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Stadelman-Behar AM, Tiffin N, Ellis J, Creswell FV, Ssebambulidde K, Nuwagira E, Richards L, Lutje V, Hristea A, Jipa RE, Vidal JE, Azevedo RGS, Monteiro de Almeida S, Kussen GB, Nogueira K, Gualberto FAS, Metcalf T, Heemskerk AD, Dendane T, Khalid A, Ali Zeggwagh A, Bateman K, Siebert U, Rochau U, van Laarhoven A, van Crevel R, Ganiem AR, Dian S, Jarvis J, Donovan J, Nguyen Thuy Thuong T, Thwaites GE, Bahr NC, Meya DB, Boulware DR, Boyles TH. Diagnostic Prediction Model for Tuberculous Meningitis: An Individual Participant Data Meta-Analysis. Am J Trop Med Hyg 2024; 111:546-553. [PMID: 39013385 PMCID: PMC11376156 DOI: 10.4269/ajtmh.23-0789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/18/2024] [Indexed: 07/18/2024] Open
Abstract
No accurate and rapid diagnostic test exists for tuberculous meningitis (TBM), leading to delayed diagnosis. We leveraged data from multiple studies to improve the predictive performance of diagnostic models across different populations, settings, and subgroups to develop a new predictive tool for TBM diagnosis. We conducted a systematic review to analyze eligible datasets with individual-level participant data (IPD). We imputed missing data and explored three approaches: stepwise logistic regression, classification and regression tree (CART), and random forest regression. We evaluated performance using calibration plots and C-statistics via internal-external cross-validation. We included 3,761 individual participants from 14 studies and nine countries. A total of 1,240 (33%) participants had "definite" (30%) or "probable" (3%) TBM by case definition. Important predictive variables included cerebrospinal fluid (CSF) glucose, blood glucose, CSF white cell count, CSF differential, cryptococcal antigen, HIV status, and fever presence. Internal validation showed that performance varied considerably between IPD datasets with C-statistic values between 0.60 and 0.89. In external validation, CART performed the worst (C = 0.82), and logistic regression and random forest had the same accuracy (C = 0.91). We developed a mobile app for TBM clinical prediction that accounted for heterogeneity and improved diagnostic performance (https://tbmcalc.github.io/tbmcalc). Further external validation is needed.
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Affiliation(s)
| | - Nicki Tiffin
- South African National Bioinformatics Institute, University of the Western Cape, Cape Town, South Africa
- Wellcome CIDRI-Africa, University of Cape Town, Cape Town, South Africa
| | - Jayne Ellis
- MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Fiona V Creswell
- MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, East Sussex, United Kingdom
| | | | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lauren Richards
- Division of Infectious Diseases, Department of Internal Medicine, Helen Joseph Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Vittoria Lutje
- Cochrane Infectious Diseases Group, Liverpool, United Kingdom
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Raluca Elena Jipa
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - José E Vidal
- Departmento de Neurologia, Instituto de Infectologia Emílio, São Paulo, Brazil
- Divisão de Clínica de Moléstias Infecciosas e Parasitárias, Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica, Unidade 49, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Renata G S Azevedo
- Departmento de Infectologia, Instituto de Infectologia Emílio, São Paulo, Brazil
| | | | | | - Keite Nogueira
- Hospital de Clinicas, Universidade Federal do Paraná, Curitiba, Brazil
| | | | - Tatiana Metcalf
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Northern Pacific Fogarty Global Health Fellowship Program, National Institutes of Health, University of Washington, Seattle, Washington
| | - Anna Dorothee Heemskerk
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Tarek Dendane
- Medical Intensive Care Unit, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Abidi Khalid
- Medical Intensive Care Unit, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Amine Ali Zeggwagh
- Medical Intensive Care Unit, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Kathleen Bateman
- Neurology Division, Department of Medicine Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Uwe Siebert
- Departments of Epidemiology and Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- UMIT TIROL-University for Health Sciences and Technology, Hall I.T., Tirol, Austria
| | - Ursula Rochau
- UMIT TIROL-University for Health Sciences and Technology, Hall I.T., Tirol, Austria
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ahmad Rizal Ganiem
- Department of Neurology Hasan Sadikin Hospital and TB/HIV Research Center Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Sofiati Dian
- Department of Neurology Hasan Sadikin Hospital and TB/HIV Research Center Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Joseph Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - 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, United Kingdom
| | - Thuong Nguyen Thuy Thuong
- 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, United Kingdom
| | - 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, United Kingdom
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, Faculty of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Tom H Boyles
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Milburn J, Ntwayagae O, Ngoni K, Suresh R, Lemme N, Northcott C, Penney J, Kinsella M, Mechie I, Ensor S, Chebani T, Grint D, Tenforde MW, Avalos A, Ramaabya D, Doyle R, Mokomane M, Mine M, Kranzer K, Jarvis JN. The Impact of GeneXpert Cerebrospinal Fluid Testing on Tuberculous Meningitis Diagnosis in Routine Care in Botswana. Open Forum Infect Dis 2024; 11:ofae489. [PMID: 39301107 PMCID: PMC11412236 DOI: 10.1093/ofid/ofae489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 08/26/2024] [Indexed: 09/22/2024] Open
Abstract
Background Tuberculous meningitis (TBM) disproportionately impacts high-HIV prevalence, resource-limited settings where diagnosis is challenging. The GeneXpert platform has utility in TBM diagnosis, but uptake remains limited. In Botswana, before the introduction of GeneXpert, tuberculosis (TB) testing was only available through mycobacterial culture at the National TB Reference Laboratory. Data describing routine use of Xpert MTB/RIF for cerebrospinal fluid (CSF) testing in resource-limited settings are scarce. Methods Electronic records for patients with CSF tested in government facilities in Botswana between 2016 and 2022 were obtained from a central online repository as part of ongoing national meningitis surveillance. Samples were excluded from 1 site where Xpert MTB/RIF is performed universally. The proportion receiving TB-specific investigation on CSF and the number positive for Mycobacterium tuberculosis following increased Xpert MTB/RIF capacity were determined. Results The proportion of CSF samples receiving TB-specific investigation increased from 4.5% (58/1288) in 2016 to 29.0% (201/693) in 2022, primarily due to increased analysis with Xpert MTB/RIF from 0.9% (11/1288) to 23.2% (161/693). There was an overall decline in the annual number of CSF samples analyzed, but the proportion with microbiologically confirmed TBM increased from 0.4% to 1.2%. The proportion of samples tested for TB that were collected from health care facilities >100 km from the National TB Reference Laboratory increased with Xpert MTB/RIF rollout from 65.9% (87/132) to 78.0% (494/633). Conclusions In Botswana, access to TB culture is challenging in remote populations; more accessible near-patient testing using Xpert MTB/RIF increased the number of patients receiving TB-specific testing on CSF and the number of confirmed TBM cases.
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Affiliation(s)
- James Milburn
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Ookeditse Ntwayagae
- Botswana University of Maryland School of Medicine Health Initiative (BUMMHI), Gaborone, Botswana
| | | | | | - Neo Lemme
- National Health Laboratory, Ministry of Health and Wellness, Gaborone, Botswana
- National Tuberculosis Reference Laboratory, Gaborone, Botswana
| | | | - James Penney
- Botswana Harvard Health Partnership, Gaborone, Botswana
| | | | - Imogen Mechie
- Botswana Harvard Health Partnership, Gaborone, Botswana
| | - Samuel Ensor
- Botswana Harvard Health Partnership, Gaborone, Botswana
| | - Tony Chebani
- Ministry of Health and Wellness, Gaborone, Botswana
| | - Daniel Grint
- Department of Infectious Disease Epidemiology and International Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Ava Avalos
- Botswana Harvard Health Partnership, Gaborone, Botswana
| | | | - Ronan Doyle
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Margaret Mokomane
- School of Allied Health Professions, University of Botswana, Gaborone, Botswana
| | - Madisa Mine
- National Health Laboratory, Ministry of Health and Wellness, Gaborone, Botswana
| | - Katharina Kranzer
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- The Health Research Unit Zimbabwe, Biomedical Research and Training, Harare, Zimbabwe
- Division of Infectious Diseases and Tropical Medicine, Medical Centra of the University of Munich, Munich, Germany
| | - Joseph N Jarvis
- Botswana Harvard Health Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Huynh J, Nhat LHT, Bao NLH, Hai HT, Thu DDA, Tram TTB, Dung VTM, Vinh DD, Ngoc NM, Donovan J, Phu NH, Van Thanh D, Thu NTA, Bang ND, Ha DTM, Nghia HDT, Van Tan L, Van LH, Thwaites G, Thuong NTT. The Ability of a 3-Gene Host Signature in Blood to Distinguish Tuberculous Meningitis From Other Brain Infections. J Infect Dis 2024; 230:e268-e278. [PMID: 38169323 PMCID: PMC11326836 DOI: 10.1093/infdis/jiad606] [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: 08/07/2023] [Revised: 12/10/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is difficult to diagnose. We investigated whether a 3-gene host response signature in blood can distinguish TBM from other brain infections. METHODS The expression of 3 genes (dual specificity phosphatase 3 [DUSP3], guanylate-binding protein [GBP5], krupple-like factor 2 [KLF2]) was analyzed by RNA sequencing of archived whole blood from 4 cohorts of Vietnamese adults: 281 with TBM, 279 with pulmonary tuberculosis, 50 with other brain infections, and 30 healthy controls. Tuberculosis scores (combined 3-gene expression) were calculated following published methodology and discriminatory performance compared using area under a receiver operator characteristic curve (AUC). RESULTS GBP5 was upregulated in TBM compared to other brain infections (P < .001), with no difference in DUSP3 and KLF2 expression. The diagnostic performance of GBP5 alone (AUC, 0.74; 95% confidence interval [CI], .67-.81) was slightly better than the 3-gene tuberculosis score (AUC, 0.66; 95% CI, .58-.73) in TBM. Both GBP5 expression and tuberculosis score were higher in participants with human immunodeficiency virus (HIV; P < .001), with good diagnostic performance of GBP5 alone (AUC, 0.86; 95% CI, .80-.93). CONCLUSIONS The 3-gene host signature in whole blood has the ability to discriminate TBM from other brain infections, including in individuals with HIV. Validation in large prospective diagnostic study is now required.
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Affiliation(s)
- Julie Huynh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, OxfordUnited Kingdom
| | | | | | - Hoang Thanh Hai
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Do Dang Anh Thu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Vu Thi Mong Dung
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Do Dinh Vinh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nghiem My Ngoc
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Joseph Donovan
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, OxfordUnited Kingdom
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- School of Medicine, Vietnam National University of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Dang Van Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Nguyen Duc Bang
- Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Ho Chi Minh City, Vietnam
| | - Dang Thi Minh Ha
- Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Le Van Tan
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, OxfordUnited Kingdom
| | - Le Hong Van
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, OxfordUnited Kingdom
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, OxfordUnited Kingdom
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4
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Chen X, Wei J, Zhang M, Su B, Ren M, Cai M, Zhang Y, Zhang T. Prevalence, incidence, and case fatality of tuberculous meningitis in adults living with HIV: a systematic review and meta-analysis. BMC Public Health 2024; 24:2145. [PMID: 39112980 PMCID: PMC11308199 DOI: 10.1186/s12889-024-19683-4] [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: 03/12/2024] [Accepted: 08/02/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) emerges as a grave complication of tuberculosis in people living with HIV (PLWH). The diagnosis and treatment of TBM pose significant challenges, leading to elevated mortality rates. To comprehensively grasp the epidemiological landscape of TBM in PLWH, a systematic review and meta-analysis were meticulously undertaken. METHODS We performed a comprehensive search in PubMed, Embase, and Web of Science from database inception to September 19th, 2023, with no limitations on the publication type. The search terms were HIV/AIDS terms (AIDS OR HIV OR PLWH) and TBM-related terms (tuberculous meningitis OR TBM). Studies included in this meta-analysis evaluated the incidence of TBM among PLWH, or we were able to calculate the incidence of TBM among PLWH from the research. RESULTS The analysis revealed that the prevalence of TBM among PLWH was 13.6% (95% CI: 6.6-25.9%), with an incidence rate of 1.5 cases per 1000 persons per year. The case fatality rate was found to be 38.1% (95% CI: 24.3-54.1%). No significant publication bias was observed. Meta-regression analysis identified the proportion of females and finance situation as factors influencing the outcomes. CONCLUSIONS Our study highlights TBM as a prevalent opportunistic infection that targets the central nervous system in PLWH. The elevated case fatality rate is especially prominent among PLWH in impoverished regions, underscores the pressing necessity for enhanced management strategies for PLWH suffering from TBM. TRIAL REGISTRATION PROSPERO; No: CRD42022338586.
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Affiliation(s)
- Xue Chen
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Beijing Key Laboratory for HIV/AIDS Research, Capital Medical University, Beijing, 100069, China
- Beijing Youan Hospital, Beijing Institute of Hepatology, Capital Medical University, Beijing, 100069, China
| | - Jiaqi Wei
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Beijing Key Laboratory for HIV/AIDS Research, Capital Medical University, Beijing, 100069, China
| | - Mei Zhang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Beijing Key Laboratory for HIV/AIDS Research, Capital Medical University, Beijing, 100069, China
| | - Bin Su
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Beijing Key Laboratory for HIV/AIDS Research, Capital Medical University, Beijing, 100069, China
| | - Meixin Ren
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Beijing Key Laboratory for HIV/AIDS Research, Capital Medical University, Beijing, 100069, China
| | - Miaotian Cai
- Department of Respiratory and Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Yulin Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China.
- Beijing Research Center for Respiratory Infectious Diseases, Beijing, 100069, China.
| | - Tong Zhang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Beijing Key Laboratory for HIV/AIDS Research, Capital Medical University, Beijing, 100069, China.
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Inbaraj LR, Manesh A, Ponnuraja C, Bhaskar A, Srinivasalu VA, Daniel BD. Comparative evaluation of intensified short course regimen and standard regimen for adults TB meningitis: a protocol for an open label, multi-center, parallel arms, randomized controlled superiority trial (INSHORT trial). Trials 2024; 25:294. [PMID: 38693583 PMCID: PMC11064413 DOI: 10.1186/s13063-024-08133-6] [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: 01/16/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Despite several incremental improvements in the management of tuberculous meningitis (TBM), the mortality rates remain high. In spite of national and international guidelines, variation in the choice, dose, and duration of drugs exist between countries and clinicians. We propose to evaluate a shorter and more effective regimen containing agents with augmented intracerebral drug exposure and anti-inflammatory approaches to improve disability-free survival among patients with TBM. Our strategy incorporates the various developments in the field of TBM over the last two decades and only few trials have evaluated a composite of these strategies in the overall outcomes of TBM. METHODS An open label, parallel arms, randomized controlled superiority trial will be conducted among 372 participants across 6 sites in India. Eligible participants will be randomly allocated in 1:1:1 ratio into one of the three arms. The intervention arm consists of 2 months of high-dose rifampicin (25 mg/kg), moxifloxacin (400 mg), pyrazinamide, isoniazid, aspirin (150 mg), and steroids followed by rifampicin, isoniazid, and pyrazinamide for 4 months. The second intervention arm includes all the drugs as per the first arm except aspirin and the patients in the control arm will receive treatment according to the National TB Elimination Program guidelines. All participants will be followed up for 1 year after the treatment. DISCUSSION: Current WHO regimens have agents with poor central nervous system drug exposure and is too long. It does not reflect the accumulating evidence in the field. We propose a comprehensive clinical trial incorporating the emerging evidence accrued over the last two decades to shorten the duration and improve the treatment outcomes. This multi-centric trial may generate crucial evidence with policy and practice implications in the treatment of TBM. TRIAL REGISTRATION Clinical Trial Registry India CTRI/2023/05/053314. Registered on 31 May 2023 ( https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=ODYzMzg=&Enc=&userName=CTRI/2023/05/053314 ). CLINICALTRIALS gov NCT05917340. Registered on 6 August 2023 ( https://classic. CLINICALTRIALS gov/ct2/show/NCT05917340 ). PROTOCOL VERSION Version 1.3 dated 12 July 2023.
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Affiliation(s)
- Leeberk Raja Inbaraj
- Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India.
| | - Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - C Ponnuraja
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Adhin Bhaskar
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Vignes Anand Srinivasalu
- Department of Clinical Research, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India
| | - Bella Devaleenal Daniel
- Department of Statistics, ICMR- National Institute for Research in Tuberculosis, Chethpet, Chennai, 600031, India.
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Guillem L, Espinosa J, Laporte-Amargos J, Sánchez A, Grijota MD, Santin M. Mortality and sequelae of tuberculous meningitis in a high-resource setting: A cohort study, 1990-2017. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2024; 42:124-129. [PMID: 36737367 DOI: 10.1016/j.eimce.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/14/2022] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Tuberculous meningitis (TBM), the most serious form of tuberculosis, results in high mortality and long-term disability in low-resource countries. We investigated temporal trends in mortality and sequelae in a high-resource low-incidence country. METHODS We performed a retrospective cohort study of all adult patients with TBM at two third-level teaching hospitals in Barcelona (Spain), between January 1990 and December 2017, assessing temporal trends in mortality and sequelae after 12 months over four consecutive 7-year time windows. Rates observed across the four periods were adjusted for covariates. RESULTS Of the 135 cases included, all but one started tuberculosis (TB) treatment and 120 (89.6%) received rifampicin, isoniazid, and pyrazinamide, with or without ethambutol. The probability of being alive at month 12 was 81.8%, with no differences among the four periods: in comparison with the 1990-1996 period, the adjusted hazard ratios and 95% confidence intervals (CI) were 2.55 (0.71-9.25), 0.70 (0.13-3.85), and 1.29 (0.28-5.91) for the 1997-2003, 2004-2010, and 2011-2017 periods respectively. Sequelae were present in 28.3% at month 12, with no differences across the four periods in the adjusted analysis: in comparison with the 1990-1996 period, the odds ratios and 95% CIs were 0.80 (0.09-7.22); 1.94 (0.21-17.96), and 2.42 (0.25-23.07) for the 1997-2003, 2004-2010, and 2011-2017 periods respectively. CONCLUSION This study shows that TBM still causes high mortality and disability even in a high-resource low-incidence TB setting and without improvement over time.
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Affiliation(s)
- Lluïsa Guillem
- Department of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Juan Espinosa
- Department of Infectious Diseases, Vall d'Hebron University Hospital, PROSICS Barcelona, Barcelona, Spain
| | - Júlia Laporte-Amargos
- Department of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Adrián Sánchez
- Department of Infectious Diseases, Vall d'Hebron University Hospital, Programa de Salut Internacional de l'Institut Català de la Salut (PROSICS), Barcelona, Spain; Mycobacterial Diseases Study Group (Grupo de estudio de Infecciones por Micobacterias, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, GEIM-SEIMC) Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Spain
| | - María D Grijota
- Tuberculosis Unit, Department of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Fundamental and Medical-Surgical Nursing, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Miguel Santin
- Tuberculosis Unit, Department of Infectious Diseases, Bellvitge University Hospital-Bellvitge Institute for Biomedical Research (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.
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7
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Yao XP, Hong JC, Jiang ZJ, Pan YY, Liu XF, Wang JM, Fan RJ, Yang BH, Zhang WQ, Fan QC, Li LX, Lin BW, Zhao M. Systemic and cerebrospinal fluid biomarkers for tuberculous meningitis identification and treatment monitoring. Microbiol Spectr 2024; 12:e0224623. [PMID: 38047697 PMCID: PMC10783035 DOI: 10.1128/spectrum.02246-23] [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: 05/29/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
IMPORTANCE Tuberculous meningitis is a life-threatening infection with high mortality and disability rates. Current diagnostic methods using cerebrospinal fluid (CSF) samples have limited sensitivity and lack predictive biomarkers for evaluating prognosis. This study's findings reveal excessive activation of the immune response during tuberculous meningitis (TBM) infection. Notably, a strong negative correlation was observed between CSF levels of monokine induced by interferon-γ (MIG) and the CSF/blood glucose ratio in TBM patients. MIG also exhibited the highest area under the curve with high sensitivity and specificity. This study suggests that MIG may serve as a novel biomarker for differentiating TBM infection in CSF or serum, potentially leading to improved diagnostic accuracy and better patient outcomes.
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Affiliation(s)
- Xiang-Ping Yao
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jian-Chen Hong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zai-Jie Jiang
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
| | - Yu-Ying Pan
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
| | - Xiao-Feng Liu
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jun-Mei Wang
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
| | - Rui-Jie Fan
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
| | - Bi-Hui Yang
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
| | - Wei-Qing Zhang
- Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Qi-Chao Fan
- Department of Infectious Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Li-Xiu Li
- Department of Oncology, Fuzhou Pulmonary Hospital of Fujian, Fuzhou, China
| | - Bi-Wei Lin
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
| | - Miao Zhao
- Department of Neurology, Institute of Neurology of First Affiliated Hospital, Institute of Neuroscience, and Fujian Key Laboratory of Molecular Neurology, Fujian Medical University, Fuzhou, China
- Department of Neurology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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8
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Muzumdar D, Bansal P, Rai S, Bhatia K. Surgery for Central Nervous System Tuberculosis in Children. Adv Tech Stand Neurosurg 2024; 49:255-289. [PMID: 38700688 DOI: 10.1007/978-3-031-42398-7_12] [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] [Indexed: 06/01/2024]
Abstract
Tuberculosis (TB) is the second most common cause of death due to a single infectious agent worldwide after COVID-19. Central nervous system tuberculosis is widely prevalent in the world, especially in the developing countries and continues to be a socioeconomic problem. It is highly devastating form of tuberculosis leading to unacceptable levels of morbidity and mortality despite appropriate antitubercular therapy. The clinical symptoms are varied and nonspecific. They can be easily overlooked. Tuberculous meningitis is the most common presentation and its sequelae viz. vasculitis, infarction and hydrocephalus can be devastating. The ensuing cognitive, intellectual, and endocrinological outcome can be a significant source of morbidity and mortality, especially in resource constrained countries. Early diagnosis and treatment of tuberculous meningitis and institution of treatment is helpful in limiting the course of disease process. The diagnosis of CNS tuberculosis remains a formidable diagnostic challenge. The microbiological methods alone cannot be relied upon. CSF diversion procedures need to be performed at the appropriate time in order to achieve good outcomes. Tuberculous pachymeningitis and arachnoiditis are morbid sequelae of tuberculous meningitis. Tuberculomas present as mass lesions in the craniospinal axis. Tuberculous abscess can mimic pyogenic abscess and requires high index of suspicion. Calvarial tuberculosis is seen in children and responds well to antituberculous chemotherapy. Tuberculosis of the spinal cord is seen similar to intracranial tuberculosis in pathogenesis but with its own unique clinical manifestations and management. Multidrug-resistant tuberculosis is a formidable problem, and alternate chemotherapy should be promptly instituted. The pathogenesis, clinical features, diagnosis, and management of central nervous system tuberculosis in children are summarized. Heightened clinical suspicion is paramount to ensure prompt investigation. Early diagnosis and treatment are essential to a gratifying outcome and prevent complications.
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Affiliation(s)
- Dattatraya Muzumdar
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Puru Bansal
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Survender Rai
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
| | - Kushal Bhatia
- Department of Neurosurgery, Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Mumbai, India
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9
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Kimuda S, Kasozi D, Namombwe S, Gakuru J, Mugabi T, Kagimu E, Rutakingirwa MK, Leon KE, Chow F, Wasserman S, Boulware DR, Cresswell FV, Bahr NC. Advancing Diagnosis and Treatment in People Living with HIV and Tuberculosis Meningitis. Curr HIV/AIDS Rep 2023; 20:379-393. [PMID: 37947980 PMCID: PMC10719136 DOI: 10.1007/s11904-023-00678-6] [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] [Accepted: 10/18/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE OF REVIEW Tuberculous meningitis (TBM) is the most severe form of tuberculosis. Inadequate diagnostic testing and treatment regimens adapted from pulmonary tuberculosis without consideration of the unique nature of TBM are among the potential drivers. This review focuses on the progress being made in relation to both diagnosis and treatment of TBM, emphasizing promising future directions. RECENT FINDINGS The molecular assay GeneXpert MTB/Rif Ultra has improved sensitivity but has inadequate negative predictive value to "rule-out" TBM. Evaluations of tests focused on the host response and bacterial components are ongoing. Clinical trials are in progress to explore the roles of rifampin, fluoroquinolones, linezolid, and adjunctive aspirin. Though diagnosis has improved, novel modalities are being explored to improve the rapid diagnosis of TBM. Multiple ongoing clinical trials may change current therapies for TBM in the near future.
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Affiliation(s)
- Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Kristoffer E Leon
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Felicia Chow
- Departments of Neurology and Medicine (Infectious Diseases), University of California San Francisco, San Francisco, CA, USA
| | - Sean Wasserman
- Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Fiona V Cresswell
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- HIV Interventions, MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
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10
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Zhu X, He N, Tong L, Gu ZH, Li H. Clinical characteristics of tuberculous meningitis in older patients compared with younger and middle-aged patients: a retrospective analysis. BMC Infect Dis 2023; 23:699. [PMID: 37853321 PMCID: PMC10585848 DOI: 10.1186/s12879-023-08700-3] [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: 06/18/2023] [Accepted: 10/12/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Few studies have analyzed the clinical characteristics and adverse factors affecting prognosis in older patients with tuberculous meningitis (TBM). This study aimed to compare the clinical characteristics of TBM in older patients with those in younger and middle-aged patients. METHODS This single-center retrospective study extracted data on the clinical features, cerebrospinal fluid changes, laboratory results, imaging features, and outcomes of patients with TBM from patient medical records and compared the findings in older patients (aged 60 years and older) with those of younger and middle-aged patients (aged 18-59 years). RESULTS The study included 197 patients with TBM, comprising 21 older patients aged 60-76 years at onset, and 176 younger and middle-aged patients aged 18-59 years at onset. Fever was common in both older (81%) and younger and middle-aged patients (79%). Compared with younger and middle-aged patients, older patients were more likely to have changes in awareness levels (67% vs. 40%), peripheral nerve dysfunction (57% vs. 29%), changes in cognitive function (48% vs. 20%), and focal seizures (33% vs. 6%), and less likely to have headache (71% vs. 93%), neck stiffness on meningeal stimulation (38% vs. 62%), and vomiting (47% vs. 68%). The Medical Research Council staging on admission of older patients was stage II (52%) and stage III (38%), whereas most younger and middle-aged patients had stage I (33%) and stage II (55%) disease. Neurological function evaluated on the 28th day of hospitalization was more likely to show poor prognosis in older patients than in younger and middle-aged patients (76% vs. 25%). Older patients had significantly higher red blood cell counts and blood glucose levels, and significantly lower serum albumin and sodium levels than those in younger and middle-aged patients. The cerebrospinal fluid protein levels, nucleated cell counts, glucose levels, and chloride levels did not differ significantly by age. CONCLUSION In patients with TBM, older patients have more severe clinical manifestations, a higher incidence of hydrocephalus and cerebral infarction, and longer hospital stays than younger and middle-aged patients. Older patients thus require special clinical attention.
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Affiliation(s)
- Xiaolin Zhu
- Department of Emergency Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, Sichuan, P. R. China
- Institute of Disaster Medicine, Sichuan University, Chengdu, 610041, Sichuan, P. R. China
- Nursing Key Laboratory of Sichuan Province, Chengdu, 610041, Sichuan, P. R. China
| | - Na He
- Department of Emergency Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, Sichuan, P. R. China
- Institute of Disaster Medicine, Sichuan University, Chengdu, 610041, Sichuan, P. R. China
- Nursing Key Laboratory of Sichuan Province, Chengdu, 610041, Sichuan, P. R. China
| | - Le Tong
- Department of Emergency Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, Sichuan, P. R. China
- Institute of Disaster Medicine, Sichuan University, Chengdu, 610041, Sichuan, P. R. China
- Nursing Key Laboratory of Sichuan Province, Chengdu, 610041, Sichuan, P. R. China
| | - Zhi Han Gu
- Emergency Department of West China Hospital of Sichuan University/Emergency Teaching and Research Department of West China Hospital of Sichuan University, Chengdu, 610041, P. R. China
| | - Hong Li
- Department of Emergency Medicine, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, Sichuan, P. R. China.
- Institute of Disaster Medicine, Sichuan University, Chengdu, 610041, Sichuan, P. R. China.
- Nursing Key Laboratory of Sichuan Province, Chengdu, 610041, Sichuan, P. R. China.
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11
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Upton CM, Wiesner L, Dooley KE, Maartens G. Cerebrospinal Fluid and Tuberculous Meningitis. Clin Infect Dis 2023; 77:158. [PMID: 36987607 DOI: 10.1093/cid/ciad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Affiliation(s)
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Kelly E Dooley
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
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12
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Mazanhanga MT, Joubert A, Castel SA, van der Merwe M, Maartens G, Dooley KE, Upton CM, Wiesner L. Liquid chromatography-tandem mass spectrometry analysis of delamanid and its metabolite in human cerebrospinal fluid using protein precipitation and on-line solid-phase extraction. J Pharm Biomed Anal 2023; 227:115281. [PMID: 36739721 PMCID: PMC10023415 DOI: 10.1016/j.jpba.2023.115281] [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: 12/19/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Abstract
The penetration of the antituberculosis drug delamanid into the central nervous system is not established. The distribution of delamanid and its major metabolite, DM-6705, into the cerebrospinal fluid requires investigation. A liquid chromatography-tandem mass spectrometry method for the quantification of delamanid and DM-6705 in human cerebrospinal fluid was developed and validated. The calibration range for both analytes was 0.300 - 30.0 ng/mL. The deuterium-labelled analogue of delamanid (delamanid-d4) and OPC-14714 were used as internal standards for delamanid and DM-6705, respectively. Samples were processed by protein precipitation followed by on-line solid-phase extraction and high-performance liquid chromatography on an Agilent 1260 HPLC system. A Phenomenex Gemini-NX C18 (5.0 µm, 50 mm × 2.0 mm) analytical column was used for on-line solid-phase extraction, and a Waters Xterra MS C18 (5.0 µm, 100 mm × 2.1 mm) analytical column for chromatographic separation using gradient elution, at a flow rate of 300 µL/min. The total run time was 7.5 min. Analytes were detected by multiple reaction monitoring on an AB Sciex 5500 triple quadrupole mass spectrometer at unit mass resolution, with electrospray ionization in the positive mode. Accuracy and precision were assessed over three independent validation batches. Extraction recoveries were more than 98% and were consistent across the analytical range. Both analytes in CSF exhibited non-specific adsorption to polypropylene tubes. The method was used to analyse cerebrospinal fluid samples from patients with pulmonary tuberculosis in an exploratory pharmacokinetic study.
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Affiliation(s)
- Marian T Mazanhanga
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anton Joubert
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sandra A Castel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marthinus van der Merwe
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kelly E Dooley
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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13
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Nightingale R, Carlin F, Meghji J, McMullen K, Evans D, van der Zalm MM, Anthony MG, Bittencourt M, Byrne A, du Preez K, Coetzee M, Feris C, Goussard P, Hirasen K, Bouwer J, Hoddinott G, Huaman MA, Inglis-Jassiem G, Ivanova O, Karmadwala F, Schaaf HS, Schoeman I, Seddon JA, Sineke T, Solomons R, Thiart M, van Toorn R, Fujiwara PI, Romanowski K, Marais S, Hesseling AC, Johnston J, Allwood B, Muhwa JC, Mortimer K. Post-TB health and wellbeing. Int J Tuberc Lung Dis 2023; 27:248-283. [PMID: 37035971 PMCID: PMC10094053 DOI: 10.5588/ijtld.22.0514] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/02/2022] [Indexed: 04/11/2023] Open
Abstract
TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.
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Affiliation(s)
- R Nightingale
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, Department of Respiratory Medicine, Liverpool University Hospitals NHS foundation Trust, Liverpool, UK
| | - F Carlin
- Department of Infectious Diseases, Liverpool University Hospitals NHS foundation Trust, Liverpool, UK
| | - J Meghji
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, Department of Respiratory Medicine, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - K McMullen
- Division of Neurology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D Evans
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M G Anthony
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M Bittencourt
- University Hospital, University of Sao Paulo School of Medicine, Sao Paulo, SP, Brazil
| | - A Byrne
- Department of Thoracic Medicine, St Vincent´s Hospital Clinical School University of New South Wales, Sydney, NSW, Australia
| | - K du Preez
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M Coetzee
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - C Feris
- Occupational Therapy Department, Windhoek Central Hospital, Ministry of Health and Social Services, Windhoek, Namibia, Division of Occupational Therapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Tygerberg, South Africa
| | - P Goussard
- Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - K Hirasen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, Paediatric Pulmonology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - J Bouwer
- Department of Psychiatry, University of the Witwatersrand, Johannesburg, South Africa
| | - G Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - M A Huaman
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - G Inglis-Jassiem
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - O Ivanova
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, German Centre for Infection Research, Partner Site Munich, Munich, Germany
| | - F Karmadwala
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - H S Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | | | - J A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa, Department of Infectious Diseases, Imperial College London, London, UK
| | - T Sineke
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - R Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg, South Africa
| | - M Thiart
- Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - R van Toorn
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg, South Africa
| | - P I Fujiwara
- Task Force, Global Plan to End TB, 2023-2030, Stop TB Partnership, Geneva, Switzerland
| | - K Romanowski
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada, Provincial TB Services, BC Centre for Disease Control, Vancouver, BC, Canada
| | - S Marais
- Division of Neurology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa, Neurology Research Group, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - J Johnston
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada, Provincial TB Services, BC Centre for Disease Control, Vancouver, BC, Canada
| | - B Allwood
- Division of Pulmonology, Department of Medicine, Faculty of Medicine, Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - J C Muhwa
- Department of Medicine, Therapeutics, Dermatology and Psychiatry, Kenyatta University, Nairobi, Kenya
| | - K Mortimer
- Department of Respiratory Medicine, Liverpool University Hospitals NHS foundation Trust, Liverpool, UK, Department of Medicine, University of Cambridge, Cambridge, UK, Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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14
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Seid G, Alemu A, Dagne B, Gamtesa DF. Microbiological diagnosis and mortality of tuberculosis meningitis: Systematic review and meta-analysis. PLoS One 2023; 18:e0279203. [PMID: 36795648 PMCID: PMC9934382 DOI: 10.1371/journal.pone.0279203] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 12/01/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) which is caused by Mycobacterium tuberculosis poses a significant public health global treat. Tuberculosis meningitis (TBM) accounts for approximately 1% of all active TB cases. The diagnosis of Tuberculosis meningitis is notably difficult due to its rapid onset, nonspecific symptoms, and the difficulty of detecting Mycobacterium tuberculosis in cerebrospinal fluid (CSF). In 2019, 78,200 adults died of TB meningitis. This study aimed to assess the microbiological diagnosis TB meningitis using CSF and estimated the risk of death from TBM. METHODS Relevant electronic databases and gray literature sources were searched for studies that reported presumed TBM patients. The quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal tools designed for prevalence studies. Data were summarized using Microsoft excel ver 16. The proportion of culture confirmed TBM, prevalence of drug resistance and risk of death were calculated using the random-effect model. Stata version 16.0 was used perform the statistical analysis. Moreover, subgroup analysis was conducted. RESULTS After systematic searching and quality assessment, 31 studies were included in the final analysis. Ninety percent of the included studies were retrospective studies in design. The overall pooled estimates of CSF culture positive TBM was 29.72% (95% CI; 21.42-38.02). The pooled prevalence of MDR-TB among culture positive TBM cases was 5.19% (95% CI; 3.12-7.25). While, the proportion of INH mono-resistance was 9.37% (95% CI; 7.03-11.71). The pooled estimate of case fatality rate among confirmed TBM cases was 20.42% (95%CI; 14.81-26.03). Based on sub group analysis, the pooled case fatality rate among HIV positive and HIV negative TBM individuals was 53.39% (95%CI; 40.55-66.24) and 21.65% (95%CI;4.27-39.03) respectively. CONCLUSION Definite diagnosis of TBM still remains global treat. Microbiological confirmation of TBM is not always achievable. Early microbiological confirmation of TBM has great importance to reduce mortality. There was high rate of MDR-TB among confirmed TBM patients. All TB meningitis isolates should be cultured and drug susceptibility tested using standard techniques.
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Affiliation(s)
- Getachew Seid
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ayinalem Alemu
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Biniyam Dagne
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
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15
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Guillem L, Espinosa J, Laporte-Amargos J, Sánchez A, Grijota MD, Santin M. Mortality and sequelae of tuberculous meningitis in a high-resource setting: A cohort study, 1990–2017. Enferm Infecc Microbiol Clin 2022. [DOI: 10.1016/j.eimc.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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16
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Pastick KA, Kagimu E, Dobbin J, Ssebambulidde K, Gakuru J, Milln J, Nakabuye B, Meya DB, Boulware DR, Cresswell FV, Bahr NC. Pregnancy-Related Tuberculous Meningitis and Immune Reconstitution Inflammatory Syndrome: A Case Series and Systematic Review. Open Forum Infect Dis 2022; 9:ofac513. [PMID: 36267255 PMCID: PMC9578166 DOI: 10.1093/ofid/ofac513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Background Tuberculosis is a leading cause of death among women of reproductive age. However, tuberculous meningitis, the most severe form of extrapulmonary tuberculosis, is rarely discussed in pregnancy despite this being a unique period of immune modulation that may predispose women to active disease. Methods We identified and described cases of tuberculous meningitis among pregnant or postpartum women screened during meningitis clinical trials in Uganda from 2018 to 2022. We conducted a systematic literature review via PubMed/Medline and Embase for all English-language publications from 1970 to 10 July 2022, to identify additional cases. Results We identified 8 cases of pregnancy-related tuberculous meningitis in Ugandan women living with human immunodeficiency virus (HIV) and 40 additional cases via systematic literature review (none HIV-positive). Of all combined cases, 50% (24/48) were diagnosed postpartum; 50% (24/48) had initial onset during pregnancy, of which 38% (9/24) had worsening of symptoms or disease relapse following pregnancy cessation. Diagnosis was missed or delayed in 33% (16/48) of cases. For those with known outcomes, maternal mortality was 23% (11/48) and fetal/neonatal mortality was 30% (13/44). Of maternal survivors, 30% (11/37) had residual neurologic deficits. Conclusions The true incidence of tuberculous meningitis in pregnancy or the postpartum period is unclear but likely underappreciated. To date, nearly all published cases have occurred in HIV-negative or otherwise immunocompetent women. Given the well-described physiological immunosuppression during pregnancy and subsequent reconstitution postpartum, physicians must be aware of tuberculous meningitis and pregnancy-related immune reconstitution inflammatory syndrome, especially in countries with a high burden of tuberculosis and in women living with HIV.
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Affiliation(s)
- Katelyn A Pastick
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joanna Dobbin
- Primary Care and Population Health, University College London, London, United Kingdom
| | | | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jack Milln
- Department of Obstetric Medicine, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Betty Nakabuye
- Department of Obstetrics and Gynecology, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Fiona V Cresswell
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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17
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Stadelman AM, Ssebambulidde K, Buller A, Tugume L, Yuquimpo K, Bakker CJ, Boulware DR, Bahr NC. Cerebrospinal fluid AFB smear in adults with tuberculous meningitis: A systematic review and diagnostic test accuracy meta-analysis. Tuberculosis (Edinb) 2022; 135:102230. [PMID: 35779498 PMCID: PMC9378497 DOI: 10.1016/j.tube.2022.102230] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) Ziehl-Neelsen acid-fast bacilli (AFB) smear is a rapid, cheap, widely available test for tuberculous meningitis (TBM). Yet, reported test sensitivity is highly variable. We performed a systematic review and meta-analysis for CSF AFB smear vs. other mycobacterial tests to diagnose TBM. METHODS We searched MEDLINE and Embase for studies reporting sensitivity and specificity of AFB smear against mycobacterial tests (reference standard) in adults (≥15 years) with suspected TBM. We used the QUADAS-2 tool to assess risk of bias. We estimated pooled sensitivity and specificity of AFB smear versus the reference standard using random-effects bivariate modeling. We used the I2 statistic to assess heterogeneity between studies. RESULTS Of 981 articles identified, 11 were eligible for inclusion with a total of 1713 participants. Seven studies were from high-TB burden settings and 4 from low-TB burden settings. The pooled sensitivity and specificity of CSF AFB smear were 8% (95%CI 3-21) and 100% (95%CI 90-100), with substantial heterogeneity in diagnostic performance (I2 >95% for both) and reference standards. CONCLUSION CSF AFB smear has poor sensitivity in most settings. If other more sensitive tests are available, those should be used preferentially rather than CSF AFB smear.
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Affiliation(s)
- Anna M Stadelman
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, PO Box 22418, Kampala, Uganda
| | - Alexandria Buller
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lillian Tugume
- Infectious Diseases Institute, College of Health Sciences, Makerere University, PO Box 22418, Kampala, Uganda
| | - Kyle Yuquimpo
- Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Caitlin J Bakker
- Health Sciences Library, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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18
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Evans EE, Avaliani T, Gujabidze M, Bakuradze T, Kipiani M, Sabanadze S, Smith AGC, Avaliani Z, Collins JM, Kempker RR. Long term outcomes of patients with tuberculous meningitis: The impact of drug resistance. PLoS One 2022; 17:e0270201. [PMID: 35749509 PMCID: PMC9232145 DOI: 10.1371/journal.pone.0270201] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 06/06/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about the impact of drug-resistance on clinical outcomes among patients with tuberculosis meningitis (TBM). METHODS A retrospective cohort study among patients treated for TBM in Tbilisi, Georgia. We performed medical chart abstraction to collect patient data. Long-term vital status was assessed using the Georgia National Death Registry. We utilized a Cox proportional-hazards model to evaluate the association of drug-resistance and mortality. RESULTS Among 343 TBM suspects, 237 had a presentation consistent with TBM. Drug resistance was suspected (n = 5) or confirmed (n = 31) in 36 patients including 30 with multidrug- or rifampin-resistance and 6 with isoniazid-resistance. Thirty-four patients had HIV. The median follow-up time was 1331 days (IQR, 852-1767). Overall, 73 of 237 (30%) people died with 50 deaths occurring during and 23 after treatment. The proportion of death was higher among patients with drug-resistant vs. drug-susceptible disease (67% vs. 24%, p<0.001) and with HIV versus no HIV (59% vs 27%, p<0.001). Mortality was significantly higher in patients with drug-resistant TBM after 90 days of treatment (aHR = 7.2, CI95% [3.6-14.3], p < 0.001). CONCLUSIONS Mortality was high among patients with drug-resistant TBM with many deaths occurring post treatment. More effective treatment options are urgently needed for drug-resistant TBM.
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Affiliation(s)
- Emily E. Evans
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Alison G. C. Smith
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Jeffrey M. Collins
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, United States of America
| | - Russell R. Kempker
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, United States of America
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19
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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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20
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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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21
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Quinn CM, Kasibante J, Namudde A, Bangdiwala AS, Kabahubya M, Nakasujja N, Lofgren S, Elliott A, Boulware DR, Meya DB, Cresswell FV. Neurocognitive outcomes of tuberculous meningitis in a primarily HIV-positive Ugandan cohort. Wellcome Open Res 2022; 6:208. [PMID: 35949653 PMCID: PMC9334841 DOI: 10.12688/wellcomeopenres.16967.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population.
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Affiliation(s)
- Carson M Quinn
- School of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alice Namudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Mable Kabahubya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Lofgren
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - Alison Elliott
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Medical Research Council/Uganda Virus Research-Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Division of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, UK
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22
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Quinn CM, Kasibante J, Namudde A, Bangdiwala AS, Kabahubya M, Nakasujja N, Lofgren S, Elliott A, Boulware DR, Meya DB, Cresswell FV. Neurocognitive outcomes of HIV-associated tuberculous meningitis. Wellcome Open Res 2021; 6:208. [PMID: 35949653 PMCID: PMC9334841 DOI: 10.12688/wellcomeopenres.16967.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 12/15/2022] Open
Abstract
Background: The toll of tuberculous meningitis (TBM) in both mortality and disability is considerable, but advancements in rehabilitation have the potential to improve the functional abilities and the quality of survivors' lives. However, the typical phenotype of neurocognitive impairment in TBM survivors remains unstudied in HIV-predominant populations in sub-Saharan Africa. Methods: We tested 36 survivors of TBM in Uganda with a comprehensive battery of neurocognitive assessments at 8 and 24 weeks after diagnosis, and compared results to a representative cohort of HIV-uninfected Ugandans. Results: While participants had a broad range of impairments at eight weeks, there was marked improvement by 24 weeks, when a phenotype of impairment including deficits in motor functioning, verbal learning and memory, processing speed, and executive function emerged. These deficits were present despite good clinician-rated functional status. The majority (23/27, 85%) had evidence of moderate to severe depression at week 8, and at week 24 (18/24, 75%). Conclusion: These findings highlight the need for more comprehensive neurocognitive assessment in the survivors of TBM, and further investment in and study of rehabilitation, including management of depression, to improve long-term outcomes in this population.
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Affiliation(s)
- Carson M Quinn
- School of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John Kasibante
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alice Namudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Mable Kabahubya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Noeline Nakasujja
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Lofgren
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - Alison Elliott
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Medical Research Council/Uganda Virus Research-Institute Uganda Research Unit on AIDS, Entebbe, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - David B Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona V Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Division of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, UK
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23
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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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24
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Whitworth LJ, Troll R, Pagán AJ, Roca FJ, Edelstein PH, Troll M, Tobin DM, Phu NH, Bang ND, Thwaites GE, Thuong NTT, Sewell RF, Ramakrishnan L. Elevated cerebrospinal fluid cytokine levels in tuberculous meningitis predict survival in response to dexamethasone. Proc Natl Acad Sci U S A 2021; 118:e2024852118. [PMID: 33658385 PMCID: PMC7958233 DOI: 10.1073/pnas.2024852118] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Adjunctive treatment with antiinflammatory corticosteroids like dexamethasone increases survival in tuberculosis meningitis. Dexamethasone responsiveness associates with a C/T variant in Leukotriene A4 Hydrolase (LTA4H), which regulates expression of the proinflammatory mediator leukotriene B4 (LTB4). TT homozygotes, with increased expression of LTA4H, have the highest survival when treated with dexamethasone and the lowest survival without. While the T allele is present in only a minority of the world's population, corticosteroids confer modest survival benefit worldwide. Using Bayesian methods, we examined how pretreatment levels of cerebrospinal fluid proinflammatory cytokines affect survival in dexamethasone-treated tuberculous meningitis. LTA4H TT homozygosity was associated with global cytokine increases, including tumor necrosis factor. Association between higher cytokine levels and survival extended to non-TT patients, suggesting that other genetic variants may also induce dexamethasone-responsive pathological inflammation. These findings warrant studies that tailor dexamethasone therapy to pretreatment cerebrospinal fluid cytokine concentrations, while searching for additional genetic loci shaping the inflammatory milieu.
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Affiliation(s)
- Laura J Whitworth
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
| | - Rajan Troll
- Trinity College, CB2 1TQ Cambridge, United Kingdom
| | - Antonio J Pagán
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
| | - Francisco J Roca
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
| | - Paul H Edelstein
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104
| | - Mark Troll
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
| | - David M Tobin
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC 27710
- Department of Immunology, Duke University School of Medicine, Durham, NC 27710
| | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Duc Bang
- Pham Ngoc Thach Hospital for Tuberculosis and Lung Disease, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7BN Oxford, United Kingdom
| | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7BN Oxford, United Kingdom
| | | | - Lalita Ramakrishnan
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, CB2 0QH Cambridge, United Kingdom;
- Medical Research Council Laboratory of Molecular Biology, CB2 0QH Cambridge, United Kingdom
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25
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Whitworth L, Coxon J, van Laarhoven A, Thuong NTT, Dian S, Alisjahbana B, Ganiem AR, van Crevel R, Thwaites GE, Troll M, Edelstein PH, Sewell R, Ramakrishnan L. A Bayesian analysis of the association between Leukotriene A4 Hydrolase genotype and survival in tuberculous meningitis. eLife 2021; 10:61722. [PMID: 33416499 PMCID: PMC7793626 DOI: 10.7554/elife.61722] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/22/2020] [Indexed: 12/15/2022] Open
Abstract
Tuberculous meningitis has high mortality, linked to excessive inflammation. However, adjunctive anti-inflammatory corticosteroids reduce mortality by only 30%, suggesting that inflammatory pathophysiology causes only a subset of deaths. In Vietnam, the survival benefit of anti-inflammatory corticosteroids was most pronounced in patients with a C/T promoter variant in the leukotriene A4 hydrolase (LTA4H) gene encoding an enzyme that regulates inflammatory eicosanoids. LTA4H TT patients with increased expression had increased survival, consistent with corticosteroids benefiting individuals with hyper-inflammatory responses. However, an Indonesia study did not find an LTA4H TT genotype survival benefit. Here using Bayesian methods to analyse both studies, we find that LTA4H TT genotype confers survival benefit that begins early and continues long-term in both populations. This benefit is nullified in the most severe cases with high early mortality. LTA4H genotyping together with disease severity assessment may target glucocorticoid therapy to patients most likely to benefit from it. Tuberculous meningitis is a serious infection of the lining of the brain, which affects over 100,000 people a year. Without treatment, it is always fatal: even with proper antibiotics, about a quarter of patients do not survive and many will have permanent brain damage. Overactive inflammation is thought to contribute to this process. Corticosteroid drugs, which dampen the inflammatory process, are therefore often used during treatment. However, they merely reduce mortality by 30%, suggesting that only some people benefit from them. Two recent studies have linked the genetic makeup of individuals who have tuberculous meningitis to how they respond to corticosteroids. There were, in particular, differences in the LTA4H gene that codes for an inflammation-causing protein. According to these results, only individuals carrying high-inflammation versions of the LTA4H gene would benefit from the treatment. Yet a third study did not find any effect of the genetic background of patients. All three papers used frequentist statistics to draw their conclusions, only examining the percentage of people who survived in each group. Yet, this type of analysis can miss important details. It also does not work well when the number of patients is small, or when the effectiveness of a drug varies during the course of an illness. Another method, called Bayesian statistics, can perform better under these limitations. In particular, it takes into account the probability of an event based on prior knowledge – for instance, that the risk of dying varies smoothly with time. Here, Whitworth et al. used Bayesian statistics to reanalyse the data from these studies, demonstrating that death rates were correlated with the type of LTA4H gene carried by patients. In particular, corticosteroid treatment worked best for people with the high inflammation versions of the gene. However, regardless of genetic background, corticosteroids were not effective if patients were extremely sick before being treated. The work by Whitworth et al. demonstrates the importance of using Bayesian statistics to examine the effectiveness of medical treatments. It could help to design better protocols for tuberculous meningitis treatment, tailored to the genetic makeup of patients.
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Affiliation(s)
- Laura Whitworth
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, MRC Laboratory of Molecular Biology, Cambridge, United Kingdom
| | | | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Sofiati Dian
- Universitas Padjadjaran, TB-HIV Research Center, Faculty of Medicine, Bandung, Indonesia.,Department of Neurology, Faculty of Medicine/Hasan Sadikin Hospital, Universitas Padjadjaran, Sumedang, Indonesia
| | - Bachti Alisjahbana
- Universitas Padjadjaran, TB-HIV Research Center, Faculty of Medicine, Bandung, Indonesia
| | - Ahmad Rizal Ganiem
- Universitas Padjadjaran, TB-HIV Research Center, Faculty of Medicine, Bandung, Indonesia.,Department of Neurology, Faculty of Medicine/Hasan Sadikin Hospital, Universitas Padjadjaran, Sumedang, Indonesia
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mark Troll
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, MRC Laboratory of Molecular Biology, Cambridge, United Kingdom
| | - Paul H Edelstein
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, MRC Laboratory of Molecular Biology, Cambridge, United Kingdom.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States
| | | | - Lalita Ramakrishnan
- Molecular Immunity Unit, Department of Medicine, University of Cambridge, MRC Laboratory of Molecular Biology, Cambridge, United Kingdom
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26
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Dodd PJ, Osman M, Cresswell FV, Stadelman AM, Lan NH, Thuong NTT, Muzyamba M, Glaser L, Dlamini SS, Seddon JA. The global burden of tuberculous meningitis in adults: A modelling study. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000069. [PMID: 36962116 PMCID: PMC10021871 DOI: 10.1371/journal.pgph.0000069] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022]
Abstract
Tuberculous meningitis (TBM) is the most lethal form of tuberculosis. The incidence and mortality of TBM is unknown due to diagnostic challenges and limited disaggregated reporting of treated TBM by existing surveillance systems. We aimed to estimate the incidence and mortality of TBM in adults (15+ years) globally. Using national surveillance data from Brazil, South Africa, the United Kingdom, the United States of America, and Vietnam, we estimated the fraction of reported tuberculosis that is TBM, and the case fatality ratios for treated TBM in each of these countries. We adjusted these estimates according to findings from a systematic review and meta-analysis and applied them to World Health Organization tuberculosis notifications and estimates to model the global TBM incidence and mortality. Assuming the case detection ratio (CDR) for TBM was the same as all TB, we estimated that in 2019, 164,000 (95% UI; 129,000-199,000) adults developed TBM globally; 23% were among people living with HIV. Almost 60% of incident TBM occurred in males and 20% were in adults 25-34 years old. 70% of global TBM incidence occurred in Southeast Asia and Africa. We estimated that 78,200 (95% UI; 52,300-104,000) adults died of TBM in 2019, representing 48% of incident TBM. TBM case fatality in those treated was on average 27%. Sensitivity analysis assuming improved detection of TBM compared to other forms of TB (CDR odds ratio of 2) reduced estimated global mortality to 54,900 (95% UI; 32,200-77,700); assuming instead worse detection for TBM (CDR odds ratio of 0.5) increased estimated mortality to 125,000 (95% UI; 88,800-161,000). Our results highlight the need for improved routine TBM monitoring, especially in high burden countries. Reducing TBM incidence and mortality will be necessary to achieve the End TB Strategy targets.
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Affiliation(s)
- Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Fiona V Cresswell
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Infectious Diseases Institute, Kampala, Uganda
- MRC-UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Anna M Stadelman
- School of Public Health, University of Minnesota, Minneapolis, MN, United States of America
| | | | - Nguyen Thuy Thuong Thuong
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Morris Muzyamba
- Tuberculosis Section, National Infection Service, Public Health England, London, United Kingdom
| | - Lisa Glaser
- Tuberculosis Section, National Infection Service, Public Health England, London, United Kingdom
| | - Sicelo S Dlamini
- Research Information Monitoring, Evaluation, and Surveillance, National Tuberculosis Control and Management Cluster, National Department of Health, Pretoria, South Africa
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
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27
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Clifford KM, Szumowski JD. Disseminated Mycobacterium bovis Infection Complicated by Meningitis and Stroke: A Case Report. Open Forum Infect Dis 2020; 7:ofaa475. [PMID: 33134425 PMCID: PMC7588105 DOI: 10.1093/ofid/ofaa475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022] Open
Abstract
We describe a case of a 19-year-old female presenting with Mycobacterium bovis meningitis, a rarely encountered infection. We discuss the use of pyrosequencing to aid in prompt diagnosis of M. bovis infection, as well as treatment strategies and challenges given the organism’s intrinsic resistance to pyrazinamide.
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Affiliation(s)
- Katherine M Clifford
- Department of Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - John D Szumowski
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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