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Tan DTM, See KC. Diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients: A mini review for clinicians. World J Crit Care Med 2024; 13:91435. [PMID: 38855275 PMCID: PMC11155508 DOI: 10.5492/wjccm.v13.i2.91435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/04/2024] [Accepted: 03/25/2024] [Indexed: 06/03/2024] Open
Abstract
Among critically ill patients, severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality. Yet, it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease. In addition, management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions, drug-disease interactions, and adverse drug reactions. To help clinicians acquire an up-to-date approach to severe tuberculosis, this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.
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Affiliation(s)
- Dominic Ti Ming Tan
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
| | - Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
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2
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Feng B, Fei X, Sun Y, Zhang X, Shang D, Zhou Y, Sheng M, Xu J, Zhang W, Ren W. Prognostic factors of adult tuberculous meningitis in intensive care unit: a single-center retrospective study in East China. BMC Neurol 2021; 21:308. [PMID: 34376174 PMCID: PMC8353730 DOI: 10.1186/s12883-021-02340-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 07/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most lethal form of tuberculosis worldwide. Data on critically ill TBM patients in the intensive care unit (ICU) of China are lacking. We tried to identify prognostic factors of adult TBM patients admitted to ICU in China. METHODS We conducted a retrospective study on adult TBM in ICU between January 2008 and April 2018. Factors associated with unfavorable outcomes at 28 days were identified by logistic regression. Factors associated with 1-year mortality were studied by Cox proportional hazards modeling. RESULTS Eighty adult patients diagnosed with TBM (age 38.5 (18-79) years, 45 (56 %) males) were included in the study. An unfavorable outcome was observed in 39 (49 %) patients and were independently associated with Acute Physiology and Chronic Health Evaluation (APACHE) II > 23 (adjusted odds ratio (aOR) 5.57, 95 % confidence interval (CI) 1.55-19.97), Sequential Organ Failure Assessment (SOFA) > 8 (aOR 9.74, 95 % CI 1.46-64.88), and mechanical ventilation (aOR 18.33, 95 % CI 3.15-106.80). Multivariate Cox regression analysis identified two factors associated with 1-year mortality: APACHE II > 23 (adjusted hazard ratio (aHR) 4.83; 95 % CI 2.21-10.55), and mechanical ventilation (aHR 9.71; 95 % CI 2.31-40.87). CONCLUSIONS For the most severe adult TBM patients of Medical Research Council (MRC) stage III, common clinical factors aren't effective enough to predict outcomes. Our study demonstrates that the widely used APACHE II and SOFA scores on admission can be used to predict short-term outcomes, while APACHE II could also be used to predict long-term outcomes of adult patients with TBM in ICU.
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Affiliation(s)
- Baobao Feng
- Department of Emergency, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, 250021, Jinan, Shandong, China.,Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, China
| | - Xiao Fei
- Department of Infectious Diseases, Weifang Yidu Central Hospital, 262500, Weifang, Shandong, China
| | - Ying Sun
- Department of Critical Care Medicine, Cheeloo College of Medicine, Shandong Provincial Chest Hospital, Shandong University, 250013, Jinan, Shandong, China
| | - Xingguo Zhang
- Department of Emergency, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, 250021, Jinan, Shandong, China.,Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, China
| | - Deya Shang
- Department of Emergency, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, 250021, Jinan, Shandong, China.,Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, China
| | - Yi Zhou
- Department of Emergency, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, 250021, Jinan, Shandong, China.,Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, China
| | - Meiyan Sheng
- Department of Critical Care Medicine, Cheeloo College of Medicine, Shandong Provincial Chest Hospital, Shandong University, 250013, Jinan, Shandong, China
| | - Jiarui Xu
- Department of Emergency, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, 250021, Jinan, Shandong, China.,Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, China
| | - Wei Zhang
- Department of Emergency, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, 250021, Jinan, Shandong, China.,Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, China
| | - Wanhua Ren
- Department of Infectious Diseases, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, 324 Jingwu Weiqi Road, 250021, Jinan, Shandong, China. .,Department of Infectious Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, China.
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3
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García-Grimshaw M, Gutiérrez-Manjarrez FA, Navarro-Álvarez S, González-Duarte A. Clinical, Imaging, and Laboratory Characteristics of Adult Mexican Patients with Tuberculous Meningitis: A Retrospective Cohort Study. J Epidemiol Glob Health 2021; 10:59-64. [PMID: 32175711 PMCID: PMC7310801 DOI: 10.2991/jegh.k.191023.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/20/2019] [Indexed: 12/21/2022] Open
Abstract
Tuberculous Meningitis (TBM) is the most common form of central nervous system Tuberculosis (TB), accounting for 5–6% of extrapulmonary TB cases. Nowadays, TBM continues to be a major topic in public health because of its high prevalence worldwide. This retrospective study aimed to describe the clinical, laboratory, and imaging characteristics at admission; and in-hospital outcome of adult Mexican patients with TBM. We collected data from medical records of patients aged ≥18 years diagnosed with TBM according to the uniform case definition for clinical research who were treated at Tijuana General Hospital between January 2015 and March 2018 and compared them according to the subtype of diagnosis. We included 41 cases (26 males, median age 28 years, range 18–57 years), 13 (31.7%) patients were HIV positive, and 21 (51.2%) were illicit drug users. At admission, 7 (17.1%) patients were in stage I, 22 (53.6%) in stage II, and 12 (29.3%) in stage III. A definitive diagnosis was established in 23 (56.1%) patients, probable in 14 (34.1%), and possible in four (9.8%). Molecular testing was positive in 83% of the cases, yielding significantly higher positive results than other microbiological studies. There were eight (19.5%) deaths, without statistical difference between mortality and not having a definitive diagnosis (p = 0.109). We found that the baseline characteristics of our population were similar to those described by other authors worldwide. In this series, molecular testing showed to be very useful when used in the early stages, particularly in subjects with subacute onset of headache, fever, weight loss, and altered mental status.
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Affiliation(s)
- Miguel García-Grimshaw
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, México.,Department of Internal Medicine, Hospital General Tijuana; Tijuana, Baja California, México
| | | | - Samuel Navarro-Álvarez
- Department of Infectious Diseases, Hospital General Tijuana; Tijuana, Baja California, México
| | - Alejandra González-Duarte
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, México
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4
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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5
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Kalita J, Misra UK, Singh VK, Pandey PC, Thomas J. Inclusion of Mechanical Ventilation in Severity Staging of Tuberculous Meningitis Improves Outcome Prediction. Am J Trop Med Hyg 2020; 103:689-695. [PMID: 32458779 DOI: 10.4269/ajtmh.20-0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Patients with tuberculous meningitis (TBM) in any stage of the British Medical Research Council (BMRC) scale, if requiring mechanical ventilation (MV), are likely to have a poor outcome. We report the usefulness of BMRC, BMRC-MV, and BMRC-hydrocephalus (BMRC-HC) staging, and Haydarpasa Meningitis Severity Index (HAMSI) scoring in predicting the outcome of TBM. One hundred ninety-seven TBM patients were analyzed from a prospectively maintained TBM registry. The severity of meningitis was categorized using BMRC (stages I-III), BMRC-MV (I-IV [MV patients were grouped as stage IV]), and BMRC-HC (I-IV [BMRC stage III patients with hydrocephalus were grouped as stage IV]). Haydarpasa Meningitis Severity Index scoring was categorized as < 6 and ≥ 6. The outcome was defined at 6 months using the modified Rankin Scale (mRS) as death, poor (mRS score > 2), or good (mRS score ≤ 2). Forty-nine (25%) patients died. BMRC-mechanical ventilation stage IV had the highest predictive value for defining death, with a sensitivity of 88% and a specificity of 86%. About 81.7% of surviving patients had a good outcome at 6 months. BMRC-mechanical ventilation stages I-III had the highest predictive value for defining good outcome, with a sensitivity of 93% and a specificity of 61%. In TBM, BMRC-MV staging has the best predictive value for defining death and disability.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Varun K Singh
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Prakash C Pandey
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Justin Thomas
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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6
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Abdulaziz ATA, Li J, Zhou D. The prevalence, characteristics and outcome of seizure in tuberculous meningitis. ACTA EPILEPTOLOGICA 2020. [DOI: 10.1186/s42494-020-0010-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractSeizures are a common finding in patients with tuberculous meningitis (TBM), and associate with four times increased risk of death and neurological disability, especially in children. It has been reported that brain inflammation, diffuse neuronal injury, and reactive gliosis may all contribute to the pathogenesis of seizures in TBM. Early seizure onset may be associated with meningeal irritation and cerebral oedema; while, the late seizures are usually due to infarction, hydrocephalus, tuberculoma and paradoxical response. Moreover, recurrent uncontrolled seizures can evolve to status epileptics resulting in an increased risk of chronic epilepsy and poor prognosis. Therefore, this review aimed to assess the frequency of seizures in patients with TBM, and discuss the etiologies, mechanisms, and characteristics of seizures in TBM. Besides, we have searched the literature to identify the prognostic factors for chronic epilepsy after TBM.
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7
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2020. [PMID: 31984242 DOI: 10.12688/wellcomeopenres.15512.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.,Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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8
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Wang MG, Luo L, Zhang Y, Liu X, Liu L, He JQ. Treatment outcomes of tuberculous meningitis in adults: a systematic review and meta-analysis. BMC Pulm Med 2019; 19:200. [PMID: 31694599 PMCID: PMC6833188 DOI: 10.1186/s12890-019-0966-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 10/18/2019] [Indexed: 02/05/2023] Open
Abstract
Background Tuberculous meningitis is the most devastating presentation of disease with Mycobacterium tuberculosis. We sought to evaluate treatment outcomes for adult patients with this disease. Methods The Ovid MEDLINE, EMBASE, Cochrane Library and Web of Science databases were searched to identify all relevant studies. We pooled appropriate data to estimate treatment outcomes at the end of treatment and follow-up. Results Among the articles identified, 22 met our inclusion criteria, with 2437 patients. In a pooled analysis, the risk of death was 24.7% (95%CI: 18.7–31.9). The risk of neurological sequelae among survivors was 50.9% (95%CI: 40.2–61.5). Patients diagnosed in stage III or human immunodeficiency virus (HIV) positive were significantly more likely to die (64.8, 53.4% respectively) during treatment. The frequency of cerebrospinal fluid (CSF) acid-fast-bacilli smear positivity was 10.0% (95% CI 5.5–17.6), 23.8% (15.2–35.3) for CSF culture positivity, and 22.3% (17.8–27.5) for CSF polymerase chain reaction positivity. We found that the headache, fever, vomiting, and abnormal chest radiograph were the most common symptoms and diagnostic findings among tuberculous meningitis patients. Conclusions Despite anti-tuberculosis treatment, adult tuberculous meningitis has very poor outcomes. The mortality rate of patients diagnosed in stage III or HIV co-infection increased significantly during treatment.
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Affiliation(s)
- Ming-Gui Wang
- Department of Respiratory and Critical Care Medicine West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, China
| | - Lan Luo
- Department of Respiratory and Critical Care Medicine West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, China
| | - Yunxia Zhang
- Chengdu Medical College, Chengdu, Sichuan Province, People's Republic of China
| | - Xiangming Liu
- Department of Respiratory and Critical Care Medicine West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, China
| | - Lin Liu
- Department of Respiratory and Critical Care Medicine, 363 Hospital, Chengdu, Sichuan Province, People's Republic of China
| | - Jian-Qing He
- Department of Respiratory and Critical Care Medicine West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041, China.
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9
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2019; 4:163. [PMID: 31984242 PMCID: PMC6964359 DOI: 10.12688/wellcomeopenres.15512.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/21/2022] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K. Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W. Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Division of Pediatric Critical Care, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A. Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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10
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Jin T, Jin Y, Lee SM. Medication Use and Risk of Delirium in Mechanically Ventilated Patients. Clin Nurs Res 2019; 30:474-481. [PMID: 31466469 DOI: 10.1177/1054773819868652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
One of the principal complications in patients in the intensive care unit, particularly in those receiving mechanical ventilation, is medication-induced delirium. The present study aimed to intensively analyze pharmaceutical factors affecting the development of delirium in mechanically ventilated patients using the electronic health records. The present study was designed as a retrospective case-control study. The delirium group included 500 mechanically ventilated patients. The non-delirium group included 2,000 patients who were hospitalized during the same period as the delirium group and received mechanical ventilation. A total of seven types of medications (narcotic analgesics, non-narcotic analgesics, psychopharmaceuticals, sleep aid medications, anticholinergics, steroids, and diuretics), conventionally used to manage mechanical ventilation, were found to be major risk factors associated with the occurrence of delirium. Since these medications are an integral part of managing mechanically ventilated patients, prudent protocol-based medication approaches are essential to decrease the risk of delirium.
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Affiliation(s)
- Taixian Jin
- The Catholic University of Korea, Seoul, Republic of Korea
| | | | - Sun-Mi Lee
- The Catholic University of Korea, Seoul, Republic of Korea
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11
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Donovan J, Figaji A, Imran D, Phu NH, Rohlwink U, Thwaites GE. The neurocritical care of tuberculous meningitis. Lancet Neurol 2019; 18:771-783. [PMID: 31109897 DOI: 10.1016/s1474-4422(19)30154-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 12/16/2022]
Abstract
Tuberculous meningitis is the most severe form of tuberculosis and often causes critical illness with high mortality. Two primary management objectives are reducing intracranial pressure, and optimising cerebral perfusion, while killing the bacteria and controlling intracerebral inflammation. However, the evidence base guiding the care of critically ill patients with tuberculous meningitis is poor and many patients do not have access to neurocritical care units. Invasive intracranial pressure monitoring is often unavailable and although new non-invasive monitoring techniques show promise, further evidence for their use is required. Optimal management regimens of neurological complications (eg, hydrocephalus and paradoxical reactions) and of hyponatraemia, which frequently accompanies tuberculous meningitis, remain to be elucidated. Advances in the field of tuberculous meningitis predominantly focus on diagnosis, inflammatory processes, and antituberculosis chemotherapy. However, clinical trials are required to provide robust evidence guiding the most effective supportive, therapeutic, and neurosurgical interventions for tuberculous meningitis that will improve morbidity and mortality.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Darma Imran
- Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Ursula Rohlwink
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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12
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Cantier M, Morisot A, Guérot E, Megarbane B, Razazi K, Contou D, Mariotte E, Canet E, De Montmollin E, Dubée V, Boulet E, Gaudry S, Voiriot G, Mayaux J, Pène F, Neuville M, Mourvillier B, Ruckly S, Bouadma L, Wolff M, Timsit JF, Sonneville R. Functional outcomes in adults with tuberculous meningitis admitted to the ICU: a multicenter cohort study. Crit Care 2018; 22:210. [PMID: 30119686 PMCID: PMC6098613 DOI: 10.1186/s13054-018-2140-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is a devastating infection in tuberculosis endemic areas with limited access to intensive care. Functional outcomes of severe adult TBM patients admitted to the ICU in nonendemic areas are not known. METHODS We conducted a retrospective multicenter cohort study (2004-2016) of consecutive TBM patients admitted to 12 ICUs in the Paris area, France. Clinical, biological, and brain magnetic resonance imaging (MRI) findings at admission associated with a poor functional outcome (i.e., a score of 3-6 on the modified Rankin scale (mRS) at 90 days) were identified by logistic regression. Factors associated with 1-year mortality were investigated by Cox proportional hazards modeling. RESULTS We studied 90 patients, of whom 61 (68%) had a score on the Glasgow Coma Scale ≤ 10 at presentation and 63 (70%) required invasive mechanical ventilation. Brain MRI revealed infarction and hydrocephalus in 38/75 (51%) and 25/75 (33%) cases, respectively. A poor functional outcome was observed in 55 (61%) patients and was independently associated with older age (adjusted odds ratio (aOR) 1.03, 95% CI 1.0-1.07), cerebrospinal fluid protein level ≥ 2 g/L (aOR 5.31, 95% CI 1.67-16.85), and hydrocephalus on brain MRI (aOR 17.2, 95% CI 2.57-115.14). By contrast, adjunctive steroids were protective (aOR 0.13, 95% CI 0.03-0.56). The multivariable adjusted hazard ratio of adjunctive steroids for 1-year mortality (47%, 95% CI 37%-59%) was 0.23 (95% CI 0.11-0.44). Among survivors at 1 year, functional independence (mRS of 0-2) was observed in 27/37 (73%, 95% CI 59%-87%) cases. CONCLUSIONS A poor functional outcome in adult TBM patients admitted to the ICU in a nonendemic area is observed in 60% of cases and is independently associated with elevated cerebrospinal fluid protein level and hydrocephalus. Our data also suggest a protective effect of adjunctive steroids, with reduced disability and mortality, irrespective of immune status and severity of disease at presentation. One-year follow-up revealed functional independence in most survivors.
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Affiliation(s)
- Marie Cantier
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75018 Paris, France
- Department of Neurology, Saint Antoine University Hospital, Assistance Publique—Hôpitaux de Paris, 184 rue du Faubourg Saint Antoine, 75011 Paris, France
| | - Adeline Morisot
- Department of Public Health, L’Archet Hospital, Nice University Hospital, Nice, France
| | - Emmanuel Guérot
- Department of Intensive Care Medicine, Georges Pompidou European Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Bruno Megarbane
- Department of Intensive Care Medicine and Toxicology, Lariboisière University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Keyvan Razazi
- Department of Intensive Care Medicine, Henri Mondor University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Damien Contou
- Department of Intensive Care Medicine, Henri Mondor University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Eric Mariotte
- Department of Intensive Care Medicine, Saint-Louis University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Emmanuel Canet
- Department of Intensive Care Medicine, Saint-Louis University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Etienne De Montmollin
- Department of Intensive Care Medicine, Saint-Denis Delafontaine Hospital, Saint-Denis, France
| | - Vincent Dubée
- Department of Intensive Care Medicine, Saint-Antoine University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Eric Boulet
- Department of Intensive Care Medicine, René Dubos Hospital, Pontoise, France
| | - Stéphane Gaudry
- Medical-Surgical Intensive Care Unit, Louis Mourier University Hospital, Assistance Publique—Hôpitaux de Paris, Colombes, France
| | - Guillaume Voiriot
- Department of Intensive Care Medicine, Tenon University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Julien Mayaux
- Department of Pneumology and Intensive Care Medicine, La Pitié-Salpêtrière University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Frédéric Pène
- Department of Intensive Care Medicine, Cochin University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
| | - Mathilde Neuville
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75018 Paris, France
| | - Bruno Mourvillier
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75018 Paris, France
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, control and care, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Stéphane Ruckly
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, control and care, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Lila Bouadma
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75018 Paris, France
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, control and care, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Michel Wolff
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75018 Paris, France
| | - Jean-François Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75018 Paris, France
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, control and care, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Romain Sonneville
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75018 Paris, France
- UMR 1148, Laboratory for Vascular and Translational Science, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - ENCEPHALITICA study group
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75018 Paris, France
- Department of Public Health, L’Archet Hospital, Nice University Hospital, Nice, France
- Department of Intensive Care Medicine, Georges Pompidou European Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
- Department of Intensive Care Medicine and Toxicology, Lariboisière University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
- Department of Intensive Care Medicine, Henri Mondor University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
- Department of Intensive Care Medicine, Saint-Louis University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
- Department of Intensive Care Medicine, Saint-Denis Delafontaine Hospital, Saint-Denis, France
- Department of Intensive Care Medicine, Saint-Antoine University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
- Department of Intensive Care Medicine, René Dubos Hospital, Pontoise, France
- Medical-Surgical Intensive Care Unit, Louis Mourier University Hospital, Assistance Publique—Hôpitaux de Paris, Colombes, France
- Department of Intensive Care Medicine, Tenon University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
- Department of Pneumology and Intensive Care Medicine, La Pitié-Salpêtrière University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
- Department of Intensive Care Medicine, Cochin University Hospital, Assistance Publique—Hôpitaux de Paris, Paris, France
- UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, control and care, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- UMR 1148, Laboratory for Vascular and Translational Science, INSERM/Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Department of Neurology, Saint Antoine University Hospital, Assistance Publique—Hôpitaux de Paris, 184 rue du Faubourg Saint Antoine, 75011 Paris, France
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Abstract
PURPOSE OF REVIEW Although rare, central nervous system (CNS) infections are increasingly being recognized in immunocompromised patients. The goal of the present review is to provide a practical diagnostic approach for the intensivist, and to briefly discuss some of the most prevalent conditions. RECENT FINDINGS Immunocompromised patients presenting with new neurological symptoms should always be suspected of a CNS infection. These infections carry a poor prognosis, especially if intracranial hypertension, severely altered mental status or seizures are present. Clinical examination and serum blood tests should be followed by brain imaging, and when no contra-indications are present, a lumbar puncture including cerebrospinal fluid PCR to identify causative organisms. Empirical therapy depends on the type of immunodeficiency. In HIV-infected patients, the most common CNS infection is cerebral toxoplasmosis, whereas in other immunocompromised patients, aspergillosis, cryptococcal meningitis and tuberculous meningitis are more prevalent. Multiple pathogens can be detected in up to 15% of patients. The diagnostic value of fast multiplex PCR has yet to be evaluated in this setting. SUMMARY CNS infections represent a rare but severe complication in immunocompromised patients. A systematic approach including early diagnosis, appropriate antimicrobial treatment, early ICU admission and aggressive measures to reduce intracranial pressure may improve outcome.
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