1
|
Dhafer Alshehri F, Mahmood Okal F, Baeshen SK, Alharbi ZG, Khojah O, Alhawsawi WK, Alamoudi S, Bahati A, Lary AI. Outcomes of central nervous system tuberculosis in Saudi Arabia: a multi-center study. Neurol Res 2024; 46:812-822. [PMID: 38855923 DOI: 10.1080/01616412.2024.2359262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 05/19/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVES Central nervous system tuberculosis (TB) (CNS-TB) can occur in several forms, including intracranial tuberculoma, tuberculous brain abscess, TB meningitis (TBM), and spinal TB. Early treatment can save lives and prevent severe neurological complications. This study aimed to describe the characteristics and post-treatment outcomes of patients with CNS-TB and identify factors associated with poor outcomes. To the best of our knowledge, this is the largest CNS-TB study till date published in Saudi Arabia. METHODS This retrospective cohort study included all patients diagnosed with CNS-TB in three tertiary centers in Saudi Arabia (King Abdulaziz Medical City in Jeddah, King Abdulaziz Medical City in Riyadh, and Al-Noor Specialist Hospital in Makkah) between 2009 and 2019. Data of patients' demographics, co-morbidities, presenting symptoms, type of CNS-TB, medical and surgical treatments, and outcome after completion of treatment were obtained from medical records. Treatment outcomes were categorized using the modified Rankin Scale for neurological disability. RESULTS A total of 140 participants were included in this study from 2009 to 2019. Good outcomes were achieved in approximately 65% of cases, whereas 35% had poor outcomes based on the modified Rankin Scale. Glasgow Coma Scale score ≤10 at presentation and TBM/tuberculoma were significantly associated with poor outcomes. Moreover, the use of corticosteroids, more than three anti-TB medications, and surgical interventions were not significantly associated with good or poor outcomes. DISCUSSION CNS-TB is associated with a high burden of long-term neurological morbidity. Early detection and treatment are crucial to prevent serious complications and decrease morbidity and mortality.
Collapse
Affiliation(s)
- Fayez Dhafer Alshehri
- Departemnt of Neuroscience, Section of Neurosurgery, King Abdul Aziz Medical City, Ministry of the National Guard Health Affairs, King Abdullah International Medical Research Center, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
| | - Fahad Mahmood Okal
- Departemnt of Neuroscience, Section of Neurosurgery, King Abdul Aziz Medical City, Ministry of the National Guard Health Affairs, King Abdullah International Medical Research Center, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
| | - Salem K Baeshen
- Neurosurgery Department, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Zeyad G Alharbi
- Neurosurgery Department, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Osama Khojah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Department of Medicine, Ministry of the National Guard Health Affairs, Jeddah, Saudi Arabia
- Department of Ophthalmology, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Waseem K Alhawsawi
- Department of Dermatology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Saeed Alamoudi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Department of Medicine, Ministry of the National Guard Health Affairs, Jeddah, Saudi Arabia
- Department of Ophthalmology, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ammar Bahati
- Neurosurgery Section, Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ahmed I Lary
- Departemnt of Neuroscience, Section of Neurosurgery, King Abdul Aziz Medical City, Ministry of the National Guard Health Affairs, King Abdullah International Medical Research Center, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| |
Collapse
|
2
|
Chen Y, Luo C, Zhou G, Wang H, Dai K, Wu W, Wang S, Su Z, Peng F, Jiang Y. The discrimination between autoimmune glial fibrillary acidic protein astrocytopathy and tuberculous meningitis. Mult Scler Relat Disord 2024; 85:105527. [PMID: 38432014 DOI: 10.1016/j.msard.2024.105527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/25/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE The differential diagnosis between autoimmune glial fibrillary acidic protein astrocytopathy (AGFAPA) mimicking tuberculous meningitis and tuberculous meningitis (TBM) remains challenging in clinical practice. This study aims to identify the clinical, laboratory parameters, and clinical score systems that may be helpful in differentiating AGFAPA from TBM. METHOD Overall 22 AGFAPA patients who were initially misdiagnosed as TBM (AGFAPA-TBM) and 30 confirmed TBM patients were included. The clinical, laboratory, imaging parameters, Thwaites systems, and Lancet consensus scoring systems (LCSS) of all patients were reviewed. Logistic regression was employed to establish a diagnostic formula to differentiate AGFAPA-TBM from TBM. The receiver operating characteristic (ROC) curve was applied to determine the best diagnostic critical point of the formula. RESULTS Urinary retention was more frequent in AGFAPA-TBM patients (72.7% vs 33.3%, p = 0.012). A significantly lower ratio of T-SPOT. TB was noted in AGFAPA-TBM patients (9.1% vs 82.1%, p < 0.001). We found the LCSS was able to differentiate AGFAPA-TBM from TBM (AUC value 0.918, 95% CI=0.897-0.924). Furthermore, we set up a new scoring system with three variables: urinary retention, T-SPOT. TB, and cerebral imaging criteria in LCSS. The proposed diagnostic score ranges from -8 to 2, and a score of ≥ 0 was suggestive of AGFAPA-TBM (AUC value 0.938, 95% CI=0.878-0.951). CONCLUSIONS This study is the first to evaluate the Thwaites system and LCSS in AGFAPA-TBM and TBM. We provide an alternative diagnostic formula to differentiate AGFAPA-TBM from TBM and suggest testing for GFAP antibodies to avoid misdiagnosis when this scoring system meets AGFAPA-TBM.
Collapse
Affiliation(s)
- Yanxiang Chen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China; Department of Neurology, Xiaolan People's Hospital of Zhongshan, 65#, Middle Section of Jucheng Avenue, Xiaolan, Zhongshan, Guangdong Province 528400, China
| | - Chongliang Luo
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St Louis, MO 63110, USA
| | - Guonan Zhou
- Department of Encephalopathy, Zhongshan Chenxinghai Hospital of Integrated Traditional Chinese and Western Medicine, 18# Zhuyuan Road, Zhongshan, Guangdong Province 528400, China
| | - Hui Wang
- Department of Neurology, Xiaolan People's Hospital of Zhongshan, 65#, Middle Section of Jucheng Avenue, Xiaolan, Zhongshan, Guangdong Province 528400, China
| | - Kai Dai
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Weijuan Wu
- Department of Neurology, Sanshui District People's Hospital, Sanshui, Foshan, Guangdong Province 528100, China
| | - Siguang Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Zhihui Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China.
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, 600# Tianhe Road, Guangzhou, Guangdong Province 510630, China.
| |
Collapse
|
3
|
Kumar VS, Kumar VS. Localization of cerebral vasculopathy following bacterial meningitis: What can we learn about postinfective ischemic sequelae? Brain Circ 2023; 9:205-213. [PMID: 38284114 PMCID: PMC10821684 DOI: 10.4103/bc.bc_97_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/03/2023] [Accepted: 03/21/2023] [Indexed: 01/30/2024] Open
Abstract
Cerebrovascular complications of bacterial meningitis account for a high incidence of mortality and postinfective neurologic sequelae. Cerebrovascular complications occurring during acute bacterial meningitis are evident from angiographic evidence demonstrating arterial occlusion and vessel wall narrowing, histopathological studies demonstrating vessel wall changes, and radiographic studies demonstrating the presence of brain infarcts. Cerebrovascular disease during bacterial meningitis has been demonstrated in of Haemophilus influenzae, Streptococcus pneumonia, Group B Streptococcus, and Mycobacterium tuberculosis models of meningitis. Despite models of bacterial meningitis showing variable patterns of cerebral vasculopathy as a contributor to different aspects of postinfectious neurological decline, very few studies describe the predominant localization of cerebral vasculopathy with different meningitis causing pathogens. Thus, this review attempts to analyze the different locations of cerebral vasculopathic changes occuring in response to different microbial pathogens and provide a pathophysiologic basis for such an observation.
Collapse
Affiliation(s)
- Vivig Shantha Kumar
- Department of Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, California, United States of America
| | - Vignarth Shantha Kumar
- Department of Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, California, United States of America
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Sy MCC, Espiritu AI, Pascual JLR. Global Frequency and Clinical Features of Stroke in Patients With Tuberculous Meningitis: A Systematic Review. JAMA Netw Open 2022; 5:e2229282. [PMID: 36048445 PMCID: PMC9437750 DOI: 10.1001/jamanetworkopen.2022.29282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Stroke in tuberculous meningitis (TBM) is associated with significant morbidity and mortality. OBJECTIVE To determine the country-specific, regional, and overall prevalence of stroke among patients with TBM, including their clinical manifestations, stroke locations, and outcomes. EVIDENCE REVIEW This systematic review searched records in MEDLINE by PubMed, Scopus, and EMBASE until July 2020 for relevant articles on the occurrence and characteristics of stroke in TBM. Randomized clinical trials and cohort studies that included a population of patients with TBM were analyzed for clinical manifestations, type of stroke, area of stroke, vascular territory, and outcomes. Studies that did not report the occurrence of stroke, reported as abstract only with no full-texts available, and articles not in English were excluded. The country-specific, regional, and overall frequencies of stroke among patients with TBM were determined; secondary analysis enumerated the summary estimates of the clinical presentations, common locations of stroke, and outcomes. The Murad tool was used to assess methodological quality. FINDINGS From 852 articles identified, 71 studies involving 2194 patients with stroke in TBM were included. The sample size for each study ranged from 17 to 806 patients. The frequency of stroke in TBM showed an estimate of 0.30 (95% CI, 0.26-0.33). The most common clinical manifestations were fever and headache. The lateral striate, middle cerebral, and medial striate arteries were typically affected. The basal ganglia, cortex and lobar, and internal capsule were the frequently involved areas of the brain. The pooled proportions of mortality and poor outcomes were 0.22 (95% CI, 0.16-0.29) and 0.51 (95% CI, 0.37-0.66), respectively. CONCLUSIONS AND RELEVANCE The results of this systematic review suggest that stroke is considerably frequent among patients with TBM. The reported frequencies of stroke in TBM and its clinical features vary across the studies and populations.
Collapse
Affiliation(s)
- Marie Charmaine C. Sy
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Adrian I. Espiritu
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
- Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Jose Leonard R. Pascual
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| |
Collapse
|
6
|
Rahimi BA, Niazi N, Rahimi AF, Faizee MI, Khan MS, Taylor WR. Treatment outcomes and risk factors of death in childhood tuberculous meningitis in Kandahar, Afghanistan: a prospective observational cohort study. Trans R Soc Trop Med Hyg 2022; 116:1181-1190. [PMID: 35902999 PMCID: PMC9717388 DOI: 10.1093/trstmh/trac066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 05/05/2022] [Accepted: 06/28/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most severe form of TB. We prospectively documented the treatment outcomes and the risk factors for death in children with TBM from Kandahar, Afghanistan. METHODS This prospective observational cohort study was conducted from February 2017 to January 2020 in hospitalised TBM children. All the patients were prospectively followed up for 12 mo. Data were analysed by using descriptive statistics, χ2 and multivariate logistic regression. RESULTS A total of 818 TBM hospitalised patients with median age 4.8 (0.8-14.5) y were recruited. Females accounted for 60.9% (498/818). Upon admission 53.9% (n=441) and 15.2% (n=124) had TBM stages II and III, respectively, and 23.2% (n=190) had focal neurological signs. The case fatality rate was 20.2% (160/794) and 30.6% (243/794) survived with neurological sequelae. Independent risk factors for death were being unvaccinated for BCG (adjusted OR [AOR] 3.8, 95% CI 1.8 to 8.1), not receiving dexamethasone (AOR 2.5, 95% CI 1.5 to 4.2), being male (AOR 2.3, 95% CI 1.5 to 3.6), history of recent weight loss (AOR 2.2, 95% CI 1.3 to 3.9) and having stage III TBM (AOR 2.0, 95% CI 1.2 to 3.3). CONCLUSIONS TBM continues to cause high morbidity and mortality in Afghan children. Strategies to reduce mortality should emphasise early diagnosis and treatment, routine use of dexamethasone and increased BCG vaccination.
Collapse
Affiliation(s)
- Bilal Ahmad Rahimi
- Corresponding author: Department of Paediatrics, Faculty of Medicine, Kandahar University, Durahi, Beside Aino Mena Town, District 10, Kandahar 3801, Afghanistan; Tel: +93700309692; E-mail:
| | - Najeebullah Niazi
- Department of Surgery, Faculty of Medicine, Kandahar University, Kandahar 3809, Afghanistan
| | - Ahmad Farshad Rahimi
- Kandahar Tuberculosis Centre, Directorate of Public Health, Kandahar 3809, Afghanistan
| | - Muhammad Ishaque Faizee
- Department of Histopathology, Faculty of Medicine, Kandahar University, Kandahar 3809, Afghanistan
| | - Mohmmad Sidiq Khan
- Head of Paediatric Ward, Mirwais Regional Hospital, Kandahar 3809, Afghanistan
| | - Walter R Taylor
- Mahidol Oxford Tropical Medicine Clinical Research unit (MORU), Mahidol University, Bangkok 10400, Thailand,Centre for Tropical Medicine and Global Health, University of Oxford, OX3 7LG, UK
| |
Collapse
|
7
|
Kumar M, Dhar N, Tiwari A, Siddiqui MS. Comparison of patterns of infarction in TB and cryptococcal meningitis. Trans R Soc Trop Med Hyg 2021; 115:1160-1167. [PMID: 33962464 DOI: 10.1093/trstmh/trab070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/21/2021] [Accepted: 04/16/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To compare the frequency and patterns of stroke, the specificity of tubercular zone (TBZ) infarction and its effect on outcomes in TB (TBM) and cryptococcal meningitis (CM). METHODS This retrospective study was conducted at two tertiary centres in India from May 2018 to July 2020. Sixty-one patients with TBM and 22 with CM were included. The primary outcome was the proportions of TBM and CM patients with infarction. Secondary outcomes included the anatomical locations of infarction and in-hospital mortality. RESULTS Infarction was noted in 52.5% of patients with TBM and in 54.5% of those with CM (p=0.87), with caudate head infarcts in 9.4% vs 41.7% (p=0.01), cerebellar in 9.4% vs 33.3% (p=0.05), thalamic in 25% vs 0% and lobar in 28.1% vs 0%, respectively. In TBM, the infarcts were located in the TBZ in 3 (9.4%), in the ischaemic zone in 23 (71.9%), while 6 (18.8%) patients showed infarcts in both, while in CM, the infarcts were in 0 (0%), 6 (50%) and 6 (50%) patients, respectively. Infarcts were not associated with in-hospital mortality, either in TBM or CM. CONCLUSION Caudate head and cerebellar infarction was more common in CM, while thalamic and lobar infarcts were more frequent in TBM. TBZ infarcts were not specific to TBM.
Collapse
Affiliation(s)
- Mritunjai Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India.,Department of Neurology, All India Institute of Medical Sciences, Raipur, 492099, India
| | - Nikita Dhar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India
| | - Ashutosh Tiwari
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, 249203, India
| | - Md Sabah Siddiqui
- Department of Internal Medicine, All India Institute of Medical Sciences, Raipur, 492099, India
| |
Collapse
|
8
|
Tuberculous Meningitis Fitting the Shoes of Incomplete Kawasaki Disease. Indian J Pediatr 2020; 87:1086-1087. [PMID: 32451831 DOI: 10.1007/s12098-020-03339-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
|
9
|
Tala-Ighil T, Greffe S, Trad S, Delaroche M, Coutte L, Rouveix E, Kahn JE, Hanslik T. [Cerebral infarction and tuberculosis: case report and literature review]. Rev Med Interne 2020; 41:704-707. [PMID: 32861533 DOI: 10.1016/j.revmed.2020.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/21/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Although tuberculous meningitis is an uncommon presentation of tuberculosis, it still remains one of the deadliest forms of this disease. In this context, the occurrence of a cerebral infarct is an aggravating factor. OBSERVATION A 48-year-old Asian man presented himself in the emergency room for dysarthria and dysphagia of progressive onset. Cerebral CT showed a recent ischemic defect of the right internal capsule. Lumbar puncture showed meningitis with low sugar levels. Pulmonary micronodules on the thoracic CT suggested tuberculosis, which was confirmed by a broncho-alveolar lavage. Anti-tuberculosis treatment and early corticosteroid resulted in an improvement of the patient's state. CONCLUSION Cerebral infarctions in patients with tuberculous meningitis are events that cannot be underestimated in terms of frequency or severity. Their poor prognosis is partly the result of insufficiently defined management, which combines anti-tuberculosis treatment and early corticosteroid therapy.
Collapse
Affiliation(s)
- T Tala-Ighil
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France.
| | - S Greffe
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - S Trad
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - M Delaroche
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - L Coutte
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - E Rouveix
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - J-E Kahn
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| | - T Hanslik
- Assistance Publique Hôpitaux de Paris, Service de médecine interne, Hôpital Ambroise Paré, 92100 Boulogne Billancourt, France; Université de Versailles Saint Quentin, UFR Simone Veil, 78000 Versailles, France
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Daniel BD, Grace GA, Natrajan M. Tuberculous meningitis in children: Clinical management & outcome. Indian J Med Res 2019; 150:117-130. [PMID: 31670267 PMCID: PMC6829784 DOI: 10.4103/ijmr.ijmr_786_17] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 12/15/2022] Open
Abstract
Although the occurrence of tuberculous meningitis (TBM) in children is relatively rare, but it is associated with higher rates of mortality and severe morbidity. The peak incidence of TBM occurs in younger children who are less than five years of age, and most children present with late-stage disease. Confirmation of diagnosis is often difficult, and other infectious causes such as bacterial, viral and fungal causes must be ruled out. Bacteriological confirmation of diagnosis is ideal but is often difficult because of its paucibacillary nature as well as decreased sensitivity and specificity of diagnostic tests. Early diagnosis and management of the disease, though difficult, is essential to avoid death or neurologic disability. Hence, a high degree of suspicion and a combined battery of tests including clinical, bacteriological and neuroimaging help in diagnosis of TBM. Children diagnosed with TBM should be managed with antituberculosis therapy (ATT) and steroids. There are studies reporting low concentrations of ATT, especially of rifampicin and ethambutol in cerebrospinal fluid (CSF), and very young children are at higher risk of low ATT drug concentrations. Further studies are needed to identify appropriate regimens with adequate dosing of ATT for the management of paediatric TBM to improve treatment outcomes. This review describes the clinical presentation, investigations, management and outcome of TBM in children and also discusses various studies conducted among children with TBM.
Collapse
Affiliation(s)
- Bella Devaleenal Daniel
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - G. Angeline Grace
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Mohan Natrajan
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| |
Collapse
|
12
|
Azeemuddin M, Alvi A, Sayani R, Khan MK, Farooq S, Beg MA, Awan S, Wasay M. Neuroimaging Findings in Tuberculosis: A Single-Center Experience in 559 Cases. J Neuroimaging 2019; 29:657-668. [PMID: 31115112 DOI: 10.1111/jon.12627] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE There is a paucity of literature related to the neuroimaging of CNS tuberculosis (TB) and largely covers pediatric CNS TB. The objective of this study was to determine the frequency of different forms of CNS TB and its associated complications and to study longitudinal disease course using computed tomography (CT) and MRI. METHODS Retrospective chart and imaging review of patients diagnosed with CNS TB in a tertiary care hospital in Pakistan over a 10-year period. A total of 452 initial brain MRI and 209 CT scans were reviewed by an expert radiologist specialized in neuroimaging. This was followed by review of 53 MRI/52 CT and 7 MRI/14 CT first and second follow-up scans, respectively. RESULTS Note that 559 patients, 296 males and 263 females were included in the study. On the initial CT scans, tuberculomas were found in 25 (12%), infarction in 54 (25%), basal meningeal enhancement in 29 (14%), and hydrocephalus in 84 (40%). On initial MRI, tuberculomas were found in 182 (40%), infarction in 120 (27%), basal meningeal enhancement in 184 (41%), and hydrocephalus in 116 (26%). On review of follow-up CT scans, 13 (25%) showed new or worsening hydrocephalus, 8 (15%) showed new infarcts, 1 exhibited new tuberculoma, and 5 showed worsening cerebral edema. On review of follow-up MRI scans, new or worsening hydrocephalus was seen in 3 (6%), new infarcts in 3 (6%), new tuberculoma in 10 (19%), worsening cerebral edema in 7 (13%), and TB myelitis in 4 (8%) patients. CONCLUSIONS Tuberculoma, hydrocephalus, and cerebral infarcts are the most prominent findings in CNS tuberculosis. Our study showed development of new lesions on subsequent neuroimaging suggesting a dynamic and progressive nature of the disease process in some individuals.
Collapse
Affiliation(s)
- Muhammad Azeemuddin
- Department of Radiology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Amna Alvi
- Department of Radiology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Raza Sayani
- Department of Radiology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Misha Khalid Khan
- Department of Radiology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Salman Farooq
- Department of Neurology, The Aga Khan University Hospital, Karachi, Pakistan
| | - M Asim Beg
- Department of Microbiology and Pathology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Safia Awan
- Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan
| | - Mohammad Wasay
- Department of Neurology, The Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
13
|
Magnetic resonance imaging spectrum of intracranial tubercular lesions: one disease, many faces. Pol J Radiol 2018; 83:e524-e535. [PMID: 30800191 PMCID: PMC6384409 DOI: 10.5114/pjr.2018.81408] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/19/2018] [Indexed: 12/13/2022] Open
Abstract
Tuberculosis is a devastating disease and has shown resurgence in recent years with the advent of acquired immunodeficiency syndrome. Central nervous system involvement is the most devastating form of the disease, comprising 10% of all tuberculosis cases. The causative organism, Mycobacterium tuberculosis, incites a granulomatous inflammatory response in the brain, the effects of which can be appreciated on magnetic resonance imaging (MRI), which can thus be used for diagnosis of the same. Neurotuberculosis can present in various patterns, which can be identified on MRI. The meningeal forms include leptomeningitis and pachymeningitis. Parenchymal forms of neurotuberculosis include tuberculoma in its various stages, tubercular cerebritis and abscess, tubercular rhombencephalitis, and tubercular encephalopathy. Each pattern has characteristic MRI appearances and differential diagnoses on imaging. Complications of neurotuberculosis, usually of tubercular meningitis, include hydrocephalus, vasculitis, and infarcts as well as cranial nerve palsies. Various MRI sequences besides the conventional ones can provide additional insight into the disease, help in quantifying the disease load, and help in differentiation of neurotuberculosis from conditions with similar imaging appearances and presentations. These can enable accurate and timely diagnosis by the radiologist and early institution of treatment in order to reduce the likelihood of permanent neurological sequelae.
Collapse
|
14
|
Goenka A, Jeena PM, Mlisana K, Solomon T, Spicer K, Stephenson R, Verma A, Dhada B, Griffiths MJ. Rapid Accurate Identification of Tuberculous Meningitis Among South African Children Using a Novel Clinical Decision Tool. Pediatr Infect Dis J 2018; 37:229-234. [PMID: 28777205 PMCID: PMC5747355 DOI: 10.1097/inf.0000000000001726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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 Early diagnosis of tuberculous meningitis (TBM) is crucial to achieve optimum outcomes. There is no effective rapid diagnostic test for use in children. We aimed to develop a clinical decision tool to facilitate the early diagnosis of childhood TBM. METHODS Retrospective case-control study was performed across 7 hospitals in KwaZulu-Natal, South Africa (2010-2014). We identified the variables most predictive of microbiologically confirmed TBM in children (3 months to 15 years) by univariate analysis. These variables were modelled into a clinical decision tool and performance tested on an independent sample group. RESULTS Of 865 children with suspected TBM, 3% (25) were identified with microbiologically confirmed TBM. Clinical information was retrieved for 22 microbiologically confirmed cases of TBM and compared with 66 controls matched for age, ethnicity, sex and geographical origin. The 9 most predictive variables among the confirmed cases were used to develop a clinical decision tool (CHILD TB LP): altered Consciousness; caregiver HIV infected; Illness length >7 days; Lethargy; focal neurologic Deficit; failure to Thrive; Blood/serum sodium <132 mmol/L; CSF >10 Lymphocytes ×10/L; CSF Protein >0.65 g/L. This tool successfully classified an independent sample of 7 cases and 21 controls with a sensitivity of 100% and specificity of 90%. CONCLUSIONS The CHILD TB LP decision tool accurately classified microbiologically confirmed TBM. We propose that CHILD TB LP is prospectively evaluated as a novel rapid diagnostic tool for use in the initial evaluation of children with suspected neurologic infection presenting to hospitals in similar settings.
Collapse
Affiliation(s)
- Anu Goenka
- Manchester Collaborative Centre for Inflammation Research, University of Manchester, UK
- Manchester Academic Health Sciences Centre, University of Manchester, UK
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
| | - Prakash M. Jeena
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Koleka Mlisana
- Department of Microbiology, National Health Laboratory Service, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, South Africa
| | - Tom Solomon
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, UK
- Walton Centre NHS Foundation Trust, UK
| | - Kevin Spicer
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Rebecca Stephenson
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
| | - Arpana Verma
- Manchester Academic Health Sciences Centre, University of Manchester, UK
- Centre for Epidemiology, Institute of Population Health, University of Manchester, UK
| | - Barnesh Dhada
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Michael J. Griffiths
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, UK
- Department of Neurology, Alder Hey Children’s NHS Trust, UK
| |
Collapse
|
15
|
Marais BJ, Heemskerk AD, Marais SS, van Crevel R, Rohlwink U, Caws M, Meintjes G, Misra UK, Mai NTH, Ruslami R, Seddon JA, Solomons R, van Toorn R, Figaji A, McIlleron H, Aarnoutse R, Schoeman JF, Wilkinson RJ, Thwaites GE. Standardized Methods for Enhanced Quality and Comparability of Tuberculous Meningitis Studies. Clin Infect Dis 2017; 64:501-509. [PMID: 28172588 PMCID: PMC5399942 DOI: 10.1093/cid/ciw757] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/10/2016] [Indexed: 01/06/2023] Open
Abstract
Tuberculous meningitis (TBM) remains a major cause of death and disability in
tuberculosis-endemic areas, especially in young children and immunocompromised adults.
Research aimed at improving outcomes is hampered by poor standardization, which limits
study comparison and the generalizability of results. We propose standardized methods for
the conduct of TBM clinical research that were drafted at an international tuberculous
meningitis research meeting organized by the Oxford University Clinical Research Unit in
Vietnam. We propose a core dataset including demographic and clinical information to be
collected at study enrollment, important aspects related to patient management and
monitoring, and standardized reporting of patient outcomes. The criteria proposed for the
conduct of observational and intervention TBM studies should improve the quality of future
research outputs, can facilitate multicenter studies and meta-analyses of pooled data, and
could provide the foundation for a global TBM data repository.
Collapse
Affiliation(s)
- Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity and the Children's Hospital at Westmead, University of Sydney, Australia
| | - Anna D Heemskerk
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Suzaan S Marais
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa.,Department of Neurology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Reinout van Crevel
- Department of Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ursula Rohlwink
- Division of Neurosurgery, University of Cape Town, South Africa
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
| | - Usha K Misra
- Sanjay Ghandi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Nguyen T H Mai
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - James A Seddon
- Department of Medicine, Imperial College London, United Kingdom
| | - Regan Solomons
- Tygerberg Children's Hospital and the Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa
| | - Ronald van Toorn
- Tygerberg Children's Hospital and the Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa
| | - Anthony Figaji
- Division of Neurosurgery, University of Cape Town, South Africa
| | - Helen McIlleron
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa
| | - Robert Aarnoutse
- Department of Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johan F Schoeman
- Tygerberg Children's Hospital and the Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa
| | - Robert J Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Observatory, 7925, Cape Town, South Africa.,Department of Medicine, Imperial College London, United Kingdom.,Francis Crick Institute Mill Hill Laboratory, London, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Nuffield Department of Medicine, University of Oxford, United Kingdom
| | | |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Xiao Y, Yu S, Xue Q, Lang S, Sun J, Feng D, Wang J. A scoring system to effectively evaluate central nervous system tuberculosis in patients with military tuberculosis. PLoS One 2017; 12:e0176651. [PMID: 28531173 PMCID: PMC5439665 DOI: 10.1371/journal.pone.0176651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/13/2017] [Indexed: 11/30/2022] Open
Abstract
There is currently no convenient way to effectively evaluate whether a miliary tuberculosis patient is complicated with central nervous system (CNS) tuberculosis. We aimed to find such a way by analyzing the clinical data of these patients. Fifty patients with confirmed miliary tuberculosis and 31 patients with confirmed miliary tuberculosis complicated with CNS tuberculosis from 2010 to 2014 were selected. Their general conditions, clinical features and laboratory tests were analyzed. Factors that were significantly different between them were chosen to performed multivariate and univariate logistic regression analyses, and factors with significant P values were used to establish a scoring system. Eight factors, i.e., age, cough, nausea, headache, hemoglobin (HGB), serum albumin (ALB), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), were significantly different (P < 0.05). Multivariate logistic regression analysis showed that ALB was the independent risk predictor (HR = 1.29, 95% CI 1.09–1.52, P < 0.01), whereas the others were non-independent predictors except age (P < 0.05). The scoring system was based on a summation of the scores of the assigned values of the seven predictors and had an area under the curve (AUC) of 0.86 to confirm CNS tuberculosis, with a sensitivity of 81.5% and a specificity of 81.4% at a score of 0.75 and with a specificity of 95.3% at a score of 2.75. In contrast, a score below -0.75 excluded CNS tuberculosis, with a sensitivity of 88.9% and a specificity of 62.7%. The scoring system should be useful to evaluate whether a miliary tuberculosis patient is complicated with CNS tuberculosis and could help doctors avoid excessive investigation.
Collapse
Affiliation(s)
- Yongjiu Xiao
- Department of Respiratory Disease, Chinese PLA General Hospital, Beijing, China
- Department of Respiratory Disease, Lanzhou General Hospital of Chinese PLA, Lanzhou, Gansu Province, China
| | - Shuqing Yu
- The Second Ward of Lanzhou Pulmonary Hospital, Lanzhou, Gansu Province, China
| | - Qingliang Xue
- Department of Respiratory Disease, Lanzhou General Hospital of Chinese PLA, Lanzhou, Gansu Province, China
| | - Shan Lang
- Department of Respiratory Disease, Chinese PLA General Hospital, Beijing, China
| | - Junping Sun
- Department of Respiratory Disease, Chinese PLA General Hospital, Beijing, China
| | - Dan Feng
- Department of Respiratory Disease, Chinese PLA General Hospital, Beijing, China
| | - Jianxin Wang
- Department of Respiratory Disease, Chinese PLA General Hospital, Beijing, China
- * E-mail:
| |
Collapse
|
18
|
Tai MLS, Viswanathan S, Rahmat K, Nor HM, Kadir KAA, Goh KJ, Ramli N, Bakar FKA, Zain NRM, Yap JF, Ong BH, Rafia MH, Tan CT. Cerebral infarction pattern in tuberculous meningitis. Sci Rep 2016; 6:38802. [PMID: 27958312 PMCID: PMC5153843 DOI: 10.1038/srep38802] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 11/15/2016] [Indexed: 11/10/2022] Open
Abstract
Tuberculous meningitis (TBM) causes significant morbidity and mortality. The primary objective was to re-examine the concept of “TB zone” and “ischaemic zone” in cerebral infarction in patients with tuberculous meningitis. The secondary objective was to evaluate cerebral infarction, vasculitis and vasospasm in tuberculous meningitis infections. Between 2009 and 2014, TBM patients were recruited. Neuroimaging was performed and findings of cerebral infarction, vasculitis and vasospasm were recorded. Infarcts were classified based on arterial supply and Hsieh’s classification. Fifty-one TBM patients were recruited of whom 34 patients (67%) had cerebral infarction. Based on Hsieh’s classification, 20 patients (59%) had infarcts in both “TB zone” and “ischaemic zones”. 12 patients (35%) had infarcts in “ischaemic zone” and two (6%) patients had infarcts in “TB zone”. In terms of vascular supply, almost all patients (35/36) had infarcts involving perforators and cortical branches. 25 patients (73%) and 14 patients (41%) had infarcts supplied by lateral lenticulostriate and medial lenticulostriate arteries respectively. 15 patients (37%) had vasculitis. Vasospasm was present in six patients (15%). 29 patients (85%) with cerebral infarction also had leptomeningeal enhancement (p = 0.002). In summary, infarcts involved mainly perforators and cortical branches, rather than “TB zone” versus “ischaemic zone”.
Collapse
Affiliation(s)
- Mei-Ling Sharon Tai
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Shanthi Viswanathan
- Department of Neurology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Kartini Rahmat
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Hazman Mohd Nor
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Khairul Azmi Abdul Kadir
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Khean Jin Goh
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Norlisah Ramli
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Fatimah Kamila Abu Bakar
- Department of Biomedical Imaging, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | | | - Jun Fai Yap
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Beng Hooi Ong
- Department of Medicine, Hospital Alor Setar. Jalan Langgar, 05460 Alor Setar, Malaysia
| | - Mohd Hanip Rafia
- Department of Neurology, Hospital Kuala Lumpur, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Chong Tin Tan
- Division of Neurology, Department of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| |
Collapse
|
19
|
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.
Collapse
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
| | | | | | | | | | | |
Collapse
|
20
|
Kumar K, Giribhattanavar P, Chandrashekar N, Patil S. Correlation of clinical, laboratory and drug susceptibility profiles in 176 patients with culture positive TBM in a tertiary neurocare centre. Diagn Microbiol Infect Dis 2016; 86:372-376. [PMID: 27717649 DOI: 10.1016/j.diagmicrobio.2016.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 09/12/2016] [Accepted: 09/20/2016] [Indexed: 11/29/2022]
Abstract
Drug resistance has increased the difficulties in control of tuberculosis infection. The present study evaluated the clinical and laboratory features among tuberculous meningitis (TBM) patients and the drug susceptibility of Mycobacterium tuberculosis (M.tb) isolated from CSF. Out of 698 CSF samples, 176 (25.21%) were M.tb culture positive. Among the clinical signs and symptoms, fever, headache and altered sensorium were found to be statistically significant (P<0.05). ELISA was a better predictor of disease and found to be statistically significant (P<0.001) in culture-proven TBM cases. Totally, 57 (32.4%) isolates were resistant to one or more drugs that include 5 (2.8%) multidrug-resistant isolates. In conclusion, the search for antibody in CSF and also CSF chloride can represent as an adjunct in the diagnosis of TBM. Screening of drug susceptibility is a very important factor and would help in better management of the disease.
Collapse
Affiliation(s)
- Kavitha Kumar
- Department of Neuromicrobiology, National Institute of Mental Health and Neuroscience, Hosur Road, Bengaluru, Karnataka 560029, India
| | - Prashant Giribhattanavar
- Department of Neuromicrobiology, National Institute of Mental Health and Neuroscience, Hosur Road, Bengaluru, Karnataka 560029, India
| | - Nagarathna Chandrashekar
- Department of Neuromicrobiology, National Institute of Mental Health and Neuroscience, Hosur Road, Bengaluru, Karnataka 560029, India
| | - Shripad Patil
- Department of Neuromicrobiology, National Institute of Mental Health and Neuroscience, Hosur Road, Bengaluru, Karnataka 560029, India.
| |
Collapse
|
21
|
Central nervous system tuberculosis: an imaging-focused review of a reemerging disease. Radiol Res Pract 2015; 2015:202806. [PMID: 25653877 PMCID: PMC4306383 DOI: 10.1155/2015/202806] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 12/11/2014] [Indexed: 11/17/2022] Open
Abstract
Central nervous system (CNS) tuberculosis is a potentially life threatening condition which is curable if the correct diagnosis is made in the early stages. Its clinical and radiologic manifestations may mimic other infectious and noninfectious neurological conditions. Hence, familiarity with the imaging presentations of various forms of CNS tuberculosis is essential in timely diagnosis, and thereby reducing the morbidity and mortality of this disease. In this review, we describe the imaging characteristics of the different forms of CNS tuberculosis, including meningitis, tuberculoma, miliary tuberculosis, abscess, cerebritis, and encephalopathy.
Collapse
|
22
|
Wasay M, Farooq S, Khowaja ZA, Bawa ZA, Ali SM, Awan S, Beg MA, Mehndiratta MM. Cerebral infarction and tuberculoma in central nervous system tuberculosis: frequency and prognostic implications. J Neurol Neurosurg Psychiatry 2014; 85:1260-4. [PMID: 24623792 DOI: 10.1136/jnnp-2013-307178] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tuberculoma and cerebral infarctions are serious complications of central nervous system (CNS) tuberculosis. However, there are no studies comparing prognostic value of tuberculoma and infarcts alone and in patients diagnosed with CNS tuberculosis. OBJECTIVE The objective of this study was to identify frequency and prognostic value of tuberculoma and cerebral infarcts in a large sample of CNS tuberculosis patients. METHODS Retrospective chart review of patients diagnosed with CNS tuberculosis in a tertiary care hospital in Pakistan over 10-year period was carried out. RESULTS There were 404 patients included in this study (mean age of 43 years). There were 209 (52%) men and 195 (48%) women. Tuberculoma were present in 202 subjects (50%) while infarcts were present in 25% patients. 147 (36%) had tuberculous meningitis (TBM) without tuberculoma or infarction on CT or MRI, 158 (39%) had TBM with intracranial tuberculomas, 60 (15%) had TBM with cerebral infarction while 39 (10%) had TBM with both tuberculoma and infarction. At discharge, 249 patients (62%) were either normal (Modified Rankin Score (MRS)=0) or mild to moderately disabled (MRS=1-3) while 82 patients (20%) had severe disability (MRS=4-5). 73 (18%) patients died (MRS=6) during hospitalisation. Using logistic regression analysis, significant predictors of poor outcome included old age, high TBM grading, presence of infarction and presence of hydrocephalus. CONCLUSIONS Tuberculomas were present in 50% of patients, while infarcts were present in 25%. Old age, TBM grading, presence of infarction and hydrocephalus were all predictors of poor outcome.
Collapse
Affiliation(s)
- Mohammad Wasay
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | - Safia Awan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - M Asim Beg
- Pathology and Microbiology, Aga Khan University, Karachi, Pakistan
| | - Man Mohan Mehndiratta
- Department of Neurology, Janakpuri Superspeciality Hospital, Janakpuri New Delhi, New Delhi, India
| |
Collapse
|
23
|
Chen CH, Chang YJ, Sy HN, Chen WL, Yen HC. Risk assessment of the outcome for cerebral infarction in tuberculous meningitis. Rev Neurol (Paris) 2014; 170:512-9. [PMID: 25194476 DOI: 10.1016/j.neurol.2014.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/10/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cerebral infarction in tuberculous meningitis is a major risk factor for permanent disability. This study assessed the clinical presentation of tuberculous meningitis and risks factors for cerebral infarction. OBSERVATION Thirty-eight adult patients with tuberculous meningitis were studied between 2002 and 2006. Clinical, radiological, and laboratory data of patients with cerebral infarction were compared with those of patients without cerebral infarction. Patients with cerebral infarction were significantly older (65.1 vs 52.1years), had higher risk assessment scores (3.7 vs 2.2), and more often had basal meningeal enhancement on imaging (92.3% vs 60.0%), mild to moderate sequelae (69.2% vs 4%), an overall poor brain outcome (69.2% vs 8%), aspirin prescription (84% vs 8%), and neurosurgical intervention for hydrocephalus (54.0% vs 16.0%). Cerebral infarction patients were also more likely to have experienced doctor-related delays in antituberculosis (61.5% vs 36%) and corticosteroid (61.5% vs 32%) therapy. DISCUSSION AND CONCLUSION The Framingham risk score would be an option for tuberculous meningitis patients to access cerebral infarction risk. Contrast-enhanced brain imaging is helpful for exploring basal meningeal enhancement, in order to obtain an early diagnosis. Antituberculosis, corticosteroid, and aspirin therapies should be started immediately when tuberculous meningitis is suspected.
Collapse
Affiliation(s)
- C-H Chen
- Division of infectious disease, department of internal medicine, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China; Department of Nursing, College of Medicine & Nursing, Hung Kuang University, Taichung, Republic of China.
| | - Y-J Chang
- Laboratory of epidemiology and biostatistics, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - H-N Sy
- Department of neurology, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - W L Chen
- Department of medical imaging, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| | - H-C Yen
- Department of neurosurgery, Changhua-Christian hospital, 135, Nanhsiau street, Changhua, Taiwan, Republic of China
| |
Collapse
|
24
|
Per H, Unal E, Poyrazoglu HG, Ozdemir MA, Donmez H, Gumus H, Uzum K, Canpolat M, Akyildiz BN, Coskun A, Kurtsoy A, Kumandas S. Childhood stroke: results of 130 children from a reference center in Central Anatolia, Turkey. Pediatr Neurol 2014; 50:595-600. [PMID: 24842257 DOI: 10.1016/j.pediatrneurol.2013.12.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 11/30/2013] [Accepted: 12/07/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although stroke among children is rare, it can cause significant morbidity and mortality. We aim to share our experience of children with arterial ischemic stroke. METHODS The initial symptoms, demographical features, risk factors, neurological examination, neuroradiological findings, and clinical follow-up data of 130 Turkish children seen between 2002 and 2013 were retrospectively analyzed. RESULTS Sixty-eight patients were male. Thirty of the children were aged from 1 to 12 months (seven of them died in this period). Focal neurological signs were the most common presentation, and hemiplegia or hemiparesis were the most common focal signs. Underlying risk factors were detected in 103 patients. Infections and congenital heart disease were the most common risk factors. Seven of the nine children with recurrent arterial ischemic strokes had one or more underlying diseases (moyamoya disease in two children along with factor V Leiden mutation, tuberculous meningitis, congenital heart disease, homocystinuria, and hemiconvulsion-hemiplegia-epilepsy syndrome). The arterial ischemic stroke was located in the middle cerebral circulation in 68 (36 left and 32 right) and in the posterior cerebral artery in 41. Eighteen children died. The neurological outcome was assessed in 98 children. Of these children, 66 children have neurological deficits and 52 children have seizures. Stroke in the first year of life is more often fatal. Recurrent stroke is associated with poor prognosis. CONCLUSION Tuberculous meningitis is still a risk factor for arterial ischemic stroke in Turkey. Arterial ischemic stroke in the first year of life and recurrent arterial ischemic stroke represent poor prognostic features.
Collapse
Affiliation(s)
- Huseyin Per
- Division of Pediatric Neurology, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Ekrem Unal
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey.
| | - Hatice Gamze Poyrazoglu
- Division of Pediatric Neurology, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Mehmet Akif Ozdemir
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Halil Donmez
- Division of Interventional Radiology, Department of Radiology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Hakan Gumus
- Division of Pediatric Neurology, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Kazım Uzum
- Division of Pediatric Cardiology, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Mehmet Canpolat
- Division of Pediatric Neurology, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Basak Nur Akyildiz
- Pediatric Intensive Care Unit, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Abdulhakim Coskun
- Division of Pediatric Radiology, Department of Radiology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Ali Kurtsoy
- Department of Neurosurgery, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Sefer Kumandas
- Division of Pediatric Neurology, Department of Pediatrics, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| |
Collapse
|
25
|
Margariti P, Sanchez-Montanez A, Delgado I, Elorza Alvarez I, Vazquez E. At-risk brain tissue identified with arterial spin labeling in neurotuberculosis. Pediatr Radiol 2013; 43:1049-52. [PMID: 23377538 DOI: 10.1007/s00247-013-2624-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/15/2012] [Accepted: 12/19/2012] [Indexed: 12/01/2022]
Abstract
A 13-year-old immunocompromised girl developed neurotuberculosis. Arterial spin labeling technique indicated areas of hypoperfusion in the vascular territories of the left posterior cerebral artery and superior cerebellar artery without restricted diffusion, suggesting early tuberculous arteritis. MR angiography confirmed vascular involvement, so adjunctive anticoagulant therapy was initiated. Complete resolution of arterial spin labeling findings was observed 1 month later. This documents early tuberculous vasculopathy revealed by arterial spin labeling in a child with neurotuberculosis. Since there may be a paucity of clinical symptoms in the evolution of arteritis in neurotuberculosis, arterial spin labeling may help indicate early hypoperfusion and alert for modification of treatment before irreversible vascular damage occurs.
Collapse
Affiliation(s)
- Persefoni Margariti
- Department of Pediatric Radiology, University Hospital Vall d'Hebron, Barcelona, Spain.
| | | | | | | | | |
Collapse
|
26
|
Quattrocchi CC, Longo D, Delfino LN, Errante Y, Aiello C, Fariello G, Bernardi B. MR differential diagnosis of acute deep grey matter pathology in paediatric patients. Pediatr Radiol 2013. [PMID: 23196927 DOI: 10.1007/s00247-012-2491-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A high metabolic demand, rich vascularization and high concentrations of ionic elements leading to the generation of oxygen free radicals, give to the deep grey matter (DGM) nuclei specific susceptibility to both acute and chronic insults, especially in paediatric patients. Reaching a diagnosis in the early stages of acute diseases in many patients is crucial for instigating prompt specific therapy leading to a favourable outcome. On the basis of a review of a 10-year in-house database and a review of the literature on CNS pathology involving the DGM nuclei in paediatric patients, we summarize the MR findings and clinical clues that may help the radiologist in the difficult differential diagnosis process. The terms "acute" and "chronic" refer to the clinical onset of the disease. MR imaging allows the detection of an injury, determination of its precise anatomical location and characterization of the signal changes. This, combined with a knowledge of specific MRI patterns, may be a roadmap to a definite diagnosis. Clinical history, physical and laboratory findings, timing of the MR examination and advanced MR imaging techniques (diffusion-weighted imaging and (1)H-MR spectroscopy), are crucial in some patients.
Collapse
|
27
|
Benseler S, Pohl D. Childhood central nervous system vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1065-78. [DOI: 10.1016/b978-0-444-52910-7.00024-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
|
28
|
Clemente Morgado T, Kinsky M, Carrara H, Rothemeyer S, Semple P. Prognostic value of computed tomography-evident cerebral infarcts in adult patients with tuberculous meningitis and hydrocephalus treated with an external ventricular drain. World Neurosurg 2012; 80:e255-60. [PMID: 23041069 DOI: 10.1016/j.wneu.2012.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 08/06/2012] [Accepted: 09/27/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Tuberculous meningitis (TBM) frequently is complicated by hydrocephalus and cerebral infarction. Previous studies have shown radiologic evidence of cerebral infarction in TBM to be an indicator of poor outcome in both adults and children. Our objective was to assess short-term mortality in adult patients with TBM and hydrocephalus treated with an external ventricular drain and to assess the prognostic value of cerebral infarction on admission computed tomography imaging within this cohort. METHODS This was a retrospective case series based on an adult intensive care unit admissions database, analyzing demographic, clinical, diagnostic, and radiologic data against short-term mortality. RESULTS A total of 25 patients managed from 2005 to 2011 were identified. Three patients were excluded. Mean age was 31 years. British Medical Research Council clinical severity grading was grade I in 9.1%, grade II in 31.8%, and grade III in 59.1%. Short-term mortality was 68.2% overall. Cerebral infarction on admission scanning was seen in 10 patients (45.5%). Prevalence of infarcts was not significantly higher in HIV-positive patients (50.0% vs. 42.9%). Mortality in the group with infarcts was 100%, compared with 41.7% in the group without infarcts. Mortality in patients with an admission Glasgow Coma Scale of 8 or less was 91.7%. Mortality in the HIV-positive group was slightly greater, but this increase did not reach statistical significance (71.4% vs. 57.1% P = 0.6). Univariate analysis showed presence of infarcts at admission, Glasgow Coma Scale ≤8 at admission and age of 30 years or more to be significantly related to mortality. There was also a statistically significantly increased mortality according to British Medical Research Council grade. CONCLUSION TBM with hydrocephalus requiring cerebrospinal diversion carries a significant short-term mortality. Within this cohort, the group of patients who have computed tomography-evident cerebral infarcts at admission has an even worse outcome, with a significantly greater short-term mortality prevalence.
Collapse
Affiliation(s)
- Tiago Clemente Morgado
- Division of Neurosurgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | | | | | | | | |
Collapse
|
29
|
Diagnosis and therapy of tuberculous meningitis in children. Tuberculosis (Edinb) 2012; 92:377-83. [DOI: 10.1016/j.tube.2012.05.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 05/22/2012] [Accepted: 05/29/2012] [Indexed: 11/22/2022]
|
30
|
Mihailidou E, Goutaki M, Nanou A, Tsiatsiou O, Kavaliotis J. Tuberculous meningitis in Greek children. ACTA ACUST UNITED AC 2011; 44:337-43. [PMID: 22200165 DOI: 10.3109/00365548.2011.639030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most severe form of Mycobacterium tuberculosis infection. Our aim was to analyze the epidemiology, clinical features, diagnostic approach, and outcome of tuberculous meningitis in childhood. METHODS During a 25-y period (1984-2008), 43 children, aged 7 months to 13 y, were hospitalized in the Paediatric Department of the referral centre for infectious diseases in Thessaloniki, Greece with the diagnosis of TBM. The patients were classified according to the clinical findings on admission as per the UK Medical Research Council (MRC) staging: stage I, 16/43 (37.2%) children; stage II, 16/43 (37.2%); and stage III 11/43 (25.6%). RESULTS Twenty-seven of the 43 patients were Greek (63%) and none had been BCG-vaccinated. A family history of tuberculosis was identified in 18 cases (42%). 35 patients (81%) had a positive tuberculin skin test. An extrameningeal site of infection was identified in 14 children (33%); pulmonary tuberculosis in 14/43 patients (5/13 miliary tuberculosis) and spondylitis in 1. All patients were treated with anti-tuberculous drugs and 36 (84%) also received corticosteroids. Complications during hospitalization (coma, seizures, cranial nerve palsy, hydrocephalus) presented in 26 patients (60%). Two patients died (5%) and 6 (14%) had permanent neurological sequelae. CONCLUSION TBM, although rare, remains a disease with significant morbidity and mortality. Early clinical diagnosis and appropriate treatment initiation are important for the prognosis.
Collapse
|
31
|
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.
Collapse
Affiliation(s)
- L Nogueira Delfino
- Department of Radiology, IRCCS, Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio 4, 00100, Rome, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
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.
Collapse
Affiliation(s)
- Gerrit Dekker
- Department of Radiology, Stellenbosch University, Stellenbosch, South Africa
| | | | | | | | | | | |
Collapse
|
33
|
Misra UK, Kalita J, Maurya PK. Stroke in tuberculous meningitis. J Neurol Sci 2011; 303:22-30. [DOI: 10.1016/j.jns.2010.12.015] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 12/20/2010] [Accepted: 12/20/2010] [Indexed: 11/26/2022]
|
34
|
Marais S, Thwaites G, Schoeman JF, Török ME, Misra UK, Prasad K, Donald PR, Wilkinson RJ, Marais BJ. Tuberculous meningitis: a uniform case definition for use in clinical research. THE LANCET. INFECTIOUS DISEASES 2010; 10:803-12. [PMID: 20822958 DOI: 10.1016/s1473-3099(10)70138-9] [Citation(s) in RCA: 555] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Suzaan Marais
- Department of Medicine, GF Jooste Hospital, Manenberg, South Africa.
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
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.
Collapse
Affiliation(s)
- R K Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh, Lucknow, India.
| |
Collapse
|
36
|
Misch M, Thomale UW, Keitzer R, Vajkoczy P. Prevention of secondary ischemic events by superficial temporal artery-middle cerebral artery bypass surgery after tuberculosis-induced vasculopathy in a 5-year-old child. J Neurosurg Pediatr 2010; 6:69-72. [PMID: 20593990 DOI: 10.3171/2010.4.peds09411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Tuberculosis-related vasculopathy and resulting ischemic events are a common finding after tuberculous meningitis (TBM) in children. The authors report on a case of recurring ischemic episodes that were refractory to repetitive endovascular procedures (transluminal angioplasty, stent insertion, in-stent vessel dilation). After failure of endovascular treatment, extracranial-intracranial (EC-IC) bypass surgery was performed to prevent further ischemia. This 5-year-old girl presented with a series of ischemic events in the left middle cerebral artery (MCA) territory 12 months after her presentation with TBM. Angiography studies showed a 50% lumen reduction of the left MCA. After failure of antithrombocyte aggregation and repeated endovascular procedures to prevent new ischemia, EC-IC bypass surgery was performed. The left superficial temporal artery-MCA bypass was found to be capable of preventing new ischemic events in the 21-month follow-up period, despite a near-total MCA occlusion on follow-up conventional and MR angiography studies. Bypass surgery seems to be a reliable tool to augment cerebral blood flow in tuberculosis-related stenoocclusive changes of cerebral vasculature after the failure of endovascular procedures.
Collapse
Affiliation(s)
- Martin Misch
- Department of Neurosurgery, Charité Campus Virchow, Medical University of Berlin, Berlin, Germany.
| | | | | | | |
Collapse
|
37
|
Misra U, Kalita J, Nair P. Role of aspirin in tuberculous meningitis: A randomized open label placebo controlled trial. J Neurol Sci 2010; 293:12-7. [DOI: 10.1016/j.jns.2010.03.025] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Revised: 03/22/2010] [Accepted: 03/24/2010] [Indexed: 10/19/2022]
|
38
|
Predictors of stroke and its significance in the outcome of tuberculous meningitis. J Stroke Cerebrovasc Dis 2009; 18:251-8. [PMID: 19560677 DOI: 10.1016/j.jstrokecerebrovasdis.2008.11.007] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Revised: 10/29/2008] [Accepted: 11/03/2008] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND AIM We sought to study the frequency and predictors of stroke in tuberculous meningitis (TBM) and its prognostic significance. DESIGN This was an observational study in a tertiary care teaching hospital. METHODS In all, 122 patients with TBM aged 4 to 82 years diagnosed on the basis of clinical, cerebrospinal fluid, and magnetic resonance imaging criteria were prospectively evaluated. Severity of meningitis was graded into stage I to III. Magnetic resonance imaging was done at admission and 3 months after treatment. Outcome was defined at 3 and 6 months as complete, partial, or poor. Predictors of stroke and its significance in long- and short-term outcome were evaluated. FINDINGS A total of 55 patients had stroke; 42 at admission and 13 developed within 3 months of 4 drug antitubercular treatment. Strokes were ischemic in 54 (hemorrhagic transformation in 7) and hemorrhagic in one. Basal ganglia infarctions were present in 30, thalamic in 9, brainstem in 10, cortical in 27, and cerebellar in 4 patients. Stoke was multiple in 29 patients. In all, 38 patients had infarctions in anterior circulation, 7 in posterior, and 10 in both. Stroke was significantly related to stage of meningitis, hydrocephalus, exudate, and hypertension. No difference was found in clinical or laboratory parameters in early and late strokes. At 6 months, 28 patients died. At 3 months there were 21 patients lost to follow up and at 6 months there were 30 patients lost to followup. Outcome is based on the rest of the patients, ie. 101 patients at 3 months and 92 patients at 6 months. CONCLUSION Stroke occurs in 45% of patients with TBM both in early and later stage, mostly in basal ganglia region, and predicts poor outcome at 3 months.
Collapse
|
39
|
van der Merwe DJ, Andronikou S, Van Toorn R, Pienaar M. Brainstem ischemic lesions on MRI in children with tuberculous meningitis: with diffusion weighted confirmation. Childs Nerv Syst 2009; 25:949-54. [PMID: 19424705 DOI: 10.1007/s00381-009-0899-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 02/04/2009] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Western Cape in South Africa has one of the highest incidences of tuberculous meningitis (TBM) in the world. Despite therapy, the outcome in children with advanced TBM remains dismal. Magnetic resonance imaging (MRI) has been shown to be superior to computed tomography (CT) in demonstrating ischemia in TBM, especially of the brainstem. The objective of this study was to characterize brainstem lesions and association with clinical findings in children with TBM by using MRI. MATERIALS AND METHODS CT and multiplanar MRI scans were performed in 30 children with proven TBM. From this group, a subgroup with radiological ischemic changes of the brainstem were identified. Radiological findings in these patients were then correlated with severity of disease, motor deficit, and outcome after 6 months. RESULTS Radiological brainstem abnormalities were identified in 14 out of 30 children. Thirty-eight brainstem lesions were confirmed to be ischemic. The severity of disease at presentation, degree of motor deficit, and developmental outcome after 6 months of the children with ischemic brainstem lesions was poorer compared to those children without brainstem involvement. However, both sensitivity and specificity of the MRI brainstem lesion detection for clinical outcome proved low. CONCLUSION A significant percentage of children with TBM have ischemic brainstem lesions. These are poorly visualized on conventional CT. MRI scanning is more sensitive in detecting these lesions and localizing them. There appears to be some association between MRI-detected brainstem lesions and clinical outcome. The exact meaning of these lesions and their implication for the patient's management require further clarification.
Collapse
Affiliation(s)
- Dirk Johannes van der Merwe
- Department of Radiology at Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa.
| | | | | | | |
Collapse
|
40
|
Gujjar AR, Srikanth SG, Umamaheshwara Rao GS. HHH regime for arteritis secondary to TB meningitis: a prospective randomized study. Neurocrit Care 2009; 10:313-7. [PMID: 19219569 DOI: 10.1007/s12028-008-9182-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Accepted: 12/17/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Tuberculous meningitis (TBM) is a fairly common, debilitating disease and is often complicated by arteritis resulting in brain infarction. Few treatment regimes specifically address this condition. Hypervolemia-hypertension-hemodilution (HHH) regime is known to be effective for treatment of vasospasm complicating subarachnoid hemorrhage. We studied the efficacy of HHH regime in patients with TBM with arteritis using a prospective, randomized study design. PATIENTS AND METHODS Patients diagnosed to have TB meningitis by clinical, CSF, and imaging findings were evaluated for arteritis, which was recognized by presence of focal neurologic deficits with or without corresponding focal hypodensities on brain CT scan. Patients with deficits of < 96 h were randomized to HHH or conservative treatment. All patents received four-first-line anti-TB drugs and Inj.dexamethasone. HHH therapy was administered over 3-9 days. Neurologic status and modified Rankin score were noted serially and at discharge. RESULTS Seven patients received HHH and 5, conservative treatment. All had hemiparesis with power 0-3/5. Median GCS was worse in HHH group (11 vs. 13). In the HHH group, 6/7 improved in motor power, and 5/7 in sensorium. In the control group, 3/5 improved in motor power and 3/5 in sensorium. Four patients died in each group. CONCLUSION HHH therapy is safe and may be beneficial in the management of patients with infective arteritis secondary to TBM. Further study in a larger group with improved monitoring of cerebral circulation is indicated.
Collapse
Affiliation(s)
- Arunodaya R Gujjar
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India.
| | | | | |
Collapse
|
41
|
MRI pattern of infarcts in basal ganglia region in patients with tuberculous meningitis. Neuroradiology 2009; 51:221-5. [DOI: 10.1007/s00234-009-0495-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Accepted: 01/06/2009] [Indexed: 11/30/2022]
|
42
|
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: 363] [Impact Index Per Article: 22.7] [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.
Collapse
|