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Lin Y, Zhang W, Xiong Y, Wang Y, Yu Q, Ma Y, Xie Y. Comparative performance of microbiological methods for the detection of tuberculous meningitis pathogens in cerebrospinal fluid. Diagn Microbiol Infect Dis 2023; 107:116025. [PMID: 37480620 DOI: 10.1016/j.diagmicrobio.2023.116025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/11/2023] [Accepted: 07/09/2023] [Indexed: 07/24/2023]
Abstract
The aim of this study was to comprehensively evaluate metagenomic next-generation sequencing (mNGS), Acid-fast bacillus stain (AFB), MGIT960 culture, polymerase-chain-reaction (PCR), and Xpert MTB/RIF in the diagnosis of tuberculous meningitis (TBM). A cohort of 280 patients who presented with suspected TBM (ie, headache or altered mental status with clinical signs of meningism) were analyzed. The sensitivities of the 5 assays for the diagnosis of TBM ranged from 10.0% to 70.0%. The AFB had the lowest sensitivity of 10.0% (0.5-45.9), while mNGS and PCR had the highest sensitivity, both at 70.0% (35.4-91.9). mNGS demonstrated a distinct advantage in identifying a wider array of pathogens, including viruses, in CSF samples. PCR was a cost-effective option with excellent sensitivity and specificity. However, no single method was statistically significantly better than any other in the diagnosis of TBM. New diagnostic techniques are urgently needed for the independent, rapid and accurate detection of Mycobacterium tuberculosis to guide the diagnosis of TBM.
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Affiliation(s)
- Yuling Lin
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Weili Zhang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Xiong
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yue Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qiuju Yu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Ma
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yi Xie
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China.
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Muacevic A, Adler JR, LNU P, Sharma K, Sharma A, Sharma N, Modi M. Comparison of Protein B Polymerase Chain Reaction (PCR) With IS6110 PCR for Diagnosis of Tuberculous Meningitis Patients. Cureus 2023; 15:e33783. [PMID: 36798623 PMCID: PMC9926138 DOI: 10.7759/cureus.33783] [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: 01/15/2023] [Indexed: 01/16/2023] Open
Abstract
Purpose Tuberculous meningitis (TBM) is a diagnostic challenge. With the conventional staining and culture techniques being too insensitive and time-consuming, and the commercial detection systems being costly, polymerase chain reaction (PCR) seems lucrative for routine laboratories. The purpose of this study was to evaluate the diagnostic potential of protein b antigen polymerase chain reaction (Pab PCR) for TBM, in comparison to IS6110. Another purpose was to compute a cut-off at which adenosine deaminase (ADA) could diagnose TBM. Material and methods This is a prospective case-control study to measure the diagnostic accuracy of PCR, BACTEC culture, Lowenstein-Jensen (LJ) culture, ADA, and acid-fast bacilli (AFB) smear tests in TBM. CSF from 50 TBM patients (10 confirmed, 40 clinically suspected) and 40 controls was subjected to Pab PCR and IS6110 PCR, and performance was compared against culture and composite reference standards. Results The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Pab PCR in diagnosing TBM were 82%, 100%, 100%, and 81.63%, respectively, and that of IS6110 PCR were 74%, 100%, 100%, and 75.47%, respectively. Both PCRs outperformed culture (p<0.001). Though performance of both PCRs was comparable (p=0.335) with excellent agreement (k=0.86), Pab PCR detected four additional cases, one culture-positive and three culture-negative clinically suspected. ADA of 6.5 IU/L was able to differentiate between TBM and non-TBM with 86% sensitivity and 63% specificity. Conclusions Molecular tools such as PCR have the potential to increase the clinician's ability to diagnose tuberculous meningitis. Pab PCR is a rapid and reliable method for diagnosing TBM in routine microbiology laboratories.
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Siahaan AMP, Tandean S, Indharty RS, Nainggolan BWM, Susanto M. Paroxysmal sympathetic hyperactivity syndrome in tuberculous meningitis with paradoxical reaction. Int J Surg Case Rep 2022; 99:107619. [PMID: 36096085 PMCID: PMC9568713 DOI: 10.1016/j.ijscr.2022.107619] [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] [Received: 08/13/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction and importance Paroxysmal sympathetic hyperactivity syndrome is frequently reported in traumatic brain injury. However, it may occur in non-traumatic brain injury, such as tuberculous meningitis with hydrocephalus. Case presentation We reported a 38-year-old male who presented with acute decrease of consciousness and hemiparesis that was developed during antitubercular drugs therapy. CT Scan showed hydrocephalus and granuloma lesion. Emergency ventriculoperitoneal shunting were performed. During treatment, the patient developed paroxysmal sympathetic syndrome during treatment that was controlled based on symptom elimination and prevention. Clinical discussion Brain tuberculosis remains a difficult problem for clinicians. Even when antitubercular drugs are administered according to protocol, paradoxical reactions can occur. If hydrocephalus develops, ventriculoperitoneal shunting is one of the options for lowering intracranial pressure. Paroxysmal sympathetic hyperactivity may occur in brain tuberculosis and should be detected as soon as possible to avoid serious morbidity. Conclusion Paroxysmal sympathetic hyperactivity may be developed in brain tuberculosis. Early identification and treatment are mandatory. Paroxysmal sympathetic hyperactivity (PSH) syndrome may be observed in non-traumatic brain injury Treatment of PSH was based on symptoms elimination and symptoms prevention. Paradoxical reaction in tuberculosis, characterized by the appearance of new clinical symptoms during antitubercular drug therapy Ventriculoperitoneal shunting to reduce intracranial pressure in hydrocephalus following meningitis tuberculosis
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Abd El-Wahab EW, Farrag T, Metwally M. A clinical rule for the prediction of meningitis in HIV patients in the era of combination antiretroviral therapy. Trans R Soc Trop Med Hyg 2021; 114:264-275. [PMID: 31768553 DOI: 10.1093/trstmh/trz107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/14/2019] [Accepted: 09/30/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The diagnosis of meningitis in HIV patients is challenging due to altered immune responses. Diagnostic scoring systems were recently proposed for use in research settings to help prompt and easy differential diagnosis. The objective of this study was to create a clinical prediction rule (CPR) for meningitis in HIV-infected patients and to address the enigma of differentiating bacterial (BM), TB (TBM) and cryptococcal (CCM) meningitis based on clinical features alone, which may be enhanced by easy-to-obtain laboratory testing. METHODS We retrospectively enrolled 352 HIV patients presenting with neurological manifestations suggesting meningitis over the last 18 y (2000-2018). Relevant clinical and laboratory information were retrieved from inpatient records. The features independently predicting meningitis or its different types in microbiologically proven meningitis cases were modelled by multivariate logistic regression to create a CPR in an exploratory data set. The performance of the meningitis diagnostic score was assessed and validated in a subset of retrospective data. RESULTS AIDS clinical stage, injecting drug use, jaundice and cryptococcal antigen seropositivity were equally important as classic meningitic symptoms in predicting meningitis. Arthralgia and elevated cerebrospinal fluid Lactate dehydrogenase (LDH) were strong predictors of BM. Patients with cryptococcal antigenemia had 25 times the probability of having CCM, whereas neurological deficits were highly suggestive of TBM. CONCLUSION The proposed CPRs have good diagnostic potential and would support decision-making in resource-poor settings.
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Affiliation(s)
- Ekram W Abd El-Wahab
- Department of Tropical Health, High Institute of Public Health, Alexandria University, 165 El Horreya Road, 21561 Alexandria, Egypt
| | - Talaat Farrag
- Department of Endemic and Infectious Diseases, Alexandria Fever Hospital, 21568 Alexandria, Egypt.,Fellow of the Tropical Health Department, High Institute of Public Health, Alexandria University, 165 El Horreya Road, 21561 Alexandria, Egypt
| | - Mohammed Metwally
- Department of Endemic and Infectious Diseases, Alexandria Fever Hospital, 21568 Alexandria, Egypt
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Purmohamad A, Azimi T, Nasiri MJ, Goudarzi M, Zangiabadian M, Sedighian H, Fooladi AAI. HIV-Tuberculous Meningitis Co-Infection: A Systematic Review and Meta-Analysis. Curr Pharm Biotechnol 2021; 22:960-968. [PMID: 32744963 DOI: 10.2174/1389201021666200730143906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/10/2020] [Accepted: 06/22/2020] [Indexed: 11/22/2022]
Abstract
Human Immunodeficiency Virus (HIV)-infected persons are at a higher risk of developing Tuberculous Meningitis (TBM). We aimed to estimate the prevalence of TBM-HIV co-infection. We systematically searched Pubmed/Medline, Embase and Cochrane library databases from January 1, 2000, to January 31, 2017, to find relevant studies. We employed the random-effects meta-analysis model to estimate the pooled prevalence of TBM-HIV co-infection. Twenty-six eligible studies showed the prevalence of HIV in TBM patients. In the pooled analyses, the prevalence of HIV was 30% (95% CI: 12-47) in patients with confirmed TBM, and 12.1% (95% CI: 7.3-19.2) in patients with suspected TBM. This study shows a high prevalence of TBM-HIV co-infection. Establishing proper diagnostic criteria and preventive measures for TBM infections could assist in the prevention and management of TBM infection, particularly TBM-HIV co-infection.
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Affiliation(s)
- Ali Purmohamad
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Taher Azimi
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad J Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Moein Zangiabadian
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Sedighian
- Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas A I Fooladi
- Applied Microbiology Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
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6
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Review of the neurological aspects of HIV infection. J Neurol Sci 2021; 425:117453. [PMID: 33895464 DOI: 10.1016/j.jns.2021.117453] [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: 08/12/2020] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/20/2022]
Abstract
There are almost 40 million people in the world who live with the human immunodeficiency virus (HIV). The neurological manifestations associated with HIV contribute to significant morbidity and mortality despite the advances made with anti-retroviral therapy (ART). This review presents an approach to classification of neurological disorders in HIV, differentiating diseases due to the virus itself and those due to opportunistic infection. The effects of antiretroviral therapy are also discussed. The emphasis is on the developing world where advanced complications of HIV itself and infections such as tuberculosis (TB), toxoplasmosis and cryptococcal meningitis remain prevalent.
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Ahlawat S, Chaudhary R, Dangi M, Bala K, Singh M, Chhillar AK. Advances in tuberculous meningitis diagnosis. Expert Rev Mol Diagn 2020; 20:1229-1241. [PMID: 33259249 DOI: 10.1080/14737159.2020.1858805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Tuberculous meningitis (TBM) is the most devastating form of central nervous system tuberculosis (TB) and causes high mortality worldwide. Nonspecific clinical manifestations and limited sensitivity of existing laboratory methods make the diagnosis elusive due to the paucibacillary nature of the infection. Areas Covered: We reviewed current literature on the adequacy and limitations of globally existing laboratory methods for diagnosing TBM. Expert opinion: TBM is deadliest among all TB forms, as the outcome may lead to death in 50% of cases, and survivors undergo irreversible neurological disorders. Therefore, early diagnosis and prompt treatment are cornerstones of effective disease management. Conventional microscopy and culture are widely used modalities but remain inadequate in most TBM cases. Although expanded use of rapid molecular tests such as real-time PCR and Xpert Ultra, even in resource-limited settings, hold promising results for TB diagnosis but need optimization for early detection of TBM. Moreover, CSF IGRA is also used but unable to differentiate between active and latent TB. Overall no single test for diagnosing TBM has adequate accuracy so, there is an urgent need to devise a point-of-care test.
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Affiliation(s)
- Sonia Ahlawat
- Centre for Biotechnology, Maharshi Dayanand University (MDU) , Rohtak, India.,Amity Institute of Biotechnology, Amity University Haryana , Manesar, India
| | - Renu Chaudhary
- Council of Scientific & Industrial Research (CSIR)-institute of Genomics and Integrative Biology (IGIB) , New Delhi, India
| | - Mehak Dangi
- Department of Bioinformatics, Maharshi Dayanand University (MDU) , Rohtak, India
| | - Kiran Bala
- Department of Neurology, University of Health Sciences (UHS) , Rohtak, India
| | - Machiavelli Singh
- Amity Institute of Biotechnology, Amity University Haryana , Manesar, India
| | - Anil Kumar Chhillar
- Centre for Biotechnology, Maharshi Dayanand University (MDU) , Rohtak, India
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8
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Abd El-Wahab EW, Hegazy Y, Farrag T, Metwally M. Spatio-temporal Distribution of Meningitis in HIV Patients in Northern Egypt (2000-2018). Curr HIV Res 2020; 18:405-414. [PMID: 32778028 DOI: 10.2174/1570162x18666200810132605] [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: 03/12/2020] [Revised: 06/08/2020] [Accepted: 07/09/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Meningitis is a leading cause of death among patients living with HIV. There is no adequate tracking of the disease occurrence, distribution and etiologic agents among this risk group in Egypt, although the pattern could differ from that of the general population. OBJECTIVES We aimed to describe the spatio-temporal distribution of meningitis in HIV patients in a region of Northern Egypt over 18 years (2000-2018). METHODS We conducted a retrospective study of 352 adult HIV patients admitted to a tertiary care fever hospital with neurological manifestations suggesting meningitis. We retrieved from inpatient records all data relevant to patient demographics, clinical presentation, diagnostic work-up, results of laboratory investigations (CSF, blood, imaging), definitive diagnosis, and in-hospital mortality. RESULTS The overall trend of over 2 decades showed fluctuating incidence of meningitis in HIV infected patients and increasing spread into rural areas, with a uniform circulation among adult males. Cryptococcal meningitis was the most common etiologic agent (26.9%) and was associated with worse outcomes. Focal neurological deficit (38.5%), cranial nerve involvement (48.1%) were common features in TB Meningitis. The mortality was high (56.8%) and was significantly associated with low CD4+ count, advanced AIDs clinical stage and the presence of co-morbidities. CONCLUSION Despite the availability of cART, meningitis, particularly cryptococcal, is common in HIV/AIDS population in Egypt. Continued efforts are desperately needed to improve the outcomes of HIV-infected patients.
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Affiliation(s)
- Ekram W Abd El-Wahab
- Department of Tropical Health, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Yamen Hegazy
- Department of Animal Medicine, Faculty of Veterinary Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Talaat Farrag
- Department of Endemic and Infectious Diseases, Alexandria Fever Hospital, Alexandria, Egypt,Fellow of Tropical Health Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Mohammed Metwally
- Department of Endemic and Infectious Diseases, Alexandria Fever Hospital, Alexandria, Egypt
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9
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Giribhattanavar P, Pirson C, Kumar K, Al-Qahtani M, Shankar R, Chandrashekar N, Patil S. IgG response to Mycobacterium tuberculosis non-polar lipids and sonicated extracts among tuberculous meningitis patients. Access Microbiol 2020; 2:acmi000131. [PMID: 32974594 PMCID: PMC7497836 DOI: 10.1099/acmi.0.000131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/08/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction The diagnosis of tuberculous meningitis (TBM) is a major global health concern due to its protean nature. There is a need to identify better biomarkers for the rapid and definitive diagnosis of TBM. Lipids have been poorly explored as diagnostic markers in TBM. Aim Non-polar lipids (NPL) and mycobacterial sonicate extract (MTSE) antigens were assessed for diagnosis of Mycobacterium tuberculosis. Methodology A total of 110 cerebrospinal fluid samples were categorized as confirmed, suspected and non-TBM cases according to clinical presentation and laboratory investigations, which were further analysed by NPL and MTSE ELISA. Results The sensitivity and specificity of the NPL ELISA were 39.6 and 96 %, respectively, whereas the MTSE ELISA was 17 % sensitive and 92 % specific. The combination of the NPL and MTSE ELISA test was superior to these tests alone, with sensitivity and specificity of 43 and 88 %, respectively. Conclusion This combination may be useful as an adjunct in the laboratory diagnosis of TBM. However, future studies in different settings among different populations, such as those with human immunodeficiency virus co-infection, are desirable to explore the full potential of biomarkers.
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Affiliation(s)
- Prashant Giribhattanavar
- Department of Neuromicrobiology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, Karnataka, India
| | - Chris Pirson
- TB Research Group, Animal and Plant Health Agency, New Haw, Addlestone, Surrey, KT15 3NB, UK
| | - Kavitha Kumar
- Department of Neuromicrobiology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, Karnataka, India
| | - Manaf Al-Qahtani
- Department of Medicine, Royal College of Surgeons in Ireland-University of Bahrain, Bahrain
| | - Ravi Shankar
- Department of Biostatistics, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, Karnataka, India
| | - Nagarathna Chandrashekar
- Department of Neuromicrobiology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, Karnataka, India
| | - Shripad Patil
- Department of Neuromicrobiology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560029, Karnataka, India
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Chaudhari KV, Toi PC, Joseph NM. Evaluation of real time polymerase chain reaction targeting mpb64 gene for diagnosis of extrapulmonary tuberculosis. Indian J Tuberc 2020; 68:242-248. [PMID: 33845959 DOI: 10.1016/j.ijtb.2020.09.009] [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: 07/25/2020] [Accepted: 09/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Paucibacillary nature of extrapulmonary tuberculosis (EPTB) has paved way for molecular methods increasingly being used for diagnosis. We undertook a study for evaluation of sensitivity and specificity of real-time polymerase chain reaction (RT-PCR) targeting mpb64 gene for diagnosis of EPTB. METHODS A total of 152 clinical samples from suspected cases of EPTB were included in this study. All samples were extracted using spin column based commercial DNA extraction kit and were subjected to RT-PCR targeting mpb64 and IS6110. Smear and culture was also done for samples whenever quantity was sufficient. Cytology report was noted from hospital information system. Receiver operating characteristic (ROC) curve analysis was done for determining cut-off Ct value for mpb64 RT-PCR. Melt curve analysis was done for samples whose cycle threshold (Ct) value was more than 37. The sensitivity and specificity of the mpb64 RT-PCR was calculated using a composite gold standard i.e., positive for one or more of the following: microscopy (including fine needle aspiration cytology (FNAC), acid-fast bacilli positivity), culture and IS6110 RT-PCR. RESULTS Out of the 152 samples, 72 (47.4%) were positive for tuberculosis by composite gold standard. Samples consisted of ascitic fluid (12), CSF (35), pus (23), lymph node aspirate (35), pleural fluid (37), synovial fluid (4), urine (1), pericardial fluid (1) and tissue bits (4). Microscopy (AFB smear including lymph node aspirate) was done for 124 samples of which 43 (34.7%) were positive. Culture results were available for 79 samples, 25 (31.6%) of which were positive and 42 (27.6%) of the 152 samples were positive by IS6110 PCR. Based on ROC and melt curve analysis, mpb64 RT-PCR was able to detect 38 (52.8%) of the 72 positive samples. In comparison to IS6110 RT PCR, 4 additional cases were detected by mpb64 RT-PCR. Compared to composite gold standard mpb64 showed overall sensitivity of 52.8%. CONCLUSION The mpb64 RT-PCR is highly specific or MTB and can be used as a supplemental test for diagnosis of EPTB along with other diagnostic tests. However the overall sensitivity of mpb64 RT-PCR is too low to be used as an independent test for diagnosis of EPTB. Combining the results of IS6110 RT PCR and mpb64 RT PCR improved the overall sensitivity and hence mpb64 can be used as an additional target for diagnosis of EPTB.
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Affiliation(s)
| | - Pampa Ch Toi
- Department of Pathology, JIPMER, Puducherry, India
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11
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Salvador GLO, Basso ACN, Barbieri PP, Leitao CA, Teixeira BCA, Neto AC. Central nervous system and spinal cord tuberculosis: Revisiting an important disease. Clin Imaging 2020; 69:158-168. [PMID: 32853843 DOI: 10.1016/j.clinimag.2020.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022]
Abstract
Tuberculosis is a worldwide pandemic. Estimated that about 25% humans are colonized by Mycobacterium tuberculosis and about 1% are believed to develop the infection in the central nervous system (CNS-TB). Given the importance of this disease and its high levels of morbidity and mortality, it is imperative that every radiologist must be reminded of the most common findings of CNS-TB as there are several related differential diagnoses for this disease. The most common form CNS-TB is tuberculous meningitis (TBM), characterized mostly by basal meningitis, but infarction, hydrocephalus and tuberculomas could be present. Intracerebral tuberculosis is characterized by tuberculomas that can have different imaging features according to their stage. Vascular and spinal complications of tuberculosis are also reported. This review compiles the classic and unusual findings regarding CNS-TB together with new diagnostic scores in which neuroimaging have an important role.
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Affiliation(s)
- Gabriel L O Salvador
- Department of Diagnostic Radiology, Hospital de Clinicas, Federal University of Parana, Curitiba, Parana, Brazil.
| | - Ana C N Basso
- Department of Diagnostic Radiology, Hospital de Clinicas, Federal University of Parana, Curitiba, Parana, Brazil
| | - Poliana P Barbieri
- Department of Diagnostic Radiology, Hospital de Clinicas, Federal University of Parana, Curitiba, Parana, Brazil
| | - Cleverson A Leitao
- Department of Diagnostic Radiology, Hospital de Clinicas, Federal University of Parana, Curitiba, Parana, Brazil
| | - Bernardo C A Teixeira
- Department of Diagnostic Radiology, Hospital de Clinicas, Federal University of Parana, Curitiba, Parana, Brazil
| | - Arnolfo C Neto
- Department of Diagnostic Radiology, Hospital de Clinicas, Federal University of Parana, Curitiba, Parana, Brazil
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12
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Daniel BD, Grace GA, Natrajan M. Tuberculous meningitis in children: Clinical management & outcome. Indian J Med Res 2019; 150:117-130. [PMID: 31670267 PMCID: PMC6829784 DOI: 10.4103/ijmr.ijmr_786_17] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 12/15/2022] Open
Abstract
Although the occurrence of tuberculous meningitis (TBM) in children is relatively rare, but it is associated with higher rates of mortality and severe morbidity. The peak incidence of TBM occurs in younger children who are less than five years of age, and most children present with late-stage disease. Confirmation of diagnosis is often difficult, and other infectious causes such as bacterial, viral and fungal causes must be ruled out. Bacteriological confirmation of diagnosis is ideal but is often difficult because of its paucibacillary nature as well as decreased sensitivity and specificity of diagnostic tests. Early diagnosis and management of the disease, though difficult, is essential to avoid death or neurologic disability. Hence, a high degree of suspicion and a combined battery of tests including clinical, bacteriological and neuroimaging help in diagnosis of TBM. Children diagnosed with TBM should be managed with antituberculosis therapy (ATT) and steroids. There are studies reporting low concentrations of ATT, especially of rifampicin and ethambutol in cerebrospinal fluid (CSF), and very young children are at higher risk of low ATT drug concentrations. Further studies are needed to identify appropriate regimens with adequate dosing of ATT for the management of paediatric TBM to improve treatment outcomes. This review describes the clinical presentation, investigations, management and outcome of TBM in children and also discusses various studies conducted among children with TBM.
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Affiliation(s)
- Bella Devaleenal Daniel
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - G. Angeline Grace
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
| | - Mohan Natrajan
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, Chennai, India
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13
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A Systematic Review and Meta-analysis of the Diagnostic Accuracy of Nucleic Acid Amplification Tests for Tuberculous Meningitis. J Clin Microbiol 2019; 57:JCM.01113-18. [PMID: 30944198 DOI: 10.1128/jcm.01113-18] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The diagnosis of tuberculous meningitis (TBM) is difficult and poses a significant challenge to physicians worldwide. Recently, nucleic acid amplification (NAA) tests have shown promise for the diagnosis of TBM, although their performance has been variable. We undertook a systematic review and meta-analysis to evaluate the diagnostic accuracy of NAA tests with cerebrospinal fluid (CSF) samples against that of culture as the reference standard or a combined reference standard (CRS) for TBM. We searched the Embase, PubMed, Web of Science, and Cochrane Library databases for the relevant records. The QUADAS-2 tool was used to assess the quality of the studies. Diagnostic accuracy measures (i.e., sensitivity and specificity) were pooled with a random-effects model. All statistical analyses were performed with STATA (version 14 IC; Stata Corporation, College Station, TX, USA), Meta-DiSc (version 1.4 for Windows; Cochrane Colloquium, Barcelona, Spain), and RevMan (version 5.3; The Nordic Cochrane Centre, the Cochrane Collaboration, Copenhagen, Denmark) software. Sixty-three studies comprising 1,381 cases of confirmed TBM and 5,712 non-TBM controls were included in the final analysis. These 63 studies were divided into two groups comprising 71 data sets (43 in-house tests and 28 commercial tests) that used culture as the reference standard and 24 data sets (21 in-house tests and 3 commercial tests) that used a CRS. Studies which used a culture reference standard had better pooled summary estimates than studies which used CRS. The overall pooled estimates of sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of the NAA tests against culture were 82% (95% confidence interval [CI], 75 to 87%), 99% (95% CI, 98 to 99%), 58.6 (95% CI, 35.3 to 97.3), and 0.19 (95% CI, 0.14 to 0.25), respectively. The pooled sensitivity, specificity, PLR, and NLR of NAA tests against CRS were 68% (95% CI, 41 to 87%), 98% (95% CI, 95 to 99%), 36.5 (95% CI, 15.6 to 85.3), and 0.32 (95% CI, 0.15 to 0.70), respectively. The analysis has demonstrated that the diagnostic accuracy of NAA tests is currently insufficient for them to replace culture as a lone diagnostic test. NAA tests may be used in combination with culture due to the advantage of time to result and in scenarios where culture tests are not feasible. Further work to improve NAA tests would benefit from the availability of standardized reference standards and improvements to the methodology.
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Diagnostic accuracy of nucleic acid amplification based assays for tuberculous meningitis: A meta-analysis. J Infect 2018; 77:302-313. [DOI: 10.1016/j.jinf.2018.04.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/26/2018] [Accepted: 04/28/2018] [Indexed: 11/18/2022]
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15
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Sharma K, Sharma M, Chaudhary L, Modi M, Goyal M, Sharma N, Sharma A, Jain A, Dhibar DP, Jain K, Khandelwal N, Ray P, Lal V, Salfinger M. Comparative evaluation of Xpert MTB/RIF assay with multiplex polymerase chain reaction for the diagnosis of tuberculous meningitis. Tuberculosis (Edinb) 2018; 113:38-42. [PMID: 30514512 DOI: 10.1016/j.tube.2018.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/04/2018] [Accepted: 09/05/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rapid and specific diagnosis of tuberculous meningitis (TBM) is of paramount importance to decrease morbidity and mortality. Therefore, the present study was undertaken to compare the efficacy of Xpert MTB/RIF assay (GXpert) and multiplex PCR (MPCR) using three targets (IS6110, MPB64 and protein B) for diagnosing tuberculous meningitis. METHODS GXpert and MPCR were performed on cerebrospinal fluid samples of 225 patients out of which 80 were culture-positive confirmed cases of TBM, 100 were 'suspected' cases of TBM and 45 were non-TBM controls. rpoB gene sequencing was done for diagnosing rifampicin (Rif) resistance in all positive cases. RESULTS GXpert and MPCR were positive in 91/180 (50.5%) and 157/180 (87.2%) confirmed or suspected TBM patients respectively. Both the tests were negative in all 45 controls. Rif resistance was detected in 14 cases by GXpert and in 13 cases by MPCR. Rif resistance was confirmed in 13 cases with rpoB gene sequencing. There was one case of false Rif resistance detected by GXpert which was Rif susceptible on rpoB gene sequencing. Cost of doing MPCR was less than USD1 whereas GXpert required USD10 per isolate. CONCLUSION MPCR has a higher sensitivity than GXpert for diagnosing TBM. MPCR is a robust and cost effective method for diagnosis of TBM in low-resource and high-endemic countries.
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Affiliation(s)
- Kusum Sharma
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Megha Sharma
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Lokesh Chaudhary
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Modi
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj Goyal
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anumiti Jain
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kajal Jain
- Department of Anaesthesiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivel Lal
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Max Salfinger
- Department of Medicine & Mycobacteriology Laboratory, National Jewish Health, Denver, CO, USA
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Pormohammad A, Nasiri MJ, Riahi SM, Fallah F. Human immunodeficiency virus in patients with tuberculous meningitis: systematic review and meta-analysis. Trop Med Int Health 2018; 23:589-595. [PMID: 29660820 DOI: 10.1111/tmi.13059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Human immunodeficiency virus (HIV)-infected individuals are at increased risk for all forms of extrapulmonary tuberculosis (TB), including tuberculous meningitis (TBM). This study aimed to investigate the frequency of HIV in patients with TBM. METHODS PubMed, Embase, Web of Science and Cochrane Library were searched for articles including relevant data. Stata version 14.0 (StataCorp, College Station, Texas, USA) was used to analyse the data. RESULTS Twenty studies were identified. The pooled frequency of HIV among adult patients with TBM was 38.0% (95% CI: 21.0-57.0; I2 = 97%). In children (under the age of 15 years), 6.0% (95% CI: 1.0-13.0; I2 = 0.0%) had HIV infection. In patients with bacterial meningitis other than TBM, 36.0% (95% CI: 19.0-53.0; I2 = 100%) were HIV-infected. CONCLUSIONS A relatively high frequency of HIV in patients with TBM was indicated by our study. Establishment of diagnostic criteria and effective treatment strategies for TBM/HIV co-infection are recommended for better management of patients with TBM+HIV.
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Affiliation(s)
- Ali Pormohammad
- Student Research Committee, Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Riahi
- Department of Epidemiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Fallah
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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17
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Seipone ID, Singh R, Patel VB, Singh A, Gordon ML, Muema DM, Dheda K, Ndung’u T. Tuberculous meningitis is associated with higher cerebrospinal HIV-1 viral loads compared to other HIV-1-associated meningitides. PLoS One 2018; 13:e0192060. [PMID: 29394269 PMCID: PMC5796705 DOI: 10.1371/journal.pone.0192060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/16/2018] [Indexed: 12/05/2022] Open
Abstract
To gain a better understanding of the immunopathogenesis of tuberculous meningitis (TBM) and identify potential diagnostic biomarkers that may discriminate TBM from other HIV-1-associated meningitides, we assessed HIV-1 viral load levels, drug resistance patterns in antiretroviral therapy (ART)-experienced patients with persistent viremia and soluble immunological analytes in peripheral blood and cerebrospinal fluid (CSF) of HIV-1 infected patients with TBM versus other meningitides. One hundred and three matched blood and CSF samples collected from HIV-1 infected patients with TBM or other meningitides presenting at a hospital in Durban, South Africa, from January 2009 to December 2011 were studied. HIV-1 RNA and 28 soluble immunological potential biomarkers were quantified in blood plasma and CSF. Viremic samples were assessed for HIV-1 drug resistance mutations. There were 16 TBM, 46 probable TBM, 35 non-TBM patients, and six unclassifiable patients. TBM and non-TBM patients did not differ in median plasma viral load but TBM patients had significantly higher median CSF viral load than non-TBM participants (p = 0.0005). No major drug resistance mutations were detected in viremic samples. Interleukin (IL)-1β, IL-17, platelet derived growth factor (PDGF)-BB, granulocyte colony stimulating factor (G-CSF) and cathelicidin were significantly elevated in the CNS of TBM participants compared to other patients although these associations were lost after correction for false discovery. Our data suggest that TB co-infection of the CNS is associated with enhanced localized HIV-1 viral replication but none of the evaluated soluble immunological potential biomarkers could reliably distinguish TBM from other HIV-associated meningitides.
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Affiliation(s)
- Ikanyeng D. Seipone
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ravesh Singh
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Microbiology, National Health Laboratory Services, KwaZulu-Natal Academic Complex, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - Vinod B. Patel
- Department of Neurology, Inkosi Albert Luthuli Central Hospital and the Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Avashna Singh
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Michelle L. Gordon
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Daniel M. Muema
- Africa Health Research Institute, Durban, South Africa
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology & Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Thumbi Ndung’u
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
- Ragon Institute of MGH, MIT and Harvard University, Cambridge, Massachusetts, United States of America
- Max Planck Institute for Infection Biology, Berlin, Germany
- * E-mail:
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18
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Abstract
Central nervous system (CNS) disease caused by Mycobacterium tuberculosis (MTB) is highly devastating. Tuberculous meningitis (TBM) is the most common form of CNS tuberculosis (TB). Rapid, sensitive, and affordable diagnostic tests are not available. Ziehl-Neelsen (ZN) stain has a very low sensitivity in cases of TBM, the sensitivity rates is of about 10-20%.The detection rate can be improved by taking large volume CSF samples (>6 ml) and prolonged slide examination (30 min). Culture of MTB from the CSF is slow and insufficiently sensitive. The sensitivity is different, which varies from 36% to 81.8%. The microscopic observation drug susceptibility (MODS) assay was recommended by the World Health Organization in 2011. The sensitivity is 65%, which is more sensitive and faster than CSF smear. Commercial PCR assays were found to be insensitive at detecting MTB in CSF samples. Many research provided the value of ADA on the TBM diagnosis. Interferon-gamma release assays (IGRAs) are not recommended for diagnosis of active TB disease. Imaging is essential in diagnosis and showing complications of CNS TB. Thwaites criteria and the Lancet consensus scoring system (LCSS) were developed to improve the diagnosis of TBM. Clinicians will continue to make judgment based on clinical examination, inflammatory CSF examinations, imaging studies, and scoring systems.
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Affiliation(s)
- Yi-Yi Wang
- Department of Neurology, Tianjin Haihe Hospital, Tianjin, P.R. China.
| | - Bing-di Xie
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, P.R. China
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19
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Faried A, Arief G, Arifin MZ, Nataprawira HM. Correlation of Lactate Concentration in Peripheral Plasma and Cerebrospinal Fluid with Glasgow Outcome Scale for Patients with Tuberculous Meningitis Complicated by Acute Hydrocephalus Treated with Fluid Diversions. World Neurosurg 2017; 111:e178-e182. [PMID: 29248780 DOI: 10.1016/j.wneu.2017.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 12/03/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Tuberculous meningitis (TBM) is an endemic infectious disease in developing countries, and it can become a serious illness in children. Treatment of TBM is more difficult and prone to failure than treatment of pulmonary tuberculosis. TBM causes hydrocephalus, cerebral edema, increased intracranial pressure, global ischemia, and neurologic deficits, which disturb cellular metabolism and increase lactate levels. A reliable, widely available clinical indicator of TBM severity is needed. Successful treatment of TBM is assessed using the Glasgow Outcome Scale (GOS). METHODS This prospective cohort study included 34 patients with TBM and acute hydrocephalus who had undergone fluid diversions and were admitted to Dr. Hasan Sadikin Hospital in Bandung from 2014 to 2015. A portable machine for blood glucose measurement was used to measure lactate concentrations. Statistical significance was defined as P ≤ 0.05. RESULTS Average levels of plasma and cerebrospinal fluid (CSF) lactate were 1.99 ± 0.70 mmol/L and 3.04 ± 1.05 mmol/L, respectively. A significantly higher level of lactate was observed in CSF compared with plasma. Preoperative plasma lactate was negatively correlated to GOS (r = -0.539; P = 0.013), and CSF lactate was negatively correlated to GOS (r = -0.412; P = 0.027). Average lactate levels in CSF (central) were higher than plasma (peripheral) levels. GOS scale of patients decreased with increased plasma and CSF lactate levels. CONCLUSIONS Examination of plasma and CSF lactate levels should be included in routine examinations to determine extent of cellular damage and GOS score in patients with TBM and acute hydrocephalus who have undergone fluid diversions.
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Affiliation(s)
- Ahmad Faried
- Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, Indonesia.
| | - Gusman Arief
- Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Muhammad Z Arifin
- Department of Neurosurgery, Faculty of Medicine, Universitas Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Heda M Nataprawira
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, Indonesia
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20
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Mason S, Reinecke CJ, Solomons R. Cerebrospinal Fluid Amino Acid Profiling of Pediatric Cases with Tuberculous Meningitis. Front Neurosci 2017; 11:534. [PMID: 29018323 PMCID: PMC5623012 DOI: 10.3389/fnins.2017.00534] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/13/2017] [Indexed: 12/03/2022] Open
Abstract
Background: In Africa, tuberculosis is generally regarded as persisting as one of the most devastating infectious diseases. The pediatric population is particularly vulnerable, with infection of the brain in the form of tuberculous meningitis (TBM) being the most severe manifestation. TBM is often difficult to diagnose in its early stages because of its non-specific clinical presentation. Of particular concern is that late diagnosis, and subsequent delayed treatment, leads to high risk of long-term neurological sequelae, and even death. Using advanced technology and scientific expertise, we are intent on further describing the biochemistry behind this devastating neuroinflammatory disease, with the goal of improving upon its early diagnosis. Method: We used the highly sensitive analytical platform of gas chromatography-mass spectrometry (GC-MS) to analyze amino acid profiles of cerebrospinal fluid (CSF) collected from a cohort of 33 South African pediatric TBM cases, compared to 34 controls. Results: Through the use of a stringent quality assurance procedure and various statistical techniques, we were able to confidently identify five amino acids as being significantly elevated in TBM cases, namely, alanine, asparagine, glycine, lysine, and proline. We found also in an earlier untargeted metabolomics investigation that alanine can be attributed to increased CSF lactate levels, and lysine as a marker of lipid peroxidation. Alanine, like glycine, is an inhibitory neurotransmitter in the brain. Asparagine, as with proline, is linked to the glutamate-glutamine cycle. Asparagine is associated with the removal of increased nitrites in the brain, whereas elevated proline coincides with the classic biochemical marker of increased CSF protein in TBM. All five discriminatory amino acids are linked to ammonia due to increased nitrites in TBM. Conclusion: A large amount of untapped biochemical information is present in CSF of TBM cases, of which amino acid profiling through GC-MS has potential in aiding in earlier diagnosis, and hence crucial earlier treatment.
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Affiliation(s)
- Shayne Mason
- Faculty of Natural Sciences, Centre for Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Carolus J Reinecke
- Faculty of Natural Sciences, Centre for Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Regan Solomons
- Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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21
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22
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Anselmo LMP, Feliciano C, Mauad F, do Nascimento MP, Pocente RC, Silva JM, Bollela VR. A predictive score followed by nucleic acid amplification for adult tuberculous meningitis diagnosis in Southern Brazil. J Neurol Sci 2017; 379:253-258. [DOI: 10.1016/j.jns.2017.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 06/12/2017] [Accepted: 06/13/2017] [Indexed: 11/30/2022]
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23
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Marais S, Lai RPJ, Wilkinson KA, Meintjes G, O'Garra A, Wilkinson RJ. Inflammasome Activation Underlying Central Nervous System Deterioration in HIV-Associated Tuberculosis. J Infect Dis 2017; 215:677-686. [PMID: 27932622 PMCID: PMC5388298 DOI: 10.1093/infdis/jiw561] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 11/15/2016] [Indexed: 02/07/2023] Open
Abstract
Tuberculous meningitis (TBM) is a frequent cause of meningitis in individuals with human immunodeficiency virus (HIV) infection, resulting in death in approximately 40% of affected patients. A severe complication of antiretroviral therapy (ART) in these patients is neurological tuberculosis–immune reconstitution inflammatory syndrome (IRIS), but its underlying cause remains poorly understood. To investigate the pathogenesis of TBM-IRIS, we performed longitudinal whole-blood microarray analysis of HIV-infected patients with TBM and reflected the findings at the protein level. Patients in whom TBM-IRIS eventually developed had significantly more abundant neutrophil-associated transcripts, from before development of TBM-IRIS through IRIS symptom onset. After ART initiation, a significantly higher abundance of transcripts associated with canonical and noncanonical inflammasomes was detected in patients with TBM-IRIS than in non-IRIS controls. Whole-blood transcriptome findings complement protein measurement from the site of disease, which together suggest a dominant role for the innate immune system in the pathogenesis of TBM-IRIS.
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Affiliation(s)
- Suzaan Marais
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Rachel P J Lai
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Katalin A Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa.,Tuberculosis Laboratory, The Francis Crick Institute, 1 Midland Road, London, UK
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa
| | - Anne O'Garra
- Laboratory of Immuno regulation and Infection, The Francis Crick Institute, London, UK.,National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Robert J Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, South Africa.,Tuberculosis Laboratory, The Francis Crick Institute, 1 Midland Road, London, UK.,Department of Medicine, Imperial College London, United Kingdom
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24
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Manke SD, Husain AA, Daginawala HF, Singh LK, Kashyap RS. Comparative Diagnostic Utility of IS6110 PCR Assay in CSF and Peripheral Blood Samples of Tuberculous Meningitis Patients: A Pilot Study from Central India. J Clin Diagn Res 2017; 11:BC13-BC17. [PMID: 28571129 DOI: 10.7860/jcdr/2017/24493.9668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/20/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Tuberculous Meningitis (TBM) is the most severe form of Central Nervous System Tuberculosis (CNS-TB) and constitutes about 6% of all Extrapulmonary TB (EPTB) cases. Most guidelines for the diagnosis and management of TBM agree on the use of simple Cerebrospinal Fluid (CSF) analysis using molecular tools like Polymerase Chain Reaction (PCR). However, the sensitivity of PCR varies while using a CSF sample. In the present study, we have compared the diagnostic utility of PCR assay in both peripheral blood and CSF sample collected from TBM cases. AIM To evaluate the application of the peripheral blood PCR assay as an alternate tool for TBM diagnosis compared to conventional CSF-PCR based system. MATERIALS AND METHODS A total of 50 TBM patients were prospectively recruited from in patient department wards of Central India Institute of Medical Sciences (CIIMS) between January 2014 - Feburary 2015. Mycobacterium tuberculosis (MTB) specific IS6110 PCR and BactT liquid culture were performed in 20 of recruited cases classified as Stage 1, 2 and 3 based on British Medical Research Council (BMRC) contemporary clinical criteria for the severity of TBM. Clinical characteristics were summarised in terms of percentages for categorical variables, i.e., age groups, gender, signs and symptoms. All statistical analysis was carried out using MedCalc software version 11.6. RESULTS Overall IS6110 PCR positivity in CSF was around 80% (16/20), which was higher than culture (29.3%) and peripheral blood (39%). Out of 8 positive cases, stage wise positivity of peripheral blood PCR assay in three TBM stages was 0% (stage1) 50% (stage 2) and 67% (Stage 3) respectively. Positivity of peripheral blood PCR was significantly more (86%) in patients with CSF culture/ IS6110 PCR positive for MTB infection with sensitivity and specificity of 50 and 100% respectively. Increased positivity rates of peripheral blood PCR was observed with decreased CSF/Blood sugar ratio in stage 3 cases, suggesting enhanced probability of mycobacterial blood dissemination in cases of TBM severity. CONCLUSION Our results suggest that although the molecular diagnosis of TBM infection in CSF remains the method of choice, peripheral blood based PCR can be used as a good alternative to CSF in case of TBM severity where the repeated CSF collection may be needed. However, study demands further validation in large cohorts to justify the present hypothesis.
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Affiliation(s)
- Sonali D Manke
- Senior Research Fellow, Research Centre, Central India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Aliabbas A Husain
- Research Associate, Research Centre, Central India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Hatim F Daginawala
- Honorary Research Consultant, Research Centre, Central India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Lokendra K Singh
- Director, Department of Neurosurgery, Central India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Rajpal S Kashyap
- Director, Research Centre, Central India Institute of Medical Sciences, Nagpur, Maharashtra, India
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25
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Britz E, Perovic O, von Mollendorf C, von Gottberg A, Iyaloo S, Quan V, Chetty V, Sriruttan C, Ismail NA, Nanoo A, Musekiwa A, Reddy C, Viljoen K, Cohen C, Govender NP. The Epidemiology of Meningitis among Adults in a South African Province with a High HIV Prevalence, 2009-2012. PLoS One 2016; 11:e0163036. [PMID: 27669564 PMCID: PMC5036788 DOI: 10.1371/journal.pone.0163036] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/01/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Meningitis is a major cause of mortality in southern Africa. We aimed to describe the aetiologies and frequencies of laboratory-confirmed fungal and bacterial meningitis among adults in a South African province with an 11% HIV prevalence, over 4 years. METHODS We conducted a retrospective, observational study of secondary laboratory data, extracted on all cerebrospinal fluid (CSF) specimens submitted to public-sector laboratories in Gauteng province from 2009 through 2012. We calculated cause-specific incidence rates in the general and HIV-infected populations and used Poisson regression to determine if trends were significant. RESULTS We identified 11,891 (10.7%) incident cases of meningitis from 110,885 CSF specimens. Cryptococcal meningitis, tuberculous meningitis and pneumococcal meningitis accounted for 62.3% (n = 7,406), 24.6% (n = 2,928) and 10.1% (n = 1,197) of cases over the four-year period. The overall incidence (cases per 100,000 persons) of cryptococcal meningitis declined by 23% from 24.4 in 2009 to 18.7 in 2012 (p <0.001) and decreased by 19% among HIV-infected persons from 178.2 to 144.7 (p <0.001). Tuberculous meningitis decreased by 40% from 11.3 in 2009 to 6.8 in 2012 (p <0.001) and decreased by 36% among HIV-infected persons from 54.4 to 34.9 (p <0.001). Pneumococcal meningitis decreased by 41% from 4.2 in 2009 to 2.5 in 2012 (p <0.001) and decreased by 38% among HIV-infected persons from 28.0 to 17.5 (p <0.001). Among cases of other bacterial meningitis (248/11,891, 2.1%), Neisseria meningitidis (n = 93), Escherichia coli (n = 72) and Haemophilus influenzae (n = 20) were the most common organisms identified. CONCLUSIONS In this high HIV-prevalence province, cryptococcal meningitis was the leading cause of laboratory-confirmed meningitis among adults. Over a 4-year period, there was a significant decrease in incidence of cryptococcal, tuberculous and pneumococcal meningitis. This coincided with expansion of the national antiretroviral treatment programme, enhanced tuberculosis control programme and routine childhood immunisation with pneumococcal conjugate vaccines.
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Affiliation(s)
- Erika Britz
- South African Field Epidemiology Training Programme, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Olga Perovic
- National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Claire von Mollendorf
- National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anne von Gottberg
- National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Samantha Iyaloo
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Vanessa Quan
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Verushka Chetty
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | | | - Nazir A. Ismail
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Ananta Nanoo
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Alfred Musekiwa
- Division of Global Health Protection, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Carl Reddy
- South African Field Epidemiology Training Programme, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Karien Viljoen
- South African Field Epidemiology Training Programme, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Cheryl Cohen
- National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P. Govender
- National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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26
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Giribhattanavar P, Kumar K, Raajasekar S, Chandrashekar N, Patil SA. Significance of immune response to Mycobacterium tuberculosis culture filtrate protein antigens in cerebrospinal fluid of tuberculous meningitis patients: A search for diagnostic marker. J Immunoassay Immunochem 2016; 38:45-57. [PMID: 27454259 DOI: 10.1080/15321819.2016.1215329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Mycobacterium tuberculosis (H37Ra) culture filtrate proteins (CFP) are explored as a diagnostic marker for tuberculous meningitis (TBM). Cerebrospinal fluid (CSF) samples from patients were categorized as confirmed (n = 47), suspected (n = 20), and non-TBM (n = 25) cases. Immune response by Western blot revealed TBM CSF samples are having heterogeneous response to CFP. CFP ELISA was 92% sensitive and 38.30% specific. ODs of confirmed TBM and non-TBM cases were significantly different (P < 0.0001) and also the suspected TBM and non-TBM cases (P = 0.0001). No significant difference noticed in TBM and suspected TBM (P = 0.90). Thus, CFP can be a better biomarker for the diagnosis of TBM.
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Affiliation(s)
- Prashant Giribhattanavar
- a Department of Neuromicrobiology , National Institute of Mental Health and Neurosciences (NIMHANS) , Bangalore , Karnataka , India
| | - Kavitha Kumar
- a Department of Neuromicrobiology , National Institute of Mental Health and Neurosciences (NIMHANS) , Bangalore , Karnataka , India
| | - Siddarth Raajasekar
- b Medical Biotechnology Division , School of Biosciences and Technology, VIT University , Vellore , India
| | - Nagarathna Chandrashekar
- a Department of Neuromicrobiology , National Institute of Mental Health and Neurosciences (NIMHANS) , Bangalore , Karnataka , India
| | - Shripad A Patil
- a Department of Neuromicrobiology , National Institute of Mental Health and Neurosciences (NIMHANS) , Bangalore , Karnataka , India
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Lekhak SP, Sharma L, Rajbhandari R, Rajbhandari P, Shrestha R, Pant B. Evaluation of multiplex PCR using MPB64 and IS6110 primers for rapid diagnosis of tuberculous meningitis. Tuberculosis (Edinb) 2016; 100:1-4. [PMID: 27553404 DOI: 10.1016/j.tube.2016.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 05/29/2016] [Accepted: 05/31/2016] [Indexed: 10/21/2022]
Abstract
Tuberculous meningitis (TBM) is one of those most serious manifestations of extra-pulmonary tuberculosis and prompt diagnosis and treatment is required for better clinical outcome. It is difficult to diagnose due to lack of rapid, sensitive, and specific tests. Newer methods, which are easy and reliable, are required to diagnose TBM at an early stage. Thus our aim was to evaluate the Multiplex polymerase chain reaction (PCR) technique, using primers directed against the insertion sequence IS6110 and MPB64 gene for the detection of Mycobacterium tuberculosis in Cerebrospinal fluid (CSF), for rapid diagnosis of TBM patients. 102 CSF samples were analyzed from patients suspected with TBM along with a control group of 10 patients having other neurological disorders. CSF sediments were analyzed individually for M. tuberculosis DNA by Multiplex PCR using two set of primers targeting insertion sequence IS6110 and gene MBp64, which is very specific for MTBC. Out of 37 patients diagnosed with TBM clinically, MPB64 PCR was positive in 22, IS6110 PCR was positive in 28, both PCR using Multiplex were positive in 34 and Microscopy was positive in one. Thus Sensitivity of MPB64 PCR, IS6110 PCR, Multiplex PCR and Microscopy were found to be 62.3%, 75.4%, 91.8% and 2.7% respectively. In non TBM group PCR was negative in all cases hence, the specificity was 100%. Multiplex PCR system using primers targeting IS6110 and MPB64, for the detection of M. tuberculosis DNA in CSF samples, has high sensitivity than any one of them alone, and could be used for the early detection of TBM in CSF samples.
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Affiliation(s)
- Sunil Prasad Lekhak
- Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal; Department of Microbiology, Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal.
| | - Laxmi Sharma
- Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Reema Rajbhandari
- Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Pravesh Rajbhandari
- Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Resha Shrestha
- Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
| | - Basant Pant
- Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal
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Mason S, Reinecke CJ, Solomons R, van Furth AM. Tuberculous meningitis in infants and children: Insights from nuclear magnetic resonance metabolomics. S AFR J SCI 2016. [DOI: 10.17159/sajs.2016/20150086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract Tuberculous meningitis (TBM) is a prevalent form of central nervous system tuberculosis (CNS-TB) and the most severe common form of bacterial meningitis in infants and children below the age of 13 years, especially in the Western Cape Province of South Africa. Research to identify markers for timely and accurate diagnosis and treatment outcomes remains high on the agenda for TBM, in respect of which the field of metabolomics is as yet largely unexploited. However, the national Department of Science and Technology (DST) recently established several biotechnology platforms at South African institutions, including one for metabolomics hosted at North-West University. We introduce this national platform for nuclear magnetic resonance (NMR) metabolomics by providing an overview of work on TBM. We focus on selected collaborative multidisciplinary approaches to this disease and conclude with the outcomes of an untargeted NMR metabolomics study of cerebrospinal fluid from TBM patients. This study enabled the formulation of a conceptual shuttle representing the unique metabolic plasticity of CNS metabolism towards the energy requirements for the microglia-driven neuroinflammatory responses, of which TBM is one example. From insights generated by this explorative NMR metabolomics investigation, we propose directions for future in-depth research strategies to address this devastating disease. In our view, the timely initiative of the DST, the operational expertise in metabolomics now available and the potential for involving national and international networks in this field of research offers remarkable opportunities for the future of metabolomics in South Africa and for an ever greater understanding of disease mechanisms.
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Marais S, Meintjes G, Lesosky M, Wilkinson KA, Wilkinson RJ. Interleukin-17 mediated differences in the pathogenesis of HIV-1-associated tuberculous and cryptococcal meningitis. AIDS 2016; 30:395-404. [PMID: 26765934 PMCID: PMC4711381 DOI: 10.1097/qad.0000000000000904] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Mycobacterium tuberculosis and Cryptococcus neoformans are major causes of meningitis in HIV-1-infected patients. Identifying differences in the inflammatory profiles of HIV-1-associated tuberculous meningitis (TBM) and cryptococcal meningitis may inform differences in immunopathogenic mechanisms in these diseases. In this study we compared the clinical and inflammatory features of HIV-1-associated TBM, and cryptococcal meningitis. METHODS A prospective study of HIV-1-infected adults who presented with either TBM [antiretroviral therapy (ART)-naive] or cryptococcal meningitis (regardless of ART prescription). Clinical and laboratory findings and concentrations of 40 inflammatory mediators measured in cerebrospinal fluid (CSF, 33 paired with blood) were compared between TBM and cryptococcal meningitis patients regardless of ART prescription and between TBM and cryptococcal meningitis patients not receiving ART. RESULTS Clinical and laboratory findings were similar in TBM (n=34) and cryptococcal meningitis (n = 19; ART prescribed: n = 10, no ART prescribed: n = 9). Exceptions included a higher median CD4 cell count [interquartile: 113 (69-199) vs. 25 (8-49) cells/μl, P = 0.0001] and higher HIV-1 median viral load [plasma: 5.46 (4.82-5.89) vs. 4.87 (4.36-5.17) log10copies/ml, P = 0.037; CSF: 6.05 (5.43-6.56) vs. 5.56 (4.52-5.80) log10copies/ml, P = 0.03] in TBM vs. cryptococcal meningitis patients not receiving ART. CSF interleukin (IL)-17A was lower in TBM compared with cryptococcal meningitis [1.00 (0.25-2.35) vs. 9.31 (1.24-23.36) pg/ml, P-adjusted = 0.03]. CONCLUSION Despite presenting with higher peripheral CD4 cell counts, TBM patients also presented with higher HIV-1 viral loads compared with cryptococcal meningitis patients, suggesting a greater propensity of M. tuberculosis compared with C. neoformans to increase HIV-1 replication in vivo. CSF IL-17A was lower in TBM; its role in the immunopathogenesis of TBM and cryptococcal meningitis deserves further research.
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Zhang J, Hu X, Hu X, Ye Y, Shang M, An Y, Gou H, Zhao Z, Peng W, Song X, Zhou Y, Kang M, Xie Y, Chen X, Lu X, Ying B, Wang L. Clinical features, Outcomes and Molecular Profiles of Drug Resistance in Tuberculous Meningitis in non-HIV Patients. Sci Rep 2016; 6:19072. [PMID: 26738994 PMCID: PMC4703954 DOI: 10.1038/srep19072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 12/02/2015] [Indexed: 02/05/2023] Open
Abstract
Tuberculous meningitis continues to be a serious problem for physicians because it is difficult to make an early diagnosis and the consequences of delaying treatment are severe. The objective of this study is to provide data for the optimization of diagnostic and timely treatment of tuberculous meningitis. Of the 401 human immunodeficiency virus (HIV)-negative tuberculous meningitis patients in our study, 332 were found to have an impaired blood brain barrier (82.8%). Nearly 17.0% of patients failed to be timely diagnosed. Headache (53.6%) and fever (48.6%) were the most common features, and Computed Tomography/Magnetic Resonance Imaging (CT/MRI) detected 96 patients (23.9%) with abnormal meningeal imaging. Cerebrospinal fluid real-time polymerase chain reaction was positive in 73.8% of the tuberculous meningitis patients, whereas, smears and cultures detected only 6.7% and 5.2%, respectively. Further analysis identified striking differences between drug-resistant and drug-susceptible tuberculous meningitis. Patients with drug resistance correlated with grave prognosis. Tuberculous meningitis diagnosis should overall embody clinical symptoms, laboratory and cerebral imaging findings, and more sensitive diagnostic approaches are still warranted. Our data suggest cerebrospinal fluid polymerase chain reaction for mycobacterial DNA and molecular drug susceptibility testing as routine assays for suspected tuberculous meningitis patients, and observation of the blood brain barrier function could be performed for individual management.
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Affiliation(s)
- Jingya Zhang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Xuejiao Hu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Yuanxin Ye
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Mengqiao Shang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Yunfei An
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Haimei Gou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Zhenzhen Zhao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Wu Peng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Xingbo Song
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Yanhong Zhou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Mei Kang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Yi Xie
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Xuerong Chen
- Division of Pulmonary Disease, Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Xiaojun Lu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Binwu Ying
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
| | - Lanlan Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, P.R China
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Chaparro JMO, Reyes-Ortiz CA, Soto R, Reynolds JW. Abdominal tuberculosis presenting as ascites in an older indigenous woman: a case report. JMM Case Rep 2015. [DOI: 10.1099/jmmcr.0.000056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- José Mauricio Ocampo Chaparro
- Jefe del Servicio de Hospitalización Geriátrica programa ‘Siéntete como en Casa’ Corporación Comfenalco-Universidad Libre; Profesor Asociado, Departamento de Medicina Familiar, Facultad de Salud, Universidad del Valle, Cali, Colombia
| | - Carlos A Reyes-Ortiz
- Division of Geriatric and Palliative Medicine, University of Texas Medical School at Houston, Houston, TX, USA
- Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA
| | - Ramiro Soto
- Especialista Medicina Familiar, Universidad del Cauca, Popayán, Colombia
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Caliman-Sturdza OA, Mihalache D, Luca CM. Performance of an interferon-gamma release assay in the diagnosis of tuberculous meningitis in children / Performanţa testului bazat pe eliberarea interferonului gamma în diagnosticul meningitei tuberculoase la copil. REV ROMANA MED LAB 2015. [DOI: 10.1515/rrlm-2015-0016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractThe new immunodiagnostic tests based on the Mycobacterium tuberculosis specific antigen, early secretory antigenic target 6 (ESAT-6) and culture filtrate protein 10 (CFP-10), showed promising results in the diagnosis of tuberculosis infection. However, there are only few studies in the published literature on performance tests in cerebrospinal fluid. We investigated whether a rapid diagnosis of tuberculous meningitis (TBM) could be established by interferon-γ blood and cerebrospinal fluid (CSF) tests in children.We used the QuantiFERON-TB Gold in Tube test (QFT-IT) on blood and the QuantiFERON-TB Gold test (QFT-G) on the CSF of 63 subjects with TBM (including 25 case of definite TBM and 38 cases of probable TBM) and 62 controls.The CSF analyses indicated possible TBM in 63.4% of cases. The sensitivity of the CSF culture for Mycobacterium tuberculosis was only 39.6%. The sensitivity of the tuberculin skin test (TST) was 49.2% and the specificity was 88.6%. The estimated sensitivities of the QFT-G for the CSF and QFT-IT for the blood in culture confirmed TBM cases (gold standard) were 84% and 80%, respectively. The estimated specificities were 98.2% for the CSF and 87.9% for the blood. This study showed that the sensitivity of QFT for the CSF could be higher than TST and culture and slightly higher in CSF than in blood. The specificity of QFT-G for the CSF was higher those of the TST, but the specificity of QFT-IT is lower.QFT-G of the CSF is a useful diagnostic marker of tuberculosis that may improve the management of TBM, but the test results must be correlated with clinical, radiological and characteristics of CSF. New researches are needed to investigate the performance of QFT-G in the CSF compared with ELISPOT and PCR
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Mason S, van Furth AM, Mienie LJ, Engelke UFH, Wevers RA, Solomons R, Reinecke CJ. A hypothetical astrocyte-microglia lactate shuttle derived from a 1H NMR metabolomics analysis of cerebrospinal fluid from a cohort of South African children with tuberculous meningitis. Metabolomics 2015; 11:822-837. [PMID: 26109926 PMCID: PMC4475545 DOI: 10.1007/s11306-014-0741-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 10/04/2014] [Indexed: 12/16/2022]
Abstract
Tuberculosis meningitis (TBM) is the most severe form of extra-pulmonary tuberculosis and is particularly intense in small children; there is no universally accepted algorithm for the diagnosis and substantiation of TB infection, which can lead to delayed intervention, a high risk factor for morbidity and mortality. In this study a proton magnetic resonance (1H NMR)-based metabolomics analysis and several chemometric methods were applied to data generated from lumber cerebrospinal fluid (CSF) samples from three experimental groups: (1) South African infants and children with confirmed TBM, (2) non-meningitis South African infants and children as controls, and (3) neurological controls from the Netherlands. A total of 16 NMR-derived CSF metabolites were identified, which clearly differentiated between the controls and TBM cases under investigation. The defining metabolites were the combination of perturbed glucose and highly elevated lactate, common to some other neurological disorders. The remaining 14 metabolites of the host's response to TBM were likewise mainly energy-associated indicators. We subsequently generated a hypothesis expressed as an "astrocyte-microglia lactate shuttle" (AMLS) based on the host's response, which emerged from the NMR-metabolomics information. Activation of microglia, as implied by the AMLS hypothesis, does not, however, present a uniform process and involves intricate interactions and feedback loops between the microglia, astrocytes and neurons that hamper attempts to construct basic and linear cascades of cause and effect; TBM involves a complex integration of the responses from the various cell types present within the CNS, with microglia and the astrocytes as main players.
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Affiliation(s)
- Shayne Mason
- Centre for Human Metabonomics, Faculty of Natural Sciences, North-West University (Potchefstroom Campus), Private Bag X6001, Potchefstroom, 2531 South Africa
| | - A. Marceline van Furth
- Department of Paediatric Infectious Diseases–Immunology and Rheumatology, Vrije Universiteit Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Lodewyk J. Mienie
- Potchefstroom Laboratory for Inborn Errors of Metabolism, Division for Biochemistry, North-West University (Potchefstroom Campus), Private Bag X6001, Potchefstroom, South Africa
| | - Udo F. H. Engelke
- Department of Laboratory Medicine, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Ron A. Wevers
- Department of Laboratory Medicine, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg, 7505 South Africa
| | - Carolus J. Reinecke
- Centre for Human Metabonomics, Faculty of Natural Sciences, North-West University (Potchefstroom Campus), Private Bag X6001, Potchefstroom, 2531 South Africa
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Infektionen. NEUROINTENSIV 2015. [PMCID: PMC7175474 DOI: 10.1007/978-3-662-46500-4_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In diesem Kapitel werden zunächst die für die Neurointensivmedizin wesentlichen bakteriellen Infektionen (Meningitis, spinale und Hirnabszesse, Spondylodiszitis, septisch-embolische Herdenzephalitis) abgehandelt, die trotz gezielt eingesetzter Antibiotika und neurochirurgischer Therapieoptionen noch mit einer erheblichen Morbidität und Mortalität behaftet sind. Besonderheiten wie neurovaskuläre Komplikationen, die Tuberkulose des Nervensystems, Neuroborreliose, Neurosyphilis und opportunistische Infektionen bei Immunsuppressionszuständen finden hierbei besondere Berücksichtigung. Der zweite Teil dieses Kapitels behandelt akute und chronische Virusinfektionen des ZNS sowie in einem gesonderten Abschnitt die HIVInfektion und HIV-assoziierte Krankheitsbilder sowie Parasitosen und Pilzinfektionen, die in Industrieländern seit Einführung der HAART bei HIV zwar eher seltener, aber mit zunehmender Globalisierung auch in unseren Breiten immer noch anzutreffen sind.
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Marais S, Wilkinson KA, Lesosky M, Coussens AK, Deffur A, Pepper DJ, Schutz C, Ismail Z, Meintjes G, Wilkinson RJ. Neutrophil-associated central nervous system inflammation in tuberculous meningitis immune reconstitution inflammatory syndrome. Clin Infect Dis 2014; 59:1638-47. [PMID: 25107295 PMCID: PMC4227574 DOI: 10.1093/cid/ciu641] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The immunopathogenesis of tuberculosis-associated immune reconstitution inflammatory syndrome (IRIS) remains incompletely understood, and we know of only 1 disease site-specific study of the underlying immunology; we recently showed that Mycobacterium tuberculosis culture positivity and increased neutrophils in the cerebrospinal fluid (CSF) of patients with tuberculous meningitis (TBM) are associated with TBM-IRIS. In this study we investigated inflammatory mediators at the disease site in patients with TBM-IRIS. METHODS We performed lumbar puncture at 3-5 time points in human immunodeficiency virus (HIV)-infected patients with TBM (n = 34), including at TBM diagnosis, at initiation of antiretroviral therapy (ART) (day 14), 14 days after ART initiation, at presentation of TBM-IRIS, and 14 days thereafter. We determined the concentrations of 40 mediators in CSF (33 paired with blood) with Luminex or enzyme-linked immunosorbent assays. Findings were compared between patients who developed TBM-IRIS (n = 16) and those who did not (TBM-non-IRIS; n = 18). RESULTS At TBM diagnosis and 2 weeks after ART initiation, TBM-IRIS was associated with severe, compartmentalized inflammation in the CSF, with elevated concentrations of cytokines, chemokines, neutrophil-associated mediators, and matrix metalloproteinases, compared with TBM-non-IRIS. Patients with TBM-non-IRIS whose CSF cultures were positive for M. tuberculosis at TBM diagnosis (n = 6) showed inflammatory responses similar to those seen in patients with TBM-IRIS at both time points. However, at 2 weeks after ART initiation, S100A8/A9 was significantly increased in patients with TBM-IRIS, compared with patients with TBM-non-IRIS whose cultures were positive at baseline. CONCLUSIONS A high baseline M. tuberculosis antigen load drives an inflammatory response that manifests clinically as TBM-IRIS in most, but not all, patients with TBM. Neutrophils and their mediators, especially S100A8/A9, are closely associated with the central nervous system inflammation that characterizes TBM-IRIS.
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Affiliation(s)
- Suzaan Marais
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine Department of Medicine, University of Cape Town, South Africa
| | - Katalin A Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine Department of Medicine, University of Cape Town, South Africa Division of Mycobacterial Research, MRC National Institute for Medical Research
| | - Maia Lesosky
- Department of Medicine, University of Cape Town, South Africa
| | - Anna K Coussens
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine
| | - Armin Deffur
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine Department of Medicine, University of Cape Town, South Africa
| | - Dominique J Pepper
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine
| | - Charlotte Schutz
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine Department of Medicine, University of Cape Town, South Africa
| | - Zahiera Ismail
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine
| | - Graeme Meintjes
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine Department of Medicine, University of Cape Town, South Africa Division of Mycobacterial Research, MRC National Institute for Medical Research
| | - Robert J Wilkinson
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine Department of Medicine, University of Cape Town, South Africa Division of Mycobacterial Research, MRC National Institute for Medical Research Department of Medicine, Imperial College London, United Kingdom
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Comparison of amplicor and GeneXpert MTB/RIF tests for diagnosis of tuberculous meningitis. J Clin Microbiol 2014; 52:3777-80. [PMID: 25056328 DOI: 10.1128/jcm.01235-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
There are no data about the comparative accuracy of commercially available nucleic acid amplification tests (GeneXpert MTB/RIF and Roche Amplicor) for the diagnosis of tuberculous meningitis (TBM). A total of 148 patients with suspected TBM were evaluated, and cultures served as the reference standard. The sensitivities and specificities (95% confidence interval [CI]) for the Amplicor and Xpert MTB/RIF tests were similar: 46 (31-60) versus 50 (33-67) and 99 (93-100) and 94 (84-99), respectively.
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Kim HJ. Importance of contrast-enhanced fluid-attenuated inversion recovery imaging to detect paradoxical expansion of tuberculoma. Int J Infect Dis 2014; 24:37-9. [DOI: 10.1016/j.ijid.2014.03.1383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 03/12/2014] [Accepted: 03/17/2014] [Indexed: 12/01/2022] Open
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Solomons RS, van Elsland SL, Visser DH, Hoek KGP, Marais BJ, Schoeman JF, van Furth AM. Commercial nucleic acid amplification tests in tuberculous meningitis--a meta-analysis. Diagn Microbiol Infect Dis 2014; 78:398-403. [PMID: 24503504 DOI: 10.1016/j.diagmicrobio.2014.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 12/29/2013] [Accepted: 01/02/2014] [Indexed: 11/19/2022]
Abstract
Although nucleic acid amplification tests (NAATs) promise a rapid, definitive diagnosis of tuberculous meningitis, the performance of first-generation NAATs was suboptimal and variable. We conducted a meta-analysis of studies published between 2003 and 2013, using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool to evaluate methodological quality. The diagnostic accuracy of newer commercial NAATs was assessed. Pooled estimates of diagnostic accuracy for commercial NAATs measured against a cerebrospinal fluid Mycobacterium tuberculosis culture-positive gold standard were sensitivity 0.64, specificity 0.98, and diagnostic odds ratio 64.0. Heterogeneity was limited; P value = 0.147 and I(2) = 33.85%. The Xpert MTB/RIF® test was evaluated in 1 retrospective study and 4 prospective studies, with pooled sensitivity 0.70 and specificity 0.97. The QUADAS-2 tool revealed low risk of bias, as well as low concerns regarding applicability. Heterogeneity was pronounced among studies of in-house tests. Commercial NAATs proved to be highly specific with greatly reduced heterogeneity compared to in-house tests. Sub-optimal sensitivity remains a limitation.
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Affiliation(s)
- Regan S Solomons
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa.
| | - Sabine L van Elsland
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa; Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Douwe H Visser
- Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Kim G P Hoek
- Division of Medical Microbiology, Faculty of Health Sciences, National Health Laboratory Service and University of Stellenbosch, Tygerberg 7505, Western Cape, South Africa
| | - Ben J Marais
- Sydney Emerging Infectious Diseases and Biosecurity Institute (SEIB) and the Children's Hospital, Westmead. C29 - Children's Hospital Westmead, The University of Sydney, Westmead, NSW 2006, Australia
| | - Johan F Schoeman
- Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg 7505, Cape, South Africa
| | - Anne M van Furth
- Department of Pediatric Infectious Diseases and Immunology, Vrije Universiteit Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
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Diagnostic accuracy of quantitative PCR (Xpert MTB/RIF) for tuberculous meningitis in a high burden setting: a prospective study. PLoS Med 2013; 10:e1001536. [PMID: 24167451 PMCID: PMC3805498 DOI: 10.1371/journal.pmed.1001536] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 09/12/2013] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is difficult to diagnose promptly. The utility of the Xpert MTB/RIF test for the diagnosis of TBM remains unclear, and the effect of host- and sample-related factors on test performance is unknown. This study sought to evaluate the sensitivity and specificity of Xpert MTB/RIF for the diagnosis of TBM. METHODS AND FINDINGS 235 South-African patients with a meningeal-like illness were categorised as having definite (culture or Amplicor PCR positive), probable (anti-TBM treatment initiated but microbiological confirmation lacking), or non-TBM. Xpert MTB/RIF accuracy was evaluated using 1 ml of uncentrifuged and, when available, 3 ml of centrifuged cerebrospinal fluid (CSF). To evaluate the incremental value of MTB/RIF over a clinically based diagnosis, test accuracy was compared to a clinical score (CS) derived using basic clinical and laboratory information. Of 204 evaluable patients (of whom 87% were HIV-infected), 59 had definite TBM, 64 probable TBM, and 81 non-TBM. Overall sensitivity and specificity (95% CI) were 62% (48%-75%) and 95% (87%-99%), respectively. The sensitivity of Xpert MTB/RIF was significantly better than that of smear microscopy (62% versus 12%; p = 0.001) and significantly better than that of the CS (62% versus 30%; p = 0.001; C statistic 85% [79%-92%]). Xpert MTB/RIF sensitivity was higher when centrifuged versus uncentrifuged samples were used (82% [62%-94%] versus 47% [31%-61%]; p = 0.004). The combination of CS and Xpert MTB/RIF (Xpert MTB/RIF performed if CS<8) performed as well as Xpert MTB/RIF alone but with a ∼10% reduction in test usage. This overall pattern of results remained unchanged when the definite and probable TBM groups were combined. Xpert MTB/RIF was not useful in identifying TBM among HIV-uninfected individuals, although the sample was small. There was no evidence of PCR inhibition, and the limit of detection was ∼80 colony forming units per millilitre. Study limitations included a predominantly HIV-infected cohort and the limited number of culture-positive CSF samples. CONCLUSIONS Xpert MTB/RIF may be a good rule-in test for the diagnosis of TBM in HIV-infected individuals from a tuberculosis-endemic setting, particularly when a centrifuged CSF pellet is used. Further studies are required to confirm these findings in different settings. Please see later in the article for the Editors' Summary.
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Decrease in the incidence of culture-positive meningitis and cerebral tuberculomas in France from 1990 to 2007. Epidemiol Infect 2013; 142:1510-6. [DOI: 10.1017/s0950268813002276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
SUMMARYWe evaluated the incidence rate of culture-positive central nervous system tuberculosis (CNS TB) in France in 2007 and its time trend between 1990 and 2007. We used a capture–recapture analysis by using data recorded in 2007 by the mandatory notification system and the national network of the National Reference Centre (NRC). The 2007 sensitivity of the NRC was 79·4%. The previous sensitivity for 2000 (75·6%) and that for 2007 yielded a pooled estimate of 77·4% (95% confidence interval 64·8–88·0), which was used to extrapolate the number of culture-positive CNS TB cases from those reported in four surveys (1990, 1995, 2000, 2007). The extrapolated number of culture-positive CNS TB cases fell from 90 to 35 between 1990 and 2007, and the extrapolated incidence rates fell from 1·6 to 0·55 cases/million (P < 0·001). This favourable trend should be closely monitored following the change of the BCG vaccination policy in 2007.
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Abstract
Tuberculous meningitis is especially common in young children and people with untreated HIV infection, and it kills or disables roughly half of everyone affected. Childhood disease can be prevented by vaccination and by giving prophylactic isoniazid to children exposed to infectious adults, although improvements in worldwide tuberculosis control would lead to more effective prevention. Diagnosis is difficult because clinical features are non-specific and laboratory tests are insensitive, and treatment delay is the strongest risk factor for death. Large doses of rifampicin and fluoroquinolones might improve outcome, and the beneficial effect of adjunctive corticosteroids on survival might be augmented by aspirin and could be predicted by screening for a polymorphism in LTA4H, which encodes an enzyme involved in eicosanoid synthesis. However, these advances are insufficient in the face of drug-resistant tuberculosis and HIV co-infection. Many questions remain about the best approaches to prevent, diagnose, and treat tuberculous meningitis, and there are still too few answers.
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Sharma K, Sinha SK, Sharma A, Nada R, Prasad KK, Goyal K, Rana SS, Bhasin DK, Sharma M. Multiplex PCR for rapid diagnosis of gastrointestinal tuberculosis. J Glob Infect Dis 2013; 5:49-53. [PMID: 23853431 PMCID: PMC3703210 DOI: 10.4103/0974-777x.112272] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Rapid and specific diagnosis of gastrointestinal tuberculosis (GITB) is of utmost importance. Aim: To evaluate Multiplex PCR (MPCR) using MPB64 and IS6110 primers specific for M. tuberculosis for rapid diagnosis of GITB. Materials and Methods: MPCR was performed on colonoscopy biopsy specimens on 11 GITB confirmed (culture/AFB/histopathology was positive), 29 GITB suspected and 30 Non GITB (control group) patients. Results: MPB64 PCR had sensitivity and specificity of 90% and 100% for confirmed GITB cases. In 29 clinically diagnosed but unconfirmed GITB cases, MPCR was positive in 72.41%. MPCR was negative in all control group patients. The overall sensitivity and specificity of microscopy, culture, histopathology and MPCR was 5%, 2% 20% and 77.5% and 100%, 100%, 100% and 100% respectively. Conclusion: MPCR has good sensitivity and specificity in diagnosing gastrointestinal tuberculosis.
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Affiliation(s)
- Kusum Sharma
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Cunha BA. The clinical and laboratory diagnosis of acute meningitis and acute encephalitis. ACTA ACUST UNITED AC 2013; 7:343-64. [PMID: 23721048 DOI: 10.1517/17530059.2013.804508] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Acute bacterial meningitis (ABM) is a life-threatening infectious disease requiring prompt antimicrobial therapy. ABM must be differentiated from systemic disorders with CNS manifestations that may mimic ABM. ABM should also be differentiated from acute meningoencephalitis (AME) and acute viral encephalitis (AVE). Nonviral causes of AME are treatable. Among the causes of AVE, Herpes simplex encephalitis (HSE) is treatable. This article reviews the clinical diagnostic approach to ABM, AME and AVE. AREAS COVERED The differential diagnostic (DDx) approach to ABM, AME and AVE is based on clinical and laboratory findings. A specific pathogen diagnosis is based on serum/cerebrospinal fluid (CSF) tests. This overview presents the diagnostic approach to ABM, AME and AVE in normal hosts (excluding brain abscesses and chronic CNS infections). EXPERT OPINION It is time critical to diagnose ABM and begin empiric antimicrobial therapy based on the known/most likely pathogen. The diagnosis of ABM depends on clinical features and the CSF profile. The CSF Gram stain and CSF lactic acid (LA) levels provide the most rapid, reliable and cost-effective tests to diagnose ABM. CSF LA levels are also the best way to diagnose partially treated acute bacterial meningitis (PTABM). In those cases of AME/AVE due to viruses with a CSF profile mimicking ABM, for example, HSE, unelevated CSF LA levels rapidly/reliably rule out ABM as a diagnostic possibility.
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Affiliation(s)
- Burke A Cunha
- Winthrop-University Hospital, Infectious Disease Division, Mineola, NY, USA.
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Ho J, Marais BJ, Gilbert GL, Ralph AP. Diagnosing tuberculous meningitis - have we made any progress? Trop Med Int Health 2013; 18:783-93. [DOI: 10.1111/tmi.12099] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Jennifer Ho
- Centre for Infectious Diseases & Microbiology - Public Health; Westmead Hospital; Sydney; NSW; Australia
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Dendane T, Madani N, Zekraoui A, Belayachi J, Abidi K, Zeggwagh AA, Abouqal R. A simple diagnostic aid for tuberculous meningitis in adults in Morocco by use of clinical and laboratory features. Int J Infect Dis 2013; 17:e461-5. [PMID: 23535301 DOI: 10.1016/j.ijid.2013.01.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 01/23/2013] [Accepted: 01/31/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The delay in diagnosis and treatment of tuberculous meningitis (TBM) is a major factor in the high mortality observed with this pathology. The distinction between bacterial meningitis (BM) and TBM by clinical features alone is often impossible, and the available biological resources remain inadequate or inaccessible, especially in developing countries. We attempted to develop a simple diagnostic algorithm on the basis of clinical and laboratory findings that could be used as an early predictor of TBM in adult patients in Morocco. METHODS We compared the clinical and laboratory features on admission of 508 adults in a medical intensive care unit in Morocco who satisfied diagnostic criteria for tuberculous (n=274) or bacterial (n=234) meningitis. Features independently predictive of TBM were modeled by multivariate logistic regression to create a diagnostic rule, and by a classification and regression tree (CART). RESULTS Six features were predictive of a diagnosis of TBM: female gender, duration of symptoms, the presence of localizing signs, white blood cell (WBC) count, the level of serum sodium, and the total cerebrospinal fluid WBC count. The sensitivity for CART was 87% and for a score >7 was 88%; specificity was 96% and 95%, respectively. The internal validation was excellent for both diagnostic methods, with a receiver operating characteristic (ROC) area of 0.906 bootstrap samples for a score >7 and 0.910 for CART. CONCLUSIONS The clinical and laboratory parameters identified in this study may help the clinician with the empiric diagnosis of TBM and could be used in settings with limited microbiological diagnostic support.
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Affiliation(s)
- Tarek Dendane
- Medical Intensive Care Unit Department, Ibn Sina University Hospital, Mohamed V Souissi University, 10000 Rabat, Morocco.
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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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Marais S, Meintjes G, Pepper DJ, Dodd LE, Schutz C, Ismail Z, Wilkinson KA, Wilkinson RJ. Frequency, severity, and prediction of tuberculous meningitis immune reconstitution inflammatory syndrome. Clin Infect Dis 2012; 56:450-60. [PMID: 23097584 PMCID: PMC3540040 DOI: 10.1093/cid/cis899] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Tuberculosis immune reconstitution inflammatory syndrome (IRIS) is a common cause of deterioration in human immunodeficiency virus (HIV)-infected patients receiving tuberculosis treatment after starting antiretroviral therapy (ART). Potentially life-threatening neurological involvement occurs frequently and has been suggested as a reason to defer ART. METHODS We conducted a prospective study of HIV-infected, ART-naive patients with tuberculous meningitis (TBM). At presentation, patients started tuberculosis treatment and prednisone; ART was initiated 2 weeks later. Clinical and laboratory findings were compared between patients who developed TBM-IRIS (TBM-IRIS patients) and those who did not (non-TBM-IRIS patients). A logistic regression model was developed to predict TBM-IRIS. RESULTS Forty-seven percent (16/34) of TBM patients developed TBM-IRIS, which manifested with severe features of inflammation. At TBM diagnosis, TBM-IRIS patients had higher cerebrospinal fluid (CSF) neutrophil counts compared with non-TBM-IRIS patients (median, 50 vs 3 cells ×10(6)/L, P = .02). Mycobacterium tuberculosis was cultured from CSF of 15 TBM-IRIS patients (94%) compared with 6 non-TBM-IRIS patients (33%) at time of TBM diagnosis; relative risk of developing TBM-IRIS if CSF was Mycobacterium tuberculosis culture positive = 9.3 (95% confidence interval [CI], 1.4-62.2). The combination of high CSF tumor necrosis factor (TNF)-α and low interferon (IFN)-γ at TBM diagnosis predicted TBM-IRIS (area under the curve = 0.91 [95% CI, .53-.99]). CONCLUSIONS TBM-IRIS is a frequent, severe complication of ART in HIV-associated TBM and is characterized by high CSF neutrophil counts and Mycobacterium tuberculosis culture positivity at TBM presentation. The combination of CSF IFN-γ and TNF-α concentrations may predict TBM-IRIS and thereby be a means to individualize patients to early or deferred ART.
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Affiliation(s)
- Suzaan Marais
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa.
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Thakur R, Sarma S, Goyal R. Comparison of DNA Extraction Protocols for Mycobacterium Tuberculosis in Diagnosis of Tuberculous Meningitis by Real-time Polymerase Chain Reaction. J Glob Infect Dis 2012; 3:353-6. [PMID: 22223998 PMCID: PMC3249990 DOI: 10.4103/0974-777x.91057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Several nucleic acid amplification techniques are available for detection of Mycobacterium tuberculosis (MTB) in pulmonary and extrapulmonary samples, but insufficient data are available on the diagnostic utility of these techniques in tubercular meningitis where bacilli load is less. The success of final amplification and detection of nucleic acid depends on successful extraction of DNA from the organism. AIMS We performed this study to compare four methods of extraction of MTB DNA from cerebrospinal fluid (CSF) samples so as to select one method of DNA extraction for amplification of nucleic acid from clinical samples. MATERIALS AND METHODS Four methods of extracting MTB DNA from CSF samples for testing by real-time polymerase chain reaction (PCR) were compared: QIAGEN(R) protocol for DNA purification using QIAamp spin procedure (manual), AMPLICOR(R) respiratory specimen preparation kit, MagNA Pure(R) kit extraction, combined manual DNA extraction with automated extraction by MagNA Pure(R). Real-time PCR was performed on COBAS TaqMan 48 Analyzer(R) with known positive and negative controls. RESULTS The detection limit for the combined manual and MagNA Pure(R) extraction protocol was found to be 100 copies of MTB DNA per reaction as against 1,000 copies of MTB DNA per reaction by the QIAGEN(R), AMPLICOR(R), and the MagNA Pure(R) extraction protocol. CONCLUSION The real-time PCR assay employing the combination of manual extraction steps with MagNA Pure(R) extraction protocol for extraction of MTB DNA proved to be better than other extraction methods in analytical sensitivity, but could not detect less than 10(2) bacilli /ml.
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Affiliation(s)
- Rajeev Thakur
- Department of Microbiology, Institute of Human Behaviour and Allied Sciences, Delhi, India
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Bi A, Nakajima C, Fukushima Y, Tamaru A, Sugawara I, Kimura A, Kawahara R, Hu Z, Suzuki Y. A rapid loop-mediated isothermal amplification assay targeting hspX for the detection of Mycobacterium tuberculosis complex. Jpn J Infect Dis 2012; 65:247-51. [PMID: 22627308 DOI: 10.7883/yoken.65.247] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A rapid, simple, and low-cost diagnostic tool for tuberculosis (TB) detection is urgently needed in countries with a high TB burden. Here, we report a novel loop-mediated isothermal amplification (LAMP) assay targeting the hspX gene for the rapid detection of Mycobacterium tuberculosis, M. bovis, M. africanum, and M. microti. The specificity of this assay was evaluated using 4 reference strains of Mycobacterium tuberculosis complex (MTC), 22 species of non-tuberculous mycobacteria (NTM), 7 non-mycobacterial species, and 50 clinical M. tuberculosis isolates. All the reference MTC strains and M. tuberculosis clinical isolates were successfully detected by this method, and there were no false-positive results with NTM or non-mycobacterial species, which demonstrates the high specificity of this assay for MTC. The detection limit was 10 copies of MTC genome within 27 min, and the detection speed of this assay was higher than that of any other isothermal methods reported so far. Because of its speed, simplicity, sensitivity, specificity, and inexpensiveness, the TB hspX LAMP assay is a potential gene diagnostic method for TB detection in developing countries with a high TB burden.
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Affiliation(s)
- Aixiao Bi
- Shanghai Key Laboratory of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Lee CN, Wang YM, Lai WF, Chen TJ, Yu MC, Fang CL, Yu FL, Tsai YH, Chang WS, Zuo C, Renshaw P. Super-paramagnetic iron oxide nanoparticles for use in extrapulmonary tuberculosis diagnosis. Clin Microbiol Infect 2012; 18:E149-57. [DOI: 10.1111/j.1469-0691.2012.03809.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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