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Qin J, Nong L, Zhu Q, Huang Z, Wu F, Li S. A Retrospective Analysis of Central and Peripheral Metabolic Characteristics in Patients with Cryptococcal Meningitis. Neurol Ther 2024; 13:763-784. [PMID: 38643256 PMCID: PMC11136911 DOI: 10.1007/s40120-024-00610-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/19/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION Most current treatment strategies and investigations on cryptococcal meningitis (CM) focus primarily on the central nervous system (CNS), often overlooking the complex interplay between the CNS and the peripheral system. This study aims to explore the characteristics of central and peripheral metabolism in patients with CM. METHODS Patients diagnosed with CM as per the hospital records of the Fourth People's Hospital of Nanning were retrospectively analyzed. Patients were divided into two groups, non-structural damage of the brain (NSDB) and structural damage of the brain (SDB), according to the presence of brain lesions as detected with imaging. Based on the presence of enlarged cerebral ventricles, the cases in the SDB group were classified into non-ventriculomegaly (NVM) and ventriculomegaly (VM). Various parameters of cerebrospinal fluid (CSF) and peripheral blood (PB) were analyzed. RESULTS A significant correlation was detected between CSF and PB parameters. The levels of CSF-adenosine dehydrogenase (ADA), CSF-protein, CSF-glucose, and CSF-chloride ions were significantly correlated with the levels of PB-aminotransferase, PB-bilirubin, PB-creatinine (Cr), PB-urea nitrogen, PB-electrolyte, PB-protein, and PB-lipid. Compared with NSDB, the levels of CSF-glucose were significantly decreased in the SDB group, while the levels of CSF-lactate dehydrogenase (LDH) and CSF-protein were significantly increased in the SDB group. In the SDB group, the levels of PB-potassium, PB-hemoglobin(Hb), and PB-albumin were significantly decreased in the patients with VM, while the level of PB-urea nitrogen was significantly increased in these patients. CONCLUSION Metabolic and structural alterations in the brain may be associated with peripheral metabolic changes.
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Affiliation(s)
- Jianglong Qin
- The Fourth People's Hospital of Nanning, 1 Chang-Gang-Two-Li Road, Nanning, Guangxi, 530023, People's Republic of China
| | - Lanwei Nong
- The Fourth People's Hospital of Nanning, 1 Chang-Gang-Two-Li Road, Nanning, Guangxi, 530023, People's Republic of China
| | - Qingdong Zhu
- The Fourth People's Hospital of Nanning, 1 Chang-Gang-Two-Li Road, Nanning, Guangxi, 530023, People's Republic of China
| | - Zhizhong Huang
- The Fourth People's Hospital of Nanning, 1 Chang-Gang-Two-Li Road, Nanning, Guangxi, 530023, People's Republic of China
| | - Fengyao Wu
- The Fourth People's Hospital of Nanning, 1 Chang-Gang-Two-Li Road, Nanning, Guangxi, 530023, People's Republic of China
| | - Sijun Li
- The Fourth People's Hospital of Nanning, 1 Chang-Gang-Two-Li Road, Nanning, Guangxi, 530023, People's Republic of China.
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Ivaska L, Herberg J, Sadarangani M. Distinguishing community-acquired bacterial and viral meningitis: Microbes and biomarkers. J Infect 2024; 88:106111. [PMID: 38307149 DOI: 10.1016/j.jinf.2024.01.010] [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: 10/24/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 02/04/2024]
Abstract
Diagnostic tools to differentiate between community-acquired bacterial and viral meningitis are essential to target the potentially lifesaving antibiotic treatment to those at greatest risk and concurrently spare patients with viral meningitis from the disadvantages of antibiotics. In addition, excluding bacterial meningitis and thus decreasing antibiotic consumption would be important to help reduce antimicrobial resistance and healthcare expenses. The available diagnostic laboratory tests for differentiating bacterial and viral meningitis can be divided microbiological pathogen-focussed methods and biomarkers of the host response. Bacterial culture-independent microbiological methods, such as highly multiplexed nucleic acid amplification tests, are rapidly making their way into the clinical practice. At the same time, more conventional host protein biomarkers, such as procalcitonin and C-reactive protein, are supplemented by newer proteomic and transcriptomic signatures. This review aims to summarise the current state and the recent advances in diagnostic methods to differentiate bacterial from viral meningitis.
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Affiliation(s)
- Lauri Ivaska
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital and University of Turku, Savitehtaankatu 5, 20521 Turku, Finland; InFLAMES Research Flagship Center, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland.
| | - Jethro Herberg
- Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, Norfolk Place, London, United Kingdom.
| | - Manish Sadarangani
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada; Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.
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Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Fabà L, Aragon V, Litjens R, Galofré-Milà N, Segura M, Gottschalk M, Doelman J. Metabolic insights and background from naturally affected pigs during Streptococcus suis outbreaks. Transl Anim Sci 2023; 7:txad126. [PMID: 38023423 PMCID: PMC10660374 DOI: 10.1093/tas/txad126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023] Open
Abstract
Streptococcus suis (S. suis) is an endemic zoonotic pathogen still lacking adequate prevention in pigs. The present case study looked back to the occurrence and consequences of S. suis outbreaks in our swine research facilities in search of new metabolic and physiological insight. From a series of outbreaks, a dataset was created including 56 pigs sampled during disease detection based on clinical signs. Pigs suspected with S. suis infection were defined as diseased (n = 28) and included pigs defined as neurologically diseased (n = 20) when severe neurological signs (central nervous system dysfunctions, i.e., opisthotonos, ataxia, and generalized tremor) were observed. Another set of 28 pigs included respective pen mates from each case and were defined as control. Representative deaths were confirmed to be caused by S. suis. Tonsillar swabs were collected and analyzed by quantitative polymerase chain reaction (qPCR) for total bacteria, total S. suis, and S. suis serotypes (SS) 2 (and/or 1/2) and 9. Blood and sera were analyzed to quantify blood gases, minerals, and S. suis reactive immunoglobulins against current isolates. Data collected included litter sibling associations, birth and weaning body weight (BW), and average daily gain (ADG) 7 d after the disease detection. In general, the disease increased pH, sO2 and the incidence of alkalosis, but reduced pCO2, glucose, Ca, P, Mg, K, and Na in blood/serum compared to control. The SS2 (and/or SS1/2) prevalence was significantly (P < 0.05) increased in neurologically diseased pigs and its relative abundance tended (P < 0.10) to increase in tonsils. In contrast, the relative abundance of total S. suis was lower (P > 0.05) in diseased pigs than control pigs. Levels of S. suis reactive IgG2 were lower, but IgM were higher (P < 0.03) in neurologically affected pigs compared to control. Furthermore, there was an increased proportion of sibling pigs that were diseased compared to control. In conclusion, our results evidence that naturally affected pigs were associated to average performing pigs without any predisease trait to highlight but a sow/litter effect. Besides, neurologically affected pigs had increased S. suis (SS2 and/or 1/2) prevalence and relative abundance, a respiratory alkalosis profile, and mineral loss.
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Affiliation(s)
- Lluís Fabà
- Trouw Nutrition R&D, Amersfoort 3811 MH, The Netherlands
| | - Virginia Aragon
- Unitat mixta d’Investigació IRTA-UAB en Sanitat Animal. Centre de Recerca en Sanitat Animal (CReSA), Campus de la Universitat Autònoma de Barcelona (UAB), Bellaterra, 08193, Catalonia, Spain
- IRTA. Programa de Sanitat Animal. Centre de Recerca en Sanitat Animal (CReSA), Campus de la Universitat Autònoma de Barcelona (UAB), Bellaterra, 08193 Catalonia, Spain
- OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), Bellaterra, Barcelona, Spain
| | - Ralph Litjens
- Trouw Nutrition R&D, Amersfoort 3811 MH, The Netherlands
| | - Núria Galofré-Milà
- Unitat mixta d’Investigació IRTA-UAB en Sanitat Animal. Centre de Recerca en Sanitat Animal (CReSA), Campus de la Universitat Autònoma de Barcelona (UAB), Bellaterra, 08193, Catalonia, Spain
- IRTA. Programa de Sanitat Animal. Centre de Recerca en Sanitat Animal (CReSA), Campus de la Universitat Autònoma de Barcelona (UAB), Bellaterra, 08193 Catalonia, Spain
- OIE Collaborating Centre for the Research and Control of Emerging and Re-Emerging Swine Diseases in Europe (IRTA-CReSA), Bellaterra, Barcelona, Spain
| | - Mariela Segura
- Faculty of Veterinary Medicine, Swine and Poultry Infectious Disease Research Centre, University of Montreal, Saint-Hyacinthe, QC, Canada
| | - Marcelo Gottschalk
- Faculty of Veterinary Medicine, Swine and Poultry Infectious Disease Research Centre, University of Montreal, Saint-Hyacinthe, QC, Canada
| | - John Doelman
- Trouw Nutrition R&D, Amersfoort 3811 MH, The Netherlands
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Wang Q, Wang Y, Yang Y, Kong Y, Peng Y. The value of elevated cerebrospinal fluid lactate concentrations in post-neurosurgical bacterial meningitis. BMC Neurol 2023; 23:377. [PMID: 37864165 PMCID: PMC10588014 DOI: 10.1186/s12883-023-03428-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/06/2023] [Indexed: 10/22/2023] Open
Abstract
Bacterial meningitis is a serious complication after neurosurgery and has a high mortality rate. Early diagnosis and timely treatment are crucial or will have disastrous consequences. The classic triad of bacterial meningitis lacks sensitivity and specificity. Therefore, the diagnosis of post-neurosurgical bacterial meningitis relies on cerebrospinal fluid. But traditional cerebrospinal fluid parameters are not completely reliable in diagnosing post-neurosurgical bacterial meningitis. Previous studies have found that CSF lactate concentration is related to bacterial meningitis. But, after the craniocerebral operation, the cerebrospinal fluid of most patients is bloody. Whether red blood cells interfere with diagnosing PNBM based on lactate concentration is limited. In the current study, we further analysis on whether red blood cells interfere with diagnosing PNBM based on lactate concentration. This study aimed to investigate the value of cerebrospinal fluid lactate concentrations in post-neurosurgical bacterial meningitis. A prospective observational study was performed on 62 patients at Kunshan First People's Hospital's intensive care unit affiliated with Jiangsu University. We found that erythrocytes do not affect cerebrospinal fluid lactate, and elevated lactate concentrations can be used as a marker for postoperative bacterial meningitis.
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Affiliation(s)
- Qin Wang
- Intensive Care Unit, The First People ' s Hospital of Kunshan Affiliated to JiangSu University, Kunshan, 215300, Jiangsu, P.R. China
| | - YongFang Wang
- Intensive Care Unit, The First People ' s Hospital of Kunshan Affiliated to JiangSu University, Kunshan, 215300, Jiangsu, P.R. China
| | - Yan Yang
- Intensive Care Unit, The First People ' s Hospital of Kunshan Affiliated to JiangSu University, Kunshan, 215300, Jiangsu, P.R. China
| | - YanXi Kong
- Intensive Care Unit, The First People ' s Hospital of Kunshan Affiliated to JiangSu University, Kunshan, 215300, Jiangsu, P.R. China
| | - Yuan Peng
- Intensive Care Unit, The First People ' s Hospital of Kunshan Affiliated to JiangSu University, Kunshan, 215300, Jiangsu, P.R. China.
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Osborn MR, Spec A, Mazi PB. Management of HIV-Associated Cryptococcal Meningitis. CURRENT FUNGAL INFECTION REPORTS 2023. [DOI: 10.1007/s12281-023-00458-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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7
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Wasek B, Arning E. Quantitation of Lactate in Cerebrospinal Fluid Using Liquid Chromatography-Electrospray-Tandem Mass Spectrometry. Methods Mol Biol 2022; 2546:253-260. [PMID: 36127595 DOI: 10.1007/978-1-0716-2565-1_23] [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: 11/29/2022]
Abstract
We describe a simple stable isotope dilution method for accurate and precise measurement of cerebrospinal fluid (CSF) lactate as a clinical diagnostic test. Lactate is produced from cellular metabolism, primarily in muscle cells, and provides a source of energy especially during instances of low oxygen levels. Measurement of lactate in CSF provides diagnostic information regarding the body's oxidative metabolism including diagnosis of lactate acidosis, aiding in the diagnosis of blood-brain barrier glucose transporter defect and differentiation between bacterial and viral meningitis. Determination of lactate in CSF (20 μL) was performed utilizing high-performance liquid chromatography coupled with electrospray positive ionization tandem mass spectrometry (HPLC-ESI-MS/MS). Lactate in CSF is determined by a 1:10 dilution with internal standard (sodium lacate-d3) and injected directly onto the HPLC-ESI-MS/MS system. Each assay is quantified using a six-point standard curve (0.625-20 mM) and has an analytical measurement range of 0.3-20 mM.
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Affiliation(s)
- Brandi Wasek
- Institute of Metabolic Disease, Baylor Scott & White Research Institute, Dallas, TX, USA.
| | - Erland Arning
- Institute of Metabolic Disease, Baylor Scott & White Research Institute, Dallas, TX, USA
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8
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Tugume L, Fieberg A, Ssebambulidde K, Nuwagira E, Williams DA, Mpoza E, Rutakingirwa MK, Kagimu E, Kasibante J, Nsangi L, Jjunju S, Musubire AK, Muzoora C, Lawrence DS, Rhein J, Meya DB, Hullsiek KH, Boulware DR, Abassi M. Association of Hyponatremia on Mortality in Cryptococcal Meningitis: A Prospective Cohort. Open Forum Infect Dis 2022; 9:ofac301. [PMID: 35891691 PMCID: PMC9307099 DOI: 10.1093/ofid/ofac301] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/15/2022] [Indexed: 11/15/2022] Open
Abstract
Background Sodium abnormalities are frequent in central nervous system infections and may be caused by cerebral salt wasting, syndrome of inappropriate antidiuretic hormone secretion, or medication adverse events. In cryptococcal meningitis (CM), the prevalence of baseline hyponatremia and whether hyponatremia adversely impacts survival is unknown. Methods We conducted a secondary analysis of data from 2 randomized trials of human immunodeficiency virus-infected adult Ugandans with CM. We grouped serum sodium into 3 categories: <125, 125-129, and 130-145 mmol/L. We assessed whether baseline sodium abnormalities were associated with clinical characteristics and survival. Results Of 816 participants with CM, 741 (91%) had a baseline sodium measurement available: 121 (16%) had grade 3-4 hyponatremia (<125 mmol/L), 194 (26%) had grade 2 hyponatremia (125-129 mmol/L), and 426 (57%) had a baseline sodium of 130-145 mmol/L. Hyponatremia (<125 mmol/L) was associated with higher initial cerebrospinal fluid (CSF) quantitative culture burden (P < .001), higher initial CSF opening pressure (P < .01), lower baseline Glasgow Coma Scale score (P < .01), and a higher percentage of baseline seizures (P = .03). Serum sodium <125 mmol/L was associated with increased 2-week mortality in unadjusted and adjusted survival analyses (adjusted hazard ratio, 1.87 [95% confidence interval, 1.26-2.79]; P < .01) compared to those with sodium 130-145 mmol/L. Conclusions Hyponatremia is common in CM and is associated with excess mortality. A standardized management approach to correctly diagnose and correct hyponatremia in CM needs to be developed and tested.
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Affiliation(s)
- Lillian Tugume
- Correspondence: Lillian Tugume, MBChB, MPH, Infectious Diseases Institute, Makerere University, PO Box 22418, Kampala, Uganda ()
| | - Ann Fieberg
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Darlisha A Williams
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edward Mpoza
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Morris K Rutakingirwa
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Enoch Kagimu
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Samuel Jjunju
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Conrad Muzoora
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David S Lawrence
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Joshua Rhein
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - David R Boulware
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Diagnostic and Prognostic Value of Cerebrospinal Fluid Lactate and Glucose in HIV-Associated Tuberculosis Meningitis. Microbiol Spectr 2022; 10:e0161822. [PMID: 35727068 PMCID: PMC9430741 DOI: 10.1128/spectrum.01618-22] [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] [Indexed: 11/20/2022] Open
Abstract
The role of cerebrospinal fluid (CSF) lactate in tuberculosis meningitis (TBM) diagnosis and prognosis is unclear. The aim of this study was to evaluate the performance of CSF lactate alone and in combination with CSF glucose in predicting a diagnosis of TBM and 14-day survival. HIV-positive Ugandan adults were investigated for suspected meningitis. The baseline CSF tests included smear microscopy; Gram stain; cell count; protein; and point-of-care glucose, lactate, and cryptococcal antigen (CrAg) assays. Where CrAg was negative or there was suspicion of TBM, a CSF Xpert MTB/RIF Ultra (Xpert Ultra) test was performed. We recorded baseline demographic and clinical data and 2-week outcomes. Of 667 patients, 25% (n = 166) had TBM, and of these, 49 had definite, 47 probable, and 70 possible TBM. CSF lactate was higher in patients with definite TBM (8.0 mmol/L; interquartile ratio [IQR], 6.1 to 9.8 mmol/L) than in those with probable TBM (3.4 [IQR, 2.5 to 7.0] mmol/L), possible TBM (2.6 [IQR 2.1 to 3.8] mmol/L), and non-TBM disease (3.5 [IQR 2.5 to 5.0] mmol/L). A 2-fold increase in CSF lactate was associated with 8-fold increased odds of definite TBM (odds ratio, 8.3; 95% confidence interval [CI], 3.6 to 19.1; P < 0.01) and 2-fold increased odds of definite/probable TBM (odds ratio, 2.3; 95% CI, 1.4 to 3.7; P < 0.001). At a cut point of >5.5 mmol/L, CSF lactate could be used to diagnose definite TBM with a sensitivity of 87.7%, specificity of 80.7%, and a negative predictive value of 98.8%. CSF lactate was not predictive of 2-week mortality. IMPORTANCE Tuberculosis meningitis (TBM) is the most severe form of tuberculosis, and its fatality is largely due to delays in diagnosis. The role of CSF lactate has not been evaluated in patients with HIV presenting with signs and symptoms of meningitis. In this study, using a point-of-care handheld lactate machine in patients with HIV-associated meningitis, we showed that high baseline CSF lactate (>5.5 mmol) may be used to rapidly identify patients with TBM and shorten the time to initiate treatment with a similar performance to the Xpert Ultra assay for definite TBM. Elevated CSF lactate levels, however, were not associated with increased 2-week mortality in patients with HIV-associated TBM. Due to moderate specificity, other etiologies of meningitis should be investigated.
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Ssebambulidde K, Gakuru J, Ellis J, Cresswell FV, Bahr NC. Improving Technology to Diagnose Tuberculous Meningitis: Are We There Yet? Front Neurol 2022; 13:892224. [PMID: 35711276 PMCID: PMC9195574 DOI: 10.3389/fneur.2022.892224] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/22/2022] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of tuberculous meningitis (TBM) remains challenging due to a paucity of high-performance diagnostics. Even those that have reasonable sensitivity are not adequate to 'rule out' TBM. Therefore, a combination of clinical factors alongside microbiological, molecular, and radiological investigations are utilized, depending on availability. A low threshold for starting empiric therapy in the appropriate clinical scenario remains crucial for good outcomes in many cases. Herein, we review the current TBM diagnostics landscape with a focus on limitations frequently encountered, such as diagnostic test performance, cost, laboratory infrastructure, and clinical expertise. Though molecular technologies, particularly GeneXpert MTB/Rif Ultra, have been a step forward, diagnosis of TBM remains difficult. We also provide an overview of promising technologies, such as cerebrospinal fluid (CSF) lactate, a new lipoarabinomannan test (FujiLAM), metagenomic next-generation sequencing, and transcriptomics that may further improve our TBM diagnostic capacity and lead to better outcomes.
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Affiliation(s)
- Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global Health and Infection, Brighton and Sussex Medicine School, Brighton, United Kingdom
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, United States
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11
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Stone NRH, Schwartz IS. Identifying the Patients Most Likely to Die from Cryptococcal Meningitis: Time to Move from Recognition to Intervention. Clin Infect Dis 2021; 73:e3083-e3084. [PMID: 33206149 DOI: 10.1093/cid/ciaa1756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Neil R H Stone
- Hospital for Tropical Diseases, University College London Hospitals, London, UK
| | - Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta Edmonton, Alberta, Canada
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