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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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Hieu TH, Hashan MR, Morsy S, Tawfik GM, Cucè F, Sharma A, Quynh TTH, Faraj HA, Qarawi ATA, Huy NT. Hyponatremia in tuberculous meningitis: A systematic review and meta-analysis. Indian J Tuberc 2021; 68:516-526. [PMID: 34752323 DOI: 10.1016/j.ijtb.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/08/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Tuberculous meningitis (TBM), manifests as the most severe involvement of the nervous system by Mycobacterium tuberculosis, it has a high mortality rate and a spectrum of systemic and neurological complications that can lead to debilitating or fatal sequelae, whereas hyponatremia is the commonly encountered life-threatening electrolyte disturbance. Thus, our study aimed to determine the prevalence, risk factors and differences in outcomes of hyponatremia in TBM. METHODS This systematic review was registered in PROSPERO (CRD42018088089). A comprehensive electronic search was conducted through ten databases to find relevant articles. RESULTS A total of 42 studies were included, 24 case reports and 18 retrospective studies. The prevalence rate of hyponatremia among TBM patients was 52% and the rate of death among those patients was 29%. The meta-regression analysis revealed that there was no significant effect of sodium level on the death rate in TBM patients (P-value = 0.9). Additionally, there was no significant difference in sodium level based on sex, and etiologies of hyponatremia. CONCLUSIONS Hyponatremia is commonly present in patient with TBM, but it is not significantly correlated to the rate of death. However, it is necessary to treat this potentially life-threatening condition appropriately according to its etiology, further research is needed on its pathophysiology in TBM, its risk factors, and the most appropriate treatment.
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Affiliation(s)
- Truong Hong Hieu
- Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam; Online Research Club, Nagasaki, Japan
| | - Mohammad Rashidul Hashan
- Online Research Club, Nagasaki, Japan; Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Sara Morsy
- Online Research Club, Nagasaki, Japan; Faculty of Medicine, Tanta University, Egypt
| | - Gehad Mohamed Tawfik
- Online Research Club, Nagasaki, Japan; Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Federica Cucè
- Online Research Club, Nagasaki, Japan; Department of Medicine, University of Padova, Padova, Italy
| | - Akash Sharma
- Online Research Club, Nagasaki, Japan; University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, India
| | - Tran Thuy Huong Quynh
- Online Research Club, Nagasaki, Japan; School of Medicine, Viet Nam National University, Viet Nam
| | - Hazem Abdelkarem Faraj
- Online Research Club, Nagasaki, Japan; Faculty of Medicine, University of Tripoli PO Box 13275 Tripoli, Libya
| | - Ahmad Taysir Atieh Qarawi
- Online Research Club, Nagasaki, Japan; Lower Westchester Medical Associates, P.C., Mount Vernon, NY, 10550, USA
| | - Nguyen Tien Huy
- School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan.
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Svensson EM, Dian S, Te Brake L, Ganiem AR, Yunivita V, van Laarhoven A, Van Crevel R, Ruslami R, Aarnoutse RE. Model-Based Meta-analysis of Rifampicin Exposure and Mortality in Indonesian Tuberculous Meningitis Trials. Clin Infect Dis 2020; 71:1817-1823. [PMID: 31665299 PMCID: PMC7643733 DOI: 10.1093/cid/ciz1071] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/24/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Intensified antimicrobial treatment with higher rifampicin doses may improve outcome of tuberculous meningitis, but the desirable exposure and necessary dose are unknown. Our objective was to characterize the relationship between rifampicin exposures and mortality in order to identify optimal dosing for tuberculous meningitis. METHODS An individual patient meta-analysis was performed on data from 3 Indonesian randomized controlled phase 2 trials comparing oral rifampicin 450 mg (~10 mg/kg) to intensified regimens including 750-1350 mg orally, or a 600-mg intravenous infusion. Pharmacokinetic data from plasma and cerebrospinal fluid (CSF) were analyzed with nonlinear mixed-effects modeling. Six-month survival was described with parametric time-to-event models. RESULTS Pharmacokinetic analyses included 133 individuals (1150 concentration measurements, 170 from CSF). The final model featured 2 disposition compartments, saturable clearance, and autoinduction. Rifampicin CSF concentrations were described by a partition coefficient (5.5%; 95% confidence interval [CI], 4.5%-6.4%) and half-life for distribution plasma to CSF (2.1 hours; 95% CI, 1.3-2.9 hours). Higher CSF protein concentration increased the partition coefficient. Survival of 148 individuals (58 died, 15 dropouts) was well described by an exponentially declining hazard, with lower age, higher baseline Glasgow Coma Scale score, and higher individual rifampicin plasma exposure reducing the hazard. Simulations predicted an increase in 6-month survival from approximately 50% to approximately 70% upon increasing the oral rifampicin dose from 10 to 30 mg/kg, and predicted that even higher doses would further improve survival. CONCLUSIONS Higher rifampicin exposure substantially decreased the risk of death, and the maximal effect was not reached within the studied range. We suggest a rifampicin dose of at least 30 mg/kg to be investigated in phase 3 clinical trials.
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Affiliation(s)
- Elin M Svensson
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Sofiati Dian
- Department of Neurology, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Lindsey Te Brake
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ahmad Rizal Ganiem
- Department of Neurology, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Vycke Yunivita
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Department of Biomedical Science, Pharmacology and Therapy Division, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Arjan van Laarhoven
- Department of Internal Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinout Van Crevel
- Department of Internal Medicine, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rovina Ruslami
- Infectious Disease Research Center, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Department of Biomedical Science, Pharmacology and Therapy Division, Universitas Padjadjaran/Hasan Sadikin Hospital, Bandung, Indonesia
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Daghmouri MA, Cherni I, Rebai L, Ghouibi C, Ghedira S, Houissa M. Muscular hypotonia as an onset manifestation of Tuberculosis meningitis in an HIV-negative patient. Clin Case Rep 2019; 7:2177-2180. [PMID: 31788274 PMCID: PMC6878069 DOI: 10.1002/ccr3.2474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/28/2019] [Accepted: 07/13/2019] [Indexed: 11/17/2022] Open
Abstract
Muscular hypotonia is considered as one of the rarest forms of initial onset signs of TBM, in addition to aphasia and hyponatremia, the awareness of those rare onset signs, a well-conducted diagnostic approach and early treatment can improve the outcome.
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Affiliation(s)
| | - Imen Cherni
- Department of anesthesiaCharles Nicolle HospitalTunisTunisia
| | - Lotfi Rebai
- Department of anesthesiaTrauma Center of Ben ArrousBen ArrousTunisia
| | - Cheima Ghouibi
- Department of anesthesiaCharles Nicolle HospitalTunisTunisia
| | - Salma Ghedira
- Department of anesthesiaCharles Nicolle HospitalTunisTunisia
| | - Mohamed Houissa
- Department of anesthesiaCharles Nicolle HospitalTunisTunisia
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Garg RK, Rizvi I, Malhotra HS, Uniyal R, Kumar N. Management of complex tuberculosis cases: a focus on drug-resistant tuberculous meningitis. Expert Rev Anti Infect Ther 2019; 16:813-831. [PMID: 30359140 DOI: 10.1080/14787210.2018.1540930] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Drug-resistant tuberculous meningitis has been reported worldwide. Isoniazid mono-resistance is the most frequent cause of drug-resistant tuberculous meningitis, a life-threatening disease. Extensive drug-resistant tuberculous meningitis has also been reported in some isolated case reports. Areas covered: We reviewed the current literature on drug-resistant tuberculous meningitis, as well as drug-resistant tuberculosis. Expert commentary: Drug-resistant tuberculous meningitis is a life-threatening disease and needs prompt diagnosis and treatment. Xpert MTB/RIF Ultra technology can detect Mycobacterium tuberculosis and rifampicin resistance in cerebrospinal fluid (CSF) even with low numbers of bacilli. The optimum antituberculosis drug regimen for multidrug-resistant tuberculous meningitis is largely unknown as no second-line antituberculosis drug-containing regimen has been tested in a randomized controlled fashion in drug-resistant tuberculous meningitis. A combination of levofloxacin, kanamycin, ethionamide, linezolid, and pyrazinamide would be an appropriate regimen because of excellent CSF profile of most of these drugs. End TB Strategy will help in checking the increasing challenge of drug-resistant tuberculous meningitis as it aims to eliminate all kinds of tuberculosis by the year 2035.
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Affiliation(s)
- Ravindra Kumar Garg
- a Department of Neurology , King George Medical University , Lucknow , India
| | - Imran Rizvi
- a Department of Neurology , King George Medical University , Lucknow , India
| | | | - Ravi Uniyal
- a Department of Neurology , King George Medical University , Lucknow , India
| | - Neeraj Kumar
- a Department of Neurology , King George Medical University , Lucknow , India
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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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Soria J, Metcalf T, Mori N, Newby RE, Montano SM, Huaroto L, Ticona E, Zunt JR. Mortality in hospitalized patients with tuberculous meningitis. BMC Infect Dis 2019; 19:9. [PMID: 30611205 PMCID: PMC6321688 DOI: 10.1186/s12879-018-3633-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 12/18/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To evaluate the mortality in hospitalized patients with tuberculous meningitis and describe factors associated with an increased risk of mortality. METHODS Retrospective study of hospitalized patients with tuberculous meningitis between 2006 and 2015 in Peru performing a generalized linear regression to identify factors predictive of in-hospital mortality. RESULTS Of 263 patients, the median age was 35 years, 72.6% were men, 38% were positive for HIV upon admission, 24% had prior TB infections and 2.3% had prior MDR-TB infections. In-hospital mortality was 30.4% of all study patients with a final diagnosis of TBM. When multivariable analysis was applied, significant associations with in-hospital mortality were seen among patients with HIV (RR 2.06; Confidence Interval 95% (95% CI) 1.44-2.94), BMRC II (RR 1.78; 95% CI 1.07-2.97), BMRC III (RR 3.11; 95% CI 1.78-5.45) and positive CSF cultures (RR 1.95; 95% CI 1.39-2.74). CONCLUSIONS In-hospital mortality is higher among patients with HIV infections, age over 40 years, positive CSF TB culture and BMRC stage II or III.
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Affiliation(s)
- Jaime Soria
- Infectious and Tropical Diseases Department, Hospital Nacional Dos de Mayo, Lima, Peru
- Northern Pacific Global Health Research Fellows Training Consortium, University of Washington, Seattle, USA
| | - Tatiana Metcalf
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Northern Pacific Global Health Research Fellows Training Consortium, University of Washington, Seattle, USA
| | - Nicanor Mori
- Universidad Nacional Mayor de San Marcos, Lima, Peru
- Northern Pacific Global Health Research Fellows Training Consortium, University of Washington, Seattle, USA
| | - Renee E. Newby
- Northern Pacific Global Health Research Fellows Training Consortium, University of Washington, Seattle, USA
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195 USA
- Hospital Nacional Dos de Mayo, Parque Historia de la Medicina Peruana, Av. Grau, 1300 Lima 1, Peru
| | | | - Luz Huaroto
- Infectious and Tropical Diseases Department, Hospital Nacional Dos de Mayo, Lima, Peru
- Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Eduardo Ticona
- Infectious and Tropical Diseases Department, Hospital Nacional Dos de Mayo, Lima, Peru
- Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Joseph R. Zunt
- Departments of Neurology, Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA USA
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Double-Blind, Randomized, Placebo-Controlled Phase II Dose-Finding Study To Evaluate High-Dose Rifampin for Tuberculous Meningitis. Antimicrob Agents Chemother 2018; 62:AAC.01014-18. [PMID: 30224533 DOI: 10.1128/aac.01014-18] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 09/04/2018] [Indexed: 11/20/2022] Open
Abstract
High doses of rifampin may help patients with tuberculous meningitis (TBM) to survive. Pharmacokinetic pharmacodynamic evaluations suggested that rifampin doses higher than 13 mg/kg given intravenously or 20 mg/kg given orally (as previously studied) are warranted to maximize treatment response. In a double-blind, randomized, placebo-controlled phase II trial, we assigned 60 adult TBM patients in Bandung, Indonesia, to standard 450 mg, 900 mg, or 1,350 mg (10, 20, and 30 mg/kg) oral rifampin combined with other TB drugs for 30 days. The endpoints included pharmacokinetic measures, adverse events, and survival. A double and triple dose of oral rifampin led to 3- and 5-fold higher geometric mean total exposures in plasma in the critical early days (2 ± 1) of treatment (area under the concentration-time curve from 0 to 24 h [AUC0-24], 53.5 mg · h/liter versus 170.6 mg · h/liter and 293.5 mg · h/liter, respectively; P < 0.001), with proportional increases in cerebrospinal fluid (CSF) concentrations and without an increase in the incidence of grade 3 or 4 adverse events. The 6-month mortality was 7/20 (35%), 9/20 (45%), and 3/20 (15%) in the 10-, 20-, and 30-mg/kg groups, respectively (P = 0.12). A tripling of the standard dose caused a large increase in rifampin exposure in plasma and CSF and was safe. The survival benefit with this dose should now be evaluated in a larger phase III clinical trial. (This study has been registered at ClinicalTrials.gov under identifier NCT02169882.).
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Cresswell FV, Bangdiwala AS, Meya DB, Bahr NC, Vidal JE, Török ME, Thao LTP, Thwaites GE, Boulware DR. Absence of cerebrospinal fluid pleocytosis in tuberculous meningitis is a common occurrence in HIV co-infection and a predictor of poor outcomes. Int J Infect Dis 2018; 68:77-78. [PMID: 29391245 DOI: 10.1016/j.ijid.2018.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/17/2018] [Accepted: 01/17/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Fiona V Cresswell
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK; Infectious Diseases Institute, Kampala, Uganda.
| | | | - David B Meya
- Infectious Diseases Institute, Kampala, Uganda; College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, KS, USA
| | - Jose E Vidal
- Department of Neurology, Instituto de Infectologia Emílio Ribas, São Paulo, Brazil; Laboratório de Investigação Médica 49, Instituto de Medicina Tropical, Universidade de São Paulo, São Paulo, Brazil
| | - M Estée Török
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - 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, UK
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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10
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Singh PK, Jain A. Epidemiological perspective of drug resistant extrapulmonary tuberculosis. World J Clin Infect Dis 2015; 5:77-85. [DOI: 10.5495/wjcid.v5.i4.77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/20/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023] Open
Abstract
Tuberculosis (TB) remains one of the leading infectious diseases causing significant morbidity and mortality worldwide. Although, pulmonary TB is the most common presentation and is the main transmissible form of the disease, extrapulmonary TB also significantly contributes to the burden of disease and can cause severe complications and disabilities. At present, the most serious issue with TB control programme is emergence of multi and extensively drug resistant Mycobacterium tuberculosis strain world-wide. As the number of drug resistant pulmonary TB is increasing around the world, the number of drug resistant TB with extrapulmonary manifestations are also on rise. However, there is surprisingly scant information in medical literatures on prevalence and impact of extrapulmonary drug-resistant TB. Here, we appraise the recent epidemiological studies that underpin the status and impact of drug resistance in TB cases with extrapulmonary manifestations.
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11
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Adding Streptomycin to an Intensified Regimen for Tuberculous Meningitis Improves Survival in HIV-Infected Patients. Interdiscip Perspect Infect Dis 2015; 2015:535134. [PMID: 26347376 PMCID: PMC4539446 DOI: 10.1155/2015/535134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/25/2015] [Indexed: 01/12/2023] Open
Abstract
In low- and middle-income countries, the mortality of HIV-associated tuberculous meningitis (TM) continues to be unacceptably high. In this observational study of 228 HIV-infected patients with TM, we compared the mortality during the first nine months of patients treated with standard antituberculosis therapy (sATT), intensified ATT (iATT), and iATT with streptomycin (iATT + STM). The iATT included levofloxacin, ethionamide, pyrazinamide, and double dosing of rifampicin and isoniazid and was given only during the hospital admission (median 7 days, interquartile range 6–9). No mortality differences were seen in patients receiving the sATT and the iATT. However, patients receiving the iATT + STM had significant lower mortality than those in the sATT group (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.24 to 0.93). After adjusting for other covariates, the mortality hazard of the iATT + STM versus the sATT remained statistically significant (adjusted HR 0.2, 95% CI 0.09 to 0.46). Other factors associated with mortality were previous ATT and low albumin concentrations. The mortality risk increased exponentially only with CD4+ lymphocyte concentrations below 100 cells/μL. In conclusion, the use of iATT resulted in a clinically important reduction in mortality compared with the standard of care only if associated with STM. The results of this study deserve further research.
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Abstract
Neurologists are often the first medical providers to evaluate patients with possible infectious meningitis. Knowledge of the clinical presentations and cerebrospinal fluid, microbiologic, and neuroimaging findings for different etiologies is essential to make a prompt diagnosis and initiate appropriate treatment. Tuberculosis is a common cause of meningitis in developing countries with a high prevalence of pulmonary tuberculosis. However, tuberculosis affects populations in every country and all neurologists need to be vigilant for possible cases of tuberculous meningitis presenting to their medical facilities. This article discusses the challenges of diagnosing and treating tuberculous meningitis and highlights recent advances in diagnostic technology.
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Affiliation(s)
- Jerome H Chin
- School of Public Health, University of California, Berkeley
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13
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Bilgrami M, O'Keefe P. Neurologic diseases in HIV-infected patients. HANDBOOK OF CLINICAL NEUROLOGY 2014; 121:1321-44. [PMID: 24365422 DOI: 10.1016/b978-0-7020-4088-7.00090-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Since the introduction of highly active antiretroviral therapy there has been an improvement in the quality of life for people with HIV infection. Despite the progress made, about 70% of HIV patients develop neurologic complications. These originate either in the central or the peripheral nervous system (Sacktor, 2002). These neurologic disorders are divided into primary and secondary disorders. The primary disorders result from the direct effects of the virus and include HIV-associated neurocognitive disorder (HAND), HIV-associated vacuolar myelopathy (VM), and distal symmetric polyneuropathy (DSP). Secondary disorders result from marked immunosuppression and include opportunistic infections and primary central nervous system lymphoma (PCNSL). A differential diagnosis which can be accomplished by detailed history, neurologic examination, and by having a good understanding of the role of HIV in various neurologic disorders will help physicians in approaching these problems. The focus of this chapter is to discuss neuropathogenesis of HIV, the various opportunistic infections, primary CNS lymphoma, neurosyphilis, CNS tuberculosis, HIV-associated peripheral neuropathies, HIV-associated neurocognitive disorder (HAND), and vacuolar myelopathy (VM). It also relies on the treatment recommendations and guidelines for the above mentioned neurologic disorders proposed by the US Centers for Disease Control and Prevention (CDC) and the Infectious Diseases Society of America.
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Affiliation(s)
- Mohammed Bilgrami
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Paul O'Keefe
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA.
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Chin JH, Mateen FJ. Central Nervous System Tuberculosis: Challenges and Advances in Diagnosis and Treatment. Curr Infect Dis Rep 2013; 15:631-635. [PMID: 24122343 DOI: 10.1007/s11908-013-0385-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Mycobacterium tuberculosis is one of the most prevalent human infections. Although the largest share of the burden of disease is in Africa and Asia, tuberculosis has a global footprint due to travel and migration. Resource constraints in many low- and middle-income countries are hampering efforts to control new infections and to prevent drug resistance. Infection of the central nervous system by Mycobacterium tuberculosis includes meningitis, tuberculoma, and abscess and carries a high morbidity and mortality. High clinical suspicion, combined with cerebrospinal fluid analysis and brain imaging studies, can improve the diagnostic certainty. The recent scale-up of nucleic acid amplification technology may allow earlier diagnosis of tuberculous meningitis in many regions of the world. Treatment of tuberculous infection of the central nervous system is usually empirical and follows conventional regimens for pulmonary tuberculosis. The optimal treatment regimen is still being elucidated and has been the subject of recent clinical trials.
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Affiliation(s)
- Jerome H Chin
- School of Public Health, University of California, Berkeley, 50 University Avenue, Berkeley, CA, 94720, USA,
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15
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Alvarez-Uria G, Midde M, Pakam R, Naik PK. Initial Antituberculous Regimen with Better Drug Penetration into Cerebrospinal Fluid Reduces Mortality in HIV Infected Patients with Tuberculous Meningitis: Data from an HIV Observational Cohort Study. Tuberc Res Treat 2013; 2013:242604. [PMID: 23997952 PMCID: PMC3753756 DOI: 10.1155/2013/242604] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 07/18/2013] [Accepted: 07/18/2013] [Indexed: 11/17/2022] Open
Abstract
Tuberculous meningitis (TM) is the deadliest form of tuberculosis. Nearly two-thirds of HIV infected patients with TM die, and most deaths occur within one month. Current treatment of TM involves the use of drugs with poor penetration into the cerebro-spinal fluid (CSF). In this study, we present the mortality before and after implementing a new antituberculous regimen (ATR) with a higher drug penetration in CSF than the standard ATR during the initial treatment of TM in an HIV cohort study. The new ATR included levofloxacin, ethionamide, pyrazinamide, and a double dose of rifampicin and isoniazid and was given for a median of 7 days (interquartile range 6-9). The new ATR was associated with an absolute 21.5% (95% confidence interval (CI), 7.3-35.7) reduction in mortality at 12 months. In multivariable analysis, independent factors associated with mortality were the use of the standard ATR versus the new ATR (hazard ratio 2.05; 95% CI, 1.2-3.5), not being on antiretroviral therapy, low CD4 lymphocyte counts, and low serum albumin levels. Our findings suggest that an intensified initial ATR, which likely results in higher concentrations of active drugs in CSF, has a beneficial effect on the survival of HIV-related TM.
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Affiliation(s)
- Gerardo Alvarez-Uria
- Department of Infectious Diseases, Bathalapalli Rural Development Trust Hospital, Kadiri Road, Anantapur District, Bathalapalli 515661, Andhra Pradesh, India
| | - Manoranjan Midde
- Department of Infectious Diseases, Bathalapalli Rural Development Trust Hospital, Kadiri Road, Anantapur District, Bathalapalli 515661, Andhra Pradesh, India
| | - Raghavakalyan Pakam
- Department of Infectious Diseases, Bathalapalli Rural Development Trust Hospital, Kadiri Road, Anantapur District, Bathalapalli 515661, Andhra Pradesh, India
| | - Praveen Kumar Naik
- Department of Infectious Diseases, Bathalapalli Rural Development Trust Hospital, Kadiri Road, Anantapur District, Bathalapalli 515661, Andhra Pradesh, India
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Garg RK, Jain A, Malhotra HS, Agrawal A, Garg R. Drug-resistant tuberculous meningitis. Expert Rev Anti Infect Ther 2013; 11:605-621. [DOI: 10.1586/eri.13.39] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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17
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Candida parapsilosis meningitis in a patient with AIDS. Report of a case and review of the literature. Rev Iberoam Micol 2013; 30:122-4. [DOI: 10.1016/j.riam.2012.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 11/18/2012] [Accepted: 11/20/2012] [Indexed: 11/24/2022] Open
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18
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Ruslami R, Ganiem AR, Dian S, Apriani L, Achmad TH, van der Ven AJ, Borm G, Aarnoutse RE, van Crevel R. Intensified regimen containing rifampicin and moxifloxacin for tuberculous meningitis: an open-label, randomised controlled phase 2 trial. THE LANCET. INFECTIOUS DISEASES 2013; 13:27-35. [DOI: 10.1016/s1473-3099(12)70264-5] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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19
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Tuberculous meningitis: diagnosis and treatment overview. Tuberc Res Treat 2011; 2011:798764. [PMID: 22567269 PMCID: PMC3335590 DOI: 10.1155/2011/798764] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Revised: 11/16/2011] [Accepted: 11/18/2011] [Indexed: 01/01/2023] Open
Abstract
Tuberculous meningitis (TBM) is the most common form of central nervous system tuberculosis (TB) and has very high morbidity and mortality. TBM is typically a subacute disease with symptoms that may persist for weeks before diagnosis. Characteristic cerebrospinal fluid (CSF) findings of TBM include a lymphocytic-predominant pleiocytosis, elevated protein, and low glucose. CSF acid-fast smear and culture have relatively low sensitivity but yield is increased with multiple, large volume samples. Nucleic acid amplification of the CSF by PCR is highly specific but suboptimal sensitivity precludes ruling out TBM with a negative test. Treatment for TBM should be initiated as soon as clinical suspicion is supported by initial CSF studies. Empiric treatment should include at least four first-line drugs, preferably isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol; the role of fluoroquinolones remains to be determined. Adjunctive treatment with corticosteroids has been shown to improve mortality with TBM. In HIV-positive individuals with TBM, important treatment considerations include drug interactions, development of immune reconstitution inflammatory syndrome, unclear benefit of adjunctive corticosteroids, and higher rates of drug-resistant TB. Testing the efficacy of second-line and new anti-TB drugs in animal models of experimental TBM is needed to help determine the optimal regimen for drug-resistant TB.
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20
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Donald PR. The chemotherapy of tuberculous meningitis in children and adults. Tuberculosis (Edinb) 2011; 90:375-92. [PMID: 20810322 DOI: 10.1016/j.tube.2010.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 07/25/2010] [Accepted: 07/26/2010] [Indexed: 11/18/2022]
Abstract
Literature dealing with antituberculosis chemotherapy of tuberculous meningitis (TBM) in adults and children is reviewed and recommendations made for the chemotherapy of TBM. Publications relating to the chemotherapy of TBM were reviewed which contribute to understanding the efficacy of different drugs and regimens in TBM treatment. The established classification of disease severity into stages I (no neurological signs and fully conscious), II (patients conscious but with neurological signs) and III (comatose or stuporous or with severe pareses) was used to compare regimens of isoniazid (INH), para-amino salicylic acid and streptomycin (INH regimens) used up to approximately 1970 with those using INH and rifampicin (RMP), supported by pyrazinamide and ethambutol or streptomycin (RMP regimens). Mortality in studies at all disease stages in adults or adults and children, with the children not distinguished, following INH regimens (12.4%, 25.2% and 55% at stages I, II and III respectively) did not differ significantly from that following introduction of RMP regimens (9.7%, 22.2% and 56% at stages I, II and III respectively), In studies of children only, mortality fell significantly following the introduction of RMP to 0%, 5.9% and 28.2% in children at stage I, II and III having been 10.2%, 22.3% and 49.4% respectively with INH regimens (P = 0.006). Following RMP regimens of 6 months duration, only 2 (1%) relapses occurred amongst 197 patients, after RMP regimens of 9-24 months only 1 (0.16%) relapse was recorded amongst 632 patients. Where INH resistance rates are <4% a directly observed INH, RMP, pyrazinamide and ethambutol for 2-months followed by INH and RMP for 4 months is recommended. If directly observed therapy cannot be practiced treatment duration should be extended to at least 9 months; if the risk of INH resistance or multidrug resistance is higher, the use of ethionamide and a fluoroquinolone and possibly cycloserine is recommended and pyrazinamide should be continued for full treatment duration. The penetration of RMP, ethambutol and streptomycin into cerebrospinal fluid is poor; higher dosages of RMP should be considered.
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MESH Headings
- Adult
- Aminosalicylic Acid
- Antibiotics, Antitubercular/therapeutic use
- Antitubercular Agents/administration & dosage
- Antitubercular Agents/therapeutic use
- Child
- Dose-Response Relationship, Drug
- Drug Therapy, Combination
- Female
- History, 18th Century
- History, 19th Century
- History, 20th Century
- History, 21st Century
- Humans
- Isoniazid/therapeutic use
- Male
- Pyrazinamide/therapeutic use
- Rifampin/therapeutic use
- Severity of Illness Index
- Streptomycin/therapeutic use
- Tuberculosis, Meningeal/cerebrospinal fluid
- Tuberculosis, Meningeal/drug therapy
- Tuberculosis, Meningeal/mortality
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Affiliation(s)
- P R Donald
- Department of Paediatrics and Child Health, Tygerberg Children's Hospital, Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa.
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21
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Duo L, Ying B, Song X, Lu X, Ye Y, Fan H, Xin J, Wang L. Molecular profile of drug resistance in tuberculous meningitis from southwest china. Clin Infect Dis 2011; 53:1067-73. [PMID: 22021920 DOI: 10.1093/cid/cir663] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is the most severe form of extrapulmonary tuberculosis and causes high mortality and morbidity. Isoniazid resistance is strongly predictive of death in patients with TBM. METHODS In the present study, using polymerase chain reaction (PCR) and Genotype MTBDRplus line-probe assay, we investigated the drug resistance in patients with TBM living in Southwest China. RESULTS Our results showed that only one-third of patients with TBM had a positive result for Mycobacterium tuberculosis culture from cerebrospinal fluid (CSF). PCR-based detection of M. tuberculosis DNA in CSF is not only an alternative diagnostic approach for TBM but also can be further used for the detection of drug resistance when combined with the MTBDRplus assay, the results of which were consistent with the classic drug susceptibility test. However, it further provided the molecular profile of the mutations can be conducted much faster than the classic drug susceptibility test can (1 day vs 30-40 days, respectively). In the studied 30 CSF samples from patients with TMB, we found a rate of 64.29% for isoniazid resistance, 39.29% for rifampicin resistance, and 32.14% for multidrug-resistant tuberculosis, which is relatively higher than the reported resistance in pulmonary tuberculosis. However, the molecular profile indicated that the most frequently observed mutations in the rpoB and katG genes are also responsible for drug resistance in TBM. CONCLUSIONS Our data suggest that the MTBDRplus line-probe assay is capable of detecting drug resistance for the CSF samples that have a PCR-positive result. We recommend PCR-based diagnosis and drug resistance test as routine assays for patients with suspected TBM.
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Affiliation(s)
- Lina Duo
- Department of Laboratory Medicine,West China Hospital, Sichuan University, Chengdu, Sichuan, China
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22
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Nelson CA, Zunt JR. Tuberculosis of the central nervous system in immunocompromised patients: HIV infection and solid organ transplant recipients. Clin Infect Dis 2011; 53:915-26. [PMID: 21960714 DOI: 10.1093/cid/cir508] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Central nervous system (CNS) tuberculosis (TB) is a devastating infection with high rates of morbidity and mortality worldwide and may manifest as meningitis, tuberculoma, abscess, or other forms of disease. Immunosuppression, due to either human immunodeficiency virus infection or solid organ transplantation, increases susceptibility for acquiring or reactivating TB and complicates the management of underlying immunosuppression and CNS TB infection. This article reviews how immunosuppression alters the clinical presentation, diagnosis, treatment, and outcome of TB infections of the CNS.
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Affiliation(s)
- Christina A Nelson
- Department of Neurology, Global Health, Medicine, and Epidemiology, University of Washington School of Medicine, Seattle, Washington, USA
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23
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Marais S, Pepper DJ, Schutz C, Wilkinson RJ, Meintjes G. Presentation and outcome of tuberculous meningitis in a high HIV prevalence setting. PLoS One 2011; 6:e20077. [PMID: 21625509 PMCID: PMC3098272 DOI: 10.1371/journal.pone.0020077] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 04/24/2011] [Indexed: 12/31/2022] Open
Abstract
Background Mycobacterium tuberculosis is a common, devastating cause of meningitis in HIV-infected persons. Due to international rollout programs, access to antiretroviral therapy (ART) is increasing globally. Starting patients with HIV-associated tuberculous meningitis (TBM) on ART during tuberculosis (TB) treatment may increase survival in these patients. We undertook this study to describe causes of meningitis at a secondary-level hospital in a high HIV/TB co-infection setting and to determine predictors of mortality in patients with TBM. Methods A retrospective review of cerebrospinal fluid findings and clinical records over a six-month period (March 2009–August 2009). Definite, probable and possible TBM were diagnosed according to published case definitions. Results TBM was diagnosed in 120/211 patients (57%) with meningitis. In 106 HIV-infected patients with TBM, six-month all-cause mortality was lower in those who received antiretroviral therapy (ART) during TB treatment; hazard ratio = 0.30 (95% CI = 0.08–0.82). Factors associated with inpatient mortality in HIV-infected patients were 1) low CD4+ count at presentation; adjusted odds ratio (AOR) = 1.4 (95% confidence interval [CI] = 1.03–1.96) per 50 cells/µL drop in CD4+ count and, 2) higher British Medical Research Council TBM disease grade (2 or 3 versus 1); AOR = 4.8 (95% CI = 1.45–15.87). Interpretation Starting ART prior to or during TB treatment may be associated with lower mortality in patients with HIV-associated TBM. Advanced HIV and worse stage of TBM disease predict in-hospital mortality in patients presenting with TBM.
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Affiliation(s)
- Suzaan Marais
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Dominique J. Pepper
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Charlotte Schutz
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Medicine, Imperial College London, London, United Kingdom
- Division of Mycobacterial Research, MRC National Institute for Medical Research, London, United Kingdom
| | - Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Infectious Diseases Unit, GF Jooste Hospital, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Medicine, Imperial College London, London, United Kingdom
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24
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Pellegrino D, Gerhardt J, Porfírio FMV, Santos EDB, Dauar RF, Oliveira ACPD, Vidal JE. Ring enhancing intracranial lesion responding to antituberculous treatment in an HIV-infected patient. Rev Inst Med Trop Sao Paulo 2011; 52:285-7. [PMID: 21049236 DOI: 10.1590/s0036-46652010000500013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 07/04/2010] [Indexed: 12/31/2022] Open
Abstract
Cerebral tuberculomas constitute a major differential diagnosis of cerebral toxoplasmosis in human immunodeficiency virus (HIV)-infected patients in developing countries. We report the case of a 34-year old woman co-infected with HIV and possible disseminated tuberculosis (hepatitis, lymphadenopathy, and pleural effusion) who presented a large and solitary intracranial mass lesion. Despite extensive diagnostic efforts, including brain, ganglionar, and liver biopsies, no definitive diagnosis was reached. However, a trial with first-line antituberculous drugs led to a significant clinical and radiological improvement. Atypical presentations of cerebral tuberculomas should always be considered in the differential diagnosis of intracranial mass lesions in HIV-infected patients and a trial with antituberculous drugs is a valuable strategy to infer the diagnosis in a subset of patients.
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Affiliation(s)
- Daniela Pellegrino
- Department of Infectious Diseases, Institute of Infectious Diseases Emilio Ribas, São Paulo, SP, Brazil
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25
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Marais S, Thwaites G, Schoeman JF, Török ME, Misra UK, Prasad K, Donald PR, Wilkinson RJ, Marais BJ. Tuberculous meningitis: a uniform case definition for use in clinical research. THE LANCET. INFECTIOUS DISEASES 2010; 10:803-12. [PMID: 20822958 DOI: 10.1016/s1473-3099(10)70138-9] [Citation(s) in RCA: 555] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Suzaan Marais
- Department of Medicine, GF Jooste Hospital, Manenberg, South Africa.
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26
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Marais S, Pepper DJ, Marais BJ, Török ME. HIV-associated tuberculous meningitis--diagnostic and therapeutic challenges. Tuberculosis (Edinb) 2010; 90:367-74. [PMID: 20880749 DOI: 10.1016/j.tube.2010.08.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 06/15/2010] [Accepted: 08/29/2010] [Indexed: 10/19/2022]
Abstract
HIV-associated tuberculous meningitis (TBM) poses significant diagnostic and therapeutic challenges and carries a dismal prognosis. In this review, we present the clinical features and management of HIV-associated TBM, and compare this to disease in HIV-uninfected individuals. Although the clinical presentation, laboratory findings and radiological features of TBM are similar in HIV-infected and HIV-uninfected patients, some important differences exist. HIV-infected patients present more frequently with extra-meningeal tuberculosis and systemic features of HIV infection. In HIV-associated TBM, clinical course and outcome are influenced by profound immunosuppression at presentation, emphasising the need for earlier diagnosis of HIV infection and initiation of antiretroviral treatment.
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Affiliation(s)
- Suzaan Marais
- Department of Medicine, GF Jooste Hospital, Manenberg 7764, South Africa.
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27
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Garg RK, Sinha MK. Tuberculous meningitis in patients infected with human immunodeficiency virus. J Neurol 2010; 258:3-13. [PMID: 20848123 DOI: 10.1007/s00415-010-5744-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 09/01/2010] [Indexed: 12/11/2022]
Abstract
Tuberculosis is the most common opportunistic infection in human immunodeficiency virus (HIV) infected persons. HIV-infected patients have a high incidence of tuberculous meningitis as well. The exact incidence and prevalence of tuberculous meningitis in HIV-infected patients are not known. HIV infection does not significantly alter the clinical manifestations, laboratory, radiographic findings, or the response to therapy. Still, some differences have been noted. For example, the histopathological examination of exudates in HIV-infected patients shows fewer lymphocytes, epithelioid cells, and Langhan's type of giant cells. Larger numbers of acid-fast bacilli may be seen in the cerebral parenchyma and meninges. The chest radiograph is abnormal in up to 46% of patients with tuberculous meningitis. Tuberculous meningitis is likely to present with cerebral infarcts and mass lesions. Cryptococcal meningitis is important in differential diagnosis. The recommended duration of treatment in HIV-infected patients is 9-12 months. The benefit of adjunctive corticosteroids is uncertain. Antiretroviral therapy and antituberculosis treatment should be initiated at the same time, regardless of CD4 cell counts. Tuberculous meningitis may be a manifestation of paradoxical tuberculosis-associated immune reconstitution inflammatory syndrome. Some studies have demonstrated a significant impact of HIV co-infection on mortality from tuberculous meningitis. HIV-infected patients with multidrug-resistant tuberculous meningitis have significantly higher mortality. The best way to prevent HIV-associated tuberculous meningitis is to diagnose and isolate infectious cases of tuberculosis promptly and administer appropriate treatment.
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Affiliation(s)
- Ravindra Kumar Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, 226003, Uttar Pradesh, India.
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28
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Abstract
Tuberculous meningitis is a severe form of extrapulmonary tuberculosis. The exact incidence and prevalence are not known. In countries with high burden of pulmonary tuberculosis, the incidence is expected to be proportionately high. Children are much more vulnerable. Human immunodeficiency virus-infected patients have a high incidence of tuberculous meningitis. The hallmark pathological processes are meningeal inflammation, basal exudates, vasculitis and hydrocephalus. Headache, vomiting, meningeal signs, focal deficits, vision loss, cranial nerve palsies and raised intracranial pressure are dominant clinical features. Diagnosis is based on the characteristic clinical picture, neuroimaging abnormalities and cerebrospinal fluid changes (increased protein, low glucose and mononuclear cell pleocytosis). Cerebrospinal fluid smear examination, mycobacterial culture or polymerase chain reaction is mandatory for bacteriological confirmation. The mortality and morbidity of tuberculous meningitis are exceptionally high. Prompt diagnosis and early treatment are crucial. Decision to start antituberculous treatment is often empirical. WHO guidelines recommend a 6 months course of antituberculous treatment; however, other guidelines recommend a prolonged treatment extended to 9 or 12 months. Corticosteroids reduce the number of deaths. Resistance to antituberculous drugs is associated with a high mortality. Patients with hydrocephalus may need ventriculo-peritoneal shunting. Bacillus Calmette-Guérin vaccination protects to some degree against tuberculous meningitis in children.
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Affiliation(s)
- R K Garg
- Department of Neurology, Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh, Lucknow, India.
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Croda MG, Vidal JE, Hernández AV, Dal Molin T, Gualberto FA, de Oliveira ACP. Tuberculous meningitis in HIV-infected patients in Brazil: clinical and laboratory characteristics and factors associated with mortality. Int J Infect Dis 2009; 14:e586-91. [PMID: 20005759 DOI: 10.1016/j.ijid.2009.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 07/08/2009] [Accepted: 08/13/2009] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Tuberculous meningitis (TBM) is a growing problem in HIV-infected patients in developing countries, where there is scarce data about this co-infection. Our objectives were to analyze the main features and outcomes of HIV-infected patients with TBM. METHODS This was a retrospective study of HIV-infected Brazilian patients admitted consecutively for TBM. All patients had Mycobacterium tuberculosis isolated from the cerebrospinal fluid (CSF). Presenting clinical and laboratory features were studied. Multivariate analysis was used to identify variables associated with death during hospitalization and at 9 months after diagnosis. Survival was estimated using the Kaplan-Meier method. RESULTS We included 108 cases (median age 36 years, 72% male). Only 15% had fever, headache, and meningeal signs simultaneously. Forty-eight percent had extrameningeal tuberculosis. The median CD4+ cell count was 65 cells/microl. Among 90 cases, 7% had primary resistance to isoniazid and 9% presented multidrug-resistant strains. The overall mortality during hospitalization was 29% and at 9 months was 41%. Tachycardia and prior highly active antiretroviral therapy (HAART) were associated with 9-month mortality. The 9-month survival rate was 22% (95% confidence interval 12-43%). CONCLUSIONS Clinical and laboratory manifestations were unspecific. Disseminated tuberculosis and severe immunosuppression were common. Mortality was high and the 9-month survival rate was low. Tachycardia and prior HAART were associated with death within 9 months of diagnosis.
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Affiliation(s)
- Mariana G Croda
- Department of Infectious Diseases, Emílio Ribas Institute of Infectious Diseases, Sao Paulo, Brazil
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Abstract
OBJECTIVE Indonesia has a concentrated but rapidly growing HIV epidemic. We examined the effect of HIV on causative organisms, clinical features and prognosis of adult meningitis. DESIGN A prospective cohort study. METHODS All adult patients at a referral hospital who underwent cerebrospinal fluid examination for suspected meningitis were examined for HIV and included in a prospective cohort study. Microbiological testing was done for common bacterial pathogens, mycobacteria and fungi. Patients were followed for at least 6 months, and logistic regression models were used to identify risk factors for mortality. RESULTS Among 185 patients who mostly presented with subacute meningitis, 60% were male and the median age was 30 years. HIV infection was present in 25% of the patients; almost two-thirds were newly confirmed, and all presented with severe immunosuppression (median CD4 cell count 13/microl, range 2-98). One-third of HIV-infected patients had cryptococcal meningitis whereas two-thirds suffered from tuberculosis. After 1 month, 41% of patients had died. HIV infection was strongly associated with 1-month mortality (adjusted odds ratio 12.15; 95% confidence interval 3.04-15.72) and death during extended follow-up (hazard ratio 2.48; 95% confidence interval 1.97-5.74). CONCLUSION Although HIV is still uncommon in the general population in Indonesia, its prevalence among adult meningitis cases already seems high. Mycobacterium tuberculosis and Cryptococcus neoformans are the main causes of meningitis in this setting, and mortality is very high, especially in HIV-infected patients. Our data suggest that adult meningitis cases in Indonesia should be screened routinely for HIV infection. Further studies are needed to address the high mortality.
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31
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Abstract
HIV-infected individuals are at increased risk for all forms of extrapulmonary tuberculosis, including tuberculous meningitis. This risk is increased at more advanced levels of immunosuppression. The time interval between onset of symptoms and presentation to medical care may vary widely, and consequently individuals may present with acute or chronic meningitis. The clinical presentation of tuberculous meningitis in HIV-infected individuals is more likely to include an altered level of consciousness, cranial imaging is more likely to show cerebral infarctions, and the yield of culture of cerebrospinal fluid may also be greater. Given that delayed initiation of therapy is a strong predictor of mortality in cases of tuberculous meningitis, clinicians must consider tuberculosis in the differential diagnosis of the HIV-infected individual with acute or chronic lymphocytic meningitis. Additional treatment considerations for HIV-infected individuals include the timing of initiation of antiretroviral therapy, the potential for drug-drug interactions, and the role of adjunctive corticosteroid therapy.
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Affiliation(s)
- Christopher Vinnard
- Division of Infectious Disease, Hospital of the University of Pennsylvania, 3400 Spruce Street, 3 Silverstein, Suite E, Philadelphia, PA 19104, USA.
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32
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Rojas C, Solari L, Herrera C, Sanchez E, Young G, Bonilla C, Hurtado R, Muñoz M, Zeladita J, Espiritu B, Shin S. Challenges of diagnosis and management of tuberculosis and HIV coinfection in resource-limited settings: a case report from Lima, Peru. ACTA ACUST UNITED AC 2008; 7:232-7. [PMID: 18812592 DOI: 10.1177/1545109708325468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We present a Peruvian human immunodeficiency virus (HIV)-positive patient receiving first-line therapy for tuberculosis who presents with neurological complications to highlight some of the major issues in the diagnosis and management of human immunodeficiency virus-related central nervous system complications in resource-poor settings. These include limited options for diagnosing extrapulmonary and drug-resistant tuberculosis; the importance of central nervous system . imaging; and the management conundrum when faced with a broad differential diagnosis. This patient was with drug-resistant tuberculosis of the brain, unmasked by immunologic recovery in the setting of recent initiation of antiretroviral treatment. We argue that aggressive and timely empiric multidrug-resistant tuberculosis treatment is important in cases where drug-resistant tuberculosis is suspected. Knowledge gaps include a limited understanding of immune reconstitution and the optimal timing of antiretroviral treatment in the setting of drug-resistant tuberculosis.
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