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Saurya S, Sharma G, Saxena BS, Gupta PK. The Role of Diffusion Tensor Imaging in CNS Tuberculosis. Cureus 2024; 16:e62998. [PMID: 39050293 PMCID: PMC11266837 DOI: 10.7759/cureus.62998] [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: 06/21/2024] [Indexed: 07/27/2024] Open
Abstract
Background and objective Tuberculosis (TB), caused by Mycobacterium tuberculosis, remains a significant global health concern, with India being a hotspot for the disease burden. Central nervous system (CNS) tuberculosis, though comprising a smaller proportion of total TB cases, is associated with significant morbidity and mortality. This study aimed to explore the utility of diffusion tensor imaging (DTI) in assessing the microstructural changes in white matter tracts associated with CNS tuberculosis. Materials and methods This study was conducted over two years at the All India Institute of Medical Sciences, Rishikesh. We employed a cross-sectional observational design and included patients with definite or highly probable tuberculous meningitis, alongside healthy controls. Results Our findings revealed a significant reduction in fractional anisotropy (FA) values in various white matter tracts of patients with CNS tuberculosis compared to healthy individuals. This reduction in FA correlated with the severity of tuberculous meningitis, particularly in the corpus callosum. Additionally, DTI highlighted distinct patterns of white matter involvement around intraparenchymal lesions, suggesting potential implications for clinical outcomes. The study emphasizes the utility of FA values in grading disease severity and prognosticating treatment outcomes in CNS tuberculosis. Conclusions Overall, this study provides valuable insights into the microstructural alterations in white matter tracts associated with CNS tuberculosis, highlighting the potential of DTI in early diagnosis, grading disease severity, and monitoring treatment response. We believe these findings will pave the way for further research to optimize the clinical management of this debilitating disease.
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Affiliation(s)
- Saurya Saurya
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Garima Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Brig Sudhir Saxena
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Puneet K Gupta
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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Sahib A, Bhatia R, Srivastava MVP, Singh MB, Komakula S, Vishnu VY, Rajan R, Gupta A, Srivastava AK, Wig N, Vikram NK, Biswas A. Escalate: Linezolid as an add on treatment in the intensive phase of tubercular meningitis. A randomized controlled pilot trial. Tuberculosis (Edinb) 2023; 142:102351. [PMID: 37394301 DOI: 10.1016/j.tube.2023.102351] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/03/2023] [Accepted: 05/21/2023] [Indexed: 07/04/2023]
Abstract
Most drugs used in the treatment of Tuberculous Meningitis have limited CNS penetration thereby limiting efficacy. CSF penetration of linezolid is 80-100%.The study was a prospective, randomized, open label with blinded outcome assessment pilot trial carried out in patients with TBM. Patients were randomized in a 1:1 ratio into two treatment groups either to receive standard ATT alone or add on oral 600 mg BD Linezolid for 4 weeks along with standard four drug ATT [HRZE/S]. Primary outcome was safety and mortality at the end of one and three months measured by intention to treat analysis. 29 patients were recruited and 27 completed three months of follow up. There was no significant difference in terms of mortality with Odds ratio (95% CI) of 2 (0.161-24.87; p = 1) at one month and 0.385 (0.058-2.538; p = 0.39) at three months. There was a significant improvement in GCS in Linezolid group at one month and mRS within the Linezolid group at one and three months. No major safety concerns were observed. The sample size is underpowered to draw any definitive conclusions but improvement in mRS and GCS as well as mortality change make a case for a large sample size trial.
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Affiliation(s)
- Akhil Sahib
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Bhushan Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Snigdha Komakula
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - V Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Roopa Rajan
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Anu Gupta
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naval K Vikram
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ashutosh Biswas
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Goyal V, Elavarasi A, Kumar A, Samal P, Garg A, Shukla G, Vishnu VY, Singh MB, Srivastava MVP. Cyclophosphamide therapy as an adjunct in refractory post-tubercular arachnoiditis. Indian J Tuberc 2022; 69:325-333. [PMID: 35760482 DOI: 10.1016/j.ijtb.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/22/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There is no satisfactory treatment for post tubercular arachnoiditis (TB arachnoiditis). We did this study to investigate the efficacy and safety of cyclophosphamide as adjuvant therapy for post TB arachnoiditis refractory to corticosteroids and anti-tubercular therapy (ATT). METHODS This was a retrospective case series of patients of refractory post TB arachnoiditis leading to paraparesis and vision loss who received cyclophosphamide as an adjuvant therapy along with standard ATT and corticosteroids. These patients were treated with intravenous cyclophosphamide (dose 500 mg/m2) once a month for 4 consecutive months after informed written consent and were assessed clinically and radiologically before and after cyclophosphamide therapy. RESULTS We had 4 patients with refractory post TB arachnoiditis of whom three became independently ambulatory. There was significant clinical as well as radiological improvement in all the patients. CONCLUSIONS Cyclophosphamide therapy could be an effective therapy for patients with refractory post TB arachnoiditis. Well-designed randomized controlled studies are essential to study the safety and efficacy of cyclophosphamide in this condition.
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Affiliation(s)
| | | | - Anand Kumar
- Department of Neurology, Banaras Hindu University, Banaras, India
| | - Priyanka Samal
- Department of Neurology, Kalinga Hospitals, Bhubaneswar, India
| | - Ajay Garg
- Department of Neuro-radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Garima Shukla
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - V Y Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Bhushan Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Huq MR, Hannan MA, Bulbul S, Ahmed A, Khan AM. A Case of Brain Tuberculosis With an Unusual Presentation Mimicking Viral Fever During a Dengue Outbreak in Bangladesh. Cureus 2022; 14:e21260. [PMID: 35186542 PMCID: PMC8843608 DOI: 10.7759/cureus.21260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 11/12/2022] Open
Abstract
Both dengue and tuberculosis are endemic in South Asian countries, including Bangladesh. Here we report an interesting case presenting as suspected dengue fever and eventually diagnosed as a case of brain tuberculosis. A 27-year-old immunocompetent male presented to us with fever, headache, retro-orbital pain, and photophobia for five days. He had no other complaints, and clinical examination findings were normal. Full blood count revealed neutrophilic leukocytosis; dengue antigen test and anti-dengue antibody test were negative. Magnetic resonance imaging (MRI) of the brain showed both supra and infra-tentorial multiple small (2-4 mm) gadolinium-enhancing lesions suggestive of tuberculomas. A cerebrospinal fluid study revealed lymphocytic pleocytosis with raised protein, low sugar level, and positive Gene Xpert MTB/RIF (Cepheid, California, US) assay test. Investigations did not reveal the involvement of other organs except for the brain. We started standard anti-tuberculosis therapy (HRZE) along with steroids and pyridoxine, and the patient became symptom-free within one week. The patient was discharged with the advice of follow-up after one month. The clinical course and all investigation findings of this case are presented. Central nervous system tuberculosis may present with non-specific signs and symptoms and may be misdiagnosed as other infections, including dengue, particularly during an ongoing epidemic. It may cause significant morbidity and mortality when the diagnosis is delayed due to its vague clinical presentation.
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Vibha D, Pillai K, Gupta P, Sudheer P, Mishra B, Oinam R, Mohan A, Tayade K, Srivastava P, Tripathi M, Srivastava A, Bhatia R, Rajan R, Pandit A, Singh R, Elavarasi A, Agarwal A, Gupta A, Das A, Radhakrishnan D, Ramanujam B, Soni K, Aggarwal R, Wig N, Trikha A. Comparison of disease profiles and three-month outcomes of patients with neurological disorders with and without COVID-19: An ambispective cohort study. Ann Indian Acad Neurol 2022; 25:218-223. [PMID: 35693663 PMCID: PMC9175394 DOI: 10.4103/aian.aian_602_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/12/2021] [Accepted: 10/12/2021] [Indexed: 11/04/2022] Open
Abstract
Objective: Methods: Results: Conclusion:
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Predictors of Infarction in Tuberculous Meningitis in Indian Patients. J Stroke Cerebrovasc Dis 2021; 30:106088. [PMID: 34536810 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/02/2021] [Accepted: 08/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Stroke is a devastating complication of tuberculous meningitis (TBM) and is an important determinant of its outcome. We propose a model which would help to predict development of infarction or cerebrovascular events in patients of TBM. METHODS A prospective study with n=129 patients of TBM were evaluated for predictors and outcomes of stroke. A diagnostic grid was formulated with clinical, laboratory and radiology as parameters to predict the vascular outcomes. All patients were followed up for mortality and disability on the basis of modified rankin score (mRS). MRI & CSF cytokines TNF-alpha, IFN- gamma & IL-6,8, 10 were measured at baseline and 3 months. The diagnosis of TBM included definite, probable & possible types and stage I & II with early and late onset of symptoms respectively. RESULTS The mortality was 16.2% and 19.4% of all patients developed stroke. The mean GCS, barthel index and mRS at admission was 57.03± 9.5,10.2±2.3 & 3.3±0.03 respectively mild to moderate infection and functional limitation. Barthel index (BI) happened to be a strong predictor [F=32.6, p=0.001, t=15.5, βeta coefficient =0.002] followed by biomarker TNF-α [F=18.9, p=0.02, t= -2.07, βeta coefficient=-0.04]. N=25 patients developed stroke with TNF-α, IL-6, IFN -γ showing statistically significant increase in all the stroke affected TBM (95% CI; 4.5 to 1.2; p=0.003). At 3 months, it was observed that mRS was statistically significant between stage I & II (95% CI; 5.4 to 2.1; p=0.04). CONCLUSIONS Our data revealed that 19.4% patients developed vascular events during the hospital stay or follow up. We recruited late onset TBM as compared to early onset. BI, TNF-α, IL6 are most potent predictors of stroke post TBM.
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Debabrata C, Sadanand D, Gobinda P, Abhiji D. A Scary Tale of Meningoencephalitis Where Aetiology Remained Elusive; But Finally, Patient Had The "Last Laugh". Neurol India 2021; 69:762-763. [PMID: 34169888 DOI: 10.4103/0028-3886.319232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Dey Sadanand
- Department of Neurology, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - Pramanick Gobinda
- Department of Radiology, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - Das Abhiji
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ, UK
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Kumar S, Singh P, Vyas S, Modi M, Agarwal V, Goyal MK, Sankhyan N. Assessment of Blood-Brain Barrier Integrity in Tuberculous Meningitis Using Dynamic Contrast-Enhanced MR Perfusion. Indian J Radiol Imaging 2021; 31:30-36. [PMID: 34316109 PMCID: PMC8299480 DOI: 10.1055/s-0041-1729119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis. The aim of the study was to quantitatively evaluate blood-brain barrier (BBB) perfusion changes in TBM patients using dynamic contrast-enhanced (DCE) MR perfusion. Methods and Material Thirty untreated patients of TBM and 10 healthy controls were prospectively evaluated by conventional imaging and DCE MR perfusion. Mean permeability indices- K trans and Ve-were calculated from multiple regions of interest (ROIs) placed in basal cisterns and comparison was done between the patients and controls. Results The permeability indices were significantly higher (where p < 0.001) in cisterns of TBM patients who showed basal meningeal enhancement when compared with healthy controls. Significant differences in permeability were observed between "enhancing" cases and controls as well as in "enhancing" cases when compared with the "non-enhancing" cases. However, no significant difference was observed in the mean cisternal value between "non-enhancing" cases and the controls. K trans with a cutoff value of > 0.0838 had 81.6% sensitivity and 78.6% specificity in differentiating cases and controls while V e mean value with a cutoff value of 0.0703 showed 86.8% sensitivity and 91.4% specificity in predicting the permeability difference between the cases and controls. Conclusion DCE MR perfusion is useful in the quantitative measurement of disruption of BBB and perfusion alterations in patients of TBM.
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Affiliation(s)
- Shruti Kumar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Paramjeet Singh
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sameer Vyas
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manish Modi
- Department of Neurology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vivek Agarwal
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manoj Kumar Goyal
- Department of Neurology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Naveen Sankhyan
- Department of Pediatric Neurology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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9
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MR vessel wall imaging in tubercular meningitis. Neuroradiology 2021; 63:1627-1634. [PMID: 33638692 DOI: 10.1007/s00234-021-02678-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Tubercular meningitis (TBM) has the propensity to cause secondary vasculitis through various mechanisms leading to development of cerebrovascular complications. These vascular involvements can be detected by vessel wall imaging (VWI). In this study, we aimed to study detailed findings of vessel wall imaging in cases of tubercular meningitis. METHODS All consecutive patients of suspected tubercular meningitis in whom diagnosis of TBM could be made according to diagnostic criteria given by Ahuja et al. were included in the study. High-resolution MR VWI and time of flight (TOF) magnetic resonance angiography (MRA) were done along with routine MRI sequences. Arteries up to second-order branches were studied, and statistical analyses were done with respect to stage of tubercular meningitis, infarctions and TOF MRA findings. RESULTS Out of all 101 cases of TBM, infarctions were found in 49 cases (48.5%), and vessel wall enhancement was seen in 67 cases (66.3%). With increasing severity of disease, more severe vascular involvement was seen on VWI. There was significant association between enhancement of individual arteries and infarctions in their territories. VWI had better sensitivity than the MRA, while MRA had better specificity than VWI for detection of vascular complications. CONCLUSION Tubercular vasculitis can be detected by VWI in the form of nodular or smooth segmental enhancement of vessel wall with or without stenosis. Incorporation of VWI in routine MR imaging can play a greater role in early detection and management of cerebrovascular complications which can help to improve prognosis of the disease.
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Maheswari EU, Bhoopathy RM, Bhanu K, Anandan H. Clinical Spectrum of Central Nervous System Tuberculosis and the Efficacy of Revised National Tuberculosis Control Program in its Management. J Neurosci Rural Pract 2019; 10:71-77. [PMID: 30765974 PMCID: PMC6337963 DOI: 10.4103/jnrp.jnrp_163_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Tuberculosis (TB) is a major global problem and poses a threat which is of considerable magnitude, with an estimated one-third of the population infected with TB bacillus. Aim The aim of this study is to study the treatment outcomes in patients with various forms of neurological TB treated with the standardized Revised National TB Control Program (RNTCP), directly observed treatment short-course (DOTS). Materials and Methods Patients diagnosed to have TBM, tuberculoma with or without spinal arachnoiditis (central nervous system tuberculosis-TB [CNS-TB]) were categorized as per the RNTCP guidelines and received DOTS Category I or Category II thrice-weekly intermittent treatment as deemed appropriate. Results The outcome of management with the standard RNTCP DOTS regimen was that a success rate (treatment completed) of 75%, the default rate of 6.6%, and a mortality of 3.3%. The target fixed by the RNTCP is to achieve a cure rate of 85%. We were able to document successful completion of treatment in 75% which is close to the target fixed by RNTCP. The default rate is 6.6% which quite negligible when compared to the unsupervised therapy which has a default rate of 50%. Conclusion The most important factor in predicting the outcome of treatment in CNS-TB is early diagnosis and the timing of initiation of antituberculous treatment. Early initiation of treatment is associated with better treatment outcomes.
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Affiliation(s)
- E Uma Maheswari
- Centre for Advanced Neurological Treatment, Department of Neurology, Tamil Nadu Government Multi Super Specialty Hospital, Chennai, Tamil Nadu, India
| | - R M Bhoopathy
- Centre for Advanced Neurological Treatment, Department of Neurology, Tamil Nadu Government Multi Super Specialty Hospital, Chennai, Tamil Nadu, India
| | - K Bhanu
- Department of Neurology, Madras Medical College, Chennai, Tamil Nadu, India
| | - Heber Anandan
- Senior Clinical Scientist, Department of Clinical Research, Dr. Agarwal's Healthcare Limited, Tirunelveli, Tamil Nadu, India
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Bahr NC, Meintjes G, Boulware DR. Inadequate diagnostics: the case to move beyond the bacilli for detection of meningitis due to Mycobacterium tuberculosis. J Med Microbiol 2019; 68:755-760. [PMID: 30994435 PMCID: PMC7176281 DOI: 10.1099/jmm.0.000975] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Tuberculosis (TB) meningitis is extremely difficult to diagnose due to its pauci-bacillary disease nature and new techniques are needed. Improved test sensitivity would allow for greater clinician confidence in diagnostic testing and has the potential to improve patient outcomes. Traditional microbiologic and molecular tests for TB meningitis focus on detection of TB bacilli and are inadequate. Smear microscopy is rapid but only ~10-15 % sensitive. Culture has 50-60 % sensitivity but is slow. Xpert MTB/Rif Ultra is a rapid, automated PCR-based assay with ~70 % sensitivity versus clinical case definition. Thus, even the best current testing may miss up to 30 % of cases. Clinicians are often left to treat empirically with prolonged regimens with significant side effects or risk a missed case that would result in death. Rather than relying strictly on microbiologic or molecular testing to diagnose TB meningitis, we propose that testing of CSF for biomarkers of host response may have an adjunctive role to play in improving the diagnosis of TB meningitis.
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Affiliation(s)
- Nathan C. Bahr
- University of Kansas, Kansas City, KS, USA
- *Correspondence: Nathan C. Bahr,
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Goyal V, Elavarasi A, Abhishek, Shukla G, Behari M. Practice Trends in Treating Central Nervous System Tuberculosis and Outcomes at a Tertiary Care Hospital: A Cohort Study of 244 Cases. Ann Indian Acad Neurol 2019; 22:37-46. [PMID: 30692758 PMCID: PMC6327709 DOI: 10.4103/aian.aian_70_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Tubercular meningitis (TBM) is a common cause of chronic meningitis in India; however, there is a paucity of literature on optimum duration and choice of drug therapy. Materials and Methods This was an ambispective cohort study. Results Two hundred and forty-four patients of central nervous system tuberculosis (CNS TB) who were seronegative for HIV were studied of whom 198 had TBM and 46 patients had tuberculoma without meningitis. Before completion of treatment, 84% of TBM patients underwent imaging. There was no difference in disability or mortality in patients, who were treated with various drug regimens in terms of duration of therapy or number of drugs at initiation of treatment. However when patients developed new complications, adding more drugs improved survival. Prolonging corticosteroid administration in patients with nonsatisfactory improvement at 8 weeks was not associated with prevention of disability. Conclusions CNS TB is treated by neurologists and physicians in India, as per their experience due to different recommendations in various guidelines. There is a tendency to decide when to stop treatment based on neuroimaging given the fear of poor outcomes associated with recurrence of the disease. The duration of treatment or choice of drugs at the start of treatment did not affect disability.
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Affiliation(s)
- Vinay Goyal
- Department of Neurology, AIIMS, New Delhi, India
| | | | - Abhishek
- Department of Neurology, AIIMS, New Delhi, India
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Mohammed H, Goyal MK, Dutta P, Sharma K, Modi M, Shah F, Shree R, Jain A, Jain G, Khandelwal N, Sharma N, Lal V. Hypothalamic and pituitary dysfunction is common in tubercular meningitis: A prospective study from a tertiary care center in Northern India. J Neurol Sci 2018; 395:153-158. [PMID: 30321796 DOI: 10.1016/j.jns.2018.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/29/2018] [Accepted: 10/07/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Current literature is poor with respect to well conducted prospective studies of hypothalamic pituitary axis (HPA) dysfunction in tubercular meningitis (TBM). As hormonal deficiencies are associated with poor clinical outcome in various neurological and non-neurological disorders, we prospectively evaluated the hypothalamic pituitary axis (HPA) dysfunction in TBM. PATIENTS AND METHODS Present study included newly diagnosed drug naive TBM patients (n = 63) at a tertiary care centre in Northern India. All patients underwent detailed clinical, radiological evaluation (Gadolinium enhanced magnetic resonance imaging of brain) and HPA hormonal profiles (electrochemiluminescence assay) both at initial presentation and at six month follow up. All the data was recorded on a predesigned proforma. RESULTS 77.8% patients had definite and 22.2% had highly probable TBM. 84.2% of patients had pituitary hormonal abnormalities at presentation. These included hyperprolactinemia (49.2%), secondary adrenal deficiency (42.9%), secondary hypogonadism (38.1%) and central hypothyroidism (9.5%). At follow up, 42.1% patients had HPA abnormalities [hyperprolactinemia (13.2%), secondary hypogonadism (15.8%), secondary adrenal deficiency (10.5%) and central hypothyroidism (10.5%)]. On multivariate logistic regression analysis, secondary hypocortisolism (Odd ratio: 4.042; 95% CI = 1.074-15.22; P = .039) was associated with poor outcome in TBM. CONCLUSION Abnormalities of HPA are common in TBM. Patients with TBM should be evaluated for dysfunction of HPA and treated accordingly.
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Affiliation(s)
| | | | - Pinaki Dutta
- Department of Endocrinology, PGIMER, Chandigarh, India
| | - Kusum Sharma
- Department of Microbiology, PGIMER, Chandigarh, India
| | - Manish Modi
- Department of Neurology, PGIMER, Chandigarh, India.
| | - Faisal Shah
- Department of Neurology, PGIMER, Chandigarh, India
| | - Ritu Shree
- Department of Neurology, PGIMER, Chandigarh, India
| | - Anumiti Jain
- Department of Neurology, PGIMER, Chandigarh, India
| | - Gourav Jain
- Department of Neurology, PGIMER, Chandigarh, India
| | | | | | - Vivek Lal
- Department of Neurology, PGIMER, Chandigarh, India
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Ghosh RN, Vyas S, Singh P, Khandelwal N, Sankhyan N, Singhi P. Perfusion magnetic resonance imaging in differentiation of neurocysticercosis and tuberculoma. Neuroradiology 2018; 61:257-263. [DOI: 10.1007/s00234-018-2118-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/16/2018] [Indexed: 12/18/2022]
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Modi M, Sharma K, Prabhakar S, Goyal MK, Takkar A, Sharma N, Garg A, Faisal S, Khandelwal N, Singh P, Sachdeva J, Shree R, Rishi V, Lal V. Clinical and radiological predictors of outcome in tubercular meningitis: A prospective study of 209 patients. Clin Neurol Neurosurg 2017; 161:29-34. [PMID: 28843114 DOI: 10.1016/j.clineuro.2017.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/11/2017] [Accepted: 08/12/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The predictors of poor outcome in tuberculous meningitis (TBM) remain to be delineated. We determined role of various clinical, radiological and cerebrospinal fluid (CSF) parameters in prediction of outcome in TBM. PATIENTS AND METHODS Current study was a prospective observational study including 209 patients of TBM. All patients underwent detailed evaluation including Gadolinium enhanced Magnetic resonance imaging (GdMRI) of brain as well as tests to detect evidence of tuberculosis elsewhere in body. They also underwent GdMRI at three and nine month follow up. All patients received treatment as per standard guidelines. RESULTS Mean age was 30.4±13.8years. 139 (66.5%) patients had definite TBM while 70 (34.5%) had highly probable TBM. 53 (25.4%) patients died. On univariate analysis, longer duration of illness, altered sensorium, stage III TBM, hydrocephalus and exudates correlated with poor outcome. On multivariate analysis presence of hydrocephalus (p=0.003; OR=3.2; 95% CI=1.5-6.7) and stage III TBM (p<0.0001; OR=8.7; 95% CI=3.7-20.2) correlated with higher risk of mortality. In addition, there was significant positive association between presence of hydrocephalus (p=0.05; OR=2.2; 95% CI=0.97-5.1), stage III TBM (p<0.0001; OR=28; 95% CI=4.9-158) and presence of altered sensorium (p=0.05; OR=22; 95% CI=0.99-4.8) with either death or survival with severe disability. CONCLUSIONS It is possible to prognosticate TBM using a combination of clinical and radiological. The duration of illness (65.9±92days) before diagnosis of TBM continues to be unacceptably long and this stresses on need to educate primary care physicians about TBM. Future studies where intensity and duration of treatment is guided by these cues may help in sorting out some of the most difficult questions in TBM, namely duration of antitubercular therapy as well as dose and duration of steroid therapy etc.
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Affiliation(s)
- M Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - K Sharma
- Department of Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - S Prabhakar
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - M K Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - A Takkar
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - A Garg
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - S Faisal
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - N Khandelwal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - P Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - J Sachdeva
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - R Shree
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - V Rishi
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | - V Lal
- Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Sharma S, Goyal MK, Sharma K, Modi M, Sharma M, Khandelwal N, Prabhakar S, Sharma N, R S, Gairolla J, Jain A, Lal V. Cytokines do play a role in pathogenesis of tuberculous meningitis: A prospective study from a tertiary care center in India. J Neurol Sci 2017; 379:131-136. [PMID: 28716226 DOI: 10.1016/j.jns.2017.06.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 05/01/2017] [Accepted: 06/01/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Though animal studies have suggested a role for proinflammatory cytokines in pathogenesis their exact role in pathogenesis of human meningeal tuberculosis continues to be controversial with different studies yielding contradictory results. AIM AND OBJECTIVES To study the levels of proinflammatory cytokines in serum and cerebrospinal fluid (CSF) of patients with tubercular meningitis (TBM) and to determine whether these correlate with disease severity. PATIENTS AND METHODS Present study included 146 patients with TBM (90- Definite TBM; 56- Probable TBM), diagnosed according to criteria laid by Ahuja et al. which were modified to include CSF nucleic acid based tests. Serum (n=146) and CSF (n=140) levels of various proinflammatory cytokines (IL-1β, IL-2, IL-6, TNF-α and IFNγ) were compared between TBM patients and healthy volunteers (n=99). These levels were correlated with various clinical, radiological and CSF parameters of TBM patients. RESULTS Proinflammatory cytokines include cytokines which promote systemic inflammation. In current study, the serum and CSF levels of various cytokines (IL-2, IL-4, IL-6, IL-1β, IFN-γ and TNF-α) were significantly elevated in TBM patients compared to controls. A significant correlation was found between a) Higher stage of TBM and various cytokines (except for serum IL-6 and CSF IFN-γ); b) High CSF TNF-α, IL-4 and IL-1β with severity of hydrocephalus; c) High CSF IL1β and IFN-γ with presence of exudates on MRI; d) Serum and CSF levels of all cytokines with poor outcome as determined by death or as defined by S and E ADL (Schwab and England activities of daily living) score or by GOS (Glasgow outcome scale) (except for interferon gamma); and e) Serum and CSF IL-4 and IL1β with presence of infarcts on MRI brain. CONCLUSION Proinflammatory cytokines play an important role in the pathogenesis of TBM and contribute significantly towards severity of disease.
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Affiliation(s)
- S Sharma
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - M K Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - K Sharma
- Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - M Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - M Sharma
- Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - N Khandelwal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - S Prabhakar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Shree R
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - J Gairolla
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - A Jain
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - V Lal
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Chatterji T, Singh S, Sen M, Singh AK, Agarwal GR, Singh DK, Srivastava JK, Singh A, Srivastava RN, Roy R. Proton NMR metabolic profiling of CSF reveals distinct differentiation of meningitis from negative controls. Clin Chim Acta 2017; 469:42-52. [PMID: 28315295 DOI: 10.1016/j.cca.2017.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 03/12/2017] [Accepted: 03/14/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) is an essential bio-fluid of the central nervous system (CNS), playing a vital role in the protection of CNS and performing neuronal function regulation. The chemical composition of CSF varies during onset of meningitis, neurodegenerative disorders (positive controls) and in traumatic cases (negative controls). METHODS The study design was broadly categorized into meningitis cases, negative controls and positive controls. Further differentiation among the three groups was carried out using Principal Component Analysis (PCA) followed by supervised Partial Least Square Discriminant Analysis (PLS-DA). RESULTS The statistical analysis of meningitis vs. negative controls using PLS-DA model resulted in R2 of 0.97 and Q2 of 0.85. There was elevation in the levels of ketone bodies, total free amino acids, glutamine, creatine, citrate and choline containing compounds (choline and GPC) in meningitis cases. Similarly, meningitis vs. positive controls resulted in R2 of 0.80 and Q2 of 0.60 and showed elevation in the levels of total free amino acids, glutamine, creatine/creatinine and citrate in the meningitis group. Four cases of HIV were identified by PLS-DA model as well as by clinical investigations. CONCLUSION On the basis of metabolic profile it was found that negative control CSF samples are more appropriate for differentiation of meningitis than positive control CSF samples.
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Affiliation(s)
- Tanushri Chatterji
- Department of Microbiology, Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS), Vibhuti Khand, Gomti Nagar, Lucknow 226010, India; Amity Institute of Biotechnology, Amity University Uttar Pradesh, Malhaur. Lucknow 226028, India
| | - Suruchi Singh
- Centre of Biomedical Research, formerly Centre of Biomedical Magnetic Resonance (CBMR), Sanjay Gandhi Postgraduate Institute of Medical Sciences Campus, Rae Bareli Road, Lucknow 226014, India
| | - Manodeep Sen
- Department of Microbiology, Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS), Vibhuti Khand, Gomti Nagar, Lucknow 226010, India.
| | - Ajai Kumar Singh
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS), Vibhuti Khand, Gomti Nagar, Lucknow 226010, India
| | - Gaurav Raj Agarwal
- Department of Radiodiagnosis, Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS), Vibhuti Khand, Gomti Nagar, Lucknow 226010, India
| | - Deepak Kumar Singh
- Department of Neurosurgery, Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS), Vibhuti Khand, Gomti Nagar, Lucknow 226010, India
| | | | - Alka Singh
- Department of Orthopaedics, King George's Medical University, Shahmina Road, Chowk, Lucknow 226003, India
| | - Rajeshwar Nath Srivastava
- Department of Orthopaedics, King George's Medical University, Shahmina Road, Chowk, Lucknow 226003, India
| | - Raja Roy
- Centre of Biomedical Research, formerly Centre of Biomedical Magnetic Resonance (CBMR), Sanjay Gandhi Postgraduate Institute of Medical Sciences Campus, Rae Bareli Road, Lucknow 226014, India.
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18
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Chen Y, Zhang J, Wang X, Wu Y, Zhu L, Lu L, Shen Q, Qin Y. HMGB1 level in cerebrospinal fluid as a complimentary biomarker for the diagnosis of tuberculous meningitis. SPRINGERPLUS 2016; 5:1775. [PMID: 27795917 PMCID: PMC5061653 DOI: 10.1186/s40064-016-3478-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 10/05/2016] [Indexed: 01/08/2023]
Abstract
Purpose High mobility group box-1 (HMGB1) is a proinflammatory, DAMP protein that participates in many pathological conditions. In this study, we evaluated the usability of CSF HMGB1 as a biomarker for the diagnosis of tuberculous meningitis (TBM). Methods A total of 59 TBM patients and 169 control patients were included in our study. CSF samples were obtained and analyzed for HMGB1 using a commercial ELISA kit. Results The mean CSF HMGB1 was 19.36 ng/ml in TBM patients (n = 59) versus 3.12 ng/ml in non-TB meningitis patients (n = 30), 2.13 ng/ml in patients with extra neural tuberculosis (n = 73), and 1.06 ng/m in controls (n = 66). According to the receiver operator characteristic curves, a cut-off value of 3.4 ng/ml was calculated, indicating that the sensitivity and specificity of CSF HMGB1 alone in diagnosis of TBM were 61.02 and 89.94 %, respectively. In patients with extra neural tuberculosis and a high risk of TBM, CSF HMGB1 seemed to be a good candidate for early differential diagnosis of TBM at the cut-off value of 3.8 ng/ml, when the sensitivity and specificity were 79.49 and 94.52 % respectively. Conclusion Our finding may prove to be clinically useful, because CSF HMGB1 ELISA can be performed in almost all clinical laboratories, especially when sophisticated technologies are either time consuming or unavailable.
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Affiliation(s)
- Yan Chen
- Department of Clinical Laboratory Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, 200072 People's Republic of China.,Department of Laboratory Diagnosis, Changhai Hospital, the Second Military Medical University, Shanghai, 200433 People's Republic of China
| | - Jun Zhang
- Department of Clinical Laboratory Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, 200433 People's Republic of China
| | - Xiaofei Wang
- Department of Clinical Laboratory Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, 200433 People's Republic of China
| | - Yu Wu
- Department of Laboratory Diagnosis, Changhai Hospital, the Second Military Medical University, Shanghai, 200433 People's Republic of China
| | - Li Zhu
- Department of Laboratory Diagnosis, Changhai Hospital, the Second Military Medical University, Shanghai, 200433 People's Republic of China
| | - Longkun Lu
- Department of Laboratory Diagnosis, Changhai Hospital, the Second Military Medical University, Shanghai, 200433 People's Republic of China
| | - Qian Shen
- Department of Laboratory Diagnosis, Changhai Hospital, the Second Military Medical University, Shanghai, 200433 People's Republic of China
| | - Yanghua Qin
- Department of Laboratory Diagnosis, Changhai Hospital, the Second Military Medical University, Shanghai, 200433 People's Republic of China
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19
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Dunphy L, Shetty P, Randhawa R, Rani KA, Duodu Y. Tuberculous meningitis in an immunocompetent male complicated by hydrocephalus. BMJ Case Rep 2016; 2016:bcr-2015-213916. [PMID: 27758813 DOI: 10.1136/bcr-2015-213916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 39-year-old man, born in India but resident in the UK for 10 years, was travelling in America when he became feverish with an altered mentation. He reported a 10-day history of fever, photophobia, headache and fatigue. His medical history included hypothyroidism and migraine. He was a non-smoker, did not consume alcohol and denied a history of drug use. He was transferred to the emergency department. Laboratory investigations confirmed hyponatraemia (sodium 128 mmol/L). A chest radiograph confirmed no focal consolidation. Further investigation with a CT brain was unremarkable. A lumbar puncture was suggestive of viral meningitis, with a raised white cell count, lymphocytosis, high protein and low glucose. His PCR was negative for enterovirus and herpes simplex virus. Further investigation with a CT thorax, abdomen and pelvis demonstrated bilateral upper-lobe infiltrations. A bronchoalveolar lavage was negative for acid alcohol fast bacilli (AAFB). A diagnosis of tuberculous meningitis was rendered following a repeat lumbar puncture. Gram stain revealed AAFB and PCR was also positive. He started antitubercular treatment and corticosteroids. A repeat CT brain demonstrated ventriculomegaly, suggestive of hydrocephalus and an MRI head revealed likely communicating hydrocephalus with basilar enhancement. He was repatriated to the UK. Eleven days post transfer, he became acutely confused and required external ventricular drain insertion. After surgical management of his hydrocephalus, there was no further neurological deterioration. He remains committed to his neurorehabilitation.
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Affiliation(s)
- Louise Dunphy
- Department of Medicine, Milton Keynes University Hospital, Eaglestone, Milton Keynes, UK
| | - Prashanth Shetty
- Department of Respiratory Medicine, Milton Keynes University Hospital, Milton Keynes, UK
| | - Rabinder Randhawa
- Department of Respiratory Medicine, Milton Keynes University Hospital, Milton Keynes, UK
| | - Kharil Amir Rani
- Department of Stroke Medicine, Milton Keynes University Hospital, Milton Keynes, UK
| | - Yaw Duodu
- Department of Stroke Medicine, Milton Keynes University Hospital, Milton Keynes, UK
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20
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Maurya PK, Singh AK, Sharma L, Kulshreshtha D, Thacker AK. Visual pathway abnormalities in tuberculous meningitis. J Clin Neurosci 2016; 33:205-208. [PMID: 27612674 DOI: 10.1016/j.jocn.2016.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 04/18/2016] [Accepted: 04/20/2016] [Indexed: 11/30/2022]
Abstract
Ophthalmological complications are common and disabling in patients with tuberculous meningitis. We aimed to study the visual pathway abnormalities in patients with tuberculous meningitis. Forty-three patients with tuberculous meningitis were subjected to visual evoked responses (VER) and neuroophthalmologic assessment. Neuroophthalmologic assessment revealed abnormalities in 22 (51.3%) patients. VER were found to be abnormal in 27 (62.8%) patients. The VER abnormalities included prolonged P100 latencies with relatively normal amplitude and significant interocular latency differences. Visual pathways abnormalities are common in patients with tuberculous meningitis and are often subclinical. Pathophysiologic explanations for electrophysiological abnormalities on VER in these patients are incompletely understood and needs further exploration.
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Affiliation(s)
- Pradeep Kumar Maurya
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India
| | - Ajai Kumar Singh
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India
| | - Lalit Sharma
- Department of Medicine, B.R.D. Medical College, Gorakhpur, India
| | - Dinkar Kulshreshtha
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India
| | - Anup Kumar Thacker
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India.
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21
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Saavedra JS, Urrego S, Toro ME, Uribe CS, García J, Hernández O, Arango JC, Pérez ÁB, Franco A, Vélez IC, Del Corral H. Validation of Thwaites Index for diagnosing tuberculous meningitis in a Colombian population. J Neurol Sci 2016; 370:112-118. [PMID: 27772738 DOI: 10.1016/j.jns.2016.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 08/21/2016] [Accepted: 09/06/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine the diagnostic accuracy of Thwaites Index (TI) in a Colombian population to distinguish meningeal tuberculosis (MTB) from bacterial meningitis (BM) and from non-tuberculous meningitis. Exploratory analyses were conducted to assess the TI's validity for patients with human immunodeficiency virus (HIV) and children above six-years-old. METHODS The study included 527 patients, the TI was calculated and results compared with those of a reference standard established by expert neurologists. Sensitivity, specificity, area under the curve of receiver-operator characteristics (AUC-ROC) and likelihood ratios were calculated. RESULTS The AUC-ROC to distinguish MTB from non-tuberculous meningitis was 0.72 (95% CI: 0.67-0.77) for HIV negative adults. AUC-ROC was 0.62 (95% CI: 0.50-0.74) for HIV positive adults and 0.83 (95% CI: 0.68-0.97) for children. For distinguishing MTB from BM the AUC-ROC was 0.78 (95% CI: 0.73-0.83); furthermore, the AUC-ROC was 0.57 (95% CI: 0.31-0.83) for HIV positive adults and 0.86 (95% CI: 0.73-0.99) for children. CONCLUSION The TI was sensitive but not specific when used to distinguish MTB from BM in HIV negative adults. In HIV positive adults the index had low diagnostic accuracy. Moreover, the TI showed discrimination capability for children over 6years; however, research with larger samples is required in these.
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Affiliation(s)
- Juan Sebastián Saavedra
- Neurology Section, Department of Internal Medicine, Faculty of Medicine, University of Antioquia, Bloque 6, Calle 64 # 51 D - 154, Medellín, Colombia
| | - Sebastián Urrego
- Neurology Section, Department of Internal Medicine, Faculty of Medicine, University of Antioquia, Bloque 6, Calle 64 # 51 D - 154, Medellín, Colombia
| | - María Eugenia Toro
- Neurology Section, Department of Internal Medicine, Faculty of Medicine, University of Antioquia, Bloque 6, Calle 64 # 51 D - 154, Medellín, Colombia
| | - Carlos Santiago Uribe
- Neurology Section, Department of Internal Medicine, Faculty of Medicine, University of Antioquia, Bloque 6, Calle 64 # 51 D - 154, Medellín, Colombia
| | - Jenny García
- Clinical Epidemiology Academic Group (GRAEPIC), Faculty of Medicine, University of Antioquia, Carrera 51 D # 62-29, Edificio Manuel Uribe Ángel, tercer piso, Medellín, Colombia
| | - Olga Hernández
- Instituto Neurológico de Colombia, Calle 55 # 46-36, Medellín, Colombia
| | - Juan Carlos Arango
- Department of Pathology, Faculty of Medicine, University of Antioquia, Bloque 13, Calle 64 N°51 D - 154, Medellín, Colombia
| | | | - Andrés Franco
- Hospital Pablo Tobón Uribe, Calle 78B # 69-240, Medellín, Colombia
| | - Isabel Cristina Vélez
- Neurology Section, Department of Internal Medicine, Faculty of Medicine, University of Antioquia, Bloque 6, Calle 64 # 51 D - 154, Medellín, Colombia
| | - Helena Del Corral
- MICROBA, School of Microbiology, University of Antioquia, Calle 67 # 53-108 Bloque 5, Medellín, Colombia.
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Cerebrospinal Fluid Arachidonate-5-Lipoxygenase Levels for the Diagnosis of Tubercular Meningitis. Indian J Pediatr 2016; 83:1025-6. [PMID: 27153831 DOI: 10.1007/s12098-016-2131-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
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Rios-Sarabia N, Hernández-González O, González-Y-Merchand J, Gordillo G, Vázquez-Rosales G, Muñoz-Pérez L, Torres J, Maldonado-Bernal C. Identification of Mycobacterium tuberculosis in the cerebrospinal fluid of patients with meningitis using nested PCR. Int J Mol Med 2016; 38:1289-95. [PMID: 27499078 DOI: 10.3892/ijmm.2016.2698] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 07/22/2016] [Indexed: 11/06/2022] Open
Abstract
Tuberculous meningitis (TBM) is the most severe form of tuberculosis. It is caused by Mycobacterium tuberculosis (M. tuberculosis; MT) and it is very difficult to diagnose. The symptoms are similar to other infectious neurological diseases, such as neurocysticercosis, neuroborreliosis, or herpes viral infection. The aim of this study was to identify tuberculosis (TB) in cases of meningitis with clinical and laboratory evidence suggestive of TBM, and to confirm our findings with molecular tests for TB infection. We recruited patients with neurological symptoms who were examined at the neurology services of Hospitals of Instituto Mexicano del Seguro Social (IMSS) in Mexico City. A total of 144 consecutive patients with suggestive infectious meningitis were initially included; 94 cases of meningitis with clinical and laboratory evidence suggestive of TBM were included, but only 50 of these cases fulfilled the criteria for probable TBM. As the controls, we included 50 cases of meningitis with clinical and laboratory evidence suggestive of non-TBM. Cerebrospinal fluid (CSF) was collected from all 100 patients (cases and controls) and tested for TB by multiplex and nested PCR analyses. Nested PCR detected 0.1 fg of M. tuberculosis DNA. TB infection was confirmed with molecular tests in 49 patients from the 50 cases suggestive of TBM and in 1 of the 50 non-TBM cases. The analysis exhibited a sensitivity of 98.0%, a specificity of 92.0%, a positive predictive value of 88.0% and a negative predictive value of 98.0%. The use CSF for the analyses proved to be effective for the rapid diagnosis of TBM using a developed system of multiplex and nested PCR analyses in patients presenting neurological symptoms.
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Affiliation(s)
- Nora Rios-Sarabia
- Medical Research Unit on Infectious Diseases, Hospital of Pediatrics, XXI Century National Medical Center, Mexican Social Security Institute, Mexico City 06720, Mexico
| | - Olivia Hernández-González
- Medical Research Unit on Infectious Diseases, Hospital of Pediatrics, XXI Century National Medical Center, Mexican Social Security Institute, Mexico City 06720, Mexico
| | - Jorge González-Y-Merchand
- Laboratory of Molecular Microbiology, Department of Microbiology, National School of Biological Sciences, National Polytechnic Institute, Mexico City 11340, Mexico
| | - Guadalupe Gordillo
- Medical Research Unit on Infectious Diseases, Hospital of Pediatrics, XXI Century National Medical Center, Mexican Social Security Institute, Mexico City 06720, Mexico
| | - Guillermo Vázquez-Rosales
- Department of Infectious Diseases, Hospital of Pediatrics, XXI Century National Medical Center, Mexican Social Security Institute, Mexico City 06720, Mexico
| | - Leopoldo Muñoz-Pérez
- Medical Research Unit on Infectious Diseases, Hospital of Pediatrics, XXI Century National Medical Center, Mexican Social Security Institute, Mexico City 06720, Mexico
| | - Javier Torres
- Medical Research Unit on Infectious Diseases, Hospital of Pediatrics, XXI Century National Medical Center, Mexican Social Security Institute, Mexico City 06720, Mexico
| | - Carmen Maldonado-Bernal
- Research Laboratory in Immunology and Proteomics, Children's Hospital of Mexico Federico Gomez, Mexico City 06720, Mexico
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Mahale RR, Mehta A, Uchil S. Estimation of cerebrospinal fluid cortisol level in tuberculous meningitis. J Neurosci Rural Pract 2015; 6:541-4. [PMID: 26752900 PMCID: PMC4692013 DOI: 10.4103/0976-3147.165421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Central nervous system (CNS) involvement in tuberculosis is around 5-10%. Of the various manifestations of CNS tuberculosis, meningitis is the most common (70-80%). Delay in diagnosis and treatment results in significant morbidity and mortality. OBJECTIVE To study the cerebrospinal fluid (CSF) cortisol levels in tubercular meningitis and compare the levels with controls. METHODS Cross-sectional, prospective, observational, hospital-based study done in 20 patients of tubercular meningitis, 20 patients of aseptic meningitis (AM) and 25 control subjects without any preexisting neurological disorders who have undergone lumbar puncture for spinal anesthesia. RESULTS Cortisol was detected in all 40 CSF samples of patients (100%). Mean CSF cortisol level was 8.82, 3.47 and 1.05 in tubercular meningitis, AM and controls, respectively. Mean CSF cortisol level in tubercular meningitis was significantly higher as compared to AM and controls (P < 0.0001). CONCLUSION Cortisol level estimation in CSF is one of the rapid, relatively inexpensive diagnostic markers in early identification of tubercular meningitis along with CSF findings of elevated proteins, hypoglycorrhachia and lymphocytic pleocytosis. This aids in earlier institution of appropriate treatment and thereby decreasing morbidity and mortality. This is the first study on the estimation of CSF cortisol level in tuberculous meningitis.
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Affiliation(s)
- Rohan R. Mahale
- Department of Neurology, M. S. Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
| | - Anish Mehta
- Department of Neurology, M. S. Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
| | - Sudhir Uchil
- Department of Medicine, M. S. Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
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Mu J, Yang Y, Chen J, Cheng K, Li Q, Wei Y, Zhu D, Shao W, Zheng P, Xie P. Elevated host lipid metabolism revealed by iTRAQ-based quantitative proteomic analysis of cerebrospinal fluid of tuberculous meningitis patients. Biochem Biophys Res Commun 2015; 466:689-95. [PMID: 26348777 DOI: 10.1016/j.bbrc.2015.08.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/09/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Tuberculous meningitis (TBM) remains to be one of the most deadly infectious diseases. The pathogen interacts with the host immune system, the process of which is largely unknown. Various cellular processes of Mycobacterium tuberculosis (MTB) centers around lipid metabolism. To determine the lipid metabolism related proteins, a quantitative proteomic study was performed here to identify differential proteins in the cerebrospinal fluid (CSF) obtained from TBM patients (n = 12) and healthy controls (n = 12). METHODS CSF samples were desalted, concentrated, labelled with isobaric tags for relative and absolute quantitation (iTRAQ™), and analyzed by multi-dimensional liquid chromatography-tandem mass spectrometry (LC-MS/MS). Gene ontology and proteomic phenotyping analysis of the differential proteins were conducted using Database for Annotation, Visualization, and Integrated Discovery (DAVID) Bioinformatics Resources. ApoE and ApoB were selected for validation by ELISA. RESULTS Proteomic phenotyping of the 4 differential proteins was invloved in the lipid metabolism. ELISA showed significantly increased ApoB levels in TBM subjects compared to healthy controls. Area under the receiver operating characteristic curve analysis demonstrated ApoB levels could distinguish TBM subjects from healthy controls and viral meningitis subjects with 89.3% sensitivity and 92% specificity. CONCLUSIONS CSF lipid metabolism disregulation, especially elevated expression of ApoB, gives insights into the pathogenesis of TBM. Further evaluation of these findings in larger studies including anti-tuberculosis medicated and unmedicated patient cohorts with other center nervous system infectious diseases is required for successful clinical translation.
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Affiliation(s)
- Jun Mu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Yongtao Yang
- Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China; Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Jin Chen
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Ke Cheng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Yongdong Wei
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Dan Zhu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Weihua Shao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Peng Zheng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Neuroscience and the Collaborative Innovation Center for Brain Science, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China; Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China.
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Sharma K, Modi M, Kaur H, Sharma A, Ray P, Varma S. rpoB gene high-resolution melt curve analysis: a rapid approach for diagnosis and screening of drug resistance in tuberculous meningitis. Diagn Microbiol Infect Dis 2015; 83:144-9. [PMID: 26254140 DOI: 10.1016/j.diagmicrobio.2015.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/11/2015] [Accepted: 06/15/2015] [Indexed: 10/23/2022]
Abstract
Timely and rapid diagnosis of multidrug resistance in tuberculous meningitis (TBM) is a challenge both for a microbiologist and neurologist. The present study was conducted to evaluate role of real-time polymerase chain reaction (PCR) using rpoB, IS6110, and MPB64 as targets in diagnosis of TBM in 110 patients and subsequent high-resolution melt (HRM) curve analysis of rpoB gene amplicons for screening of drug resistance. The sensitivity of smear, culture, and real-time PCR was 1.8%, 10.9%, and 83.63%, respectively. All 120 control patients showed negative results. With HRM rpoB analysis, rifampicin resistance was detected in 3 out of 110 cases of TBM (3.33%). Subsequently, results of HRM analysis were confirmed by rpoB gene sequencing, and mutations were observed at 516 (2 patients) and 531 (1 patient) codons, respectively. rpoB HRM analysis can be a promising tool for rapid diagnosis and screening of drug resistance in TBM patients in 90minutes.
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Affiliation(s)
- Kusum Sharma
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Yang Y, Mu J, Chen G, Zhan Y, Zhong J, Wei Y, Cheng K, Qin B, You H, Xie P. iTRAQ-based quantitative proteomic analysis of cerebrospinal fluid reveals NELL2 as a potential diagnostic biomarker of tuberculous meningitis. Int J Mol Med 2015; 35:1323-32. [PMID: 25760060 DOI: 10.3892/ijmm.2015.2131] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 02/17/2015] [Indexed: 11/06/2022] Open
Abstract
Tuberculous meningitis (TBM) is a serious complication of tuberculosis that affects the central nervous system. As TBM may result in permanent sequelae and death, rapid, accurate diagnostic tests using novel biomarkers are required for the early diagnosis and treatment of TBM. A quantitative proteomic study was therefore performed to identify differential proteins in the cerebrospinal fluid (CSF) obtained from TBM patients (n=12) and healthy controls (n=12). CSF samples were labelled with iTRAQ™ and analyzed by LC-MS/MS. Gene ontology and Pathway analysis were conducted using DAVID bioinformatics resources. Neural epidermal growth factor-like like 2 (NELL2) with the largest fold-change value was selected for validation by western blotting. Proteomic phenotyping revealed over-representation in two inflammation-associated processes, complement and coagulation cascades as well as cell adhesion molecules. Western blotting showed a significant decrease in NELL2 levels in TBM subjects compared to healthy controls. The AUC analysis revealed NELL2 was able to distinguish TBM subjects from healthy controls with 83.3% sensitivity and 75% specificity. In conclusion, the results showed that CSF NELL2 is a potential diagnostic biomarker for TBM. Further evaluation of these findings in larger studies including anti-tuberculosis medicated and unmedicated patient cohorts with other intracranial infectious diseases is required for clinical translation.
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Affiliation(s)
- Yongtao Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Jun Mu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Guanghui Chen
- Institute of Neuroscience, Chongqing Medical University, Chongqing, P.R. China
| | - Yuan Zhan
- Institute of Neuroscience, Chongqing Medical University, Chongqing, P.R. China
| | - Jiaju Zhong
- Institute of Neuroscience, Chongqing Medical University, Chongqing, P.R. China
| | - Youdong Wei
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ke Cheng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Bin Qin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Hongmin You
- Institute of Neuroscience, Chongqing Medical University, Chongqing, P.R. China
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
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Kaur H, Sharma K, Modi M, Sharma A, Rana S, Khandelwal N, Prabhakar S, Varma S. Prospective Analysis of 55 Cases of Tuberculosis Meningitis (TBM) in North India. J Clin Diagn Res 2015; 9:DC15-9. [PMID: 25737987 PMCID: PMC4347078 DOI: 10.7860/jcdr/2015/11456.5454] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/01/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION To assess the clinical profile, laboratory and neuroimaging data of adult tuberculous meningitis (TBM) patients and to determine the predictors of mortality. MATERIALS AND METHODS A total of 55 TBM patients and 60 controls were enrolled in this prospective study. Detailed clinical, radiological, biochemical and microbiological evaluation was performed. STATISTICAL ANALYSIS Done using SPSS 15.0 for Windows. P value of <0.05 was considered to be significant. RESULTS 61.8% were males and majority of the study subjects belonged to age group of 21-40 years. Duration of symptoms in all cases was >14 days and commonly included fever, headache, neck rigidity, altered sensorium and vomiting. Biochemical features of cerebrospinal fluid (CSF) showed significant results where 94.5%, 85.45%,83.63% and 81.81% of patients showed CSF sugar levels <2/3 corresponding blood sugar, proteins>100mg%, CSF total leucocyte count of >20 cells/mm(3) and ADA >9.5IU/L respectively while neuroimaging revealed hydrocephalus, basal exudates and meningeal enhancement as significant findings. More than half of TBM patients presented in stage II of disease and overall mortality was 43.63%. A model for prediction of mortality in TBM cases was framed which included variables of age>40 years, past history of tuberculosis (TB), presence of basal exudates and hydrocephalus. CONCLUSION TBM is a serious extrapulmonary form of TB and should arise suspicion in mind of clinician based on clinical, laboratory and radiologic results. Further, a model for prediction of mortality in such patients may be helpful for early intervention and better prognosis.
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Affiliation(s)
- Harsimran Kaur
- Senior Resident, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Kusum Sharma
- Associate Professor, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Manish Modi
- Assistant Professor, Department of Neurology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Aman Sharma
- Assistant Professor, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Satyawati Rana
- Professor, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Niranjan Khandelwal
- Professor and Head, Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Sudesh Prabhakar
- Professor and Head, Department of Neurology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
| | - Subhash Varma
- Professor and Head, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
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Diagnostic efficacy of adenosine deaminase levels in cerebrospinal fluid in patients of tubercular meningitis: A comparison with PCR for Mycobacterium Tuberculosis. Ann Neurosci 2014; 17:126-30. [PMID: 25205888 PMCID: PMC4116978 DOI: 10.5214/ans.0972-7531.1017306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Revised: 01/13/2010] [Accepted: 02/25/2010] [Indexed: 11/17/2022] Open
Abstract
Background The rapid diagnosis of Tubercular meningitis (TBM) is fundamental to clinical outcome. The key to diagnosis lies in Cerebrospinal fluid (CSF) analysis and radiological investigations. There are numerous lacunae in the confirmation of diagnosis of TBM from CSF. Purpose The aim of present study was to compare the efficacy of CSF adenosine deaminase (ADA) level assays and Polymerase chain reaction (PCR) for Mycobacterium tuberculosis (M. tuberculosis) in the diagnosis of TBM. Methods Fifty four adult patients with suspected TBM and 37 controls were included in the study and CSF analyzed for ADA and PCR for M. tuberculosis. The cases were subdivided into definite (5), highly probable (22), probable (22) and possible TBM (5) as per previously validated criteria. The first two were grouped as "most likely" TBM (27) and last two as "unconfirmed" TBM (27). Results The mean ADA of the "most likely" TBM was 29±24, "unconfirmed" TBM was 21 ± 15 and controls were 4.8±2.2 U/L. The ADA levels correlated with CSF proteins, absolute lymphocyte count and the staging of the disease. Using a cut off level of >L10 U/L, CSF ADA had a sensitivity of 92.5% and specificity of 97%. PCR for M. tuberculosis was positive in 12 out of 27 "most likely" TBM cases, 5 out of 27 "unconfirmed" TBM cases and 3 out of 37 controls. PCR for M. tuberculosis had a sensitivity of 44.5% and specificity of 92% in the "most likely" TBM cases. Conclusions: ADA is a rapid, inexpensive and sensitive test in the diagnosis of TBM. It is more sensitive than AFB smear and culture. PCR is another rapid test in the diagnosis of TBM with a good specificity, even in those patients already on presumptive anti-tuberculous treatment. However, despite the sensitivity and specificity of CSF ADA, it should be corroborated with AFB smear and CSF PCR.
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Hou D, Qu H, Zhang X, Li N, Liu C, Ma X. Multi-slice computed tomography 5-minute delayed scan is superior to immediate scan after contrast media application in characterization of intracranial tuberculosis. Med Sci Monit 2014; 20:1556-62. [PMID: 25183433 PMCID: PMC4160133 DOI: 10.12659/msm.890719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background The aim of this study was to determine whether the diagnosis of intracranial tuberculosis (TB) can be improved when multi-slice computed tomography (MSCT) scans are taken with a 5-min delay after contrast media application. Material/Methods Pre- and post-contrast CT scans of the head were obtained from 30 patients using a 16-slice spiral CT. Dual-phase acquisition was performed immediately and 5 min after contrast agent injection. Diagnostic values of different images were compared using a scoring system applied by 2 experienced radiologists. Results We found 526 lesions in 30 patients, including 22 meningeal thickenings, 235 meningeal tuberculomas/tubercles, and 269 parenchymal tuberculomas/tubercles. Images obtained with 5-min delayed scan time were superior in terms of lesion size and meningeal thickening outlining in all disease types (P<0.01). The ability to distinguish between vascular sections from the cerebral sulcus and tubercle was also improved (P<0.01). Conclusions Image acquisition with 5-min delay after contrast agent injection should be performed as a standard scanning protocol to diagnose intracranial TB.
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Affiliation(s)
- Dailun Hou
- Division of Computed Tomography, Department of Radiology, Shandong University School of Medicine, Thoracic Hospital, Shandong, China (mainland)
| | - Huifang Qu
- Division of Computed Tomography, Department of Radiology, Shandong University School of Medicine, Thoracic Hospital, Shandong, China (mainland)
| | - Xu Zhang
- Division of Computed Tomography, Department of Radiology, Shandong University School of Medicine, Thoracic Hospital, Shandong, China (mainland)
| | - Ning Li
- Division of Computed Tomography, Department of Radiology, Shandong University School of Medicine, Shandong Chest Hospital, Jinan, China (mainland)
| | - Cheng Liu
- Division of Computed Tomography, Department of Radiology, Shandong University School of Medicine, Thoracic Hospital, Shandong, China (mainland)
| | - Xiangxing Ma
- Department of Radiology, Qilu Hospital, Shandong University, Shandong, China (mainland)
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Peng T, Zhou Y, Li J, Li J, Wan W, Jia Y. Detection of Delta-like 1 ligand for the diagnosis of tuberculous meningitis: An effective and rapid diagnostic method. J Int Med Res 2014; 42:728-36. [PMID: 24651996 DOI: 10.1177/0300060513498669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 06/16/2013] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate the diagnostic value of Delta-like 1 ligand (DLL1) in cerebrospinal fluid (CSF) and serum, in tuberculous meningitis (TBM). METHODS Patients with a definite diagnosis of central nervous system infection (TBM, viral meningitis/encephalitis or bacterial meningitis) were prospectively enrolled alongside patients with intracranial metastatic tumour and patients with no diagnosis (who served as controls). DLL1 content in CSF and serum was measured quantitatively by enzyme-linked immunosorbent assay; analyses were blinded. RESULTS A total of 173 patients were enrolled: 62 with TBM; 38 with viral meningitis/encephalitis; 26 with bacterial meningitis; 17 with intracranial metastatic tumour; 30 with no diagnosis. CSF DLL1 content was highest for TBM; there were no differences in CSF DLL1 between the other groups. Serum DLL1 content was highest for the TBM and intracranial metastatic tumour groups, with significant differences between the TBM group and the viral meningitis/encephalitis, bacterial meningitis and nondiagnosed groups. There were no differences in serum DLL1 between the viral meningitis/encephalitis, bacterial meningitis and nondiagnosed groups, or between the TBM group and the tumour group. CONCLUSION As a new biomarker, DLL1 may be of great clinical importance in the diagnosis of TBM.
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Affiliation(s)
- Tao Peng
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Zhou
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jinyi Li
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jinghong Li
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wencui Wan
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanjie Jia
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Patil SA, Kavitha AK, Madhusudan AP, Netravathi M. COMPARATIVE EVALUATION OF ELISA AND DOT-BLOT FOR THE DIAGNOSIS OF TUBERCULOUS MENINGITIS. J Immunoassay Immunochem 2013; 34:404-13. [DOI: 10.1080/15321819.2012.755630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Gwer S, Chacha C, Newton CR, Idro R. Childhood acute non-traumatic coma: aetiology and challenges in management in resource-poor countries of Africa and Asia. Paediatr Int Child Health 2013; 33:129-38. [PMID: 23930724 DOI: 10.1179/2046905513y.0000000068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This review examines the best available evidence on the aetiology of childhood acute non-traumatic coma in resource-poor countries (RPCs), discusses the challenges associated with management, and explores strategies to address them. METHODS Publications in English and French which reported on studies on the aetiology of childhood non-traumatic coma in RPCs are reviewed. Primarily, the MEDLINE database was searched using the keywords coma, unconsciousness, causality, aetiology, child, malaria cerebral, meningitis, encephalitis, Africa, Asia, and developing countries. RESULTS 14 records were identified for inclusion in the review. Cerebral malaria (CM) was the commonest cause of childhood coma in most of the studies conducted in Africa. Acute bacterial meningitis (ABM) was the second most common known cause of coma in seven of the African studies. Of the studies in Asia, encephalitides were the commonest cause of coma in two studies in India, and ABM was the commonest cause of coma in Pakistan. Streptococcus pneumoniae was the most commonly isolated organism in ABM. Japanese encephalitis, dengue fever and enteroviruses were the viral agents most commonly isolated. CONCLUSION Accurate diagnosis of the aetiology of childhood coma in RPCs is complicated by overlap in clinical presentation, limited diagnostic resources, disease endemicity and co-morbidity. For improved outcomes, studies are needed to further elucidate the aetiology of childhood coma in RPCs, explore simple and practical diagnostic tools, and investigate the most appropriate specific and supportive interventions to manage and prevent infectious encephalopathies.
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Affiliation(s)
- Samson Gwer
- Department of Medical Physiology, Kenyatta University, Kenya.
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Sharma SR, Lynrah KG, Sharma N, Lyngdoh M. Directly observed treatment, short course in tuberculous meningitis: Indian perspective. Ann Indian Acad Neurol 2013; 16:82-4. [PMID: 23661969 PMCID: PMC3644788 DOI: 10.4103/0972-2327.107717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 06/10/2012] [Accepted: 06/20/2012] [Indexed: 11/30/2022] Open
Abstract
Background: Effectiveness of intermittent short course chemotherapy for tuberculous meningitis (TBM) has not been well studied. There are scarce reported studies on this issue in the world literature. Neurologists all over India are reluctant to accept Directly Observed Treatment Short course (DOTS) for TBM since its introduction in India. Aim: We did a prospective study to assess effectiveness of Revised National TB Control Program (RNTCP-DOTS) regimes among TBM patients. Materials and Methods: In this study we include the TBM patients admitted from September 2008 to March 2011. All were referred to RNTCP for treatment. Diagnostic Algorithm as per RNTCP guidelines was strictly followed and treatment outcome and follow-up status were recorded. We exclude HIV and pediatric age group. Results: A total of 42 cases registered for DOTS regimen were included in the study, of which 35 completed the treatment (83%). All the patients were started with DOTS but finally 78% received actual DOTS. All patients were given 9 months intermitted regimen as per RNTCP guidelines. Seven patients died during the treatment (16%). Conclusion: We found intermitted short course chemotherapy was effective in TBM.
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Affiliation(s)
- Shri Ram Sharma
- Department of Neurology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India, Shillong, India)
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Zhang B, Lv K, Bao J, Lu C, Lu Z. Clinical and laboratory factors in the differential diagnosis of tuberculous and cryptococcal meningitis in adult HIV-negative patients. Intern Med 2013; 52:1573-8. [PMID: 23857088 DOI: 10.2169/internalmedicine.52.0168] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective It is difficult to make the differential diagnosis between tuberculous meningitis (TBM) and cryptococcal meningitis (CM) when the smear is negative. The objective of this study was to create a diagnostic rule for differentiating TBM from CM in adult HIV-negative patients based on clinical and laboratory features. Methods The clinical and laboratory data of 219 adult HIV-negative patients satisfying the diagnostic criteria for tuberculous (n=100) and cryptococcal (n=119) meningitis hospitalized at the Third Affiliated Hospital of Sun Yat-Sen University during the period 2000-2009 were retrospectively analyzed. Features found to be independently predictive of tuberculous meningitis were modeled using a multivariate logistic regression to create a diagnostic rule. The performance of the diagnostic rule was assessed using a prospective test data method. Results Six factors were found to be predictive of a diagnosis of tuberculous meningitis: gender, mental disorders, vision and/or hearing damage, proteins in the cerebrospinal fluid, the total cerebrospinal fluid white cell count and the coexistence of tuberculosis in peripheral organs. The diagnostic rule developed using these features exhibited 78.0% sensitivity, 95.2% specificity, 92.9% positive predictive value and 84.4% negative predictive value. The corresponding values for the diagnostic rule were 70.0% and 88.0% using prospective test data. Conclusion Clinical and laboratory features can be helpful in the differential diagnosis of tuberculous meningitis and cryptococcal meningitis in adult HIV-negative patients.
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Affiliation(s)
- Bingjun Zhang
- Department of Neurology, the Third Affiliated Hospital of Sun Yat-sen University, China
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Sastry AS, Bhat K S, Kumudavathi. The Diagnostic Utility of Bact/ALERT and Nested PCR in the Diagnosis of Tuberculous Meningitis. J Clin Diagn Res 2013; 7:74-8. [PMID: 23450650 DOI: 10.7860/jcdr/2012/5098.2674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 11/07/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The early laboratory diagnosis of Tuberculous Meningitis (TBM) is crucial, to start the antitubercular chemotherapy and to prevent its complications. However, the conventional methods are either less sensitive or time consuming. Hence, the diagnostic potentials of BacT/ALERT and Polymerase Chain Reaction (PCR) was evaluated in this study. MATERIAL AND METHOD The study group comprised of 62 cases and 33 controls. The cases were divided according to Ahuja's criteria into the confirmed (two cases), highly probable (19 cases), probable (26 cases) and the possible (15 cases) subgroups. Ziehl Neelsen's (ZN) and Auramine Phenol (AP) staining, Lowenstein Jensen (LJ) medium culture, BacT/ALERT and nested Polymerase Chain Reaction (PCR) which targeted IS6110 were carried out on all the patients. OBSERVATION AND RESULTS The sensitivity of the LJ culture was 3.22%. BacT/ALERT showed a sensitivity and a specificity of 25.80% and 100% and those of nested PCR were found to be 40.32% and 96.97% respectively. The mean detection time of growth of the LJ culture was 31.28 days, whereas that of BacT/ALERT was 20.68 days. The contamination rate in the LJ culture and BacT/ALERT were 7.2% and 5.8% respectively. CONCLUSION Nested PCR was found to be more sensitive, followed by BacT/ALERT as compared to the LJ culture and smear microscopy. As both false negative and false positive results have been reported for nested PCR, so it should not be used alone as a criterion for initiating or terminating the therapy, but it should be supported by clinical, radiological, cytological and other microbiological findings.
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Chaidir L, Ganiem AR, Vander Zanden A, Muhsinin S, Kusumaningrum T, Kusumadewi I, van der Ven A, Alisjahbana B, Parwati I, van Crevel R. Comparison of real time IS6110-PCR, microscopy, and culture for diagnosis of tuberculous meningitis in a cohort of adult patients in Indonesia. PLoS One 2012; 7:e52001. [PMID: 23284850 PMCID: PMC3528723 DOI: 10.1371/journal.pone.0052001] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Accepted: 11/09/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bacteriological confirmation of tuberculous (TB) meningitis is difficult. Culture is slow and microscopy has insufficient sensitivity. We evaluated real time PCR targeting insertion sequence IS6110 among 230 consecutive adult patients with subacute meningitis in a referral hospital in Indonesia. METHODS Cerebrospinal fluid (CSF) samples were examined using microscopy, solid and liquid culture, and real time IS6110-PCR with a fluorescence-labeled probe using DNA extracted from CSF. CSF samples from 40 non-infectious neurology patients were used as negative controls. IS6110-PCR results were linked with clinical and CSF characteristics. RESULTS Most patients presented with subacute meningitis, after a median of 14 days of symptoms (range 7-30). After exclusion of cryptococcal and bacterial meningitis, 207 patients were classified as definite or probable TB meningitis; 17.9% with HIV infection. Among this group IS6110-PCR gave the highest positivity rate (68%, 95% CI 62-74%) compared with microscopy of ZN-stained slides (11%, 95% CI 7-15%), and mycobacterial culture using solid (36%, 95% CI 29-42%) and liquid (44%, 95% CI 37-51%) media. IS6110-PCR was positive in 92% of patients with culture-positive and 42% of patients with culture-negative probable TB meningitis. Among culture-negative patients, a positive PCR was associated with a history of TB treatment, a longer duration of illness, a higher CSF cell count and protein, and a lower CSF glucose. IS6110-PCR was negative in all CSF samples from non-meningitis control patients. CONCLUSIONS Real time IS6110-PCR is a quick, sensitive, and specific test for diagnosing of TB meningitis in this setting. Its performance in other (less-developed) settings needs further study.
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Affiliation(s)
- Lidya Chaidir
- Health Research Unit, Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung, Indonesia.
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Vibha D, Bhatia R, Prasad K, Srivastava MVP, Tripathi M, Kumar G, Singh MB. Validation of diagnostic algorithm to differentiate between tuberculous meningitis and acute bacterial meningitis. Clin Neurol Neurosurg 2012; 114:639-44. [PMID: 22244850 DOI: 10.1016/j.clineuro.2011.12.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 11/10/2011] [Accepted: 12/21/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Discrimination between tuberculous and acute bacterial meningitis is difficult by clinical features alone and laboratory methods may only supplement the clinical suspicion. We aimed to validate the diagnostic criteria by Thwaites et al. [1] and construct our own diagnostic predictors based on the clinical and laboratory features. METHODS 380 patients of acute bacterial meningitis (ABM) and 210 patients of tuberculous meningitis (TBM) were enrolled retrospectively from June 2004 to June 2007 and prospectively from July 2007 to September 2008. HIV positive patients were excluded. Detailed history, clinical examination CSF analysis, haematological, biochemical investigations and imaging was performed in all patients. RESULTS Factors associated with the diagnosis of TBM in the present study included rural area of residence, longer duration of disease, presence of clear CSF, lower percentage of CSF neutrophils, presence of diplopia and hemiparesis. On validation, age did not appear as a significant factor in our population. The diagnostic algorithm from our study group had a sensitivity of 95.71% and specificity of 97.63%. CONCLUSIONS The diagnostic criterion has a fair validation in our population when the age factor is excluded. The rule is useful in HIV negative patients with low CSF sugar and negative organism yield in the CSF.
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Affiliation(s)
- Deepti Vibha
- Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
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Chatterjee S. Brain tuberculomas, tubercular meningitis, and post-tubercular hydrocephalus in children. J Pediatr Neurosci 2011; 6:S96-S100. [PMID: 22069437 PMCID: PMC3208909 DOI: 10.4103/1817-1745.85725] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Central nervous system tuberculosis in children presents commonly as tubercular meningitis, post-tubercular meningitis hydrocephalus, and much more rarely as space-occupying lesions known as tuberculomas. The occurrence of this condition, though previously reported only in the developing world, is now frequently reported in human immunodeficiency virus positive migrants in the western world. The exact pathogenesis of this condition is still incompletely understood, and the mainstay of treatment is chemotherapeutic regimes. Neurosurgical intervention is rarely necessary, and is confined to cases of hydrocephalus after tubercular meningitis and to large tubeculomas with space-occupying effects.
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Affiliation(s)
- Sandip Chatterjee
- Department of Neurosurgery, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
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Kataria J, Rukmangadachar LA, Hariprasad G, O J, Tripathi M, Srinivasan A. Two dimensional difference gel electrophoresis analysis of cerebrospinal fluid in tuberculous meningitis patients. J Proteomics 2011; 74:2194-203. [DOI: 10.1016/j.jprot.2011.06.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 06/01/2011] [Accepted: 06/18/2011] [Indexed: 12/14/2022]
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Sensitivity and specificity of immunocytochemical staining of mycobacterial antigens in the cytoplasm of cerebrospinal fluid macrophages for diagnosing tuberculous meningitis. J Clin Microbiol 2011; 49:3388-91. [PMID: 21795512 DOI: 10.1128/jcm.01323-11] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The sensitivity and specificity of immunocytochemical staining of mycobacterial antigens in the cytoplasm of cerebrospinal fluid (CSF) macrophages for diagnosis of tuberculous meningitis (TBM) was prospectively compared with Ahuja criteria from 393 consecutive CSF specimens. The assay can play an important role for the diagnosis of TBM, with sensitivity of 73.5% and specificity of 90.7%.
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Kusum S, Aman S, Pallab R, Kumar SS, Manish M, Sudesh P, Subhash V, Meera S. Multiplex PCR for rapid diagnosis of tuberculous meningitis. J Neurol 2011; 258:1781-7. [PMID: 21455603 DOI: 10.1007/s00415-011-6010-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 03/09/2011] [Accepted: 03/11/2011] [Indexed: 11/29/2022]
Abstract
Rapid and specific diagnosis of tubercular meningitis is of paramount importance to decrease morbidity and mortality. The aim of the study was to evaluate multiplex PCR using protein b, MPB 64, and IS6110 primers directed against M. tuberculosis complex for the diagnosis of tuberculous meningitis (TBM). Multiplex PCR was performed on 18 TBM confirmed cases (culture was positive), 92 clinically suspected TBM cases and 100 non-TBM (control group) patients. Multiplex PCR had a sensitivity of 94.4% for confirmed cases and specificity of 100% for confirmed TBM cases. In 92 clinically diagnosed but unconfirmed TBM cases, multiplex PCR was positive in 84.78% cases. The overall sensitivity of microscopy, culture and multiplex cases were 1.81, 16.73, and 86.63% and specificity was 100, 100, and 100% respectively. Multiplex PCR using protein b, MPB 64, and IS6110 primers has a high sensitivity and specificity in diagnosis of tubercular meningitis.
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Affiliation(s)
- Sharma Kusum
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Rodrigues MG, Lin J, Masruha MR, Vilanova LCP, Minett TSC. Prognostic factors predicting a fatal outcome in HIV-negative children with neurotuberculosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2011; 68:755-60. [PMID: 21049188 DOI: 10.1590/s0004-282x2010000500015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 03/26/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify prognostic factors predicting a fatal outcome in HIV-negative children with neurotuberculosis based on clinical, epidemiological, and laboratory findings. METHOD The clinical records of all in-patients diagnosed with neurotuberculosis from 1982 to 2005 were evaluated retrospectively. The following prognostic parameters were examined: gender, age, close contact with a tuberculosis-infected individual, vaccination for bacillus Calmette-Guérin, purified protein derivative (PPD) of tuberculin results, concomitant miliary tuberculosis, seizures, CSF results, and hydrocephalus. RESULTS One hundred forty-one patients diagnosed with neurotuberculosis were included. Seventeen percent of the cases resulted in death. The factors that were correlated with a negative outcome included lack of contact with a tuberculosis-infected individual, negative PPD reaction, coma, and longer hospitalisation time. A multiple logistic regression analysis was performed to identify which of these factors most often resulted in death. CONCLUSION Coma at diagnosis, lack of tuberculosis contact, and a non-reactive PPD were the most important predictors of fatality in patients with neurotuberculosis.
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Affiliation(s)
- Murilo Gimenes Rodrigues
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil.
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Dhanwal DK, Vyas A, Sharma A, Saxena A. Hypothalamic pituitary abnormalities in tubercular meningitis at the time of diagnosis. Pituitary 2010; 13:304-10. [PMID: 20495961 DOI: 10.1007/s11102-010-0234-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Tubercular meningitis (TBM) is the most dreaded form of extra pulmonary tuberculosis associated with high morbidity and mortality. Various hypothalamic pituitary hormonal abnormalities have been reported to occur years after recovery from disease but there are no systematic studies in the literature to evaluate the pituitary hypothalamic dysfunction in patients with TBM at the time of presentation. Therefore, the present study was designed to evaluate hypothalamic pituitary abnormalities in newly diagnosed patients with TBM. Patient case series. This prospective study included 75 untreated adult patients with TBM diagnosed as "definite", "highly probable" and "probable" TBM by Ahuja's criteria and in clinical stage 1, 2 or 3 at the time of presentation to hospital. Basal hormonal profile was measured by electrochemilumniscence technique for serum cortisol, luetinizing hormone (LH), follicular stimulating hormone (FSH), prolactin (PRL), thyrotropin (TSH), free tri-iodothyronine (fT3), and free thyroxine (fT4). All patients were subjected to MRI to image brain and hypothalamic pituitary axis and CT for adrenal glands. Thirty-two (42.7%) cases showed relative or absolute cortisol insufficiency. Twenty-three (30.7%) cases showed central hypothyroidism and 37 (49.3%) cases had hyperprolactinemia. No patient had evidence of diabetes insipidus. Multiple hormone deficiency was seen in 22 (29.3%) cases. MRI of hypothalamic pituitary axis using dynamic scanning and thin cuts revealed abnormalities in 10 (13.3%) of the cases. CT adrenal gland was normal in all the patients. Tubercular meningitis is associated with both hormonal and structural abnormalities in the hypothalamic pituitary axis at the time of diagnosis.
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Affiliation(s)
- Dinesh Kumar Dhanwal
- Department of Medicine, Maulana Azad Medical College and Associated Hospitals, New Delhi 110002, India
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Panicker JN, Nagaraja D, Subbakrishna DK, Venkataswamy MM, Chandramuki A. Role of the BACTEC radiometric method in the evaluation of patients with clinically probable tuberculous meningitis. Ann Indian Acad Neurol 2010; 13:128-31. [PMID: 20814497 PMCID: PMC2924511 DOI: 10.4103/0972-2327.64637] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 08/02/2009] [Accepted: 11/14/2009] [Indexed: 12/03/2022] Open
Abstract
Background: Confirmation of tuberculous meningitis (TBM) and initiation of treatment are often delayed due to limitations in isolating Mycobacterium tuberculosis from cerebrospinal fluid (CSF). Objectives: To evaluate the role of the BACTEC radiometric method in a clinical setting for the early diagnosis of TBM. Materials and Methods: Patients meeting criteria for clinically probable TBM over a 3 year period were included. Clinical features, results of CSF investigations (protein, glucose, cell count, Ziehl-Neelsen staining, culture in Löwenstein-Jensen (LJ) medium and BACTEC) and brain CT imaging were reviewed. Drug sensitivity was tested using BACTEC. Patients were started on standard treatment and functional outcome, and response at discharge and follow-up were assessed. Patients were divided according to whether or not M. tuberculosis was isolated by BACTEC and the clinical, radiological, and laboratory features compared. Results: Sixty patients were evaluated. The mean age was 30 years ± 11.7 years. Headache and fever were the most common symptoms and the mean duration was 26 days. CT findings were hydrocephalus (n=21), basal exudates (n=16), and tuberculoma (n=14). In 40 patients, M. tuberculosis was isolated by BACTEC and average 15 days was required for detection, whereas it was 30 days in LJ medium. Results of drug-sensitivity testing (n=32) were obtained average 7 days after isolation. Patients from whom M. tuberculosis had been isolated by BACTEC more often had tuberculomas in CT imaging (P=0.018). Conclusion: Use of the BACTEC method allows early confirmation in patients with clinically probable TBM. It can guide clinicians in the rational use of anti-tuberculosis treatment by confirming diagnosis and identifying drug- sensitivity.
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Affiliation(s)
- Jalesh N Panicker
- Departments of Neurology, Biostatistics and Neuromicrobiology, National Institute of Mental Health and Neurosciences, Bangalore - 560 029, India.
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Hsu PC, Yang CC, Ye JJ, Huang PY, Chiang PC, Lee MH. Prognostic factors of tuberculous meningitis in adults: a 6-year retrospective study at a tertiary hospital in northern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2010; 43:111-8. [PMID: 20457427 DOI: 10.1016/s1684-1182(10)60018-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 04/25/2009] [Accepted: 06/11/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE To investigate the clinical features, laboratory test results, imaging data, and prognostic predictors of tuberculous meningitis (TBM) in adults. METHODS We retrospectively reviewed 108 adult patients with a diagnosis of TBM over a 6-year period. Patients were divided into "definite" and "probable" groups, depending on the diagnosis made by (1) positive culture, or polymerase chain reaction, of Mycobacterium tuberculosis (TB) from the cerebrospinal fluid (CSF); or (2) the isolation of TB elsewhere, or chest radiography consistent with active pulmonary TB, or imaging studies of the brain consistent with TBM, or clinical improvement on treatment. These two groups were compared for their clinical features, images, laboratory test results, and 9-month mortality rates to identify prognostic predictors. RESULTS Compared with the "probable" group (n = 62), the "definite" group (n = 46) had a higher mortality rate (50.0%vs. 30.6%, p = 0.041) and more consciousness disturbance (78.3%vs. 51.6%, p = 0.005), hydrocephalus (63.4%vs. 40.7%, p= 0.029) and isolation of TB from extra-CSF specimens (41.3%vs. 22.6%, p = 0.037). Old age (p = 0.002), consciousness change (p = 0.032), and hydrocephalus (p = 0.047) were poor prognostic indicators in the "definite" group as assessed by univariate analysis. Severity of TBM at admission and delayed anti-TB therapy resulted in a poor prognosis for all patients. Multiple logistic regression analysis showed that old age and hydrocephalus were independent factors for mortality. Adjunctive steroid therapy over 2 weeks improved survival in both the "definite" (p = 0.002) and "probable" (p = 0.035) groups, but more than 4 weeks of use had no significant effect on mortality. Steroid treatment, therefore, may improve the outcome of patients with TBM. CONCLUSION Old age, advanced stage of TBM at admission, hydrocephalus, and positive TB culture or polymerase chain reaction of CSF are factors associated with a poor prognosis for TBM. Early diagnosis and treatment, including short term steroid use, are mandatory for clinical care of adult patients with TBM.
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Affiliation(s)
- Po-Chang Hsu
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Rana SV, Chacko F, Lal V, Arora SK, Parbhakar S, Sharma SK, Singh K. To compare CSF adenosine deaminase levels and CSF-PCR for tuberculous meningitis. Clin Neurol Neurosurg 2010; 112:424-30. [PMID: 20347212 DOI: 10.1016/j.clineuro.2010.02.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 02/13/2010] [Accepted: 02/20/2010] [Indexed: 10/19/2022]
Abstract
This study was planned to compare the adenosine deaminase (ADA) levels and polymerase chain reaction (PCR) in cerebrospinal fluid (CSF) as a rapid method to diagnose tuberculosis meningitis (TBM). Fifty-four adult patients with suspected TBM and 37 controls were included in this study. The median ADA level was 21U/L of most likely TBM, 14U/L of unconfirmed TBM and 5U/L of controls. PCR for Mycobacterium tuberculosis was positive in 12 out of 27 most likely TBM cases, 5 out of 27 unconfirmed TBM cases and 3 out of 37 controls. Using a cut off level of >10U/L, CSF-ADA had a sensitivity of 92.5% and specificity of 97% for the diagnosis of TBM. PCR for M. tuberculosis had a sensitivity of 44.5% and specificity 92% in the most likely TBM cases. This study shows that CSF-ADA is a more sensitive indicator than PCR for the diagnosis of M. tuberculosis.
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Affiliation(s)
- S V Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education And Research, Chandigarh, India.
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Srikantha U, Morab JV, Sastry S, Abraham R, Balasubramaniam A, Somanna S, Devi I, Bangalore CA, Pandey P. Outcome of ventriculoperitoneal shunt placement in Grade IV tubercular meningitis with hydrocephalus: a retrospective analysis in 95 patients. Clinical article. J Neurosurg Pediatr 2009; 4:176-83. [PMID: 19645554 DOI: 10.3171/2009.3.peds08308] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hydrocephalus is the most common complication of tubercular meningitis (TBM). Relieving hydrocephalus by ventriculoperitoneal (VP) shunt placement has been considered beneficial in patients in Palur Grade II or III. The role of VP shunt placement in those of Grade IV is controversial and the general tendency is to avoid its use. Some authors have suggested that patients in Grade IV should receive a shunt only if their condition improves with a trial placement of an external ventricular drain (EVD). In the present study, the authors assessed the outcome of VP shunt placement in patients in Grade IV TBM with hydrocephalus to examine the factors predicting outcome and to determine whether a trial with an EVD is absolutely necessary prior to shunt placement. METHODS Ninety-five consecutive cases of TBM with hydrocephalus in which the patients underwent VP shunt placement were retrospectively analyzed, and direct VP shunts were placed whenever possible. An EVD was placed first only in the presence of deranged blood parameters. Outcomes were assessed both in the short and long term. RESULTS The mean patient age was 17.5 years (range 1-55 years). Fifty-two patients underwent direct VP shunt placement, and the remaining 43 received EVDs first. Overall, 33 and 45% of patients had favorable short- and long-term outcomes, respectively. Age older than 3 years and duration of altered sensorium < or = 3 days were predictive of a favorable short-term outcome. Glasgow Coma Scale score at presentation was predictive of long-term outcome. Of the patients who did not improve with placement of an EVD prior to VP shunt insertion, 24 and 18% had favorable short- and long-term outcomes, respectively; this was not significantly different from the outcome in the patients who underwent direct VP shunt placement. CONCLUSIONS Direct VP shunt placement is an effective option in patients with Grade IV TBM with hydrocephalus. Age and duration of altered sensorium are predictive of short-term outcome, while Glasgow Coma Scale score at presentation predicts long-term outcome. Ventriculoperitoneal shunts should be considered even in patients who do not improve with an EVD.
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Affiliation(s)
- Umesh Srikantha
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
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Haldar S, Sharma N, Gupta VK, Tyagi JS. Efficient diagnosis of tuberculous meningitis by detection of Mycobacterium tuberculosis DNA in cerebrospinal fluid filtrates using PCR. J Med Microbiol 2009; 58:616-624. [PMID: 19369523 DOI: 10.1099/jmm.0.006015-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Tuberculous meningitis (TBM) is the most devastating form of meningitis and prompt diagnosis holds the key to its management. Conventional microbiology has limited utility and nucleic acid-based methods have not been widely accepted for various reasons. In view of the paucibacillary nature of cerebrospinal fluid (CSF) and the recent demonstration of free Mycobacterium tuberculosis DNA in clinical specimens, the present study was designed to evaluate the utility of CSF 'filtrates' for the diagnosis of TBM using PCR. One hundred and sixty-seven CSF samples were analysed from patients with 'suspected' TBM (n=81) and a control group including other cases of meningitis or neurological disorders (n=86). CSF 'sediments' and 'filtrates' were analysed individually for M. tuberculosis DNA by quantitative real-time PCR (qRT-PCR) and conventional PCR. Receiver-operating characteristic curves were generated from qRT-PCR data and cut-off values of 84 and 30 were selected for calling a 'filtrate' or 'sediment' sample positive, respectively. Based on these, TBM was diagnosed with 87.6% and 53.1% sensitivity (P<0.001) in 'filtrates' and 'sediments', respectively, and with 92% specificity each. Conventional devR and IS6110 PCR were also significantly more sensitive in 'filtrates' versus 'sediments' (sensitivity of 87.6% and 85.2% vs 31% and 39.5%, respectively; P<0.001). The qRT-PCR test yielded a positive likelihood ratio of 11 and 6.6 by analysing 'filtrate' and 'sediment' fractions, respectively, which establishes the superiority of the 'filtrate'-based assay over the 'sediment' assay. PCR findings were separately verified in 10 confirmed cases of TBM, where M. tuberculosis DNA was detected using devR PCR assays in 'sediment' and 'filtrate' fractions of all samples. From this study, we conclude that (i) CSF 'filtrates' contain a substantial amount of M. tuberculosis DNA and (ii) 'filtrates' and not 'sediments' are likely to reliably provide a PCR-based diagnosis in 'suspected' TBM patients.
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Affiliation(s)
- Sagarika Haldar
- Department of Biotechnology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Neera Sharma
- Department of Biochemistry and Department of Pediatrics, Dr Ram Manohar Lohia Hospital, New Delhi 110001, India
| | - V K Gupta
- Department of Biochemistry and Department of Pediatrics, Dr Ram Manohar Lohia Hospital, New Delhi 110001, India
| | - Jaya Sivaswami Tyagi
- Department of Biotechnology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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Evaluation of cerebral infarction in tuberculous meningitis by diffusion weighted imaging. J Infect 2008; 57:298-306. [PMID: 18760486 DOI: 10.1016/j.jinf.2008.07.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Revised: 07/15/2008] [Accepted: 07/16/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ischemic complications are known to occur in tuberculous meningitis (TBM). They are usually seen in patients with TBM having a more severe disease. Diffusion weighted imaging (DWI) provides information regarding tissue ischemia at an early stage as compared to conventional magnetic resonance imaging (MRI). METHODS Ischemic complications in human immunodeficiency virus (HIV) negative TBM were evaluated using DWI and T2 weighted imaging in 30 patients in the present study. The imaging was performed at baseline within 7 days of admission and in case of any neurological deterioration during follow up. The outcome was assessed by the modified Barthel's index at 1 year follow up. A score of >/=12 was taken as a poor outcome, while a score of <12 was considered as good outcome. RESULT Seventeen of these 30 patients had infarcts, and the total number of infarcts seen was 42. Thirty eight lesions were acute/sub acute and four were chronic infarcts. Out of the 38 acute/sub acute infarcts 34 were visible both on T2 weighted imaging and on DWI, while four were seen only on DWI. The volume of infarcts as seen by DWI was significantly larger as compared to conventional T2 weighted imaging (p = 0.019). Six patients had a poor outcome, five from the infarct group and one from the non-infarct group. CONCLUSION DWI demonstrates a larger area of infarction and may also be useful in the early detection of infarction. It should be used as an additional sequence along with conventional imaging in patients with TBM while they are on a follow up on anti tuberculous treatment. The information obtained by DWI may be of value in explaining the clinical condition of the patient as well as in the management and prognostication.
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