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Abstract
Tuberculosis (TB) is a global health problem especially in the Indian subcontinent imposing significant physical, psychosocial and economic burden on the society. Most national programs define TB cure as completion of treatment with improvement in clinical symptoms, microbiological and radiological clearance. However, follow up these patients for long-term sequelae or complications has not got adequate attention. Post-TB lung disease, neurological deficits and spinal deformities are some of the post-TB sequelae reported in adults, with scanty data available for children. With this review authors attempt to discuss various post-TB disease manifestations and the risk factors associated with their development in children. They address the need to create awareness amongst physicians involved in managing children with TB and obtain more scientific data in this field.
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Affiliation(s)
- Ritika Goyal
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Centre for Child Health, BLK MAX Hospital, Pusa Road, New Delhi, 110056, India
| | - Ankit Parakh
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Centre for Child Health, BLK MAX Hospital, Pusa Road, New Delhi, 110056, India.
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Madan M, Sehgal R, Tuli IP, Mehta A, Gera R. Outcome of tuberculous meningitis in children aged 9 months to 12 years at the end of intensive phase of treatment. Indian J Tuberc 2023; 70 Suppl 1:S104-S115. [PMID: 38110252 DOI: 10.1016/j.ijtb.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/25/2023] [Accepted: 05/10/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Tuberculous meningitis (TBM) is associated with high morbidity and mortality. Most of the literature focuses on outcomes at the end of therapy when it may be too late for intervention to improve the outcomes. So, the present study addresses outcomes by the end of intensive course of therapy. METHODS It was a prospective cohort observational study that enrolled 80 patients with TBM between 9 months and 12 years of age. Participants were classified into Definite, Probable and Possible TBM using Marais criteria. Survival/Mortality was evaluated at the end of hospital stay. Demographic, clinical, cerebrospinal fluid and radiological parameters were evaluated for predictors of morbidity and mortality. Standardized tools were used to assess possible impairments in different domains at the end of intensive phase of treatment, namely Gross Motor Functional Classification System for motor functional ability, Pediatric-Mini Mental score examination (MMSE), Blantyre Coma Scale (BCS) score and Vineland Social Maturity Scale (VSMS) for cognitive outcome, Auditory Brainstem Evoked Responses for hearing outcome and using Teller's/Snellen's visual acuity charts to assess visual impairment. RESULTS A high Mortality rate of 42.5% was seen in the enrolled patients. Out of the total 80 patients, 20% recovered completely while 36.25% survived with disability (morbidity). Motor, Hearing, Cognitive and Vision impairment was present in 33.3%, 4%, 33.3% and 48.9% of the survivors respectively. On multivariate regression, raised intracranial tension and stage III disease were significantly associated with mortality. Morbidity was significantly associated with Stage III disease on multivariate analysis. CONCLUSIONS Despite advances in treatment, Tuberculous meningitis is associated with high burden of deaths and devastating neurological sequelae. Timely diagnosis and intervention of neurological impairments is needed to improve the outcome of TBM in survivors.
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Affiliation(s)
- Mansi Madan
- Department of Paediatrics, VMMC and Safdarjung Hospital, New Delhi, 110029, India
| | - Rachna Sehgal
- Department of Paediatrics, VMMC and Safdarjung Hospital, New Delhi, 110029, India.
| | - Isha Preet Tuli
- Department of Otorhinolaryngology, VMMC and Safdarjung Hospital, New Delhi, 110029, India
| | - Anuj Mehta
- Department of Ophthalmology, VMMC and Safdarjung Hospital, New Delhi, 110029, India
| | - Rani Gera
- Department of Paediatrics, VMMC and Safdarjung Hospital, New Delhi, 110029, India
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Sharma V, Rajeshwari K, Kumar D, Gupta G. Clinicoepidemiological Profile and Prognostic Factors in Neurotuberculosis in Children. ANNALS OF CHILD NEUROLOGY 2023. [DOI: 10.26815/acn.2022.00409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
Purpose: This study aimed to determine the clinicoepidemiological profile and prognostic factors in children with neurotuberculosis.Methods: An observational study was conducted at a tertiary care hospital on 50 children diagnosed with neurotuberculosis. The demographic profile, clinical details, and all investigations were recorded on a predetermined form and datasheet for analysis, and disability severity was graded using the modified Rankin Scale.Results: Fifty patients were enrolled (male-to-female ratio, 1.08:1). Younger children (1 to 3 years) were more commonly affected. Most patients were malnourished, and only 58% had been immunized with the Bacillus Calmette-Guerin vaccine. Fever was the most common symptom (96%) followed by headache, altered consciousness, vomiting, seizures, and abnormal posture. On cerebrospinal fluid (CSF) analysis, 87% of patients showed pleocytosis with lymphocytic predominance. More than 80% of patients had CSF protein levels >100 mg/dL and CSF glucose levels <60 mg/dL. Common findings on neuroimaging were hydrocephalus (76%), basal meningeal enhancement (60%), basal exudates (52%), and parenchymal infarcts (32%). We noted a mortality rate of 40%, of whom 87.5% had modified British Medical Research Council (BMRC) stage 3 tubercular meningitis (TBM). All patients who survived stage 3 TBM had a severe disability, and over 50% of patients with stage 2 TBM had moderate to severe disabilities.Conclusion: Young age, lower socioeconomic status, BMRC stages 2 and 3, abnormal posture, hydrocephalus, and the presence of basal exudates were associated with poor outcomes. High suspicion is needed for early diagnosis and prevention of disability and mortality.
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Igbokwe V, Ruby LC, Sultanli A, Bélard S. Post-tuberculosis sequelae in children and adolescents: a systematic review. THE LANCET. INFECTIOUS DISEASES 2023; 23:e138-e150. [PMID: 36963920 DOI: 10.1016/s1473-3099(23)00004-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 03/26/2023]
Abstract
In 2020, an estimated total of 155 million people had survived tuberculosis. Among this number, a sizable proportion have considerable post-tuberculosis morbidity, as shown for the adult population. This systematic review aims to identify the spectrum and prevalence of post-tuberculosis sequelae in children and adolescents. Four databases were systematically searched from database inception to Feb 7, 2022, for literature on post-treatment outcomes of tuberculosis acquired during childhood. Of the 4613 identified publications, 71 studies were included in this systematic review. Studies on cohorts with comparably rare (most of which were extrapulmonary) tuberculosis presentations, such as spinal tuberculosis and tuberculous meningitis were over-represented; however, no study assessed long-term sequelae in a cohort with an average childhood tuberculosis spectrum. The descriptive analysis includes long-term outcomes of 3529 paediatric patients 1 month to 36 years after confirmed (47%) or clinical (53%) tuberculosis. In a considerable proportion of children, a broad spectrum of post-tuberculosis sequelae were identified, ranging from radiological residua after pulmonary tuberculosis, to disabling deformities after musculoskeletal and cutaneous tuberculosis, to somatic and psychosocial impairment after tuberculous meningitis. A better understanding and comprehensive assessment of post-tuberculosis sequelae in children are needed to improve tuberculosis care beyond antituberculous treatment.
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Affiliation(s)
- Vanessa Igbokwe
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lisa C Ruby
- Department of Infectious Diseases, and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ayten Sultanli
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany; German Center for Infection Research, Tübingen, Germany
| | - Sabine Bélard
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany; German Center for Infection Research, Tübingen, Germany.
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Charumbira MY, Berner K, Louw QA. Functioning Problems Associated with Health Conditions with Greatest Disease Burden in South Africa: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192315636. [PMID: 36497710 PMCID: PMC9735592 DOI: 10.3390/ijerph192315636] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 05/05/2023]
Abstract
A notable rise in health-related disability for which evidence-based rehabilitation is beneficial is evident in low-to-middle income countries. This scoping review aimed to systematically identify and map the most common functioning problems associated with health conditions that contribute most to disability in South Africa using the International Classification of Functioning, Disability and Health (ICF) framework. Peer-reviewed evidence published from January 2006 to December 2021 was systematically searched from five databases. Some 268 studies reporting on functioning problems (impairments, activity limitations, and participation restrictions) in South African adults (>18 years) related to 10 health conditions were included. A total of 130 different functioning problems were mapped to the ICF. The most prevalent problems (top 20) were related to mobility, pain, and mental health but spanned across several ICF domains and were mostly in patients at primary care. The high prevalence and wide range of functioning problems may be particularly burdensome on an already strained primary health care (PHC) system. This points towards targeted planning of innovative strategies towards strengthening rehabilitation service delivery at primary care to address these complexities where there is an inadequate rehabilitation workforce.
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Atkins S, Heimo L, Carter DJ, Ribas Closa M, Vanleeuw L, Chenciner L, Wambi P, Sidney-Annerstedt K, Egere U, Verkuijl S, Brands A, Masini T, Viney K, Wingfield T, Lönnroth K, Boccia D. The socioeconomic impact of tuberculosis on children and adolescents: a scoping review and conceptual framework. BMC Public Health 2022; 22:2153. [PMID: 36419146 PMCID: PMC9686126 DOI: 10.1186/s12889-022-14579-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) has been repeatedly shown to have socioeconomic impacts in both individual-level and ecological studies; however, much less is known about this effect among children and adolescents and the extent to which being affected by TB during childhood and adolescence can have life-course implications. This paper describes the results of the development of a conceptual framework and scoping review to review the evidence on the short- and long-term socioeconomic impact of tuberculosis on children and adolescents. OBJECTIVES To increase knowledge of the socioeconomic impact of TB on children and adolescents. METHODS We developed a conceptual framework of the socioeconomic impact of TB on children and adolescents, and used scoping review methods to search for evidence supporting or disproving it. We searched four academic databases from 1 January 1990 to 6 April 2021 and conducted targeted searches of grey literature. We extracted data using a standard form and analysed data thematically. RESULTS Thirty-six studies (29 qualitative, five quantitative and two mixed methods studies) were included in the review. Overall, the evidence supported the conceptual framework, suggesting a severe socioeconomic impact of TB on children and adolescents through all the postulated pathways. Effects ranged from impoverishment, stigma, and family separation, to effects on nutrition and missed education opportunities. TB did not seem to exert a different socioeconomic impact when directly or indirectly affecting children/adolescents, suggesting that TB can affect this group even when they are not affected by the disease. No study provided sufficient follow-up to observe the long-term socioeconomic effect of TB in this age group. CONCLUSION The evidence gathered in this review reinforces our understanding of the impact of TB on children and adolescents and highlights the importance of considering effects during the entire life course. Both ad-hoc and sustainable social protection measures and strategies are essential to mitigate the socioeconomic consequences of TB among children and adolescents.
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Affiliation(s)
- S Atkins
- WHO Collaborating Centre On Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Faculty of Social Sciences, Tampere University, Tampere, Finland.
| | - L Heimo
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - D J Carter
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - M Ribas Closa
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - L Vanleeuw
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - L Chenciner
- Royal Free London NHS Foundation Trust, London, UK
| | - P Wambi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - K Sidney-Annerstedt
- WHO Collaborating Centre On Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - U Egere
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - S Verkuijl
- WHO Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - A Brands
- WHO Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - T Masini
- WHO Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - K Viney
- WHO Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - T Wingfield
- WHO Collaborating Centre On Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - K Lönnroth
- WHO Collaborating Centre On Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - D Boccia
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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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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Tuberculous Meningitis in Children: Reducing the Burden of Death and Disability. Pathogens 2021; 11:pathogens11010038. [PMID: 35055986 PMCID: PMC8778027 DOI: 10.3390/pathogens11010038] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/29/2022] Open
Abstract
Tuberculous meningitis disproportionately affects young children. As the most devastating form of tuberculosis, it is associated with unacceptably high rates of mortality and morbidity even if treated. Challenging to diagnose and treat, tuberculous meningitis commonly causes long-term neurodisability in those who do survive. There remains an urgent need for strengthened surveillance, improved rapid diagnostics technology, optimised anti-tuberculosis drug therapy, investigation of new host-directed therapy, and further research on long-term functional and neurodevelopmental outcomes to allow targeted intervention. This review focuses on the neglected field of paediatric tuberculous meningitis and bridges current clinical gaps with research questions to improve outcomes from this crippling disease.
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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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Nimkar S, Joshi S, Kinikar A, Valvi C, Devaleenal DB, Thakur K, Bendre M, Khwaja S, Ithape M, Kattagoni K, Paradkar M, Gupte N, Gupta A, Suryavanshi N, Mave V, Dooley KE, Arenivas A. Mullen Scales of Early Learning Adaptation for Assessment of Indian Children and Application to Tuberculous Meningitis. J Trop Pediatr 2021; 67:fmaa034. [PMID: 32620972 PMCID: PMC8496186 DOI: 10.1093/tropej/fmaa034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Tuberculous meningitis (TBM) results in significant morbidity and mortality among children worldwide. Associated neurocognitive complications are common but not well characterized. The Mullen Scales of Early Learning (MSEL), a well-established measure for assessment of neurodevelopment, has not yet been adapted for use in India. This study's goal was to adapt the MSEL for local language and culture to assess neurocognition among children in India, and apply the adapted measure for assessment of children with TBM. METHODS Administration of MSEL domains was culturally adapted. Robust translation procedures for instructions took place for three local languages: Marathi, Hindi and Tamil. Multilingual staff compared instructions against the original version for accuracy. The MSEL stimuli and instructions were reviewed by psychologists and pediatricians in India to identify items concerning for cultural bias. RESULTS MSEL stimuli unfamiliar to children in this setting were identified and modified within Visual Reception, Fine-Motor, Receptive Language and Expressive Language Scales. Item category was maintained for adaptations of items visually or linguistically different from those observed in daily life. Adjusted items were administered to six typically developing children to determine modification utility. Two children diagnosed with confirmed TBM (ages 11 and 29 months) were evaluated with the adapted MSEL before receiving study medications. Skills were below age-expectation across visual reception, fine motor and expressive language domains. CONCLUSIONS This is the first study to assess children with TBM using the MSEL adapted for use in India. Future studies in larger groups of Indian children are warranted to validate the adapted measure.
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Affiliation(s)
- Smita Nimkar
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
- Department of Health and Biomedical Sciences, Symbiosis International (Deemed) University, Lavale, Pune, India
| | - Suvarna Joshi
- Department of Health and Biomedical Sciences, Symbiosis International (Deemed) University, Lavale, Pune, India
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Chhaya Valvi
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - D Bella Devaleenal
- Department of Clinical Research, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Kiran Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Manjushree Bendre
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Saltanat Khwaja
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Mahesh Ithape
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Krishna Kattagoni
- Department of Clinical Research, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Mandar Paradkar
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Nikhil Gupte
- Divisions of Clinical Pharmacology and Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amita Gupta
- Divisions of Clinical Pharmacology and Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nishi Suryavanshi
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Vidya Mave
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
- Divisions of Clinical Pharmacology and Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ana Arenivas
- Department of Rehabilitation Psychology and Neuropsychology, The Institute for Rehabilitation and Research (TIRR) Memorial Hermann, Houston, TX, USA
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
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Sulaiman T, Medi S, Erdem H, Senbayrak S, Ozturk-Engin D, Inan A, Civljak R, Nechifor M, Akbulut A, Crisan A, Ozguler M, Namiduru M, Savic B, Dulovic O, Pehlivanoglu F, Sengoz G, Yasar K, Inal AS, Parlak E, Johansen IS, Kursun E, Parlak M, Yilmaz E, Yilmaz G, Gul HC, Oncul O, Siméon S, Tattevin P, Ulu-Kilic A, Alabay S, Beovic B, Catroux M, Hansmann Y, Harxhi A, Sener A, Ozkaya HD, Cağ Y, Agalar C, Vahaboglu H, Ugur BK, Hasbun R. The diagnostic utility of the "Thwaites' system" and "lancet consensus scoring system" in tuberculous vs. non-tuberculous subacute and chronic meningitis: multicenter analysis of 395 adult patients. BMC Infect Dis 2020; 20:788. [PMID: 33096990 PMCID: PMC7585215 DOI: 10.1186/s12879-020-05502-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) represents a diagnostic and management challenge to clinicians. The "Thwaites' system" and "Lancet consensus scoring system" are utilized to differentiate TBM from bacterial meningitis but their utility in subacute and chronic meningitis where TBM is an important consideration is unknown. METHODS A multicenter retrospective study of adults with subacute and chronic meningitis, defined by symptoms greater than 5 days and less than 30 days for subacute meningitis (SAM) and greater than 30 days for chronic meningitis (CM). The "Thwaites' system" and "Lancet consensus scoring system" scores and the diagnostic accuracy by sensitivity, specificity, and area under the curve of receiver operating curve (AUC-ROC) were calculated. The "Thwaites' system" and "Lancet consensus scoring system" suggest a high probability of TBM with scores ≤4, and with scores of ≥12, respectively. RESULTS A total of 395 patients were identified; 313 (79.2%) had subacute and 82 (20.8%) with chronic meningitis. Patients with chronic meningitis were more likely caused by tuberculosis and had higher rates of HIV infection (P < 0.001). A total of 162 patients with TBM and 233 patients with non-TBM had unknown (140, 60.1%), fungal (41, 17.6%), viral (29, 12.4%), miscellaneous (16, 6.7%), and bacterial (7, 3.0%) etiologies. TMB patients were older and presented with lower Glasgow coma scores, lower CSF glucose and higher CSF protein (P < 0.001). Both criteria were able to distinguish TBM from bacterial meningitis; only the Lancet score was able to differentiate TBM from fungal, viral, and unknown etiologies even though significant overlap occurred between the etiologies (P < .001). Both criteria showed poor diagnostic accuracy to distinguish TBM from non-TBM etiologies (AUC-ROC was <. 5), but Lancet consensus scoring system was fair in diagnosing TBM (AUC-ROC was .738), sensitivity of 50%, and specificity of 89.3%. CONCLUSION Both criteria can be helpful in distinguishing TBM from bacterial meningitis, but only the Lancet consensus scoring system can help differentiate TBM from meningitis caused by fungal, viral and unknown etiologies even though significant overlap occurs and the overall diagnostic accuracy of both criteria were either poor or fair.
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Affiliation(s)
- Tarek Sulaiman
- Department of Internal Medicine, Section of Infectious Diseases, UT Health McGovern Medical School, University of Texas Health Sciences Center, 6431 Fannin St. 2.112 MSB, Houston, Texas, 77030m, USA
| | - Sai Medi
- Department of Internal Medicine, Section of Infectious Diseases, UT Health McGovern Medical School, University of Texas Health Sciences Center, 6431 Fannin St. 2.112 MSB, Houston, Texas, 77030m, USA
| | - Hakan Erdem
- Department of Infectious Diseases and Clinical Microbiology, Umut Hospital, Ordu, Turkey
| | - Seniha Senbayrak
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, HaydarpaşaTraining and Research Hospital, Istanbul, Turkey
| | - Derya Ozturk-Engin
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Asuman Inan
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, HaydarpaşaTraining and Research Hospital, Istanbul, Turkey
| | - Rok Civljak
- Department of Infectious Diseases, Dr. Fran Mihaljevic University Hospital for Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Mihai Nechifor
- Department of Pharmacology, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Ayhan Akbulut
- Department of Infectious Diseases and Clinical Microbiology, Firat University School of Medicine, Elazig, Turkey
| | - Alexandru Crisan
- Department of Infectious Diseases, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Muge Ozguler
- Medical Sciences University Elazığ Education and Research Hospital Infectious Diseases and Clinical Microbiology Department, Elazığ, Turkey
| | - Mustafa Namiduru
- Department of Infectious Diseases and Clinical Microbiology, Gaziantep University School of Medicine, Gaziantep, Turkey
| | - Branislava Savic
- Institute of Microbiology and Immunology, National Reference Laboratory for Tuberculosis, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Olga Dulovic
- Clinic for Infectious and Tropical Diseases, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Filiz Pehlivanoglu
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Gonul Sengoz
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Kadriye Yasar
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Ayse Seza Inal
- Department of Infectious Diseases and Clinical Microbiology, Cukurova University School of Medicine, Adana, Turkey
| | - Emine Parlak
- Department of Infectious Diseases and Clinical Microbiology, Ataturk University School of Medicine, Erzurum, Turkey
| | | | - Ebru Kursun
- Department of Infectious Diseases and Clinical Microbiology, Baskent University School of Medicine, Adana, Turkey
| | - Mehmet Parlak
- Department of Infectious Diseases and Clinical Microbiology, Ataturk University School of Medicine, Erzurum, Turkey
| | - Emel Yilmaz
- Department of Infectious Diseases and Clinical Microbiology, Uludag University School of Medicine, Bursa, Turkey
| | - Gulden Yilmaz
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, GülhaneTraining and Research Hospital, Istanbul, Turkey
| | - Hanefi Cem Gul
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, Gülhane Medical Faculty, Istanbul, Turkey
| | - Oral Oncul
- Department of Infectious Diseases and Clinical Microbiology, Istanbul University School of Medicine, Istanbul, Turkey
| | - Soline Siméon
- Department of Infectious and Tropical Diseases, University Hospital of Pontchaillou, Rennes, France
| | - Pierre Tattevin
- Department of Infectious and Tropical Diseases, University Hospital of Pontchaillou, Rennes, France
| | - Aysegul Ulu-Kilic
- Department of Infectious Diseases and Clinical Microbiology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Selma Alabay
- Department of Infectious Diseases and Clinical Microbiology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Bojana Beovic
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia
| | - Melanie Catroux
- Department of Infectious Diseases, Poitiers University Hospital, Poitiers, France
| | - Yves Hansmann
- Department of Infectious Diseases, University Hospital, Strasbourg, France
| | - Arjan Harxhi
- Service of Infectious Disease, University Hospital Center of Tirana, Tirana, Albania
| | - Alper Sener
- Department of Infectious Diseases and Clinical Microbiology, Onsekiz Mart University School of Medicine, Canakkale, Turkey
| | - Hacer Deniz Ozkaya
- Department of Infectious Diseases and Clinical Microbiology, Cigli Regional Education Hospital, Izmir, Turkey
| | - Yasemin Cağ
- Department of Infectious Diseases and Clinical Microbiology, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Canan Agalar
- Department of Clinical Microbiology and Infectiıus Diseases, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Haluk Vahaboglu
- Department of Infectious Diseases and Clinical Microbiology, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Berna Kaya Ugur
- Department of Anesthesiology and Reanimation, Gaziantep University School of Medicine, Gaziantep, Turkey
| | - Rodrigo Hasbun
- Department of Internal Medicine, Section of Infectious Diseases, UT Health McGovern Medical School, University of Texas Health Sciences Center, 6431 Fannin St. 2.112 MSB, Houston, Texas, 77030m, USA.
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Davis AG, Nightingale S, Springer PE, Solomons R, Arenivas A, Wilkinson RJ, Anderson ST, Chow FC. Neurocognitive and functional impairment in adult and paediatric tuberculous meningitis. Wellcome Open Res 2019; 4:178. [PMID: 31984243 PMCID: PMC6971841 DOI: 10.12688/wellcomeopenres.15516.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2019] [Indexed: 12/20/2022] Open
Abstract
In those who survive tuberculous meningitis (TBM), the long-term outcome is uncertain; individuals may suffer neurocognitive, functional and psychiatric impairment, which may significantly affect their ability to lead their lives as they did prior to their diagnosis of TBM. In children who survive, severe illness has occurred at a crucial timepoint in their development, which can lead to behavioural and cognitive delay. The extent and nature of this impairment is poorly understood, particularly in adults. This is in part due to a lack of observational studies in this area but also inconsistent inclusion of outcome measures which can quantify these deficits in clinical studies. This leads to a paucity of appropriate rehabilitative therapies available for these individuals and their caregivers, as well as burden at a socioeconomic level. In this review, we discuss what is known about neurocognitive impairment in TBM, draw on lessons learnt from other neurological infections and discuss currently available and emerging tools to evaluate function and cognition and their value in TBM. We make recommendations on which measures should be used at what timepoints to assess for impairment, with a view to optimising and standardising assessment of neurocognitive and functional impairment in TBM research.
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Affiliation(s)
- Angharad G Davis
- University College London, Gower Street, London, WC1E 6BT, UK.,Francis Crick Institute, Midland Road, London, NW1 1AT, UK.,Institute of Infectious Diseases and Molecular Medicine. Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Sam Nightingale
- HIV Mental Health Research Unit, University of Cape Town,, Observatory, 7925, South Africa
| | - Priscilla E Springer
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Regan Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ana Arenivas
- The Institute for Rehabilitation and Research Memorial Hermann, Department of Rehabilitation Psychology and Neuropsychology,, Houston, Texas, USA.,Baylor College of Medicine, Department of Physical Medicine and Rehabilitation, Houston, Texas, USA
| | - Robert J Wilkinson
- Francis Crick Institute, Midland Road, London, NW1 1AT, UK.,Department of Infectious Diseases, Imperial College London, London, W2 1PG, UK.,Wellcome Centre for Infectious Disease Research in Africa, Institute of Infectious Diseases and Molecular Medicine at Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| | - Suzanne T Anderson
- MRC Clinical Trials Unit at UCL, University College London, London, WC1E 6BT, UK.,Evelina Community, Guys and St Thomas' NHS Trust, 5 Dugard Way, London, SE11 4TH, UK
| | - Felicia C Chow
- Weill Institute of Neurosciences, Department of Neurology and Division of Infectious Diseases, University of California, San Francisco, California, USA
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13
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Seddon JA, Tugume L, Solomons R, Prasad K, Bahr NC. The current global situation for tuberculous meningitis: epidemiology, diagnostics, treatment and outcomes. Wellcome Open Res 2019; 4:167. [PMID: 32118118 PMCID: PMC7029758 DOI: 10.12688/wellcomeopenres.15535.1] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 12/13/2022] Open
Abstract
Tuberculous meningitis (TBM) results from dissemination of M. tuberculosis to the cerebrospinal fluid (CSF) and meninges. Ischaemia, hydrocephalus and raised intracranial pressure frequently result, leading to extensive brain injury and neurodisability. The global burden of TBM is unclear and it is likely that many cases are undiagnosed, with many treated cases unreported. Untreated, TBM is uniformly fatal, and even if treated, mortality and morbidity are high. Young age and human immunodeficiency virus (HIV) infection are potent risk factors for TBM, while Bacillus Calmette-Guérin (BCG) vaccination is protective, particularly in young children. Diagnosis of TBM usually relies on characteristic clinical symptoms and signs, together with consistent neuroimaging and CSF parameters. The ability to confirm the TBM diagnosis via CSF isolation of M. tuberculosis depends on the type of diagnostic tests available. In most cases, the diagnosis remains unconfirmed. GeneXpert MTB/RIF and the next generation Xpert Ultra offer improved sensitivity and rapid turnaround times, and while roll-out has scaled up, availability remains limited. Many locations rely only on acid fast bacilli smear, which is insensitive. Treatment regimens for TBM are based on evidence for pulmonary tuberculosis treatment, with little consideration to CSF penetration or mode of drug action required. The World Health Organization recommends a 12-month treatment course, although data on which to base this duration is lacking. New treatment regimens and drug dosages are under evaluation, with much higher dosages of rifampicin and the inclusion of fluoroquinolones and linezolid identified as promising innovations. The inclusion of corticosteroids at the start of treatment has been demonstrated to reduce mortality in HIV-negative individuals but whether they are universally beneficial is unclear. Other host-directed therapies show promise but evidence for widespread use is lacking. Finally, the management of TBM within health systems is sub-optimal, with drop-offs at every stage in the care cascade.
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Affiliation(s)
- James A Seddon
- Department of Infectious Diseases, Imperial College London, London, W2 1PG, UK
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Regan Solomons
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Nathan C Bahr
- Department of Infectious Diseases, University of Kansas, Kansas City, KS, USA
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14
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Cresswell FV, Te Brake L, Atherton R, Ruslami R, Dooley KE, Aarnoutse R, Van Crevel R. Intensified antibiotic treatment of tuberculosis meningitis. Expert Rev Clin Pharmacol 2019; 12:267-288. [PMID: 30474434 DOI: 10.1080/17512433.2019.1552831] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Meningitis is the most severe manifestation of tuberculosis, resulting in death or disability in over 50% of those affected, with even higher morbidity and mortality among patients with HIV or drug resistance. Antimicrobial treatment of Tuberculous meningitis (TBM) is similar to treatment of pulmonary tuberculosis, although some drugs show poor central nervous system penetration. Therefore, intensification of antibiotic treatment may improve TBM treatment outcomes. Areas covered: In this review, we address three main areas: available data for old and new anti-tuberculous agents; intensified treatment in specific patient groups like HIV co-infection, drug-resistance, and children; and optimal research strategies. Expert commentary: There is good evidence from preclinical, clinical, and modeling studies to support the use of high-dose rifampicin in TBM, likely to be at least 30 mg/kg. Higher dose isoniazid could be beneficial, especially in rapid acetylators. The role of other first and second line drugs is unclear, but observational data suggest that linezolid, which has good brain penetration, may be beneficial. We advocate the use of molecular pharmacological approaches, physiologically based pharmacokinetic modeling and pharmacokinetic-pharmacodynamic studies to define optimal regimens to be tested in clinical trials. Exciting data from recent studies hold promise for improved regimens and better clinical outcomes in future.
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Affiliation(s)
- Fiona V Cresswell
- a Clinical Research Department , London School of Hygiene and Tropical Medicine , London , UK.,b Research Department , Infectious Diseases Institute , Kampala , Uganda
| | - Lindsey Te Brake
- c Department of Pharmacy , Radboud Institute of Health Sciences, Radboud Center for Infectious Diseases Radboud university medical center , Nijmegen , The Netherlands
| | - Rachel Atherton
- b Research Department , Infectious Diseases Institute , Kampala , Uganda
| | - Rovina Ruslami
- d TB-HIV Research Centre, Faculty of Medicine , Universitas Padjadjaran , Bandung , Indonesia
| | - Kelly E Dooley
- e Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Rob Aarnoutse
- c Department of Pharmacy , Radboud Institute of Health Sciences, Radboud Center for Infectious Diseases Radboud university medical center , Nijmegen , The Netherlands
| | - Reinout Van Crevel
- f Department of Internal Medicine and Radboud Center for Infectious Diseases , Radboud university medical center , Nijmegen , the Netherlands.,g Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
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15
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Abstract
Prevention and management of opportunistic infections in children is particularly relevant in an era demonstrating an increased prevalence of immunocompromising conditions. The presence of an unusual organism which results in serious infection in a child should therefore always raise the consideration of immune compromise. The more common opportunistic infections have become easier to recognize in recent times due to improved awareness and more refined diagnostic testing. Targeted treatment is usually followed by long-term prophylactic medication. The impact of these conditions on patient outcome is of clear significance and certainly warrants further discussion.
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16
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Abstract
BACKGROUND Tuberculous meningitis (TBM) is the main form of tuberculosis that affects the central nervous system and is associated with high rates of death and disability. Most international guidelines recommend longer antituberculous treatment (ATT) regimens for TBM than for pulmonary tuberculosis disease to prevent relapse. However, longer regimens are associated with poor adherence, which could contribute to increased relapse, development of drug resistance, and increased costs to patients and healthcare systems. OBJECTIVES To compare the effects of short-course (six months) regimens versus prolonged-course regimens for people with tuberculous meningitis (TBM). SEARCH METHODS We searched the following databases up to 31 March 2016: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; EMBASE; LILACS; INDMED; and the South Asian Database of Controlled Clinical Trials. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials. We also checked article reference lists and contacted researchers in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) and prospective cohort studies of adults and children with TBM treated with antituberculous regimens that included rifampicin for six months or longer than six months. The primary outcome was relapse, and included studies required a minimum of six months follow-up after completion of treatment. DATA COLLECTION AND ANALYSIS Two review authors (SJ and HR) independently assessed the literature search results for eligibility, and performed data extraction and 'Risk of bias' assessments of the included studies. We contacted study authors for additional information when necessary. Most data came from single arm cohort studies without a direct comparison so we pooled the findings for each group of cohorts and presented them separately using a complete-case analysis. We assessed the quality of the evidence narratively, as using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was inappropriate with no direct comparisons between short- and prolonged-course regimens. MAIN RESULTS Four RCTs and 12 prospective cohort studies met our inclusion criteria, and included a total of 1881 participants with TBM. None of the included RCTs directly compared six months versus longer regimens, so we analysed all data as individual cohorts to obtain relapse rates in each set of cohorts.We included seven cohorts of participants treated for six months, with a total of 458 participants. Three studies were conducted in Thailand, two in South Africa, and one each in Ecuador and Papua New Guinea between the 1980s and 2009. We included 12 cohorts of participants treated for longer than six months (ranging from eight to 16 months), with a total of 1423 participants. Four studies were conducted in India, three in Thailand and one each in China, South Africa, Romania, Turkey and Vietnam, between the late 1970s and 2011.The proportion of participants classified as having stage III disease (severe) was higher in the cohorts treated for six months (33.2% versus 16.9%), but the proportion with known concurrent HIV was higher in the cohorts treated for longer (0/458 versus 122/1423). Although there were variations in the treatment regimens, most cohorts received isoniazid, rifampicin, and pyrazinamide during the intensive phase.Investigators achieved follow-up beyond 18 months after completing treatment in three out of the seven cohorts treated for six months, and five out of the 12 cohorts treated for eight to 16 months. All studies had potential sources of bias in their estimation of the relapse rate, and comparisons between the cohorts could be confounded.Relapse was an uncommon event across both groups of cohorts (3/369 (0.8%) with six months treatment versus 7/915 (0.8%) with longer), with only one death attributed to relapse in each group.Overall, the proportion of participants who died was higher in the cohorts treated for longer than six months (447/1423 (31.4%) versus 58/458 (12.7%)). However, most deaths occurred during the first six months in both treatment cohorts, which suggested that the difference in death rate was not directly related to duration of ATT but was due to confounding. Clinical cure was higher in the group of cohorts treated for six months (408/458 (89.1%) versus longer than six months (984/1336 (73.7%)), consistent with the observations for deaths.Few participants defaulted from treatment with six months treatment (4/370 (1.1%)) versus longer treatment (8/355 (2.3%)), and adherence was not well reported. AUTHORS' CONCLUSIONS In all cohorts most deaths occurred in the first six months; and relapse was uncommon in all participants irrespective of the regimen. Further inferences are probably inappropriate given this is observational data and confounding is likely. These data are almost all from participants who are HIV-negative, and thus the inferences will not apply to the efficacy and safety of the six months regimens in HIV-positive people. Well-designed RCTs, or large prospective cohort studies, comparing six months with longer treatment regimens with long follow-up periods established at initiation of ATT are needed to resolve the uncertainty regarding the safety and efficacy of six months regimens for TBM.
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Affiliation(s)
- Sophie Jullien
- Jigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Hannah Ryan
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUK
| | - Manish Modi
- Postgraduate Institute of Medical Education and ResearchDepartment of NeurologyChandigarh 160 012India
| | - Rohit Bhatia
- All India Institute of Medical SciencesDepartment of NeurologyNew DelhiIndia110029
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17
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Rohlwink UK, Donald K, Gavine B, Padayachy L, Wilmshurst JM, Fieggen GA, Figaji AA. Clinical characteristics and neurodevelopmental outcomes of children with tuberculous meningitis and hydrocephalus. Dev Med Child Neurol 2016; 58:461-8. [PMID: 26888419 PMCID: PMC4855638 DOI: 10.1111/dmcn.13054] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2015] [Indexed: 12/23/2022]
Abstract
AIM Tuberculous meningitis (TBM) is a lethal and commonly occurring form of extra-pulmonary tuberculosis in children, often complicated by hydrocephalus which worsens outcome. Despite high mortality and morbidity, little data on the impact on neurodevelopment exists. We examined the clinical characteristics, and clinical and neurodevelopmental outcomes of TBM and hydrocephalus. METHOD Demographic and clinical data (laboratory and radiological findings) were prospectively collected on children treated for probable and definite TBM with hydrocephalus. At 6 months, clinical outcome was assessed using the Paediatric Cerebral Performance Category Scale and neurodevelopmental outcome was assessed with the Griffiths Mental Development Scale - Extended Version. RESULTS Forty-four patients (median age 3y 3mo, range 3mo-13y 1mo, [SD 3y 5mo]) were enrolled. The mortality rate was 16%, three patients (6.8%) were in a persistent vegetative state, two were severely disabled (4.5%), and 11 (25%) suffered mild-moderate disability. All cases demonstrated neurodevelopmental deficits relative to controls. Multiple or large infarcts were prognostic of poor outcome. INTERPRETATION Neurological and neurodevelopmental deficits are common after paediatric TBM with hydrocephalus, and appear to be related to ongoing cerebral ischaemia and consequent infarction. The impact of TBM on these children is multidimensional and presents short- and long-term challenges.
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Affiliation(s)
- Ursula K Rohlwink
- Division of NeurosurgeryPaediatric NeurosurgeryRed Cross War Memorial Children's HospitalUniversity of Cape TownCape TownSouth Africa,Clinical and Infectious Disease Research InitiativeInstitute of Infectious Disease and Molecular MedicineUniversity of Cape TownCape TownSouth Africa
| | - Kirsty Donald
- Division of Developmental PaediatricsDepartment of Paediatrics and Child HealthRed Cross War Memorial Children's HospitalUniversity of Cape TownCape TownSouth Africa
| | - Bronwyn Gavine
- Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Llewellyn Padayachy
- Division of NeurosurgeryPaediatric NeurosurgeryRed Cross War Memorial Children's HospitalUniversity of Cape TownCape TownSouth Africa
| | - Jo M Wilmshurst
- Paediatric NeurologyDepartment of Paediatrics and Child HealthRed Cross War Memorial Children's HospitalUniversity of Cape TownCape TownSouth Africa
| | - Graham A Fieggen
- Division of NeurosurgeryPaediatric NeurosurgeryRed Cross War Memorial Children's HospitalUniversity of Cape TownCape TownSouth Africa
| | - Anthony A Figaji
- Division of NeurosurgeryPaediatric NeurosurgeryRed Cross War Memorial Children's HospitalUniversity of Cape TownCape TownSouth Africa
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18
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Erdem H, Senbayrak S, Gencer S, Hasbun R, Karahocagil MK, Sengoz G, Karsen H, Kaya S, Civljak R, Inal AS, Pekok AU, Celen MK, Deniz S, Ulug M, Demirdal T, Namiduru M, Tekin R, Guven T, Parlak E, Bolukcu S, Avci M, Sipahi OR, Nayman-Alpat S, Yaşar K, Pehlivanoğlu F, Yilmaz E, Ates-Guler S, Mutlu-Yilmaz E, Tosun S, Sirmatel F, Şahin-Horasan E, Akbulut A, Johansen IS, Simeon S, Batirel A, Öztoprak N, Cag Y, Catroux M, Hansmann Y, Kadanali A, Turgut H, Baran AI, Gul HC, Karaahmetoglu G, Sunnetcioglu M, Haykir-Solay A, Denk A, Ayaz C, Kose S, Gorenek L. Tuberculous and brucellosis meningitis differential diagnosis. Travel Med Infect Dis 2015; 13:185-91. [PMID: 25801665 DOI: 10.1016/j.tmaid.2015.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/18/2015] [Accepted: 02/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Thwaites and Lancet scoring systems have been used in the rapid diagnosis of tuberculous meningitis (TBM). However, brucellar meningoencephalitis (BME) has similar characteristics with TBM. The ultimate aim of this study is to infer data to see if BME should be included in the differential diagnosis of TBM when these two systems suggest the presence of TBM. METHOD BME and TBM patients from 35 tertiary hospitals were included in this study. Overall 294 adult patients with BME and 190 patients with TBM were enrolled. All patients involved in the study had microbiological confirmation for either TBM or BME. Finally, the Thwaites and Lancet scoring systems were assessed in both groups. RESULTS The Thwaites scoring system more frequently predicted BME cases (n = 292, 99.3%) compared to the TBM group (n = 182, 95.8%) (P = 0.017). According to the Lancet scoring system, the mean scores for BME and TBM were 9.43 ± 1.71 and 11.45 ± 3.01, respectively (P < 0.001). In addition, TBM cases were classified into "probable" category more significantly compared to BME cases, and BME cases were categorized into the "possible" category more frequently. CONCLUSIONS When the Thwaites or Lancet scoring systems indicate TBM, brucellar etiology should also be taken into consideration particularly in endemic countries.
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Affiliation(s)
- Hakan Erdem
- GATA Haydarpasa Training Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey.
| | - Seniha Senbayrak
- Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Serap Gencer
- Lutfi Kirdar Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Rodrigo Hasbun
- The University of Texas Health Science Center at Houston, Medical School, Department of Infectious Diseases, USA
| | - Mustafa Kasim Karahocagil
- Yuzuncuyil University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Van, Turkey
| | - Gonul Sengoz
- Haseki Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Hasan Karsen
- Harran University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Sanliurfa, Turkey
| | - Selçuk Kaya
- Karadeniz Technical University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Trabzon, Turkey
| | - Rok Civljak
- Dr. Fran Mihaljevic University Hospital for Infectious Diseases, Department of Infectious Diseases, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Ayşe Seza Inal
- Cukurova University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Adana, Turkey
| | - Abdullah Umut Pekok
- Private Erzurum Sifa Hospital, Department of Infectious Diseases and Clinical Microbiology, Erzurum, Turkey
| | - Mustafa Kemal Celen
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Secil Deniz
- Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Mehmet Ulug
- Private Umit Hospital, Department of Infectious Diseases and Clinical Microbiology, Eskisehir, Turkey
| | - Tuna Demirdal
- Katip Celebi University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Mustafa Namiduru
- Gaziantep University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Gaziantep, Turkey
| | - Recep Tekin
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Tumer Guven
- Ankara Atatürk Training & Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Emine Parlak
- Ataturk University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Erzurum, Turkey
| | - Sibel Bolukcu
- Bezmi Alem Vakif University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Meltem Avci
- Izmir Bozyaka Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Oğuz Reşat Sipahi
- Bezmi Alem Vakif University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Saygin Nayman-Alpat
- Osmangazi University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Eskisehir, Turkey
| | - Kadriye Yaşar
- Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Filiz Pehlivanoğlu
- Haseki Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Emel Yilmaz
- Uludag University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Bursa, Turkey
| | - Selma Ates-Guler
- Sutcu Imam University, School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Kahramanmaras, Turkey
| | - Esmeray Mutlu-Yilmaz
- Samsun Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Samsun, Turkey
| | - Selma Tosun
- Izmir Bozyaka Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Fatma Sirmatel
- Izzet Baysal University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Bolu, Turkey
| | - Elif Şahin-Horasan
- Mersin University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Mersin, Turkey
| | - Ayhan Akbulut
- Firat University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Elazig, Turkey
| | | | - Soline Simeon
- University Hospital of Pontchaillou, Department of Infectious and Tropical Diseases, Rennes, France
| | - Ayşe Batirel
- Lutfi Kirdar Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Nefise Öztoprak
- Antalya Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Antalya, Turkey
| | - Yasemin Cag
- Lutfi Kirdar Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Melanie Catroux
- Poitiers University Hospital, Department of Infectious Diseases, France
| | - Yves Hansmann
- University Hospital, Department of Infectious Diseases, Strasbourg, France
| | - Ayten Kadanali
- Umraniye Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Huseyin Turgut
- Pamukkale University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Denizli, Turkey
| | - Ali Irfan Baran
- Yuzuncuyil University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Van, Turkey
| | - Hanefi Cem Gul
- Gulhane Medical Academy, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Gokhan Karaahmetoglu
- GATA Haydarpasa Training Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Mahmut Sunnetcioglu
- Yuzuncuyil University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Van, Turkey
| | - Asli Haykir-Solay
- Igdir State Hospital, Department of Infectious Diseases and Clinical Microbiology, Igdir, Turkey
| | - Affan Denk
- Firat University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Elazig, Turkey
| | - Celal Ayaz
- Dicle University School of Medicine, Department of Infectious Diseases and Clinical Microbiology, Diyarbakir, Turkey
| | - Sukran Kose
- Tepecik Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
| | - Levent Gorenek
- GATA Haydarpasa Training Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
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van Toorn R, Solomons R. Update on the diagnosis and management of tuberculous meningitis in children. Semin Pediatr Neurol 2014; 21:12-8. [PMID: 24655399 DOI: 10.1016/j.spen.2014.01.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Tuberculous meningitis (TBM), the most devastating manifestation of tuberculosis, is often missed or overlooked because of nonspecific symptoms and difficulties in diagnosis. It continues to be an important cause of neurologic handicap in resource-poor countries. Owing to the suboptimal performance of diagnostic tests of TBM, diagnosis relies on thorough history, clinical examination, and relevant investigations. The development of affordable, accurate diagnostic tests for TBM in resource-poor settings remains a priority. Short intensified treatment is safe and effective in both human immunodeficiency virus (HIV)-infected and HIV-uninfected children. Treatment of tuberculous hydrocephalus depends on the level of the cerebrospinal fluid obstruction. Corticosteroids reduce risk of neurodisability and death in HIV-uninfected children. Thalidomide should be considered in children compromised by tuberculosis abscesses and tuberculous-related optochiasmic arachnoiditis. In resource-poor countries, home-based TBM treatment after initial in-hospital stabilization is feasible in carefully selected patients. Early diagnosis and treatment of TBM is the single most important factor determining outcome.
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Affiliation(s)
- Ronald van Toorn
- Department of Paediatrics and Child Health, Stellenbosch University, Western Cape, South Africa.
| | - Regan Solomons
- Department of Paediatrics and Child Health, Stellenbosch University, Western Cape, South Africa
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Doherty AM, Kelly J, McDonald C, O'Dywer AM, Keane J, Cooney J. A review of the interplay between tuberculosis and mental health. Gen Hosp Psychiatry 2013; 35:398-406. [PMID: 23660587 DOI: 10.1016/j.genhosppsych.2013.03.018] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 03/18/2013] [Accepted: 03/26/2013] [Indexed: 01/05/2023]
Abstract
AIMS Tuberculosis and mental illness share common risk factors including homelessness, HIV positive serology, alcohol/substance abuse and migrant status leading to frequent comorbidity. We sought to generate a comprehensive literature review that examines the complex relationship between tuberculosis and mental illness. METHODS A literature search was conducted in MedLine, Ovid and Psychinfo, with further examination of the references of these articles. In total 316 articles were identified. It was not possible to conduct a formal meta-analysis due to the absence of randomised controlled data. RESULTS Rates of mental illness of up to 70% have been identified in tuberculosis patients. Medications used in the treatment of common mental illnesses, such as depression, may have significant interactions with anti-tuberculosis agents, especially isoniazid and increasingly linezolid. Many medications used in the treatment of tuberculosis can have significant adverse psychiatric effects and some medications such as rifampicin may reduce the effective doses of anti-psychotics y their enzyme induction actions. Treatment with agents such as cycloserine has been associated with depression, and there have been reported cases of psychosis with most anti-tuberculous agents. Mental illness and substance abuse may also affect compliance with treatment, with attendant public health concerns. CONCLUSIONS As a result of the common co-morbidity of mental illness and tuberculosis, it is probable that physicians will encounter previously undiagnosed mental illness among patients with tuberculosis. Similarly, psychiatrists are likely to meet tuberculosis among their patients. It is important that both psychiatrists and physicians are aware of the potential for interactions between the drugs used to treat tuberculosis and psychiatric conditions.
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Mihailidou E, Goutaki M, Nanou A, Tsiatsiou O, Kavaliotis J. Tuberculous meningitis in Greek children. ACTA ACUST UNITED AC 2011; 44:337-43. [PMID: 22200165 DOI: 10.3109/00365548.2011.639030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most severe form of Mycobacterium tuberculosis infection. Our aim was to analyze the epidemiology, clinical features, diagnostic approach, and outcome of tuberculous meningitis in childhood. METHODS During a 25-y period (1984-2008), 43 children, aged 7 months to 13 y, were hospitalized in the Paediatric Department of the referral centre for infectious diseases in Thessaloniki, Greece with the diagnosis of TBM. The patients were classified according to the clinical findings on admission as per the UK Medical Research Council (MRC) staging: stage I, 16/43 (37.2%) children; stage II, 16/43 (37.2%); and stage III 11/43 (25.6%). RESULTS Twenty-seven of the 43 patients were Greek (63%) and none had been BCG-vaccinated. A family history of tuberculosis was identified in 18 cases (42%). 35 patients (81%) had a positive tuberculin skin test. An extrameningeal site of infection was identified in 14 children (33%); pulmonary tuberculosis in 14/43 patients (5/13 miliary tuberculosis) and spondylitis in 1. All patients were treated with anti-tuberculous drugs and 36 (84%) also received corticosteroids. Complications during hospitalization (coma, seizures, cranial nerve palsy, hydrocephalus) presented in 26 patients (60%). Two patients died (5%) and 6 (14%) had permanent neurological sequelae. CONCLUSION TBM, although rare, remains a disease with significant morbidity and mortality. Early clinical diagnosis and appropriate treatment initiation are important for the prognosis.
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