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Venkatakrishna SSB, Vasileiadi E, Siu Navarro YJ, Hanze Villavicencio KL, Miranda-Schaeubinger M, Schoeman S, Roy SG, Otero HJ, Andronikou S. Miliary meningeal tuberculosis - an unusual imaging presentation for an early definitive diagnosis. Childs Nerv Syst 2024; 40:2279-2285. [PMID: 38867108 DOI: 10.1007/s00381-024-06480-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/28/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE Tuberculous meningitis (TBM) causes significant morbidity and mortality in young children. Early treatment can be initiated with magnetic resonance (MR) imaging diagnosis. We present MR-detectable miliary meningeal TB in two patients. CASE 1: A 9-year-old girl developed fevers, cough, lethargy, and seizures. Brain MRI demonstrated multiple, small, T2-dark, rim-enhancing lesions, associated with cranial nerve and leptomeningeal enhancement. CSF showed pleocytosis, low glucose, and high protein. Chest CT showed mediastinal lymphadenopathy, multiple small interstitial lung nodules, and a splenic hypo enhancing lesion. Serial bronchoalveolar lavage studies were Xpert MTB/RIF and acid-fast negative. Endobronchial US-guided biopsy of a subcarinal lymph node was positive for Xpert MTB PCR. She was started on a 4-drug treatment for TBM and dexamethasone. Contact tracing revealed a remote positive contact with pulmonary tuberculosis. CASE 2: A 17-year-old female with Crohn's disease on adalimumab developed refractory ear infections despite multiple courses of antibiotics. She underwent myringotomy, with negative aerobic ear fluid culture. Brain MRI, obtained due to persistent otorrhea, showed multiple, small, round, T2-dark lesions. CSF studies were normal. CT chest, abdomen, and pelvis to assess for disseminated disease showed left upper lobe tree-in-bud nodules, hypoattenuating splenic lesions and a left obturator internus abscess with adjacent osteomyelitis. She underwent CT-guided aspiration of the obturator muscle collection, bronchoscopy with bronchoalveolar lavage, biopsy of two preexisting chronic skin lesions, and ear fluid aspiration. QuantiFERON Gold was positive. Ear fluid was Xpert MTB/RIF assay and acid-fast stain positive. Cultures from the ear fluid, skin tissue, muscle tissue, and alveolar lavage showed growth of acid-fast bacilli. She was started on 4-drug therapy and prednisone. CONCLUSION Our cases highlight that TBM in many cases remains a diagnostic dilemma - both our patients presented in a prolonged atypical manner. The term miliary TB not only refers to a pattern of interstitial nodules on chest radiographs but also indicates the hematogenous spread of the disease and concurrent pulmonary and extrapulmonary involvement with high risk of TB meningitis. We promote the use of the term miliary meningeal TB - in both cases, the neuroimaging diagnosis of TB preceded both chest imaging and laboratory confirmation of the disease. Miliary meningeal nodules on MRI may have characteristic T2 low signal and may be more conspicuous in children and immunocompromised individuals where background basal meningeal enhancement is less prominent.
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Affiliation(s)
| | | | | | | | | | - Sean Schoeman
- Children's Hospital of Philadelphia, Philadelphia, USA
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2
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Mertiri L, Freiling JT, Desai NK, Kralik SF, Huisman TAGM. Pediatric and adult meningeal, parenchymal, and spinal tuberculosis: A neuroimaging review. J Neuroimaging 2024; 34:179-194. [PMID: 38073450 DOI: 10.1111/jon.13177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 03/12/2024] Open
Abstract
Neurotuberculosis is defined as a tuberculous infection of the meninges, brain parenchyma, vessels, cranial and spinal nerves, spinal cord, skull, and spine that can occur either in a localized or in a diffuse form. It is a heterogeneous disease characterized by many imaging appearances and it has been defined as "the great mimicker" due to similarities with many other conditions. The diagnosis of central nervous system (CNS) tuberculosis (TB) is based on clinical presentation, neuroimaging findings, laboratory and microbiological findings, and comprehensive evaluation of the response to anti-TB drug treatment. However, the absence of specific symptoms, the wide spectrum of neurological manifestations, the myriad of imaging findings, possible inconclusive laboratory results, and the paradoxical reaction to treatment make the diagnosis often challenging and difficult, potentially delaying adequate treatment with possible devastating short-term and long-term neurologic sequelae. Familiarity with the imaging characteristics helps in accurate diagnosis and may prevent or limit significantly morbidity and mortality. The goal of this review is to provide a comprehensive up-to-date overview of the conventional and advanced imaging features of CNS TB for radiologists, neuroradiologists, and pediatric radiologists. We discuss the most typical neurotuberculosis imaging findings and their differential diagnosis in children and adults with the goal to provide a global overview of this entity.
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Affiliation(s)
- Livja Mertiri
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - John T Freiling
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Nilesh K Desai
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Thierry A G M Huisman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
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Ullah R, Saeed S, Rafael HA, Nishat N, Rosario-Curcio J, Gul A. Co-occurrence of Tuberculous Meningitis and Intestinal Perforation in Abdominal Tuberculosis (TB): A Report of a Rare Case From Pakistan. Cureus 2024; 16:e55132. [PMID: 38558686 PMCID: PMC10979716 DOI: 10.7759/cureus.55132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Tuberculosis (TB) remains a significant global health concern, with millions affected worldwide each year. Extrapulmonary TB, particularly involving the digestive tract and central nervous system, poses distinctive difficulties in both diagnosis and treatment. We report a case involving a 15-year-old girl with a history of intestinal TB on anti-tuberculous therapy who presented with symptoms suggestive of meningitis, along with abdominal pain and distension. Our initial suspicion was tuberculous meningitis, considering the underlining abdominal TB, which was later supported by cerebrospinal fluid analysis showing lymphocytic-predominant pleocytosis and positive acid-fast bacilli staining. Concurrently, the patient developed hemodynamic instability and severe abdominal pain, which on repeat X-rays of the abdomen showed air under the diaphragms, prompting surgical exploration and revealing multiple ileal perforations. Histopathological examination confirmed TB as the cause of perforation. This case highlights the diagnostic and therapeutic complexities of concurrent tuberculous meningitis and intestinal TB perforation. Early recognition and interdisciplinary management are crucial for optimal patient outcomes.
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Affiliation(s)
- Rizwan Ullah
- Internal Medicine, Hayatabad Medical Complex Peshawar, Peshawar, PAK
| | - Saad Saeed
- Internal Medicine, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | | | - Nadia Nishat
- Family Medicine, Adichunchanagiri Institute of Medical Sciences, Mandya, IND
| | | | - Aiysha Gul
- Obstetrics and Gynaecology, Mardan Medical Complex, Mardan, PAK
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4
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Muzumdar D, Bansal P, Rai S, Bhatia K. Surgery for Central Nervous System Tuberculosis in Children. Adv Tech Stand Neurosurg 2024; 49:255-289. [PMID: 38700688 DOI: 10.1007/978-3-031-42398-7_12] [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] [Indexed: 06/01/2024]
Abstract
Tuberculosis (TB) is the second most common cause of death due to a single infectious agent worldwide after COVID-19. Central nervous system tuberculosis is widely prevalent in the world, especially in the developing countries and continues to be a socioeconomic problem. It is highly devastating form of tuberculosis leading to unacceptable levels of morbidity and mortality despite appropriate antitubercular therapy. The clinical symptoms are varied and nonspecific. They can be easily overlooked. Tuberculous meningitis is the most common presentation and its sequelae viz. vasculitis, infarction and hydrocephalus can be devastating. The ensuing cognitive, intellectual, and endocrinological outcome can be a significant source of morbidity and mortality, especially in resource constrained countries. Early diagnosis and treatment of tuberculous meningitis and institution of treatment is helpful in limiting the course of disease process. The diagnosis of CNS tuberculosis remains a formidable diagnostic challenge. The microbiological methods alone cannot be relied upon. CSF diversion procedures need to be performed at the appropriate time in order to achieve good outcomes. Tuberculous pachymeningitis and arachnoiditis are morbid sequelae of tuberculous meningitis. Tuberculomas present as mass lesions in the craniospinal axis. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Tuberculosis of the spinal cord is seen similar to intracranial tuberculosis in pathogenesis but with its own unique clinical manifestations and management. Multidrug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. Heightened clinical suspicion is paramount to ensure prompt investigation. Early diagnosis and treatment are essential to a gratifying outcome and prevent complications.
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Affiliation(s)
- Dattatraya Muzumdar
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Puru Bansal
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Survender Rai
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Kushal Bhatia
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
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Daniel BD, Selladurai E, Balaji S, Venkatesan A, Venkatesan M, Giridharan P, Shanmugam S, Natrajan S, Karunaianantham R, Kandasamy D, Subramani R, Muthuramalingam K, Pramila SK, Hissar S, Dooley KE, Thakur KT. Clinical and diagnostic features of central nervous system tuberculosis in Indian children - a descriptive study. Ther Adv Infect Dis 2024; 11:20499361241274251. [PMID: 39290458 PMCID: PMC11406600 DOI: 10.1177/20499361241274251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 07/23/2024] [Indexed: 09/19/2024] Open
Abstract
Background Children with tuberculous meningitis (TBM) present with diagnostic challenges as they often have atypical clinical features. Objective To describe the baseline characteristic features of children diagnosed with central nervous system (CNS) TB (TBM and tuberculoma). Design Retrospective descriptive study. Methods Children less than 12 years presenting with neurological signs and symptoms were assessed for a therapeutic TBM trial eligibility. The results of their clinical, laboratory, neuroimaging, cerebrospinal fluid evaluations were analysed for TBM diagnosis. Results Of 600 children evaluated, 61(10%) had CNS tuberculosis; TBM 47, tuberculoma 14. 20(33%) had definite TBM. Mean age of children with TBM was 5 ± 3.4 years. Of 47, 13(28%), 21(45%) and 13(28%) had grade I, II, and III disease respectively. Abnormalities suggestive of TBM in MRI and computed tomography brain were observed in 76% (26/34) and 77% (24/31) respectively. Abnormal cerebrospinal fluid white blood cell count, protein and glucose were observed in 56% (24/43), 49% (22/45), 47% (21/45) respectively. Among 41 patients with TBM followed up until discharge, five died. Conclusion Younger children with TBM have severe forms. Confirmatory results may not be available in all. A holistic approach to care including addressing complications of hydrocephalus and strokes is needed.
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Affiliation(s)
- Bella Devaleenal Daniel
- ICMR - National Institute for Research in Tuberculosis, No 1, Mayor Satyamoorthy Road, Chetpet, Chennai 600031, India
| | | | - Sarath Balaji
- Institute of Child Health, Madras Medical College, Chennai, India
| | | | | | | | | | | | | | - Devika Kandasamy
- ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | | | | | - Snegha K Pramila
- ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Syed Hissar
- ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Kelly E Dooley
- John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kiran T Thakur
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
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He RL, Liu Y, Tan Q, Wang L. The rare manifestations in tuberculous meningoencephalitis: a review of available literature. Ann Med 2023; 55:342-347. [PMID: 36598144 PMCID: PMC9828632 DOI: 10.1080/07853890.2022.2164348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Aim: Tuberculous meningitis is an infectious disease of the central nervous system caused by Mycobacterium tuberculosis (M. tuberculosis). It mainly involves the meninges and brain parenchyma, as well as the spinal cord and meninges; Disability and mortality rates are high. In recent years, due to the increase of drug-resistant tuberculosis patients, population mobility and the prevalence of acquired immune deficiency syndrome, the incidence rate of tuberculosis has increased significantly, and tuberculous meningitis has also increased.Methods: At present, tuberculosis is still a worldwide infectious disease that seriously threatens human health, especially in underdeveloped and developing countries. China is the largest developing country in the world with a large population.Results: The situation of tuberculosis prevention and control is grim. Its disability rate is the highest in tuberculosis infection. In addition to the common non-specific manifestations, tuberculous meningoencephalitis may also have rare manifestations of stroke, hearing loss and visual loss.Conclusion: Understanding and timely improvement of corresponding examinations and targeted treatment will help improve the prognosis of patients.
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Affiliation(s)
- Rong Li He
- Department of Infection Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yun Liu
- Department of Infection Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Quanhui Tan
- Department of Infection Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lan Wang
- Department of Infection Disease, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Shi Y, Zhang C, Pan S, Chen Y, Miao X, He G, Wu Y, Ye H, Weng C, Zhang H, Zhou W, Yang X, Liang C, Chen D, Hong L, Su F. The diagnosis of tuberculous meningitis: advancements in new technologies and machine learning algorithms. Front Microbiol 2023; 14:1290746. [PMID: 37942080 PMCID: PMC10628659 DOI: 10.3389/fmicb.2023.1290746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023] Open
Abstract
Tuberculous meningitis (TBM) poses a diagnostic challenge, particularly impacting vulnerable populations such as infants and those with untreated HIV. Given the diagnostic intricacies of TBM, there's a pressing need for rapid and reliable diagnostic tools. This review scrutinizes the efficacy of up-and-coming technologies like machine learning in transforming TBM diagnostics and management. Advanced diagnostic technologies like targeted gene sequencing, real-time polymerase chain reaction (RT-PCR), miRNA assays, and metagenomic next-generation sequencing (mNGS) offer promising avenues for early TBM detection. The capabilities of these technologies are further augmented when paired with mass spectrometry, metabolomics, and proteomics, enriching the pool of disease-specific biomarkers. Machine learning algorithms, adept at sifting through voluminous datasets like medical imaging, genomic profiles, and patient histories, are increasingly revealing nuanced disease pathways, thereby elevating diagnostic accuracy and guiding treatment strategies. While these burgeoning technologies offer hope for more precise TBM diagnosis, hurdles remain in terms of their clinical implementation. Future endeavors should zero in on the validation of these tools through prospective studies, critically evaluating their limitations, and outlining protocols for seamless incorporation into established healthcare frameworks. Through this review, we aim to present an exhaustive snapshot of emerging diagnostic modalities in TBM, the current standing of machine learning in meningitis diagnostics, and the challenges and future prospects of converging these domains.
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Affiliation(s)
- Yi Shi
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Chengxi Zhang
- School of Materials Science and Engineering, Shandong Jianzhu University, Jinan, China
| | - Shuo Pan
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yi Chen
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Xingguo Miao
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
| | - Guoqiang He
- Postgraduate Training Base Alliance of Wenzhou Medical University, Wenzhou, China
- Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, China
| | - Yanchan Wu
- School of Electrical and Information Engineering, Quzhou University, Quzhou, China
| | - Hui Ye
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
| | - Chujun Weng
- The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, China
| | - Huanhuan Zhang
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Wenya Zhou
- School and Hospital of Stomatology, Wenzhou Medical University, Wenzhou, China
| | - Xiaojie Yang
- Wenzhou Medical University Renji College, Wenzhou, China
| | - Chenglong Liang
- The First School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Dong Chen
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
- Wenzhou Central Blood Station, Wenzhou, China
| | - Liang Hong
- Department of Infectious Diseases, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feifei Su
- Department of Infectious Diseases, Wenzhou Central Hospital, Wenzhou, China
- Department of Infectious Diseases, Wenzhou Sixth People’s Hospital, Wenzhou, China
- Wenzhou Key Laboratory of Diagnosis and Treatment of Emerging and Recurrent Infectious Diseases, Wenzhou, China
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8
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Laya BF, Concepcion NDP, Andronikou S, Abdul Manaf Z, Atienza MIM, Sodhi KS. Imaging recommendations and algorithms for pediatric tuberculosis: part 2-extrathoracic tuberculosis. Pediatr Radiol 2023; 53:1782-1798. [PMID: 37074457 DOI: 10.1007/s00247-023-05650-5] [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: 03/09/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/20/2023]
Abstract
Despite advances in diagnosis and treatment in recent years, tuberculosis (TB) remains a global health concern. Children are amongst the most vulnerable groups affected by this disease. Although TB primarily involves the lungs and mediastinal lymph nodes, it can affect virtually any organ system of the body. Along with clinical history combined with physical examination and laboratory tests, various medical imaging tools help establish the diagnosis. Medical imaging tests are also helpful for follow-up during therapy, to assess complications and exclude other underlying pathologies. This article aims to discuss the utility, strengths and limitations of medical imaging tools in the evaluation of suspected extrathoracic TB in the pediatric population. Imaging recommendations for the diagnosis will be presented along with practical and evidence-based imaging algorithms to serve as a guide for both radiologists and clinicians.
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Affiliation(s)
- Bernard F Laya
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines
- Department of Radiology, St. Luke's Medical Center College of Medicine William H. Quasha Memorial, Quezon City, Philippines
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Global City, Rizal Drive cor. 32nd St. and 5th Ave., 1634, Taguig, Philippines
| | - Nathan David P Concepcion
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines.
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Global City, Rizal Drive cor. 32nd St. and 5th Ave., 1634, Taguig, Philippines.
| | - Savvas Andronikou
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, and the Children's Hospital of Philadelphia, Philadelphia, USA
| | - Zaleha Abdul Manaf
- Al Islam Specialist Hospital, Kuala Lumpur, Malaysia
- Faculty of Medicine, Bioscience & Nursing, MAHSA University, Kuala Lumpur, Malaysia
| | - Maria Isabel M Atienza
- Institute of Pediatrics and Child Health, St Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines
- Department of Pediatrics, St. Luke's Medical Center College of Medicine William H. Quasha Memorial, Quezon City, Philippines
| | - Kushaljit Singh Sodhi
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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9
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Mahomed N, Kilborn T, Smit EJ, Chu WCW, Young CYM, Koranteng N, Kasznia-Brown J, Winant AJ, Lee EY, Sodhi KS. Tuberculosis revisted: classic imaging findings in childhood. Pediatr Radiol 2023; 53:1799-1828. [PMID: 37217783 PMCID: PMC10421797 DOI: 10.1007/s00247-023-05648-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 05/24/2023]
Abstract
Tuberculosis (TB) remains one of the major public health threats worldwide, despite improved diagnostic and therapeutic methods. Tuberculosis is one of the main causes of infectious disease in the chest and is associated with substantial morbidity and mortality in paediatric populations, particularly in low- and middle-income countries. Due to the difficulty in obtaining microbiological confirmation of pulmonary TB in children, diagnosis often relies on a combination of clinical and radiological findings. The early diagnosis of central nervous system TB is challenging with presumptive diagnosis heavily reliant on imaging. Brain infection can present as a diffuse exudative basal leptomeningitis or as localised disease (tuberculoma, abscess, cerebritis). Spinal TB may present as radiculomyelitis, spinal tuberculoma or abscess or epidural phlegmon. Musculoskeletal manifestation accounts for 10% of extrapulmonary presentations but is easily overlooked with its insidious clinical course and non-specific imaging findings. Common musculoskeletal manifestations of TB include spondylitis, arthritis and osteomyelitis, while tenosynovitis and bursitis are less common. Abdominal TB presents with a triad of pain, fever and weight loss. Abdominal TB may occur in various forms, as tuberculous lymphadenopathy or peritoneal, gastrointestinal or visceral TB. Chest radiographs should be performed, as approximately 15% to 25% of children with abdominal TB have concomitant pulmonary infection. Urogenital TB is rare in children. This article will review the classic radiological findings in childhood TB in each of the major systems in order of clinical prevalence, namely chest, central nervous system, spine, musculoskeletal, abdomen and genitourinary system.
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Affiliation(s)
- Nasreen Mahomed
- University of Witwatersrand, 7 York Road Parktown, Johannesburg, 2193, South Africa.
| | - Tracy Kilborn
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Elsabe Jacoba Smit
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Winnie Chiu Wing Chu
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Catherine Yee Man Young
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Nonceba Koranteng
- University of Witwatersrand, 7 York Road Parktown, Johannesburg, 2193, South Africa
| | | | - Abbey J Winant
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, USA
| | - Kushaljit Singh Sodhi
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
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10
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Chaudhary N, Gupta BK, Poudel A, Kafle M, Singh N, Chaudhary HP. Stroke in a child with pulmonary tuberculosis and pleural effusion-An important clue for the diagnosis of disseminated central nervous system tuberculosis. Clin Case Rep 2023; 11:e6945. [PMID: 36789297 PMCID: PMC9914082 DOI: 10.1002/ccr3.6945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 11/18/2022] [Accepted: 01/23/2023] [Indexed: 02/12/2023] Open
Abstract
Central nervous system tuberculosis (CNS-TB) is one of the most devastating and life-threatening conditions having high mortality and morbidity. Here, we report a 12-year-old child with pulmonary tuberculosis and pleural effusion presenting with ischemic stroke as an important manifestation of central nervous system tuberculosis.
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Affiliation(s)
- Nagendra Chaudhary
- Department of PediatricsUniversal College of Medical SciencesBhairahawaNepal
| | - Binod Kumar Gupta
- Department of PediatricsUniversal College of Medical SciencesBhairahawaNepal
| | - Astha Poudel
- Department of PediatricsUniversal College of Medical SciencesBhairahawaNepal
| | - Manish Kafle
- Department of PediatricsUniversal College of Medical SciencesBhairahawaNepal
| | - Neeva Singh
- Department of PediatricsUniversal College of Medical SciencesBhairahawaNepal
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11
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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.
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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
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12
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Yiek SH, Wong ASH. Challenges and Controversies in the Management of Tuberculous Meningitis with Hydrocephalus: A Systematic Review and Sarawak Institution's Experience. Asian J Neurosurg 2022; 17:189-198. [PMID: 36120621 PMCID: PMC9473842 DOI: 10.1055/s-0042-1750781] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Abstract
Introduction To date, there are no standard practice guidelines available and no universal consensus regarding treatment protocol in management of tuberculous meningitis (TBM) with hydrocephalus. Over the years, diverse views have existed in neurosurgical management of TBM with hydrocephalus. Some authors advocate ventriculo-peritoneal (VP) shunt, while others suggest that external ventricular drainage (EVD) may be the preferable neurosurgical procedure for a poor-grade patient.
Method We systematically reviewed published literature and presented our institution's experience. We performed a retrospective case study in our Sarawak neurosurgical center from 2018 to 2020. We tabulated the outcome according to preoperative classifications, which were Vellore Grading (VG), Modified Vellore Grading (MVG), British Medical Research Council Classification (MRC), and others: author-defined.
Result In our center, there were 20 cases of TBM with hydrocephalus treated by EVD and VP shunt from 2018 to 2020. We systematically searched published medical literature, and 23 articles were retrieved and analyzed. Poor outcomes were observed in poor-grade patients, especially VG/MVG 3/4 and MRC 3, from both institution and systemic review data. Shunt complication rate was lower in our center as compared with published literature.
Conclusion Unfortunately, morbidity and mortality were approximately twofold higher in poor-grade as compared with good-grade patients. However, about one-third of poor-grade patients achieved a good outcome. Cerebrospinal fluid (CSF) diversion would be an unavoidable treatment for hydrocephalus. Poor-grade patients tend to have cerebral infarcts in addition to hydrocephalus. An extended duration of EVD placement could be a potential measure to assess Glasgow coma scale recovery and monitor serial CSF samples.
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Affiliation(s)
- Siew-Hong Yiek
- Department of Neurosurgery, Sarawak General Hospital, Malaysia
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13
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Cao X, Yang Q, Zhou X, Lv K, Zhou Z, Sun F, Ruan Q, Zhang J, Shao L, Geng D. Cerebral Infarction and Evan's Ratio on MRI Affect the Severity and Prognosis of Tuberculosis Meningitis Patients. Diagnostics (Basel) 2022; 12:1264. [PMID: 35626418 PMCID: PMC9141437 DOI: 10.3390/diagnostics12051264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/03/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) is widely used in the diagnosis of tuberculous meningitis (TBM) and its complications. We aimed to explore the relationship between MRI features and neurological deficits and TBM patients’ prognosis. Methods: patients diagnosed with TBM were subjected to a neurological evaluation on admission and divided into groups based on the Medical Research Council (MRC) scale. After several years of follow-up, the patients were further divided into groups according to the Modified Rankin Score (MRS). Their MR images were analyzed for meningeal enhancement, tuberculomas, infarction, hydrocephalus, and abscess, including the location and size of the lesion. Any changes in MRI features during the follow-up were recorded. MRI features between groups were compared, and the relationship between dynamic changes in images and Rankin grading was explored. Results: We found significant differences in acute cerebral infarction (ACI) and old cerebral infarctions (OCI) between the MRC groups, and the ORs of ACI and OCI were 21.818 (95% CI: 2.440−195.075) and 6.788 (95% CI: 1.516−30.392), respectively. There were significant differences in ACI, OCI, and Evan’s ratio between the MRS groups (p < 0.05), and the ORs of ACI, OCI, and hydrocephalus were 6.375 (95% CI: 1.501−27.080), 5.556 (95% CI: 1.332−23.177), and 9.139 (95% CI: 2.052−40.700), respectively. The changes of Evan’s ratio were related to the MRS grading (r = 0.335, p = 0.040). Conclusions: For patients with TBM, the presence of ACI or OCI is associated with neurological deficits, and ACI, OCI, and hydrocephalus can be regarded as poor prognostic predictors. Changes in Evan’s ratio will affect the outcome.
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Affiliation(s)
- Xin Cao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China; (X.C.); (K.L.); (J.Z.); (D.G.)
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Shanghai 200040, China
| | - Qingluan Yang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xian Zhou
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Kun Lv
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China; (X.C.); (K.L.); (J.Z.); (D.G.)
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Shanghai 200040, China
| | - Zhe Zhou
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
| | - Feng Sun
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Qiaoling Ruan
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jun Zhang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China; (X.C.); (K.L.); (J.Z.); (D.G.)
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Shanghai 200040, China
| | - Lingyun Shao
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China; (Q.Y.); (X.Z.); (Z.Z.); (F.S.); (L.S.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Daoying Geng
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai 200040, China; (X.C.); (K.L.); (J.Z.); (D.G.)
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Reasearch, Shanghai 200040, China
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14
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Starke JR, Erkens C, Ritz N, Kitai I. Strengthening Tuberculosis Services for Children and Adolescents in Low Endemic Settings. Pathogens 2022; 11:158. [PMID: 35215101 PMCID: PMC8877840 DOI: 10.3390/pathogens11020158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 01/22/2023] Open
Abstract
In low tuberculosis-burden countries, children and adolescents with the highest incidence of tuberculosis (TB) infection or disease are usually those who have immigrated from high-burden countries. It is, therefore, essential that low-burden countries provide healthcare services to immigrant and refugee families, to assure that their children can receive proper testing, evaluation, and treatment for TB. Active case-finding through contact tracing is a critical element of TB prevention in children and in finding TB disease at an early, easily treated stage. Passive case-finding by evaluating an ill child is often delayed, as other, more common infections and conditions are suspected initially. While high-quality laboratory services to detect Mycobacterium tuberculosis are generally available, they are often underutilized in the diagnosis of childhood TB, further delaying diagnosis in some cases. Performing research on TB disease is difficult because of the low number of cases that are spread over many locales, but critical research on the evaluation and treatment of TB infection has been an important legacy of low-burden countries. The continued education of medical providers and the involvement of educational, professional, and non-governmental organizations is a key element of maintaining awareness of the presence of TB. This article provides the perspective from North America and Western Europe but is relevant to many low-endemic settings. TB in children and adolescents will persist in low-burden countries as long as it persists throughout the rest of the world, and these wealthy countries must increase their financial commitment to end TB everywhere.
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Affiliation(s)
- Jeffrey R. Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, TX 77030, USA
| | - Connie Erkens
- KNCV Tuberculosis Foundation, 2516 AB The Hague, The Netherlands;
| | - Nicole Ritz
- Department of Paediatrics and Paediatric Infectious Diseases, Children’s Hospital, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland;
- Mycobacterial and Migrant Health Research Group, Department of Clinical Research, University of Basel Children’s Hospital, University of Basel, 4031 Basel, Switzerland
| | - Ian Kitai
- Department of Pediatrics, Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada;
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15
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The diagnostic challenge of atypical tuberculous meningitis in children from rural area. EUR J INFLAMM 2022. [DOI: 10.1177/1721727x221122718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Tuberculous meningitis (TBM) is a severe form of Mycobacterium tuberculosis infection, while its diagnosis is still a challenge in children. Here, six children with atypical TBM were retrospectively reviewed and the main findings were displayed as follows. The enrolled cases exhibited non-specific symptoms on admission, mainly including fever ( n = 5), headache ( n = 3), vomiting ( n = 5), and drowsiness ( n = 3), but no typical symptoms of TB infection. Two of them exhibited progressive symptoms under routine treatment. Cerebrospinal fluid (CSF) examinations revealed increased white blood cells and proteins, as well as decreased glucose and chloride in all cases. Chest imaging identified the possibly of pulmonary tuberculous in 2 cases. Cranial CT and MRI revealed neuroimaging abnormality in 1 and 3 cases, respectively. In addition, next-generation sequencing directly supported the diagnosis of TBM in case 5. To sum up, TBM should be highly suspected in children with central nervous system infection, when there are no improvements under routine treatment and/or the presence of progressive symptoms. Timely rechecking of CSF combined with cranial imaging is feasible and valuable for the diagnosis of TBM.
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16
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Tuberculous Meningitis in Children: Reducing the Burden of Death and Disability. Pathogens 2021; 11:pathogens11010038. [PMID: 35055986 PMCID: PMC8778027 DOI: 10.3390/pathogens11010038] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022] Open
Abstract
Tuberculous meningitis disproportionately affects young children. As the most devastating form of tuberculosis, it is associated with unacceptably high rates of mortality and morbidity even if treated. Challenging to diagnose and treat, tuberculous meningitis commonly causes long-term neurodisability in those who do survive. There remains an urgent need for strengthened surveillance, improved rapid diagnostics technology, optimised anti-tuberculosis drug therapy, investigation of new host-directed therapy, and further research on long-term functional and neurodevelopmental outcomes to allow targeted intervention. This review focuses on the neglected field of paediatric tuberculous meningitis and bridges current clinical gaps with research questions to improve outcomes from this crippling disease.
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Solomons RS, Nieuwoudt ST, Seddon JA, van Toorn R. Risk factors for ischemic stroke in children with tuberculous meningitis. Childs Nerv Syst 2021; 37:2625-2634. [PMID: 33856542 DOI: 10.1007/s00381-021-05163-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/09/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Cerebrovascular complications are commonly observed in children with tuberculous meningitis. We aimed to determine which clinical factors were associated with stroke at admission in children with tuberculous meningitis and, in children stroke-free at admission, which factors were associated with development of stroke on treatment. METHODS We analysed a cohort of 474 children diagnosed with 'definite' and 'probable' tuberculous meningitis, with prospectively collected data, at Tygerberg Hospital, Cape Town, South Africa from 1985 to 2005. We considered either hemiparesis or radiological arterial ischemic infarction as evidence of stroke. RESULTS At admission, 339 (71.5%) children presented with stroke. Features associated with stroke at admission included age <3 years (odds ratio (OR) 3.70; 95% confidence interval (CI): 2.44-5.63; p < 0.01), convulsions (OR: 2.25; 95% CI: 1.46-3.45; p < 0.01) and hydrocephalus (OR: 1.63; 95% CI: 1.05-2.53; p = 0.03). In the group of children without stroke at admission (n = 135), 33 (24.4%) developed stroke by 1 month. Similar factors predicted stroke and included age <3 years (OR: 2.60; 95% CI: 1.17-5.80; p = 0.02), convulsions (OR: 2.25; 95% CI: 1.46-3.45; p < 0.01), CSF cell count <10 or >500/L (OR: 3.12; 95% CI: 1.03-9.43; p = 0.04) and hydrocephalus (OR: 2.99; 95% CI: 1.30-6.89; p = 0.01). CONCLUSION A large proportion of children with tuberculous meningitis present with stroke at admission. Of those with no evidence of stroke at admission, a quarter develop stroke by 1 month, suggesting that there could be a brief window in which to give preventive therapy.
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Affiliation(s)
- Regan S Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Sarel T Nieuwoudt
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A Seddon
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Ronald van Toorn
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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18
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Manyelo CM, Chegou NN, Seddon JA, Snyders CI, Mutavhatsindi H, Manngo PM, Walzl G, Stanley K, Solomons RS. Serum and cerebrospinal fluid host proteins indicate stroke in children with tuberculous meningitis. PLoS One 2021; 16:e0250944. [PMID: 33930055 PMCID: PMC8087017 DOI: 10.1371/journal.pone.0250944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/19/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Stroke is a common complication in children with tuberculous meningitis (TBM). Host proteins may give us insight into the mechanisms of stroke in TBM and serve as biomarkers for detection of stroke, however, they have not been widely explored. In this study, we compared the concentrations of cerebrospinal fluid (CSF) and serum proteins between children who had TBM-related stroke and children with TBM without stroke. Methods We collected CSF and serum from 47 children consecutively admitted to the Tygerberg Academic Hospital in Cape Town, South Africa between November 2016, and November 2017, on suspicion of having TBM. A multiplex platform was used to measure the concentrations of 69 host proteins in CSF and serum from all study participants. Results After classification of study participants, 23 (48.9%) out of the 47 study participants were diagnosed with TBM, of which 14 (60.9%) demonstrated radiological arterial ischemic infarction. The levels of lipocalin-2, sRAGE, IP-10/ CXCL10, sVCAM-1, MMP-1, and PDGF-AA in CSF samples and the levels of D-dimer, ADAMTS13, SAA, ferritin, MCP-1/ CCL2, GDF-15 and IL-13 in serum samples were statistically different between children who had TBM-related stroke and children with TBM without stroke. After correcting for multiple testing, only the levels of sVCAM-1, MMP-1, sRAGE, and IP-10/ CXCL10 in CSF were statistically different between the two groups. CSF and serum protein biosignatures indicated stroke in children diagnosed with TBM with up to 100% sensitivity and 88.9% specificity. Conclusion Serum and CSF proteins may serve as biomarkers for identifying individuals with stroke amongst children diagnosed with TBM at admission and may guide us to understand the biology of stroke in TBM. This was a pilot study, and thus further investigations in larger studies are needed.
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Affiliation(s)
- Charles M. Manyelo
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Novel N. Chegou
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - James A. Seddon
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Candice I. Snyders
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hygon Mutavhatsindi
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Portia M. Manngo
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gerhard Walzl
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kim Stanley
- Division of Molecular Biology and Human Genetics, DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan S. Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
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Tuberculous Meningitis: Pathogenesis, Immune Responses, Diagnostic Challenges, and the Potential of Biomarker-Based Approaches. J Clin Microbiol 2021; 59:JCM.01771-20. [PMID: 33087432 PMCID: PMC8106718 DOI: 10.1128/jcm.01771-20] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB), causing high mortality or disability. Clinical management of the disease is challenging due to limitations of the existing diagnostic approaches. Our knowledge on the immunology and pathogenesis of the disease is currently limited. More research is urgently needed to enhance our understanding of the immunopathogenesis of the disease and guide us toward the identification of targets that may be useful for vaccines or host-directed therapeutics. Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB), causing high mortality or disability. Clinical management of the disease is challenging due to limitations of the existing diagnostic approaches. Our knowledge on the immunology and pathogenesis of the disease is currently limited. More research is urgently needed to enhance our understanding of the immunopathogenesis of the disease and guide us toward the identification of targets that may be useful for vaccines or host-directed therapeutics. In this review, we summarize the current knowledge about the immunology and pathogenesis of TBM and summarize the literature on existing and new, especially biomarker-based, approaches that may be useful in the management of TBM. We identify research gaps and provide directions for research which may lead to the development of new tools for the control of the disease in the near future.
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20
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Soma SK, Lingappa L, Raju S, Konanki R, Gaur AK, Mohan A, Mohanlal S. Clinical Profile, Yield of Cartridge-based Nucleic Acid Amplification Test (GeneXpert), and Outcome in Children with Tubercular Meningitis. J Pediatr Neurosci 2021; 15:224-230. [PMID: 33531936 PMCID: PMC7847089 DOI: 10.4103/jpn.jpn_92_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/18/2019] [Indexed: 11/24/2022] Open
Abstract
Background: GeneXpert MTB/RIF is a test for early, rapid diagnosis of tubercular meningitis (TBM). Aim: The aim of this article was to study the clinical profile, radiological features, yield of GeneXpert, neurosurgical interventions, and outcome of TBM in children. Settings and Design: This was a retrospective and prospective observational study. Materials and Methods: Diagnosis was based on the uniform research definition criteria and was staged according to the British Medical Research Council. Mantoux test, analysis of cerebrospinal fluid (CSF), CSF GeneXpert, and radiological investigations were performed. Results: Of 36 patients, 50% were aged 1–5 years. Fever (100%), headache (82%), altered sensorium (80%), and vomiting (66%) were common features. Twelve (33%) had contact with active case of tuberculosis; 32 received Bacille Calmette Guarin vaccination. Neurological features included severe deterioration in sensorium (Glasgow Coma Scale < 8) (38%), mild and moderate deficit in sensorium (31%), hemiparesis (41%), and involvement of sixth (25%) and seventh (22%) cranial nerves. Cerebral vision impairment (25%), papilledema (25%), and dystonia (22%) were other findings. CSF GeneXpert was positive in 37% (12/33) patients. Hydrocephalus and basal exudates (75%) were noted on neuro-imaging. Surgical intervention was performed in children with hydrocephalus (13/27). Omayya reservoir was placed in seven children, of which five needed conversion to ventriculoperitoneal (VP) shunt; direct VP shunt was carried out in six (6/13). Good outcome was noted in 78% at discharge. Stage III TBM (P = 0.0001), cerebral infarcts (P = 0.0006), and motor deficits (P = 0.03) were associated with poor outcome. Sequelae included learning difficulties with poor scholastic performance (31.5%). Conclusion: GeneXpert has high diagnostic specificity, but negative results do not rule out TBM. CSF GeneXpert provided quick results. Placement of Ommaya reservoir in TBM stage II and III with hydrocephalus was not successful. Hydrocephalus was managed conservatively with success (53%).
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Affiliation(s)
- Santosh K Soma
- Department of pediatric Neurology and Neuro-rehabilitation, Rainbow Children's Hospital and Perinatal Centre, Hyderabad, Telangana, India
| | - Lokesh Lingappa
- Department of pediatric Neurology and Neuro-rehabilitation, Rainbow Children's Hospital and Perinatal Centre, Hyderabad, Telangana, India
| | - Subodh Raju
- Department of Neurosurgery, Rainbow Children's Hospital and Perinatal Centre, Hyderabad, Telangana, India
| | - Ramesh Konanki
- Department of pediatric Neurology and Neuro-rehabilitation, Rainbow Children's Hospital and Perinatal Centre, Hyderabad, Telangana, India
| | - Amit K Gaur
- Department of pediatric Neurology and Neuro-rehabilitation, Rainbow Children's Hospital and Perinatal Centre, Hyderabad, Telangana, India
| | - Ashwini Mohan
- Department of pediatric Neurology and Neuro-rehabilitation, Rainbow Children's Hospital and Perinatal Centre, Hyderabad, Telangana, India
| | - Smilu Mohanlal
- Department of pediatric Neurology and Neuro-rehabilitation, Rainbow Children's Hospital and Perinatal Centre, Hyderabad, Telangana, India
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Garg R, Paliwal V. Hydrocephalus in Tuberculous Meningitis - Pearls and Nuances. Neurol India 2021; 69:S330-S335. [DOI: 10.4103/0028-3886.332275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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22
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Soni N, Kumar S, Shimle A, Ora M, Bathla G, Mishra P. Cerebrovascular complications in tuberculous meningitis-A magnetic resonance imaging study in 90 patients from a tertiary care hospital. Neuroradiol J 2020; 33:3-16. [PMID: 31589101 PMCID: PMC7005991 DOI: 10.1177/1971400919881188] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cerebrovascular complications of tuberculous meningitis (TBM) are associated with increased morbidity and mortality. We retrospectively reviewed clinicoradiological findings of 90 TBM patients who presented to a tertiary care hospital, with emphasis on frequency and distribution of infarcts on diffusion imaging and pattern of vascular involvement on magnetic resonance (MR) angiography (MRA). MATERIALS AND METHODS MR images of 90 TBM patients at presentation (2012-2018) were coanalyzed by two radiologists for tuberculomas, leptomeningeal enhancement (LM), hydrocephalus, infarct and vascular abnormalities. Infarcts were categorized based on location ("tubercular" (TB) or "ischemic" zones) and arterial supply (perforators and cortical branches). Clinical and laboratory findings were correlated with imaging data. RESULTS Ninety TBM patients (age 10-82 years) were enlisted after application of inclusion criteria. Tuberculomas were most common (100%) followed by LM (84.4%), cerebral infarcts (57.7%) and hydrocephalus (29%). Location-wise, 35% infarcts were in ischemic, 13% in TB and 15% in both zones. According to arterial supply, infarcts equally (50%) involved perforators from the lateral lenticulostriate and posterior cerebral (PCA)/basilar artery (BA) followed by medial lenticulostriate arteries (23%). MRA was available in 74.4% and abnormal in 43.2%. The middle cerebral artery was frequently involved (76%) followed by the anterior cerebral artery (38%), internal carotid artery (31%), PCA and BA. Six had diffuse narrowing with a paucity of distal vessels. Cerebral infarction was associated with hydrocephalus (p = .0019) and vasculitis (p < .001). CONCLUSION In TBM, strokes are common and mainly involve the perforators and cortical branches. MR is the imaging modality of choice for early diagnosis and timely management.
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Affiliation(s)
- Neetu Soni
- Neuroradiology Department,
University
of Iowa Hospitals and Clinics, USA
| | - Sunil Kumar
- Radiology Department, Sanjay Gandhi
Postgraduate Institute of Medical Sciences
(SGPGIMS),
India
| | - Anil Shimle
- Radiology Department, Sanjay Gandhi
Postgraduate Institute of Medical Sciences
(SGPGIMS),
India
| | - Manish Ora
- Nuclear Medicine Department,
SGPGIMS,
India
| | - Girish Bathla
- Radiology Department,
University
of Iowa Hospitals and Clinics, USA
| | - Prabhakar Mishra
- Department of Biostatistics and Health
Informatics,
SGPGIMS,
India
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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.
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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
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Muzumdar D, Vedantam R, Chandrashekhar D. Tuberculosis of the central nervous system in children. Childs Nerv Syst 2018; 34:1925-1935. [PMID: 29978252 DOI: 10.1007/s00381-018-3884-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/22/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Central nervous system tuberculosis (CNS TB) in children is still a socioeconomic problem in developing countries. It has varied manifestations, symptoms are nonspecific, diagnosis can be challenging, and treatment may be difficult. It is often missed or overlooked. Among the various pathological entities, tuberculous meningitis is the most common and devastating manifestation. The resultant vasculitis, infarction, and hydrocephalus can be life-threatening. It can have grave cognitive, intellectual, and endocrine sequelae if not treated in time resulting in handicap, especially in resource constraint countries. Early diagnosis and treatment of tuberculous meningitis is the single most important factor determining outcome. Tuberculous hydrocephalus needs to be recognized early, and cerebrospinal fluid diversion procedure needs to be performed in adequate time to prevent morbidity or mortality in some cases. Tuberculous pachymeningitis and arachnoiditis are rare in children. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Drug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. AIM The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. CONCLUSION Heightened clinical suspicion, early diagnosis, appropriate antituberculous treatment, and surgery in relevant situation are essential for a gratifying outcome and preventing complications.
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Affiliation(s)
- Dattatraya Muzumdar
- Department of Neurosurgery, King Edward VII Memorial Hospital, Parel, Mumbai, 400012, India.
| | - Rajshekhar Vedantam
- Department of Neurological Sciences, Christian Medical College Hospital, Vellore, India
| | - Deopujari Chandrashekhar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Marine Lines, Mumbai, India
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Wilkinson RJ, Rohlwink U, Misra UK, van Crevel R, Mai NTH, Dooley KE, Caws M, Figaji A, Savic R, Solomons R, Thwaites GE. Tuberculous meningitis. Nat Rev Neurol 2017; 13:581-598. [PMID: 28884751 DOI: 10.1038/nrneurol.2017.120] [Citation(s) in RCA: 285] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tuberculosis remains a global health problem, with an estimated 10.4 million cases and 1.8 million deaths resulting from the disease in 2015. The most lethal and disabling form of tuberculosis is tuberculous meningitis (TBM), for which more than 100,000 new cases are estimated to occur per year. In patients who are co-infected with HIV-1, TBM has a mortality approaching 50%. Study of TBM pathogenesis is hampered by a lack of experimental models that recapitulate all the features of the human disease. Diagnosis of TBM is often delayed by the insensitive and lengthy culture technique required for disease confirmation. Antibiotic regimens for TBM are based on those used to treat pulmonary tuberculosis, which probably results in suboptimal drug levels in the cerebrospinal fluid, owing to poor blood-brain barrier penetrance. The role of adjunctive anti-inflammatory, host-directed therapies - including corticosteroids, aspirin and thalidomide - has not been extensively explored. To address this deficit, two expert meetings were held in 2009 and 2015 to share findings and define research priorities. This Review summarizes historical and current research into TBM and identifies important gaps in our knowledge. We will discuss advances in the understanding of inflammation in TBM and its potential modulation; vascular and hypoxia-mediated tissue injury; the role of intensified antibiotic treatment; and the importance of rapid and accurate diagnostics and supportive care in TBM.
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Affiliation(s)
- Robert J Wilkinson
- Department of Medicine, Imperial College London, Norfolk Place, London W2 1PG, UK
- The Francis Crick Institute, Midland Road, London NW1 2AT, UK
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Republic of South Africa
| | - Ursula Rohlwink
- Division of Neurosurgery, University of Cape Town, Anzio Road, Observatory 7925, Republic of South Africa
| | - Usha Kant Misra
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Reinout van Crevel
- Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Nguyen Thi Hoang Mai
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam
| | - Kelly E Dooley
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, Maryland 21287, USA
| | - Maxine Caws
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Anthony Figaji
- Division of Neurosurgery, University of Cape Town, Anzio Road, Observatory 7925, Republic of South Africa
| | - Rada Savic
- UCSF School of Pharmacy, Department, Bioengineering, 1700 4th Street, San Francisco, California 94158, UA
| | - Regan Solomons
- Faculty of Health Sciences, Stellenbosch University, Tygerberg Hospital, Francie van Zijl Drive, Tygerberg 7505, Cape Town, Republic of South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road, Oxford OX3 9FZ, UK
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Mandal N, Anand PK, Gautam S, Das S, Hussain T. Diagnosis and treatment of paediatric tuberculosis: An insight review. Crit Rev Microbiol 2017; 43:466-480. [PMID: 28502224 DOI: 10.1080/1040841x.2016.1262813] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Tuberculosis (TB) is a major public health problem, invading all age groups world-wide. It is an opportunistic infection affecting the individuals alone or with co-infections. Childhood TB is a neglected aspect and a significant health problem in epidemic areas. It constitutes more than 20% of TB incidence. Pediatric TB exists in the shadow of adult TB. The clinicians concentrate on pulmonary manifestation of TB, whereas it is a major problem in both pulmonary and extra-pulmonary infections. The rate of infection with this disease is mostly associated with poverty, social disruption and human immunodeficiency virus (HIV) infection. The diagnosis of extra-pulmonary TB (EPTB) is more difficult than pulmonary TB (PTB). Delayed diagnosis and executive treatment contribute to increase in the mortality rate in endemic areas. This article provides the evidence-based simple and safe screening method, indicating rapid, highly sensitive and specific diagnostic tests for pulmonary and EPTB in children. The most important aspect of treatment is the correct course of anti-tubercular drugs. This review serves the purpose of quick reference for microbiologists, epidemiologists, academicians, students and researchers. It provides guidance regarding early diagnosis and treatment accuracy of pediatric TB.
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Affiliation(s)
| | | | - Subhash Gautam
- b National Institute of Medical Statistics , New Delhi , India
| | - Shritam Das
- c Division of NCDs, Regional Medical Research Centre , Bhubaneswar , India
| | - Tahziba Hussain
- d Regional Medical Research Centre (ICMR) , Bhubaneswar , India
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Chiappini E, Lo Vecchio A, Garazzino S, Marseglia GL, Bernardi F, Castagnola E, Tomà P, Cirillo D, Russo C, Gabiano C, Ciofi D, Losurdo G, Bocchino M, Tortoli E, Tadolini M, Villani A, Guarino A, Esposito S. Recommendations for the diagnosis of pediatric tuberculosis. Eur J Clin Microbiol Infect Dis 2016; 35:1-18. [PMID: 26476550 DOI: 10.1007/s10096-015-2507-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/07/2015] [Indexed: 01/10/2023]
Abstract
Tuberculosis (TB) is still the world's second most frequent cause of death due to infectious diseases after HIV infection, and this has aroused greater interest in identifying and managing exposed subjects, whether they are simply infected or have developed one of the clinical variants of the disease. Unfortunately, not even the latest laboratory techniques are always successful in identifying affected children because they are more likely to have negative cultures and tuberculin skin test results, equivocal chest X-ray findings, and atypical clinical manifestations than adults. Furthermore, they are at greater risk of progressing from infection to active disease, particularly if they are very young. Consequently, pediatricians have to use different diagnostic strategies that specifically address the needs of children. This document describes the recommendations of a group of scientific societies concerning the signs and symptoms suggesting pediatric TB, and the diagnostic approach towards children with suspected disease.
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Rohlwink UK, Kilborn T, Wieselthaler N, Banderker E, Zwane E, Figaji AA. Imaging Features of the Brain, Cerebral Vessels and Spine in Pediatric Tuberculous Meningitis With Associated Hydrocephalus. Pediatr Infect Dis J 2016; 35:e301-10. [PMID: 27213261 PMCID: PMC5024759 DOI: 10.1097/inf.0000000000001236] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric tuberculous meningitis (TBM) leads to high rates of mortality and morbidity. Prompt diagnosis and initiation of treatment are challenging; imaging findings play a key role in establishing the presumptive diagnosis. General brain imaging findings are well reported; however, specific data on cerebral vascular and spinal involvement in children are sparse. METHODS This prospective cohort study examined admission and followed up computed tomography brain scans and magnetic resonance imaging scans of the brain, cerebral vessels (magnetic resonance angiogram) and spine at 3 weeks in children treated for TBM with hydrocephalus (HCP; inclusion criteria). Exclusion criteria were no HCP on admission, treatment of HCP or commencement of antituberculosis treatment before study enrollment. Imaging findings were examined in association with outcome at 6 months. RESULTS Forty-four patients (median age 3.3 [0.3-13.1] years) with definite (54%) or probable TBM were enrolled. Good clinical outcome was reported in 72%; the mortality rate was 16%. Infarcts were reported in 66% of patients and were predictive of poor outcome. Magnetic resonance angiogram abnormalities were reported in 55% of patients. Delayed tuberculomas developed in 11% of patients (after starting treatment). Spinal pathology was more common than expected, occurring in 76% of patients. Exudate in the spinal canal increased the difficulty of lumbar puncture and correlated with high cerebrospinal fluid protein content. CONCLUSION TBM involves extensive pathology in the central nervous system. Severe infarction was predictive of poor outcome although this was not the case for angiographic abnormalities. Spinal disease occurs commonly and has important implications for diagnosis and treatment. Comprehensive imaging of the brain, spine and cerebral vessels adds insight into disease pathophysiology.
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Affiliation(s)
- Ursula K Rohlwink
- From the *Division of Neurosurgery, Pediatric Neurosurgery, †Division of Pediatric Radiology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa; and ‡University of Swaziland, Kwaluseni, Swaziland
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Chang PT, Yang E, Swenson DW, Lee EY. Pediatric Emergency Magnetic Resonance Imaging: Current Indications, Techniques, and Clinical Applications. Magn Reson Imaging Clin N Am 2016; 24:449-80. [PMID: 27150329 DOI: 10.1016/j.mric.2015.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
MR imaging plays an important role in the detection and characterization of several pediatric disease entities that can occur in the emergent setting because of its cross-sectional imaging capability, lack of ionizing radiation exposure, and superior soft tissue contrast. In the age of as low as reasonably achievable, these advantages have made MR imaging an increasingly preferred modality for diagnostic evaluations even in time-sensitive settings. In this article, the authors discuss the current indications, techniques, and clinical applications of MR imaging in the evaluation of pediatric emergencies.
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Affiliation(s)
- Patricia T Chang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - David W Swenson
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Edward Y Lee
- Division of Thoracic Imaging, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Sangani SV, Parikh S. Can sonographic measurement of optic nerve sheath diameter be used to detect raised intracranial pressure in patients with tuberculous meningitis? A prospective observational study. Indian J Radiol Imaging 2015; 25:173-6. [PMID: 25969641 PMCID: PMC4419427 DOI: 10.4103/0971-3026.155869] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
CNS Tuberculosis can manifest as meningitis, arachnoiditis and a tuberculoma. The rupture of a tubercle into the subarachnoid space leads to Tuberculosis Meningitis (TBME); the resulting hypersensitivity reaction can lead to an elevation of the intracranial pressure and hydrocephalus. While bedside optic nerve sheath diameter (ONSD) ultrasonography (USG) can be a sensitive screening test for elevated intracranial pressure in adult head injury, little is known regarding ONSD measurements in Tuberculosis Meningitis.
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Affiliation(s)
- Shruti V Sangani
- Department of Emergency Medicine, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| | - Samira Parikh
- Department of Emergency Medicine, BJ Medical College, Civil Hospital, Ahmedabad, Gujarat, India
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Abstract
Tuberculosis (TB) is a major, but often unrecognised, cause of disease and death in young children from countries with high TB incidence rates among adults. It is also relevant to paediatricians in low-incidence countries, such as Australia, because of increased international travel, immigration and refugee resettlement. This manuscript provides a brief overview of the global TB disease burden, the natural history of disease in children, and offers guidance on the prevention, diagnosis and treatment of TB in children.
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Affiliation(s)
- Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity, Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia
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Abstract
Many clinicians regard tuberculosis as an adult pulmonary disease, but tuberculosis (TB) is a major cause of disease, both pulmonary and extrapulmonary, and death in young children from TB-endemic countries, especially in areas affected by poverty, social disruption, and human immunodeficiency virus (HIV) infection. This article reviews the disease burden and the natural history of disease in children with TB. It also provides guidance regarding the diagnosis, treatment, and prevention of TB in children.
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Affiliation(s)
- Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity (MBI) and The Children's Hospital at Westmead, University of Sydney, Westmead, New South Wales 2145, Australia
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505, South Africa
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van Toorn R, Solomons R. Update on the diagnosis and management of tuberculous meningitis in children. Semin Pediatr Neurol 2014; 21:12-8. [PMID: 24655399 DOI: 10.1016/j.spen.2014.01.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Tuberculous meningitis (TBM), the most devastating manifestation of tuberculosis, is often missed or overlooked because of nonspecific symptoms and difficulties in diagnosis. It continues to be an important cause of neurologic handicap in resource-poor countries. Owing to the suboptimal performance of diagnostic tests of TBM, diagnosis relies on thorough history, clinical examination, and relevant investigations. The development of affordable, accurate diagnostic tests for TBM in resource-poor settings remains a priority. Short intensified treatment is safe and effective in both human immunodeficiency virus (HIV)-infected and HIV-uninfected children. Treatment of tuberculous hydrocephalus depends on the level of the cerebrospinal fluid obstruction. Corticosteroids reduce risk of neurodisability and death in HIV-uninfected children. Thalidomide should be considered in children compromised by tuberculosis abscesses and tuberculous-related optochiasmic arachnoiditis. In resource-poor countries, home-based TBM treatment after initial in-hospital stabilization is feasible in carefully selected patients. Early diagnosis and treatment of TBM is the single most important factor determining outcome.
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Affiliation(s)
- Ronald van Toorn
- Department of Paediatrics and Child Health, Stellenbosch University, Western Cape, South Africa.
| | - Regan Solomons
- Department of Paediatrics and Child Health, Stellenbosch University, Western Cape, South Africa
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Solari L, Soto A, Agapito JC, Acurio V, Vargas D, Battaglioli T, Accinelli RA, Gotuzzo E, van der Stuyft P. The validity of cerebrospinal fluid parameters for the diagnosis of tuberculous meningitis. Int J Infect Dis 2013; 17:e1111-5. [PMID: 23973430 DOI: 10.1016/j.ijid.2013.06.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 06/03/2013] [Accepted: 06/04/2013] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To assess the diagnostic validity of laboratory cerebrospinal fluid (CSF) parameters for discriminating between tuberculous meningitis (TBM) and other causes of meningeal syndrome in high tuberculosis incidence settings. METHODS From November 2009 to November 2011, we included patients with a clinical suspicion of meningitis attending two hospitals in Lima, Peru. Using a composite reference standard, we classified them as definite TBM, probable TBM, and non-TBM cases. We assessed the validity of four CSF parameters, in isolation and in different combinations, for diagnosing TBM: adenosine deaminase activity (ADA), protein level, glucose level, and lymphocytic pleocytosis. RESULTS One hundred and fifty-seven patients were included; 59 had a final diagnosis of TBM (18 confirmed and 41 probable). ADA was the best performing parameter. It attained a specificity of 95%, a positive likelihood ratio of 10.7, and an area under the receiver operating characteristics curve of 82.1%, but had a low sensitivity (55%). None of the combinations of CSF parameters achieved a fair performance for 'ruling out' TBM. CONCLUSIONS Finding CSF ADA greater than 6 U/l in patients with a meningeal syndrome strongly supports a diagnosis of TBM and permits the commencement of anti-tuberculous treatment.
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Affiliation(s)
- Lely Solari
- Unit of General Epidemiology and Disease Control, Institute of Tropical Medicine of Antwerp, Nationalestraat 155, B-2000 Antwerp, Belgium; Unidad de Análisis y Generación de Evidencias en Salud Publica (UNAGESP), Instituto Nacional de Salud del Peru, Lima, Peru.
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Britton P, Perez-Velez CM, Marais BJ. Diagnosis, treatment and prevention of tuberculosis in children. NEW SOUTH WALES PUBLIC HEALTH BULLETIN 2013; 24:15-21. [PMID: 23849022 DOI: 10.1071/nb12100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In Australia, tuberculosis notification rates have plateaued at a low level and disease is highly concentrated in immigrant communities where children may be affected. Many clinicians regard tuberculosis as an adult disease, hence it is rarely considered in the differential diagnosis of sick children. This paper provides a brief overview of the natural history of the disease in children to demonstrate the importance of taking a careful tuberculosis exposure history. It also provides guidance regarding the diagnosis, treatment and prevention of tuberculosis in children. The management of paediatric cases is not difficult if important differences with adult disease are carefully considered; these differences are discussed in detail.
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Raut T, Garg RK, Jain A, Verma R, Singh MK, Malhotra HS, Kohli N, Parihar A. Hydrocephalus in tuberculous meningitis: Incidence, its predictive factors and impact on the prognosis. J Infect 2013; 66:330-7. [PMID: 23291048 DOI: 10.1016/j.jinf.2012.12.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 12/24/2012] [Accepted: 12/26/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hydrocephalus is one of the most common complications of tuberculous meningitis. The present study evaluated the incidence, predictive factors and impact of hydrocephalus on overall prognosis of tuberculous meningitis. MATERIAL AND METHODS In a prospective cohort study, all patients fulfilling the inclusion criteria of tuberculous meningitis underwent clinical and cerebrospinal fluid evaluation, together with magnetic resonance imaging of the brain. Patients were treated with antituberculosis drugs and dexamethasone. Follow up neuroimaging was done after 6 months. Hydrocephalus was assessed using Evan's index. RESULTS Of 80 patients with tuberculous meningitis, 52(65%) had hydrocephalus at presentation. During follow up, 8 new patients developed hydrocephalus. Factors associated with hydrocephalus included advanced stage of disease, severe disability, duration of illness > 2 months, diplopia, seizures, visual impairment, papilledema, cranial nerve palsy, hemiparesis, CSF total cell count > 100/cu.mm, CSF protein > 2.5 g/l. Neuroimaging factors that were significantly associated with hydrocephalus included basal exudates, tuberculoma and infarcts. Multivariate analysis revealed visual impairment, cranial nerve palsy and the presence of basal exudates as significant predictors of hydrocephalus. In 13 patients, with early tuberculous meningitis, there was complete resolution of hydrocephalus. Hydrocephalus was significantly associated with mortality and poor outcome. CONCLUSION Hydrocephalus occurs in approximately two-third of patients with tuberculous meningitis and has an unfavorable impact on the prognosis. Hydrocephalus in early stages of tuberculous meningitis may resolve completely.
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Affiliation(s)
- Tushar Raut
- Department of Neurology, King George Medical University, Uttar Pradesh, Lucknow 226003, India
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Abstract
Tuberculous (TB) meningitis is common in resource-poor communities but also occurs in developed countries where the diagnosis is frequently delayed because of unfamiliarity with the disease. TB meningitis develops whenever a small intracranial tuberculoma (Rich focus) ruptures causing predominantly basal meningitis. This results in hydrocephalus, cranial nerve palsies, and ischemic brain injury secondary to tuberculous vasculitis. The primary source of TB is usually the lung. Early diagnosis is difficult because patients tend to present subacutely with nonspecific symptoms such as fever, cough, vomiting, listlessness, and failure to thrive. Lumbar puncture typically shows clear and colorless CSF with a low, predominantly lymphocytic, leukocytosis and raised protein and low glucose levels. Decision to treat is mostly clinical because of difficulty in demonstrating TB bacilli on routine smear and time needed for culture. A positive TB contact, Mantoux skin test, chest radiograph, CT/MRI brain scan, PCR for tuberculosis on CSF, and demonstration of TB bacilli from extraneural sources are invaluable in supporting a diagnosis of TB meningitis. Current World Health Organization guidelines recommend treatment with a four-drug regimen for 2 months, followed by a two-drug regimen for 10 months, the total duration of treatment being 12 months. Corticosteroids reduce mortality without changing neurological morbidity. Outcome relates closely to age and stage of disease.
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Affiliation(s)
- J F Schoeman
- Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa.
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Misra UK, Kalita J, Singh AP, Prasad S. Vascular Endothelial Growth Factor in Tuberculous Meningitis. Int J Neurosci 2012; 123:128-32. [DOI: 10.3109/00207454.2012.743127] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Patkar D, Narang J, Yanamandala R, Lawande M, Shah GV. Central Nervous System Tuberculosis. Neuroimaging Clin N Am 2012; 22:677-705. [DOI: 10.1016/j.nic.2012.05.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Affiliation(s)
- Carlos M Perez-Velez
- Grupo Tuberculosis Valle-Colorado and Clínica León XIII, IPS Universidad de Antioquia, Medellín, Colombia
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Pehlivanoglu F, Yasar KK, Sengoz G. Tuberculous meningitis in adults: a review of 160 cases. ScientificWorldJournal 2012; 2012:169028. [PMID: 22619611 PMCID: PMC3349112 DOI: 10.1100/2012/169028] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Accepted: 11/24/2011] [Indexed: 11/20/2022] Open
Abstract
Objective. This study aimed to evaluate epidemiological, clinical, laboratory, and neuroimaging features of 160 adult patients with tuberculous meningitis (TBM) according to “Thwaites' diagnostic index.” Methods. The subjects of this retrospective study are the patients with TBM who were followed up between years 1998 and 2009 in a tertiary referral hospital. Diagnosis of TBM was based on clinical, laboratory, and neuroimaging signs and Thwaites' diagnostic index. Results. Mycobacterium tuberculosis was isolated from CSF in 59 of 148 patients. Seventeen percent of the patients died, 71% recovered completely, and 13% recovered with neurological sequel at the end of the sixth month. Conclusions. Despite new developments in laboratory or neuroimaging techniques, the diagnosis of TBM is still based on clinical features with the help of laboratory. Early diagnosis by suspecting TBM may prevent therapy delay and may result in decrease in the mortality and morbidity.
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Affiliation(s)
- Filiz Pehlivanoglu
- Department of Infectious Diseases and Clinical Microbiology, Haseki Training and Research Hospital, Istanbul 34300, Turkey.
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von Bezing H, Andronikou S, van Toorn R, Douglas T. Are linear measurements and computerized volumetric ratios determined from axial MRI useful for diagnosing hydrocephalus in children with tuberculous meningitis? Childs Nerv Syst 2012; 28:79-85. [PMID: 21809022 DOI: 10.1007/s00381-011-1536-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 07/15/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aimed to evaluate linear measurements and computerized volumetric ratios on axial magnetic resonance imaging (MRI) scans against the diagnosis of hydrocephalus in children with tuberculous meningitis (TBM). METHODS MRI scans and clinical notes of children with culture positive TBM were reviewed. Patients with surgical drainage of ventricles were considered positive for hydrocephalus. Alternatively, predefined radiological criteria of hydrocephalus in combination with any clinical criteria were considered positive for hydrocephalus. Axial T2-weighted MRI scans were used for measurement by a radiologist. Linear measurements included the Evans index, frontal-occipital horn ratio, and frontal-occipital horn width ratio. Computer-assisted segmentation of the MRI volume was performed on a slice-by-slice basis using the number of pixels comprising each region to calculate the ratios: ventricular volume: brain volume and cerebrospinal fluid (CSF)/(brain + CSF) for all slices and for a single slice at the level of the lateral ventricles. RESULTS Twenty-two children (mean age 3.7 years) comprised ten patients with a 'final' diagnosis of hydrocephalus (six communicating, four non-communicating). None of the linear measurements showed a statistical correlation with the 'final' diagnosis of hydrocephalus. The frontal-occipital horn width ratio (FOHWR) (p = 0.09) was the closest to demonstrate statistical significance. The highest sensitivity was attained with FOR (90%) followed by FOHWR (85%). The highest specificity was reached with FOHWR (70%). Volumetric ratios were inferior to linear measures. CONCLUSION Linear measures of hydrocephalus in TBM were more reliable than volumetric ratios. Hydrocephalus can be quantified most reliably using the FOHWR. This is useful for serial follow-up and for research of TBM.
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Affiliation(s)
- Helga von Bezing
- Department of Radiology, University of Stellenbosch, Stellenbosch, South Africa.
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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.
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Tuberculous meningitis: diagnosis and treatment overview. Tuberc Res Treat 2011; 2011:798764. [PMID: 22567269 PMCID: PMC3335590 DOI: 10.1155/2011/798764] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Revised: 11/16/2011] [Accepted: 11/18/2011] [Indexed: 01/01/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis (TB) and has very high morbidity and mortality. TBM is typically a subacute disease with symptoms that may persist for weeks before diagnosis. Characteristic cerebrospinal fluid (CSF) findings of TBM include a lymphocytic-predominant pleiocytosis, elevated protein, and low glucose. CSF acid-fast smear and culture have relatively low sensitivity but yield is increased with multiple, large volume samples. Nucleic acid amplification of the CSF by PCR is highly specific but suboptimal sensitivity precludes ruling out TBM with a negative test. Treatment for TBM should be initiated as soon as clinical suspicion is supported by initial CSF studies. Empiric treatment should include at least four first-line drugs, preferably isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol; the role of fluoroquinolones remains to be determined. Adjunctive treatment with corticosteroids has been shown to improve mortality with TBM. In HIV-positive individuals with TBM, important treatment considerations include drug interactions, development of immune reconstitution inflammatory syndrome, unclear benefit of adjunctive corticosteroids, and higher rates of drug-resistant TB. Testing the efficacy of second-line and new anti-TB drugs in animal models of experimental TBM is needed to help determine the optimal regimen for drug-resistant TB.
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Triulzi F, Doneda C, Parazzini C. Neuroimaging of pediatric brain infections. Expert Rev Anti Infect Ther 2011; 9:737-51. [PMID: 21692676 DOI: 10.1586/eri.11.38] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Neuroimaging plays an important and growing role in the diagnosis and therapeutic management of pediatric brain infections. This article describes the spectrum of imaging findings associated with major pediatric viral and bacterial brain infections, outlining the role of current imaging technology in the differential diagnoses of brain injury, detection of complications and therapy monitoring. MRI is the tool of choice in the evaluation of brain infections and particular attention is devoted to the role of diffusion-weighted imaging and magnetic resonance spectroscopy. This article considers viral and bacterial infection in their different modalities of presentation as congenital, acute and subacute/chronic disease. With regard to congenital infections, the growing role of fetal MRI as a valuable complement to ultrasound in the prenatal assessment of brain damage is emphasized.
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Affiliation(s)
- Fabio Triulzi
- Department of Pediatric Radiology and Neuroradiology, Children's Hospital V. Buzzi, Milan, Italy.
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Patterns of complications of neonatal and infant meningitis on MRI by organism: A 10 year review. Eur J Radiol 2011; 80:821-7. [DOI: 10.1016/j.ejrad.2010.10.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 09/30/2010] [Accepted: 10/08/2010] [Indexed: 11/22/2022]
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Nogueira Delfino L, Fariello G, Lancella L, Marabotto C, Menchini L, Devito R, Errante Y, Quattrocchi CC, Longo D. Central nervous system tuberculosis in non-HIV-positive children: a single-center, 6 year experience. Radiol Med 2011; 117:669-78. [PMID: 22095412 DOI: 10.1007/s11547-011-0743-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 04/07/2011] [Indexed: 12/21/2022]
Abstract
PURPOSE The aim of this paper is to describe the imaging features of central nervous system (CNS) tuberculosis on computed tomography (CT) and magnetic resonance imaging (MRI) studies in non-HIV-positive children. MATERIALS AND METHODS A retrospective descriptive evaluation was conducted on imaging studies obtained from ten children admitted to our hospital over a 6-year period who fulfilled criteria for a diagnosis of CNS tuberculosis. Data were collected with regard to patients' clinical, laboratory and demographic characteristics, as well as results of radiological investigation. RESULTS We studied ten children, of whom five were boys and five were girls and whose mean age was 4 (range 7 months to 16) years. Neuroradiological findings on the first imaging study were basal meningeal enhancement (100%), hydrocephalus (70%), infarcts (90%), tuberculomas (40%) and cranial nerve involvement (20%). Follow-up studies revealed basal meningeal enhancement, hydrocephalus, and infarcts in all patients, tuberculomas in 70% and cranial nerve involvement in 50%. Only one patient showed a pattern of miliary tuberculosis. CONCLUSIONS CNS tuberculosis is still an important cause of childhood morbidity and mortality even in nonimmunosuppressed children. Because prompt diagnosis results in earlier treatment, it is crucial to be aware of tuberculous meningitis and its complications at imaging, especially because of the impact on patients' prognosis.
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Affiliation(s)
- L Nogueira Delfino
- Department of Radiology, IRCCS, Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio 4, 00100, Rome, Italy.
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Dekker G, Andronikou S, van Toorn R, Scheepers S, Brandt A, Ackermann C. MRI findings in children with tuberculous meningitis: a comparison of HIV-infected and non-infected patients. Childs Nerv Syst 2011; 27:1943-9. [PMID: 21494882 DOI: 10.1007/s00381-011-1451-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 04/04/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Radiological studies on HIV infection in tuberculous meningitis (TBM) in children are limited to small, retrospective studies using CT features. They report that HIV-infected children are less likely to display meningovascular enhancement, tuberculoma formation and obstructive hydrocephalus. No similar MRI-based studies were found in the literature. PURPOSE The purpose of this study is to compare the MRI features of TBM in HIV-infected and uninfected children. METHODS Retrospective descriptive study comparing clinical, laboratory and MRI features of 8 HIV-infected and 19 HIV-uninfected children with TBM. RESULTS Intense basal meningeal enhancement occurred less frequently (p = 0.31) in HIV-infected children whilst cerebral atrophy was more commonly encountered (p = 0.06) Neither finding was however of statistical significance. All HIV-infected children had visible meningeal nodules on MR imaging compared to 72% in HIV-uninfected children with TBM. No differences were noted regarding number or location of infarcts and presence of hydrocephalus. Hydrocephalus in HIV-infected children was exclusively of communicating nature. CONCLUSIONS The MRI criteria for diagnosis of TBM apply to HIV-infected children. The presence of nodular meningeal disease in all HIV-infected children has not previously been reported and requires further investigation.
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Affiliation(s)
- Gerrit Dekker
- Department of Radiology, Stellenbosch University, Stellenbosch, South Africa
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Schoeman JF, Janse van Rensburg A, Laubscher JA, Springer P. The role of aspirin in childhood tuberculous meningitis. J Child Neurol 2011; 26:956-62. [PMID: 21628697 DOI: 10.1177/0883073811398132] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Arterial stroke is the main cause of poor outcome in childhood tuberculous meningitis. Aspirin has an antithrombotic action at low dose and anti-ischemic and anti-inflammatory properties, which are dose-related. The aim of the study was to explore the possible benefits of aspirin in children with tuberculous meningitis. A total of 146 consecutive children with a diagnosis of probable tuberculous meningitis were studied. Patients were randomized into 3 groups: (1) placebo group, (2) low-dose aspirin group, and (3) high-dose aspirin group. Twenty-nine additional patients who received aspirin before admission were excluded from the randomized study, but continued on low-dose aspirin. Aspirin, irrespective of dose, did not show any significant benefit regarding morbidity (hemiparesis and developmental outcome) and mortality. Aspirin was well tolerated, but 1 death was probably related to aspirin. The fact that the outcome of the high-dose aspirin group compared favorably with the other treatment groups despite younger age and more severe neurological involvement at baseline needs further investigation.
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Affiliation(s)
- Johan F Schoeman
- Department of Pediatrics and Child Health, Tygerberg Children's Hospital Faculty of Health Sciences, Stellenbosch University, South Africa.
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