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Mane SS, Janardhanan J, Ramakrishnan S, Shah A, Pustake M, Mandal AR. Predictors of outcomes in children with Central Nervous System tuberculosis. Indian J Tuberc 2022; 69:166-171. [PMID: 35379397 DOI: 10.1016/j.ijtb.2021.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/11/2021] [Accepted: 06/09/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Central Nervous system tuberculosis (CNS-Tb) is the most lethal form of extra-pulmonary tuberculosis in children. The lack of markers of outcome provides little information on the efficacy of the current treatment protocols for CNS-Tb and thus results in a higher mortality rate than other extrapulmonary manifestations of tuberculosis. This study aims to identify significant factors that will reliably predict the outcomes at discharge in children admitted with CNS-Tb. METHODS AND MATERIAL This is a prospective observational study in children with neurotuberculosis admitted at a tertiary care hospital. Clinical presentations at the time of admission were studied. Outcomes at the end of in-patient care (completely cured, survival with some/severe disability or death) were correlated with clinical, laboratory, microbiological, and radiological parameters. Univariate and multivariate analyses were applied to study the parameters and a p-value ≤ 0.05 with a confidence interval (CI) of 95% was considered as statistically significant. FINDINGS The study included 100 children between 4 months and 12 years of age with a mean of 5.84 (±3.5) years. At discharge, 55% of children recovered completely, 20% had some or severe disability and 25% died. On multivariate analysis, high CSF protein (p = 0.050) and drug resistance (p = 0.034) were highly associated with fatality. Meningeal enhancements with basal exudates (p = 0.021) and CSF lymphocyte count >90% were highly associated with survival with disability. Stage I disease at presentation (p < 0.0001) was the only variable associated with complete recovery. INTERPRETATION Reliable prognostic markers for CNS-Tb can aid in predicting the efficacy of the current treatment and the anticipated outcome in the children with this disease. FUNDING This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Affiliation(s)
- Sushant S Mane
- Department of Paediatrics, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, 400008, India
| | - Jyothi Janardhanan
- Department of Paediatrics, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, 400008, India
| | - Sharanya Ramakrishnan
- Department of Paediatrics, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, 400008, India
| | - Aniruddh Shah
- Department of Paediatrics, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, 400008, India
| | - Manas Pustake
- Department of Paediatrics, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, 400008, India.
| | - Anindita R Mandal
- Department of Paediatrics, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, 400008, India
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2
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Ocampo FF, Espiritu AI, Jamora RDG. Current status and challenges in the care of patients with bacterial meningitis in the Philippines: A scoping review. Trop Med Int Health 2021; 27:38-48. [PMID: 34861085 DOI: 10.1111/tmi.13704] [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] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Bacterial meningitis is associated with high morbidity and mortality if not treated early. Due to the high disease burden, there are barriers in the provision of healthcare services for these patients, especially in low- to middle-income countries, such as the Philippines. We aimed to give an overview of healthcare services delivery and identify gaps in the provision of care for patients with bacterial meningitis in the Philippines. METHOD We conducted a scoping review on the available literature on the epidemiology, research, health services delivery, diagnostics and management of Filipino patients with bacterial meningitis. A qualitative summary of the results was conducted to provide an overview of the findings. RESULTS There is a paucity of epidemiological data and research on bacterial meningitis. Healthcare expenditure remains out-of-pocket, with limited coverage from the national health insurance programme. There is an inadequate number of neurologists as well as inequities in the distribution of manpower and facilities due to the devolution of the healthcare system. Diagnosis remains a challenge due to the inaccessibility of tests for CSF analysis. Costs of antibiotics, adjunctive treatment, neurosurgical interventions and rehabilitation are also prohibitive. Outbreaks can be prevented by strengthening existing surveillance systems and improving vaccination coverage against the most common causative organisms. CONCLUSION Enormous challenges still exist with regards to health services delivery in patients with bacterial meningitis in the Philippines in terms of epidemiologic data and research, access to healthcare facilities and diagnostic tools, healthcare costs, surveillance systems and immunisation against causative pathogens.
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Affiliation(s)
- Ferron F Ocampo
- Bataan Peninsula Medical Center, Dinalupihan, Bataan, Philippines.,Institute for Neurosciences, St. Luke's Medical Center, Quezon City and Global City, Philippines
| | - Adrian I Espiritu
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.,Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines.,Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Roland Dominic G Jamora
- Institute for Neurosciences, St. Luke's Medical Center, Quezon City and Global City, Philippines.,Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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3
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Abstract
Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells, and physical irritants. However, inappropriately triggered or sustained inflammation can respectively initiate, propagate, or prolong disease. Post-hemorrhagic (PHH) and post-infectious hydrocephalus (PIH) are the most common forms of hydrocephalus worldwide. They are treated using neurosurgical cerebrospinal fluid (CSF) diversion techniques with high complication and failure rates. Despite their distinct etiologies, clinical studies in human patients have shown PHH and PIH share similar CSF cytokine and immune cell profiles. Here, in light of recent work in model systems, we discuss the concept of "inflammatory hydrocephalus" to emphasize potential shared mechanisms and potential therapeutic vulnerabilities of these disorders. We propose that this change of emphasis could shift our thinking of PHH and PIH from a framework of life-long neurosurgical disorders to that of preventable conditions amenable to immunomodulation.
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4
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Banga S, Azad C, Gupta R, Sawal N, Mahajan V, Chander J, Guglani V. Changing Clinicoradiologic Spectrum of Intracranial Neurotuberculosis in Children: A Cross-sectional Study. J Child Neurol 2020; 35:879-888. [PMID: 32677487 DOI: 10.1177/0883073820938594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neurotuberculosis is among the most severe type of tuberculosis with high mortality and morbidity in all age groups. Various sociodemographic and disease-/treatment-related factors have emerged over the years that can affect clinical and radiologic features of neurotuberculosis. OBJECTIVE To investigate various clinical and neuroradiologic presentations of neurotuberculosis. METHODOLOGY This cross-sectional study was done in a tertiary care center of northern India. The patients between the ages of 3 months and 18 years with newly diagnosed neurotuberculosis were enrolled after taking informed consent. RESULTS A total of 78 patients (37% males) were enrolled. Fifty-six patients (72%) had tubercular meningitis (TBM) and 22 (28%) isolated tuberculomas. Very high percentage of patients in both the groups was BCG vaccinated. In the tubercular meningitis group, fever (68%), headache (59%), and vomiting (54%) were the most common complaints whereas in the tuberculoma group, seizures (95.5%) were the main complaint and systemic symptoms were rare. In tubercular meningitis patients, cerebrospinal fluid-based studies showed cartridge-based nucleic acid amplification test (Xpert MTB/RIF) positivity for Mycobacterium tuberculosis in 17.6% cases, whereas on gastric aspirate and sputum examination, acid-fast bacilli were seen in 30.7% and cartridge-based nucleic acid amplification test was positive in 19% patients. On neuroimaging, hydrocephalus was seen in 44.6% of tubercular meningitis patients, infarcts in 32%, and basal exudates in 12% patients only; coexistent tuberculomas were seen in 53%. CONCLUSION Compared with the available literature, the present study showed a smaller percentage of children <5 years of age, stage III tubercular meningitis cases, and typical neuroradiologic findings like hydrocephalus and basal exudates and more tuberculomas associated with tubercular meningitis.
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Affiliation(s)
- Sumiti Banga
- Department of Pediatrics, 29746Government Medical College and Hospital, Chandigarh, India
| | - Chandrika Azad
- Department of Pediatrics, 29746Government Medical College and Hospital, Chandigarh, India
| | - Rekha Gupta
- Department of Radiodiagnosis, 29746Government Medical College and Hospital, Chandigarh, India
| | - Nishit Sawal
- Department of General Medicine, 29746Government Medical College and Hospital, Chandigarh, India
| | - Vidushi Mahajan
- Department of Pediatrics, 29746Government Medical College and Hospital, Chandigarh, India
| | - Jagdish Chander
- Department of Microbiology, 29746Government Medical College and Hospital, Chandigarh, India
| | - Vishal Guglani
- Department of Pediatrics, 29746Government Medical College and Hospital, Chandigarh, India
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5
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Karimy JK, Reeves BC, Damisah E, Duy PQ, Antwi P, David W, Wang K, Schiff SJ, Limbrick DD, Alper SL, Warf BC, Nedergaard M, Simard JM, Kahle KT. Inflammation in acquired hydrocephalus: pathogenic mechanisms and therapeutic targets. Nat Rev Neurol 2020; 16:285-296. [PMID: 32152460 DOI: 10.1038/s41582-020-0321-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
Hydrocephalus is the most common neurosurgical disorder worldwide and is characterized by enlargement of the cerebrospinal fluid (CSF)-filled brain ventricles resulting from failed CSF homeostasis. Since the 1840s, physicians have observed inflammation in the brain and the CSF spaces in both posthaemorrhagic hydrocephalus (PHH) and postinfectious hydrocephalus (PIH). Reparative inflammation is an important protective response that eliminates foreign organisms, damaged cells and physical irritants; however, inappropriately triggered or sustained inflammation can respectively initiate or propagate disease. Recent data have begun to uncover the molecular mechanisms by which inflammation - driven by Toll-like receptor 4-regulated cytokines, immune cells and signalling pathways - contributes to the pathogenesis of hydrocephalus. We propose that therapeutic approaches that target inflammatory mediators in both PHH and PIH could address the multiple drivers of disease, including choroid plexus CSF hypersecretion, ependymal denudation, and damage and scarring of intraventricular and parenchymal (glia-lymphatic) CSF pathways. Here, we review the evidence for a prominent role of inflammation in the pathogenic mechanism of PHH and PIH and highlight promising targets for therapeutic intervention. Focusing research efforts on inflammation could shift our view of hydrocephalus from that of a lifelong neurosurgical disorder to that of a preventable neuroinflammatory condition.
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Affiliation(s)
- Jason K Karimy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Eyiyemisi Damisah
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Phan Q Duy
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Prince Antwi
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Wyatt David
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin Wang
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Steven J Schiff
- Departments of Neurosurgery, Engineering Science & Mechanics, and Physics; Center for Neural Engineering, The Pennsylvania State University, University Park, PA, USA
| | - David D Limbrick
- Departments of Neurosurgery and Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Seth L Alper
- Division of Nephrology and Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Maiken Nedergaard
- Center for Translational Neuromedicine, University of Rochester Medical Center, Rochester, NY, USA.,Center for Translational Neuromedicine, Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristopher T Kahle
- Departments of Neurosurgery, Pediatrics, and Cellular & Molecular Physiology and Yale-Rockefeller NIH Centers for Mendelian Genomics, Yale School of Medicine, New Haven, CT, USA.
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6
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Fatema K, Rahman MM, Akhter S, Akter N, Paul BC, Begum S, Begum F. Clinicoradiologic Profile and Outcome of Children With Tubercular Meningitis in a Tertiary Care Hospital in Bangladesh. J Child Neurol 2020; 35:195-201. [PMID: 31726924 DOI: 10.1177/0883073819884169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Children are most vulnerable to tubercular meningitis. Neuroimaging is an important initial investigation in tubercular meningitis. OBJECTIVE This study was done to describe the clinical profile, neuroimaging changes, and clinical outcome in children with tubercular meningitis. METHODOLOGY This was an observational cohort study on children with tubercular meningitis, between January 2012 and June 2018. Tubercular meningitis was diagnosed on the basis of clinical criteria, cerebrospinal fluid analysis, neuroimaging, and response to antitubercular drug treatment. Preferably magnetic resonance imaging (MRI) with contrast was done. RESULT Out of 79 pediatric patients, 17 patients were lost during follow-up; thus, a total of 62 patients were studied. Mean age at presentation was 7.040 (±3.99 SD) year, 51.6% children were male. Rural children were more affected. Twenty eight (45.2 patients had contact with a person with tuberculosis. Only 3 (4.8%) patients presented within 10 days of duration of illness. Most of the cases (67.7%) were in stage 2 at the time of diagnosis. The most common clinical feature was fever, seizure, and signs of meningeal irritation (all present in 12.9%). In neuroimaging most common findings were tuberculoma (50%), hydrocephalus (54.8%), and basal meningeal enhancement (33.8%). Regarding outcome, 6 (9.67%) patients expired and 47 (75%) patients had sequelae. The most common complications were hydrocephalus (30.64%) and intellectual disability (12.9 ). Hydrocephalus was the most common neuroimaging finding among the patients who expired (33%). CONCLUSION Hydrocephalus is the most common neuroimaging finding. Normal neuroimaging is associated with good outcome whereas all the patients who died had abnormal neuroimaging.
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Affiliation(s)
- Kanij Fatema
- Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Md Mizanur Rahman
- Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Shaheen Akhter
- Department of Pediatric Neurology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Naznin Akter
- Department of Pediatrics, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Bikush Chandra Paul
- Medical Officer, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Suraiya Begum
- Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Fahmida Begum
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
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7
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A Child with Tuberculous Meningitis Complicated by Cortical Venous and Cerebral Sino-Venous Thrombosis. Indian J Pediatr 2019; 86:371-378. [PMID: 30623313 DOI: 10.1007/s12098-018-2830-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 11/30/2018] [Indexed: 01/30/2023]
Abstract
Stroke is common in tuberculous meningitis. Stroke commonly affects the tubercular zone, comprising the anterior part of the thalamus, caudate and the internal capsule (anterior limb and genu). Stroke, in tuberculous meningitis is predominantly arterial ischemic stroke, and is due to infiltrative, proliferative or necrotizing arteritis. Rarely, aneurysm formation and mycotic aneurysms have also been described. The authors describe the clinical and autopsy findings of a 27-mo-old boy with tuberculous meningitis whose course was complicated by arterial and venous strokes, and nonresponse to adequate and appropriate antitubercular therapy.
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8
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Robertson FC, Lepard JR, Mekary RA, Davis MC, Yunusa I, Gormley WB, Baticulon RE, Mahmud MR, Misra BK, Rattani A, Dewan MC, Park KB. Epidemiology of central nervous system infectious diseases: a meta-analysis and systematic review with implications for neurosurgeons worldwide. J Neurosurg 2018:1-20. [PMID: 29905514 DOI: 10.3171/2017.10.jns17359] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/24/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVECentral nervous system (CNS) infections cause significant morbidity and mortality and often require neurosurgical intervention for proper diagnosis and treatment. However, neither the international burden of CNS infection, nor the current capacity of the neurosurgical workforce to treat these diseases is well characterized. The objective of this study was to elucidate the global incidence of surgically relevant CNS infection, highlighting geographic areas for targeted improvement in neurosurgical capacity.METHODSA systematic literature review and meta-analysis were performed to capture studies published between 1990 and 2016. PubMed, EMBASE, and Cochrane databases were searched using variations of terms relating to CNS infection and epidemiology (incidence, prevalence, burden, case fatality, etc.). To deliver a geographic breakdown of disease, results were pooled using the random-effects model and stratified by WHO region and national income status for the different CNS infection types.RESULTSThe search yielded 10,906 studies, 154 of which were used in the final qualitative analysis. A meta-analysis was performed to compute disease incidence by using data extracted from 71 of the 154 studies. The remaining 83 studies were excluded from the quantitative analysis because they did not report incidence. A total of 508,078 cases of CNS infections across all studies were included, with a total sample size of 130,681,681 individuals. Mean patient age was 35.8 years (range: newborn to 95 years), and the male/female ratio was 1:1.74. Among the 71 studies with incidence data, 39 were based in high-income countries, 25 in middle-income countries, and 7 in low-income countries. The pooled incidence of studied CNS infections was consistently highest in low-income countries, followed by middle- and then high-income countries. Regarding WHO regions, Africa had the highest pooled incidence of bacterial meningitis (65 cases/100,000 people), neurocysticercosis (650/100,000), and tuberculous spondylodiscitis (55/100,000), whereas Southeast Asia had the highest pooled incidence of intracranial abscess (49/100,000), and Europe had the highest pooled incidence of nontuberculous vertebral spondylodiscitis (5/100,000). Overall, few articles reported data on deaths associated with infection. The limited case fatality data revealed the highest case fatality for tuberculous meningitis/spondylodiscitis (21.1%) and the lowest for neurocysticercosis (5.5%). In all five disease categories, funnel plots assessing for publication bias were asymmetrical and suggested that the results may underestimate the incidence of disease.CONCLUSIONSThis systematic review and meta-analysis approximates the global incidence of neurosurgically relevant infectious diseases. These results underscore the disproportionate burden of CNS infections in the developing world, where there is a tremendous demand to provide training and resources for high-quality neurosurgical care.
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Affiliation(s)
- Faith C Robertson
- 1Harvard Medical School.,2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Department of Neurosurgery, Boston, Massachusetts
| | - Jacob R Lepard
- 3Department of Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Rania A Mekary
- 2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Department of Neurosurgery, Boston, Massachusetts.,4MCPHS University, Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, Boston
| | - Matthew C Davis
- 3Department of Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Ismaeel Yunusa
- 2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Department of Neurosurgery, Boston, Massachusetts.,4MCPHS University, Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, Boston
| | - William B Gormley
- 1Harvard Medical School.,2Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Department of Neurosurgery, Boston, Massachusetts.,5Department of Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ronnie E Baticulon
- 6University of the Philippines College of Medicine, Philippine General Hospital, Manila, Philippines
| | - Muhammad Raji Mahmud
- 7Department of Surgery, National Hospital Abuja, PMB 425, Federal Capital Territory, Nigeria
| | - Basant K Misra
- 8Department of Neurosurgery & Gamma Knife Radiosurgery, P. D. Hinduja National Hospital, Mahim, Mumbai, India
| | - Abbas Rattani
- 9Meharry Medical College, School of Medicine, Nashville, Tennessee.,10Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; and
| | - Michael C Dewan
- 10Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; and.,11Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kee B Park
- 10Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; and
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9
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Goenka A, Jeena PM, Mlisana K, Solomon T, Spicer K, Stephenson R, Verma A, Dhada B, Griffiths MJ. Rapid Accurate Identification of Tuberculous Meningitis Among South African Children Using a Novel Clinical Decision Tool. Pediatr Infect Dis J 2018; 37:229-234. [PMID: 28777205 PMCID: PMC5747355 DOI: 10.1097/inf.0000000000001726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early diagnosis of tuberculous meningitis (TBM) is crucial to achieve optimum outcomes. There is no effective rapid diagnostic test for use in children. We aimed to develop a clinical decision tool to facilitate the early diagnosis of childhood TBM. METHODS Retrospective case-control study was performed across 7 hospitals in KwaZulu-Natal, South Africa (2010-2014). We identified the variables most predictive of microbiologically confirmed TBM in children (3 months to 15 years) by univariate analysis. These variables were modelled into a clinical decision tool and performance tested on an independent sample group. RESULTS Of 865 children with suspected TBM, 3% (25) were identified with microbiologically confirmed TBM. Clinical information was retrieved for 22 microbiologically confirmed cases of TBM and compared with 66 controls matched for age, ethnicity, sex and geographical origin. The 9 most predictive variables among the confirmed cases were used to develop a clinical decision tool (CHILD TB LP): altered Consciousness; caregiver HIV infected; Illness length >7 days; Lethargy; focal neurologic Deficit; failure to Thrive; Blood/serum sodium <132 mmol/L; CSF >10 Lymphocytes ×10/L; CSF Protein >0.65 g/L. This tool successfully classified an independent sample of 7 cases and 21 controls with a sensitivity of 100% and specificity of 90%. CONCLUSIONS The CHILD TB LP decision tool accurately classified microbiologically confirmed TBM. We propose that CHILD TB LP is prospectively evaluated as a novel rapid diagnostic tool for use in the initial evaluation of children with suspected neurologic infection presenting to hospitals in similar settings.
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Affiliation(s)
- Anu Goenka
- Manchester Collaborative Centre for Inflammation Research, University of Manchester, UK
- Manchester Academic Health Sciences Centre, University of Manchester, UK
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
| | - Prakash M. Jeena
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Koleka Mlisana
- Department of Microbiology, National Health Laboratory Service, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, South Africa
| | - Tom Solomon
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, UK
- Walton Centre NHS Foundation Trust, UK
| | - Kevin Spicer
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Rebecca Stephenson
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
| | - Arpana Verma
- Manchester Academic Health Sciences Centre, University of Manchester, UK
- Centre for Epidemiology, Institute of Population Health, University of Manchester, UK
| | - Barnesh Dhada
- Department of Paediatrics and Child Health, Pietermaritzburg Metropolitan Hospitals Complex, South Africa
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, South Africa
| | - Michael J. Griffiths
- Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, UK
- Department of Neurology, Alder Hey Children’s NHS Trust, UK
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10
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Israni AV, Dave DA, Mandal A, Singh A, Sahi PK, Das RR, Shah A. Tubercular meningitis in children: Clinical, pathological, and radiological profile and factors associated with mortality. J Neurosci Rural Pract 2016; 7:400-4. [PMID: 27365958 PMCID: PMC4898109 DOI: 10.4103/0976-3147.181475] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Childhood tuberculosis is a major public health problem in developing countries with tubercular meningitis being a serious complication with high mortality and morbidity. AIM To study the clinicopathological as well as radiological profile of childhood tuberculous meningitis (TBM) cases. SETTINGS AND DESIGN Prospective, observational study including children <14 years of age with TBM admitted in a tertiary care hospital from Western India. SUBJECTS AND METHODS TBM was diagnosed based on predefined criteria. Glassgow coma scale (GCS) and intracranial pressure (ICP) was recorded. Staging was done as per British Medical Council Staging System. Mantoux test, chest X-ray, cerebrospinal fluid (CSF) examination, neuroimaging, and other investigations were done to confirm TB. STATISTICAL ANALYSIS USED STATA software (version 9.0) was used for data analysis. Various risk factors were determined using Chi-square tests, and a P< 0.05 was considered significant. RESULTS Forty-seven children were included, of which 11 (24.3%) died. Fever was the most common presenting symptom, and meningismus was the most common sign. Twenty-nine (62%) children presented with Stage III disease. Stage III disease, low GCS, and raised ICP were predictors of mortality. Findings on neuroimaging or CSF examination did not predict mortality. CONCLUSIONS Childhood TBM presents with nonspecific clinical features. Stage III disease, low GCS, lack of Bacillus Calmette-Guérin vaccination at birth and raised ICP seem to the most important adverse prognostic factors.
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Affiliation(s)
- Anil V Israni
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Divya A Dave
- Department of Pediatrics, Medical College Baroda and SSG Hospital, Vadodara, Gujarat, India
| | - Anirban Mandal
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Amitabh Singh
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Puneet K Sahi
- Department of Pediatrics, Kalawati Saran Children Hospital, New Delhi, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Arpita Shah
- Department of Pathology, Toprani Advanced Lab Systems, Vadodara, Gujarat, India
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11
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Guler SK, Güneş N, Cokal BG, Yoldas T. Tuberculous ventriculitis as a relapse following central nervous system tuberculoma. Neurol Sci 2014; 36:167-9. [PMID: 24985158 DOI: 10.1007/s10072-014-1861-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 06/18/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Selda Keskin Guler
- Department of Neurology, Ankara Training and Research Hospital, Şükriye district, Ulucanlar Avenue, No: 89, 06340, Ankara, Altındağ, Turkey,
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12
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BCG vaccination in patients with severe combined immunodeficiency: complications, risks, and vaccination policies. J Allergy Clin Immunol 2014; 133:1134-41. [PMID: 24679470 DOI: 10.1016/j.jaci.2014.02.028] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 02/12/2014] [Accepted: 02/17/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Severe combined immunodeficiency (SCID) is a syndrome characterized by profound T-cell deficiency. BCG vaccine is contraindicated in patients with SCID. Because most countries encourage BCG vaccination at birth, a high percentage of patients with SCID are vaccinated before their immune defect is detected. OBJECTIVES We sought to describe the complications and risks associated with BCG vaccination in patients with SCID. METHODS An extensive standardized questionnaire evaluating complications, therapeutics, and outcomes regarding BCG vaccination in patients given a diagnosis of SCID was widely distributed. Summary statistics and association analysis was performed. RESULTS Data on 349 BCG-vaccinated patients with SCID from 28 centers in 17 countries were analyzed. Fifty-one percent of the patients had BCG-associated complications, 34% disseminated and 17% localized (a 33,000- and 400-fold increase, respectively, over the general population). Patients receiving early vaccination (≤1 month) showed an increased prevalence of complications (P = .006) and death caused by BCG-associated complications (P < .0001). The odds of experiencing complications among patients with T-cell numbers of 250/μL or less at diagnosis was 2.1 times higher (95% CI, 1.4-3.4 times higher; P = .001) than among those with T-cell numbers of greater than 250/μL. BCG-associated complications were reported in 2 of 78 patients who received antimycobacterial therapy while asymptomatic, and no deaths caused by BCG-associated complications occurred in this group. In contrast, 46 BCG-associated deaths were reported among 160 patients treated with antimycobacterial therapy for a symptomatic BCG infection (P < .0001). CONCLUSIONS BCG vaccine has a very high rate of complications in patients with SCID, which increase morbidity and mortality rates. Until safer and more efficient antituberculosis vaccines become available, delay in BCG vaccination should be considered to protect highly vulnerable populations from preventable complications.
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Kumar S, Kumar R, Radotra BD, Singh M. Tubercular ventriculitis: an uncommon entity. Indian J Pediatr 2014; 81:608-10. [PMID: 23625471 DOI: 10.1007/s12098-013-1047-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 04/10/2013] [Indexed: 11/24/2022]
Abstract
Although tubercular meningitis is common in children, tubercular ventriculitis is uncommon. The authors report a 3-mo-old infant who had tubercular ventriculitis secondary to disseminated tuberculosis.
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Affiliation(s)
- Suresh Kumar
- Department of Pediatrics, Advanced Pediatric Centre (APC), Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
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14
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Rodrigues MG, Lin J, Masruha MR, Vilanova LCP, Minett TSC. Prognostic factors predicting a fatal outcome in HIV-negative children with neurotuberculosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2011; 68:755-60. [PMID: 21049188 DOI: 10.1590/s0004-282x2010000500015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 03/26/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify prognostic factors predicting a fatal outcome in HIV-negative children with neurotuberculosis based on clinical, epidemiological, and laboratory findings. METHOD The clinical records of all in-patients diagnosed with neurotuberculosis from 1982 to 2005 were evaluated retrospectively. The following prognostic parameters were examined: gender, age, close contact with a tuberculosis-infected individual, vaccination for bacillus Calmette-Guérin, purified protein derivative (PPD) of tuberculin results, concomitant miliary tuberculosis, seizures, CSF results, and hydrocephalus. RESULTS One hundred forty-one patients diagnosed with neurotuberculosis were included. Seventeen percent of the cases resulted in death. The factors that were correlated with a negative outcome included lack of contact with a tuberculosis-infected individual, negative PPD reaction, coma, and longer hospitalisation time. A multiple logistic regression analysis was performed to identify which of these factors most often resulted in death. CONCLUSION Coma at diagnosis, lack of tuberculosis contact, and a non-reactive PPD were the most important predictors of fatality in patients with neurotuberculosis.
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Affiliation(s)
- Murilo Gimenes Rodrigues
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, SP, Brazil.
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van Well GTJ, Paes BF, Terwee CB, Springer P, Roord JJ, Donald PR, van Furth AM, Schoeman JF. Twenty years of pediatric tuberculous meningitis: a retrospective cohort study in the western cape of South Africa. Pediatrics 2009; 123:e1-8. [PMID: 19367678 DOI: 10.1542/peds.2008-1353] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Tuberculous meningitis is the most severe extrapulmonary complication of tuberculosis, with high morbidity and mortality rates. The objective of this study was to assess the relationship between presenting clinical characteristics and outcome of pediatric tuberculous meningitis. PATIENTS AND METHODS We present a retrospective cohort study of all of the children diagnosed with tuberculous meningitis in a large university hospital in South Africa between January 1985 and April 2005. We compared demographic, clinical, and diagnostic characteristics with clinical outcome after 6 months of treatment. RESULTS We included 554 patients. Common characteristics on admission were young age (82%; <5 years), stage II or III tuberculous meningitis (97%), nonspecific symptoms existing for >1 week (58%), poor weight gain or weight loss (91%), loss of consciousness (96%), motor deficit (63%), meningeal irritation (98%), raised intracranial pressure (23%), brainstem dysfunction (39%), and cranial nerve palsies(27%). Common features of tuberculous meningitis on computed tomography scan of the brain were hydrocephalus (82%), periventricular lucency (57%), infarctions(32%), and basal meningeal enhancement (75%). Clinical outcome after 6 months was as follows: normal (16%), mild sequelae (52%), severe sequelae (19%), and death (13%). All of the patients diagnosed with stage I tuberculous meningitis had normal outcome. Factors associated with poor outcome in univariate analyses were as follows: African ethnicity, young age, HIV coinfection, stage III tuberculous meningitis, absence of headache and vomiting, convulsions, decreased level of consciousness,motor deficits, cranial nerve palsies, raised intracranial pressure, brain stem dysfunction and radiographic evidence of hydrocephalus, periventricular lucency, and infarction. Ethnicity, stage of disease, headache, convulsions, motor function, brainstem dysfunction, and cerebral infarctions were independently associated with poor outcome in multivariate logistic regression analysis. CONCLUSIONS Tuberculous meningitis starts with nonspecific symptoms and is often only diagnosed when brain damage has already occurred. Earlier diagnosis will improve outcome significantly. We were able to identify presenting variables independently associated with poor clinical outcome.
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Affiliation(s)
- Gijs T J van Well
- Departments of Pediatrics and Infectious Diseases, VU University Medical Center, Amsterdam, Netherlands; Department of Pediatrics, Maastricht University Medical Center, Maastricht, Netherlands.
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Abstract
The treatment of tuberculosis in children has evolved towards a short course regimen based on 6 months therapy with isoniazid and rifampin supplemented during the first 2 months with pyrazinamide in the case of pulmonary tuberculosis due to susceptible organisms. In the presence of adult type tuberculosis (upper lobe infiltration and cavitation) or in case of increased risk of drug - resistant organisms, a fourth drug is added initially. Extra pulmonary tuberculosis is generally treated similarly to pulmonary disease, except disseminated disease and meningitis, which are treated during 9 to 12 months. The treatment of children co-infected by HIV is more complex due to increased risk of drug resistant organisms and by interaction between rifampin and anti-retroviral agents. Concerning latent tuberculosis infection, the association of isoniazid and rifampin for 3 months is recommended. The drug treatment of tuberculosis should be integrated in a global approach comprising the detection of new cases, organisation of the treatment and follow up of the child to ensure the completion of treatment.
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Affiliation(s)
- M Albertini
- Sevice de pédiatrie, CHU de Nice, hôpital de l'Archet-II, 06202 Nice cedex 03, France.
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Saitoh A, Pong A, Waecker NJ, Leake JAD, Nespeca MP, Bradley JS. Prediction of neurologic sequelae in childhood tuberculous meningitis: a review of 20 cases and proposal of a novel scoring system. Pediatr Infect Dis J 2005; 24:207-12. [PMID: 15750455 DOI: 10.1097/01.inf.0000154321.61866.2d] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite effective antituberculous medications, the mortality and morbidity remain high in children with tuberculous meningitis (TBM). The traditional clinical staging for TBM developed by Lincoln et al in 1960 has been widely used to predict long term neurologic sequelae (NS). In the current era of critical care medicine and corticosteroid therapy, a new scoring system is needed to predict NS more accurately in children with TBM. METHODS We reviewed all available cases of TBM in San Diego, CA, during 1991-2001 retrospectively, and we developed a novel scoring system to predict NS in children with TBM. We assessed a tuberculous meningitis acute neurologic (TBAN) score at day 0 and on day 3 of hospitalization, to compare children who subsequently developed severe NS with those who did not. RESULTS Among 20 children with TBM, 7 children developed severe NS and 1 child died during hospitalization. The TBAN score was higher on day 0 in those with severe NS (5.5 versus 2.0, P = 0.09), and the difference became statistically significant by day 3 of hospitalization (5.5 versus 0.0, P = 0.02). Sensitivity and specificity of the TBAN score (> or =4) on day 0 (75 and 92%) and day 3 (88 and 100%) to predict severe NS were superior to the traditional clinical staging system on day 0 (63 and 58%). CONCLUSIONS The TBAN score is an objective marker for predicting severe NS in children with TBM.
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Affiliation(s)
- Akihiko Saitoh
- Division of Infectious Diseases, Department of Pediatrics, University of California, San Diego, CA, USA
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Abstract
PURPOSE Central nervous system (CNS) tuberculosis remains a public health problem, particularly in developing countries. The aim of this study is to characterize neuroradiologic findings of various intracranial lesions. METHODS We retrospectively reviewed data of 122 patients with CNS tuberculosis, without immunosuppression. CT scan was performed in all patients, whereas 17 patients had CT scan and MRI. RESULTS We included 74 women (61%) and 48 men (39%) with a mean age of 37 years (17 -88y). 18 patients (14,7%) had a history of tuberculosis. Tuberculous meningitis was the most frequent clinical presentation (119 cases). Mycobacterium tuberculosis was isolated in cerebrospinal fluid of 18 patients (15%). Several types of lesions were identified : hydrocephalus (35 cases), tuberculomas (29 cases), leptomeningitis (26 cases), infarction (15 cases), abcesses (2 cases). Hydrocephalus was associated to other lesions in 26 cases. Communication hydrocephalus was present in 28 cases. Multiple tuberculomas were seen in 23 cases (80%), with miliary aspects in some cases. In 3 cases, tuberculoma was present without meningitis. Patients with leptomeningitis showed thick meningeal contrast enhancement involving all basal cisterns. Infarction resulted from arterial englobement or embols, and involved the area of middle cerebral artery (12 cases). CONCLUSION Central nervous system tuberculosis has different appearences, mostly hydrocephalus and tuberculomas. MR with contrast is necessary for diagnosis and for follow-up during treatment.
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Abstract
The lack of specific symptoms and signs in patients with tuberculous meningitis makes early diagnosis difficult. To our knowledge, there has been no report in the literature focusing on tuberculous meningitis patients younger than 1 year of age. In this report, we reviewed the clinical features and laboratory findings of seven infants with tuberculous meningitis encountered during a 15-year period. All patients had fever, cough, and alternation of consciousness at presentation. Five patients had bulging anterior fontanel, and five had generalized tonic-clonic seizures. The purified protein derivative skin test was positive in six patients. Six patients had hyponatremia. All seven patients had abnormal cerebrospinal fluid findings, and six of them demonstrated cell counts less than 500 cells/mm(3) with lymphocytic predominance. Brain sonography examination revealed hydrocephalus in all seven patients. Therefore we conclude that antituberculosis therapy should be promptly initiated in any young infant with a clinical impression of meningitis in the context of cerebrospinal fluid white cell count of less than 500 cells/mm(3) and lymphocytic predominance, hyponatremia, and hydrocephalus.
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Affiliation(s)
- Yu-Ren Tung
- Department of Pediatrics, Chang Gung Memorial Hospital, Niao Sung, Kaohsiung County, Taiwan
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