more vulnerable. Human immunodeficiency virus-infected patients have a high incidence of tuberculous meningitis. The hallmark pathological processes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Headache, vomiting, meningeal signs, focal deficits, vision loss, cranial nerve palsies and raised intracranial pressure are dominant clinical features. Diagnosis is based on the characteristic clinical picture, neuroimaging abnormalities and cerebrospinal fluid changes (increased protein, low glucose and mononuclear cell pleocytosis). Cerebrospinal fluid smear examination, mycobacterial culture or polymerase chain reaction is mandatory for bacteriological confirmation. The mortality and morbidity of tuberculous meningitis are exceptionally high. Prompt diagnosis and early treatment are crucial. Decision to start antituberculous treatment is often empirical. WHO guidelines recommend a 6 months course of antituberculous treatment; however, other guidelines recommend a prolonged treatment extended to 9 or 12 months. Corticosteroids reduce the number of deaths. Resistance to antituberculous drugs is associated with a high mortality. Patients with hydrocephalus may need ventriculo-peritoneal shunting. Bacillus Calmette-Guérin vaccination protects to some degree against tuberculous meningitis in children.
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Affiliation(s)
- R K Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh, Lucknow, India.
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19
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Ionita CC, Siddiqui AH, Levy EI, Hopkins LN, Snyder KV, Gibbons KJ. Acute ischemic stroke and infections. J Stroke Cerebrovasc Dis 2010; 20:1-9. [PMID: 20538486 DOI: 10.1016/j.jstrokecerebrovasdis.2009.09.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Revised: 08/24/2009] [Accepted: 09/10/2009] [Indexed: 11/26/2022] Open
Abstract
We present an overview of multiple infections in relation to acute ischemic stroke and the therapeutic options available. Conditions that are a direct cause of stroke (infectious endocarditis, meningoencephalitides, and human immunodeficiency virus infection), the pathophysiologic mechanism responsible for stroke, and treatment dilemmas are presented. Independently or in conjunction with conventional risk factors, chronic and acute infections can trigger an acute ischemic stroke through an accelerated process of atherosclerosis and immunohematologic alterations. Acute ischemic stroke has a negative impact on the antibacterial immune response, leading to stroke-induced immunodepression and infections, the most common poststroke medical complications. Poststroke infections are independent predictors of poor outcome. Antibiotic trials for poststroke infection prevention are reviewed. Although antibiotic prophylaxis is not the standard of care in acute stroke, current guidelines support prompt treatment of stroke-related infections.
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Affiliation(s)
- Catalina C Ionita
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York.
| | - Adnan H Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Radiology and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - L Nelson Hopkins
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Radiology and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
| | - Kevin J Gibbons
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York; Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York
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20
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MRI to demonstrate diagnostic features and complications of TBM not seen with CT. Childs Nerv Syst 2009; 25:941-7. [PMID: 19107489 DOI: 10.1007/s00381-008-0785-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Computed tomography (CT) findings in children with tuberculous meningitis (TBM) often do not explain the clinical presentation and may even be normal. Magnetic resonance imaging (MRI) has the potential to diagnose TBM with greater sensitivity than CT and also to detect more infarcts. AIM The aim of this study was to determine whether MRI demonstrates features and complications of TBM not present on CT. MATERIALS AND METHODS Retrospective, blinded evaluation and comparison of CT and MRI findings in children with TBM were performed. RESULTS Of 30 children included, MRI demonstrated eight more with basal enhancement and four more with infarctions. Overall, MRI demonstrated an additional 104 sites of infarction (of a total 172) than CT. Of these, 89 were acute and visualized only on diffusion-weighted image. MRI showed five more patients with unilateral and two more with bilateral basal ganglia infarcts than CT as well as 19 brainstem infarcts. Hydrocephalus was equally detected by MRI and CT. CONCLUSION MRI is superior to CT for diagnosing TBM (by detecting basal enhancement in more patients) and prognosis (by detecting many more infarcts in strategic locations). The role of CT is defined for the acute setting in detecting hydrocephalus for surgical management.
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21
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[Treatment of extrapulmonary tuberculosis and complicated forms of pulmonary tuberculosis]. An Pediatr (Barc) 2009; 69:271-8. [PMID: 18775275 DOI: 10.1157/13125824] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Tuberculosis is one of the most important health problems worldwide. In developed countries there is an increased number of cases due to different reasons. The most likely determinant cause is from immigrants coming from high endemic areas. This phenomenon is a direct cause of the increase in extrapulmonary and complicated pulmonary forms of tuberculosis. There are only a few controlled clinical trials evaluating therapies for extrapulmonary tuberculosis. Consequently, documented evidence is scarce, particularly in paediatrics. The majority of therapeutic recommendations are based on series of cases or expert opinions, with a lack of uniformity provided by the different consensus of the main scientific societies. The main objective of this fourth consensus by the Tuberculosis Study Group of the Spanish Society of Paediatric Infectious Diseases (Sociedad Española de Infectología Pediátrica, SEIP) is to perform a thorough revision of the data obtained from scientific literature, in order to establish recommendations for the treatment of extrapulmonary tuberculosis and complicated forms of pulmonary tuberculosis, adapted to the characteristics and drugs available in Spain.
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A comparative study of thin-layer cross-sectional anatomic morphology and CT images of the basal cistern and its application in acute craniocerebral traumas. Surg Radiol Anat 2008; 31:129-38. [DOI: 10.1007/s00276-008-0417-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 09/08/2008] [Indexed: 10/21/2022]
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Camara B, Ly Ba A, Faye PM, Ba A, Ba I, Dia Ndour S, Ba M, Sow HD. [Tuberculosis meningitis in a Senegalese pediatric hospital: report of 14 cases]. Arch Pediatr 2008; 15:322-4. [PMID: 18512280 DOI: 10.1016/j.arcped.2008.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin Microbiol Rev 2008; 21:243-61, table of contents. [PMID: 18400795 DOI: 10.1128/cmr.00042-07] [Citation(s) in RCA: 358] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Tuberculosis of the central nervous system (CNS) is a highly devastating form of tuberculosis, which, even in the setting of appropriate antitubercular therapy, leads to unacceptable levels of morbidity and mortality. Despite the development of promising molecular diagnostic techniques, diagnosis of CNS tuberculosis relies largely on microbiological methods that are insensitive, and as such, CNS tuberculosis remains a formidable diagnostic challenge. Insights into the basic neuropathogenesis of Mycobacterium tuberculosis and the development of an appropriate animal model are desperately needed. The optimal regimen and length of treatment are largely unknown, and with the rising incidence of multidrug-resistant strains of M. tuberculosis, the development of well-tolerated and effective antibiotics remains a continued need. While the most widely used vaccine in the world largely targets this manifestation of tuberculosis, the BCG vaccine has not fulfilled the promise of eliminating CNS tuberculosis. We put forth this review to highlight the current understanding of the neuropathogenesis of M. tuberculosis, to discuss certain epidemiological, clinical, diagnostic, and therapeutic aspects of CNS tuberculosis, and also to underscore the many unmet needs in this important field.
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Affiliation(s)
- Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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