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Wang L, Gu Z, Chen X, Yu X, Meng X. Analysis of risk factors for long-term mortality in patients with stage II and III tuberculous meningitis. BMC Infect Dis 2024; 24:656. [PMID: 38956526 PMCID: PMC11218231 DOI: 10.1186/s12879-024-09561-0] [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: 01/30/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVE To investigate risk factors associated with long-term mortality in patients with stage II and III tuberculous meningitis (TBM). METHODS This retrospective analysis examined patients who were first diagnosed with stage II and III TBM at West China Hospital of Sichuan University between January 1, 2018 and October 1, 2019. Patients were followed via telephone and categorized into survival and mortality groups based on 4-year outcomes. Multivariate logistic regression identified independent risk factors for long-term mortality in stage II and III TBM. RESULTS In total, 178 patients were included, comprising 108 (60.7%) males and 36 (20.2%) non-survivors. Mean age was 36 ± 17 years. Compared to survivors, non-survivors demonstrated significantly higher age, heart rate, diastolic blood pressure, blood glucose, rates of headache, neurological deficits, cognitive dysfunction, impaired consciousness, hydrocephalus, and basal meningeal inflammation. This group also exhibited significantly lower Glasgow Coma Scale (GCS) scores, blood potassium, albumin, and cerebrospinal fluid chloride. Multivariate analysis revealed age (OR 1.042; 95% CI 1.015-1.070; P = 0.002), GCS score (OR 0.693; 95% CI 0.589-0.814; P < 0.001), neurological deficits (OR 5.204; 95% CI 2.056-13.174; P < 0.001), and hydrocephalus (OR 2.680; 95% CI 1.081-6.643; P = 0.033) as independent mortality risk factors. The ROC curve area under age was 0.613 (95% CI 0.506-0.720; P = 0.036) and 0.721 (95% CI 0.615-0.826; P < 0.001) under GCS score. CONCLUSION Advanced age, reduced GCS scores, neurological deficits, and hydrocephalus were identified as independent risk factors for mortality in stage II and III TBM patients.
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Affiliation(s)
- Ling Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, China
- Disaster Medical Center, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, 610041, China
| | - Zhihan Gu
- Department of Emergency Medicine, Laboratory of Emergency Medicine, School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoli Chen
- Department of Emergency Medicine, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, China
- Disaster Medical Center, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, 610041, China
| | - Xiaomin Yu
- Department of Emergency Medicine, West China Hospital, Sichuan University/ West China School of Nursing, Sichuan University, Chengdu, China
- Disaster Medical Center, Sichuan University, Chengdu, China
- Nursing Key Laboratory of Sichuan Province, Chengdu, 610041, China
| | - Xiandong Meng
- Mental Health Center, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, 610041, China.
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Jin W, Qifu C, Hong Y, Hua H, Xuelin L, Xiaomin W, Shuihua L, Mutong F. Intracranial tuberculomas diagnosed with Xpert MTB/RIF Ultra assay of formalin-fixed paraffin-embedded brain tissues and treated with an optimized antituberculosis regimen: A case report. Heliyon 2024; 10:e32462. [PMID: 38961962 PMCID: PMC11219345 DOI: 10.1016/j.heliyon.2024.e32462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 05/07/2024] [Accepted: 06/04/2024] [Indexed: 07/05/2024] Open
Abstract
Diagnosis of intracranial tuberculoma remains a challenge due to its rarity, non-specific clinical presentation, and radiological findings. Herein, we describe a case of intracranial tuberculomas in a male diabetic patient who presented headache and vomiting on admission. Neuroimaging findings indicated multiple ring contrast-enhanced lesions with extensive perilesional edema. However, a cerebrospinal fluid (CSF) examination was normal. When a biopsy of brain lesions was performed, pathological characteristics of tuberculosis were absent and acid-fast staining was negative. A tuberculosis diagnosis was subsequently obtained from an Xpert MTB/RIF Ultra assay of formalin-fixed paraffin-embedded brain tissue. The patient was treated with an optimized anti-tuberculosis regimen which included high-dose intravenous administration of rifampicin and isoniazid, and oral administration of linezolid. The patient recovered well and exhibited marked clinical improvement. This case report demonstrates that when CSF analysis does not indicate the presence of intracranial tuberculomas, analysis of formalin-fixed paraffin-embedded brain tissue specimens with the Xpert MTB/RIF Ultra assay may be able to confirm a diagnosis. Furthermore, a high dose of rifampicin and isoniazid plus linezolid may improve patient outcome.
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Affiliation(s)
- Wang Jin
- Division of Pulmonary Diseases Department, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
- National Clinical Research Center for Infectious Disease, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Chen Qifu
- Department of Neurosurgery, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Yu Hong
- Department of Pathology, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Huang Hua
- Department of Radiology, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Li Xuelin
- Department of Clinical Laboratory, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Wang Xiaomin
- National Clinical Research Center for Infectious Disease, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Lu Shuihua
- Division of Pulmonary Diseases Department, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
- National Clinical Research Center for Infectious Disease, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Fang Mutong
- Division of Pulmonary Diseases Department, The Third People's Hospital of Shenzhen, Southern University of Science and Technology, Shenzhen, Guangdong, China
- National Clinical Research Center for Infectious Disease, Southern University of Science and Technology, Shenzhen, Guangdong, China
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Madadi AK, Sohn MJ. Comprehensive Therapeutic Approaches to Tuberculous Meningitis: Pharmacokinetics, Combined Dosing, and Advanced Intrathecal Therapies. Pharmaceutics 2024; 16:540. [PMID: 38675201 PMCID: PMC11054600 DOI: 10.3390/pharmaceutics16040540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Tuberculous meningitis (TBM) presents a critical neurologic emergency characterized by high mortality and morbidity rates, necessitating immediate therapeutic intervention, often ahead of definitive microbiological and molecular diagnoses. The primary hurdle in effective TBM treatment is the blood-brain barrier (BBB), which significantly restricts the delivery of anti-tuberculous medications to the central nervous system (CNS), leading to subtherapeutic drug levels and poor treatment outcomes. The standard regimen for initial TBM treatment frequently falls short, followed by adverse side effects, vasculitis, and hydrocephalus, driving the condition toward a refractory state. To overcome this obstacle, intrathecal (IT) sustained release of anti-TB medication emerges as a promising approach. This method enables a steady, uninterrupted, and prolonged release of medication directly into the cerebrospinal fluid (CSF), thus preventing systemic side effects by limiting drug exposure to the rest of the body. Our review diligently investigates the existing literature and treatment methodologies, aiming to highlight their shortcomings. As part of our enhanced strategy for sustained IT anti-TB delivery, we particularly seek to explore the utilization of nanoparticle-infused hydrogels containing isoniazid (INH) and rifampicin (RIF), alongside osmotic pump usage, as innovative treatments for TBM. This comprehensive review delineates an optimized framework for the management of TBM, including an integrated approach that combines pharmacokinetic insights, concomitant drug administration strategies, and the latest advancements in IT and intraventricular (IVT) therapy for CNS infections. By proposing a multifaceted treatment strategy, this analysis aims to enhance the clinical outcomes for TBM patients, highlighting the critical role of targeted drug delivery in overcoming the formidable challenges presented by the blood-brain barrier and the complex pathophysiology of TBM.
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Affiliation(s)
- Ahmad Khalid Madadi
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjin-gu, Busan 47392, Republic of Korea;
| | - Moon-Jun Sohn
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjin-gu, Busan 47392, Republic of Korea;
- Department of Neurosurgery, Neuroscience & Radiosurgery Hybrid Research Center, College of Medicine, Inje University Ilsan Paik Hospital, 170, Juhwa-ro, Ilsanseo-gu, Goyang City 10380, Republic of Korea
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Maharani K, Dian S, Ganiem AR, Imran D, Estiasari R, Ardiansyah E, Andini PW, Kristina F, Pangeran D, Chaidir L, Alisjahbana B, Rukmana A, Kusumaningrum A, Adawiyah R, Subekti D, Yunihastuti E, Yunus RE, Waslia L, van Ingen J, van Laarhoven A, Hamers RL, van Crevel R. Clinical presentation, management, and outcome of suspected central nervous system infections in Indonesia: a prospective cohort study. Infection 2024; 52:583-595. [PMID: 38315377 PMCID: PMC10954958 DOI: 10.1007/s15010-023-02170-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/27/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Little is known about the etiology, clinical presentation, management, and outcome of central nervous system (CNS) infections in Indonesia, a country with a high burden of infectious diseases and a rising prevalence of HIV. METHODS We included adult patients with suspected CNS infections at two referral hospitals in a prospective cohort between April 2019 and December 2021. Clinical, laboratory, and radiological assessments were standardized. We recorded initial and final diagnoses, treatments, and outcomes during 6 months of follow-up. RESULTS Of 1051 patients screened, 793 were diagnosed with a CNS infection. Patients (median age 33 years, 62% male, 38% HIV-infected) presented a median of 14 days (IQR 7-30) after symptom onset, often with altered consciousness (63%), motor deficits (73%), and seizures (21%). Among HIV-uninfected patients, CNS tuberculosis (TB) was most common (60%), while viral (8%) and bacterial (4%) disease were uncommon. Among HIV-infected patients, cerebral toxoplasmosis (41%) was most common, followed by CNS TB (19%), neurosyphilis (15%), and cryptococcal meningitis (10%). A microbiologically confirmed diagnosis was achieved in 25% of cases, and initial diagnoses were revised in 46% of cases. In-hospital mortality was 30%, and at six months, 45% of patients had died, and 12% suffered from severe disability. Six-month mortality was associated with older age, HIV, and severe clinical, radiological and CSF markers at presentation. CONCLUSION CNS infections in Indonesia are characterized by late presentation, severe disease, frequent HIV coinfection, low microbiological confirmation and high mortality. These findings highlight the need for earlier disease recognition, faster and more accurate diagnosis, and optimized treatment, coupled with wider efforts to improve the uptake of HIV services.
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Affiliation(s)
- Kartika Maharani
- Department of Neurology, Faculty of Medicine, Dr. Cipto Mangunkusumo, General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Sofiati Dian
- Department of Neurology, Faculty of Medicine, Dr. Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia.
- Research Center for Care and Control of Infectious Disease (RC3ID), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.
| | - Ahmad Rizal Ganiem
- Department of Neurology, Faculty of Medicine, Dr. Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia
- Research Center for Care and Control of Infectious Disease (RC3ID), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Darma Imran
- Department of Neurology, Faculty of Medicine, Dr. Cipto Mangunkusumo, General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Riwanti Estiasari
- Department of Neurology, Faculty of Medicine, Dr. Cipto Mangunkusumo, General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Edwin Ardiansyah
- Research Center for Care and Control of Infectious Disease (RC3ID), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Putri Widya Andini
- Department of Neurology, Faculty of Medicine, Dr. Cipto Mangunkusumo, General Hospital, Universitas Indonesia, Jakarta, Indonesia
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Fransisca Kristina
- Research Center for Care and Control of Infectious Disease (RC3ID), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - David Pangeran
- Department of Neurology, Faculty of Medicine, Dr. Cipto Mangunkusumo, General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Lidya Chaidir
- Research Center for Care and Control of Infectious Disease (RC3ID), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Bachti Alisjahbana
- Research Center for Care and Control of Infectious Disease (RC3ID), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Andriansjah Rukmana
- Department of Microbiology, Faculty of Medicine, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Ardiana Kusumaningrum
- Department of Microbiology, Faculty of Medicine, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Robiatul Adawiyah
- Department of Parasitology, Faculty of Medicine, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Decy Subekti
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Evy Yunihastuti
- Department of Internal Medicine, Faculty of Medicine, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Reyhan Eddy Yunus
- Department of Radiology, Faculty of Medicine, Dr. Cipto Mangunkusumo General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Lia Waslia
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Jakko van Ingen
- Department of Microbiology, Radboud Centre for Infectious Diseases (RCI), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Arjan van Laarhoven
- Department of Internal Medicine, Radboud Centre for Infectious Diseases (RCI), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raph L Hamers
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud Centre for Infectious Diseases (RCI), Radboud University Medical Centre, Nijmegen, The Netherlands
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Collins JM, Kipiani M, Jin Y, Sharma AA, Tomalka JA, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Blumberg HM, Benkeser D, Jones DP, Peloquin C, Kempker RR. Pharmacometabolomics in TB Meningitis - understanding the pharmacokinetic, metabolic, and immune factors associated with anti-TB drug concentrations in cerebrospinal fluid. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.14.23299982. [PMID: 38168338 PMCID: PMC10760251 DOI: 10.1101/2023.12.14.23299982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Poor penetration of many anti-tuberculosis (TB) antibiotics into the central nervous system (CNS) is thought to be a major driver of morbidity and mortality in TB meningitis (TBM). While the amount of a particular drug that crosses into the cerebrospinal fluid (CSF) varies from person to person, little is known about the host factors associated with interindividual differences in CSF concentrations of anti-TB drugs. In patients diagnosed with TBM from the country of Georgia (n=17), we investigate the association between CSF concentrations of anti-TB antibiotics and multiple host factors including serum drug concentrations and CSF concentrations of metabolites and cytokines. We found >2-fold differences in CSF concentrations of anti-TB antibiotics from person to person for all drugs tested including cycloserine, ethambutol, imipenem, isoniazid, levofloxacin, linezolid, moxifloxacin pyrazinamide, and rifampin. While serum drug concentrations explained over 40% of the variation in CSF drug concentrations for cycloserine, isoniazid, linezolid, and pyrazinamide (adjusted R 2 >0.4, p<0.001 for all), there was no evidence of an association between serum concentrations of imipenem and ethambutol and their respective CSF concentrations. CSF concentrations of carnitines were significantly associated with concentrations of ethambutol and imipenem (q<0.05), and imipenem was the only antibiotic significantly associated with CSF cytokine concentrations. These results indicate that there is high interindividual variability in CSF drug concentrations in patients treated for TBM, which is only partially explained by differences in serum drug concentrations and not associated with concentrations of cytokines and chemokines in the CSF.
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Asare-Baah M, Johnston L, Ramirez-Hiller T, Séraphin MN, Lauzardo M. Central Nervous System Tuberculosis: Risk Factors for Mortality in a Propensity Score-Matched Case-Control Study. Open Forum Infect Dis 2023; 10:ofad559. [PMID: 38088977 PMCID: PMC10715679 DOI: 10.1093/ofid/ofad559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Indexed: 12/30/2023] Open
Abstract
Background Despite advancements in tuberculosis (TB) control and treatment in the United States (US), patients with central nervous system TB (CNS-TB) continue to experience significantly higher mortality rates than those without CNS-TB. This raises concerns regarding clinical management and the need for a deeper understanding of the risk factors contributing to these deaths. This study aimed to determine the predictors of mortality in patients with CNS-TB. Methods We conducted a retrospective 1:2 propensity score-matched case-control study. Cases were TB patients diagnosed with TB of the meninges, brain, spinal cord, or peripheral nerves, as documented in the Florida Department of Health (FDOH) TB registry, between 2009 and 2021. Controls were TB patients without CNS-TB, also reported in the FDOH TB registry during the same timeframe. We employed conditional logistic regression models to investigate the factors contributing to mortality in cases compared with controls. Results We analyzed data from 116 cases and 232 matched controls. Patients with CNS-TB had a 5.69-fold higher risk of death than those without CNS-TB (adjusted odds ratio [aOR], 5.69 [95% confidence interval {CI}, 2.91-11.6]). Increased risk of death was associated with human immunodeficiency virus (HIV) coinfection (aOR, 1.93 [95% CI, .82-4.37]) and diabetes (aOR, 3.13 [95% CI, 1.28-7.47]). Miliary TB and non-HIV immunosuppression were significantly associated with being a case, while cavitary TB was less likely to be associated with being a case. Conclusions Clinical management should prioritize screening and close monitoring of patients with HIV coinfection and diabetes to improve patient outcomes.
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Affiliation(s)
- Michael Asare-Baah
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida,Gainesville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Lori Johnston
- Bureau of Tuberculosis Control, Florida Department of Health, Tallahassee, Florida, USA
| | - Tatiana Ramirez-Hiller
- Pediatric Research Hub, Department of Pediatrics, College of Medicine, University of Florida,Gainesville, Florida, USA
| | - Marie Nancy Séraphin
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida,Gainesville, Florida, USA
| | - Michael Lauzardo
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida,Gainesville, Florida, USA
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Cabrera JA, Mota M. Same Pathogen, Different Manifestations: A Case of Extrapulmonary Tuberculosis. Cureus 2023; 15:e50436. [PMID: 38222214 PMCID: PMC10785197 DOI: 10.7759/cureus.50436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 01/16/2024] Open
Abstract
Tuberculosis (TB) remains the most prevalent contagious disease worldwide and a significant cause of morbidity, ranking as the second most deadly disease globally. The transmission of the disease occurs through aerosols via the respiratory route, predominantly affecting pulmonary tissue. However, the pathogen can disseminate and infect any organ within the body. Up to 15% of patients exhibit extrapulmonary involvement. The case involves a 59-year-old male who presented to the emergency department complaining of abdominal pain and subfebrile episodes, without any other significant symptoms or findings on physical examination. Laboratory investigations revealed elevated inflammatory markers and abnormal liver biochemistry parameters. A computed tomography (CT) scan showed a neoformative lesion in the liver - a collection with a vascularized, thick, irregular wall. This raised the possibility of a potentially hypervascular hepatic neoformation or an encysted inflammatory lesion. The patient was started on empirical broad-spectrum antibiotics and was admitted to the Internal Medicine ward for further investigation. Later, the patient began to exhibit a decline in overall condition, a slowed and less complex speech pattern, loss of balance, and distal tremors in the upper limbs, as well as a symmetric and distal reduction in strength in all four limbs. A cerebral CT scan revealed no significant abnormalities, and a lumbar puncture yielded no immediate notable findings. Simultaneously, a repeated abdominal CT scan showed the previously known hepatic lesion, albeit with features more indicative of a multiloculated collection. An aspirative biopsy of the hepatic abscess was conducted. From the extensive analysis conducted, a positive PCR result for mycobacterium tuberculosis was identified in both the pus from the hepatic abscess and the cerebrospinal fluid. This led to the conclusion that the case presented was an instance of extrapulmonary TB involving the liver and the central nervous system. Following the identification of the causative agent, the patient commenced antibacterial therapy comprising rifampicin, ethambutol, and isoniazid with adjunctive dexamethasone. Despite targeted treatment and instituted supportive therapy, the patient exhibited an unfavorable progression and eventually succumbed 57 days after diagnosis. This case highlights an unusual manifestation of a patient with disseminated extrapulmonary TB, emphasizing the importance of early diagnostic suspicion for clinicians. The unfavorable disease progression despite appropriate targeted treatment prompts reflection on whether the delay in diagnosis and provision of anti-TB drugs may have played a major role in the prognosis of the patient.
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Affiliation(s)
- Joana A Cabrera
- Internal Medicine, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Margarida Mota
- Infectious Diseases, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
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Xu L, Wu H, Zhou H, Zhou X, Sun Y. Purulent meningitis and secondary epilepsy caused by Mycobacterium iranicum infection: A case report. Int J Infect Dis 2023; 135:5-7. [PMID: 37327856 DOI: 10.1016/j.ijid.2023.06.002] [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: 03/14/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023] Open
Abstract
Mycobacterium iranicum is characterized by rapid growth and orange-pigmented scotochromogenic colonies. However, it is uncommon for M. iranicum to invade the central nervous system. A man nearly 60 years old was referred to our hospital because of a seizure and unconsciousness. After admission, the patient had fever and dizziness without obvious abnormalities in the cerebrospinal fluid, except for an increase in neutrophils. Metagenomic next-generation sequencing and DNA testing were positive for M. iranicum. The patient was treated with imipenem, minocycline, moxifloxacin, and linezolid, and he gradually recovered during follow-up.
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Affiliation(s)
- Liaoyang Xu
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Huijuan Wu
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China; Department of Neurology, Jinzhou Medical University, Jinzhou, China
| | - Hang Zhou
- Department of Hematology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Xinyu Zhou
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China; Department of Neurology, The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, China.
| | - Yong Sun
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China; Department of Neurosurgery, The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, China.
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9
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Subedi RC, Acharya S, Adhikari A, Banmala S, Shiwakoti TK, Karki P, Gurung S, Bhatta B, Kharbuja N, Paudel R. Disseminated tuberculosis in an immunocompetent woman from the Himalayan region of Nepal: A case report. Clin Case Rep 2023; 11:e7754. [PMID: 37546164 PMCID: PMC10397472 DOI: 10.1002/ccr3.7754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/04/2023] [Accepted: 07/16/2023] [Indexed: 08/08/2023] Open
Abstract
Disseminated tuberculosis (TB) resulting from lymphohematogenous dissemination of Mycobacterium tuberculosis during primary infection or reactivation of latent disease is rare among young immunocompetent patients. Central nervous system TB (CNS TB) is one of the most challenging clinical diagnoses with high fatality. Here, we describe a young immunocompetent female with no known comorbidities initially presented with military pulmonary TB and later developed CNS TB. This presentation of disseminated TB in immunocompetent patient warrant early diagnosis and treatment.
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Affiliation(s)
| | - Subi Acharya
- Department of PediatricsPatan Academy of Health SciencesLalitpurNepal
| | - Ayush Adhikari
- Department of Anesthesia and Critical CareTribhuvan University Teaching HospitalKathmanduNepal
| | - Sabin Banmala
- Department of Emergency MedicineSindhuli HospitalSindhuliNepal
| | - Tibbin Kumar Shiwakoti
- Department of General Practice and Emergency MedicineKarnali Academy of Health SciencesJumlaNepal
| | | | - Shekhar Gurung
- Department of Emergency MedicineChattarapati Free Health Clinic Community HospitalKathmanduNepal
| | - Bhuwan Bhatta
- Department of Internal MedicineKantipur HospitalKathmanduNepal
| | - Naresh Kharbuja
- Department of NeurologyGrande International HospitalKathmanduNepal
| | - Raju Paudel
- Department of NeurologyGrande International HospitalKathmanduNepal
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10
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Shen J, Lackey E, Shah S. Neurosarcoidosis: Diagnostic Challenges and Mimics A Review. Curr Allergy Asthma Rep 2023; 23:399-410. [PMID: 37256482 PMCID: PMC10230477 DOI: 10.1007/s11882-023-01092-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE OF REVIEW Neurosarcoidosis is a rare manifestation of sarcoidosis that is challenging to diagnose. Biopsy confirmation of granulomas is not sufficient, as other granulomatous diseases can present similarly. This review is intended to guide the clinician in identifying key conditions to exclude prior to concluding a diagnosis of neurosarcoidosis. RECENT FINDINGS Although new biomarkers are being studied, there are no reliable tests for neurosarcoidosis. Advances in serum testing and imaging have improved the diagnosis for key mimics of neurosarcoidosis in certain clinical scenarios, but biopsy remains an important method of differentiation. Key mimics of neurosarcoidosis in all cases include infections (tuberculosis, fungal), autoimmune disease (vasculitis, IgG4-related disease), and lymphoma. As neurosarcoidosis can affect any part of the nervous system, patients should have a unique differential diagnosis tailored to their clinical presentation. Although biopsy can assist with excluding mimics, diagnosis is ultimately clinical.
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Affiliation(s)
- Jeffrey Shen
- Duke Department of Medicine, Division of Rheumatology and Immunology, Duke University, 40 Duke Medicine Cir Clinic 1J, Durham, NC, 27710, USA.
| | - Elijah Lackey
- Duke Department of Neurology, Duke University, 40 Duke Medicine Cir Clinic 1L, Durham, NC, 27701, USA
| | - Suma Shah
- Duke Department of Neurology, Duke University, 40 Duke Medicine Cir Clinic 1L, Durham, NC, 27701, USA
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11
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Carabalí-Isajar ML, Rodríguez-Bejarano OH, Amado T, Patarroyo MA, Izquierdo MA, Lutz JR, Ocampo M. Clinical manifestations and immune response to tuberculosis. World J Microbiol Biotechnol 2023; 39:206. [PMID: 37221438 DOI: 10.1007/s11274-023-03636-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/29/2023] [Indexed: 05/25/2023]
Abstract
Tuberculosis is a far-reaching, high-impact disease. It is among the top ten causes of death worldwide caused by a single infectious agent; 1.6 million tuberculosis-related deaths were reported in 2021 and it has been estimated that a third of the world's population are carriers of the tuberculosis bacillus but do not develop active disease. Several authors have attributed this to hosts' differential immune response in which cellular and humoral components are involved, along with cytokines and chemokines. Ascertaining the relationship between TB development's clinical manifestations and an immune response should increase understanding of tuberculosis pathophysiological and immunological mechanisms and correlating such material with protection against Mycobacterium tuberculosis. Tuberculosis continues to be a major public health problem globally. Mortality rates have not decreased significantly; rather, they are increasing. This review has thus been aimed at deepening knowledge regarding tuberculosis by examining published material related to an immune response against Mycobacterium tuberculosis, mycobacterial evasion mechanisms regarding such response and the relationship between pulmonary and extrapulmonary clinical manifestations induced by this bacterium which are related to inflammation associated with tuberculosis dissemination through different routes.
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Grants
- a Fundación Instituto de Inmunología de Colombia (FIDIC), Carrera 50#26-20, Bogotá 111321, Colombia
- a Fundación Instituto de Inmunología de Colombia (FIDIC), Carrera 50#26-20, Bogotá 111321, Colombia
- a Fundación Instituto de Inmunología de Colombia (FIDIC), Carrera 50#26-20, Bogotá 111321, Colombia
- a Fundación Instituto de Inmunología de Colombia (FIDIC), Carrera 50#26-20, Bogotá 111321, Colombia
- b PhD Program in Biomedical and Biological Sciences, Universidad del Rosario, Carrera 24#63C-69, Bogotá 111221, Colombia
- c Health Sciences Faculty, Universidad de Ciencias Aplicadas y Ambientales (UDCA), Calle 222#55-37, Bogotá 111166, Colombia
- d Faculty of Medicine, Universidad Nacional de Colombia, Carrera 45#26-85, Bogotá 111321, Colombia
- e Medicine Department, Hospital Universitario Mayor Mederi, Calle 24 # 29-45, Bogotá 111411. Colombia
- e Medicine Department, Hospital Universitario Mayor Mederi, Calle 24 # 29-45, Bogotá 111411. Colombia
- f Universidad Distrital Francisco José de Caldas, Carrera 3#26A-40, Bogotá 110311, Colombia
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Affiliation(s)
- Mary Lilián Carabalí-Isajar
- Fundación Instituto de Inmunología de Colombia (FIDIC), Carrera 50#26-20, 111321, Bogotá, Colombia
- Biomedical and Biological Sciences Programme, Universidad del Rosario, Carrera 24#63C-69, 111221, Bogotá, Colombia
| | | | - Tatiana Amado
- Fundación Instituto de Inmunología de Colombia (FIDIC), Carrera 50#26-20, 111321, Bogotá, Colombia
| | - Manuel Alfonso Patarroyo
- Fundación Instituto de Inmunología de Colombia (FIDIC), Carrera 50#26-20, 111321, Bogotá, Colombia
- Faculty of Medicine, Universidad Nacional de Colombia, Carrera 45#26-85, 111321, Bogotá, Colombia
| | - María Alejandra Izquierdo
- Medicine Department, Hospital Universitario Mayor Mederi, Calle 24 # 29-45, 111411, Bogotá, Colombia
| | - Juan Ricardo Lutz
- Medicine Department, Hospital Universitario Mayor Mederi, Calle 24 # 29-45, 111411, Bogotá, Colombia.
| | - Marisol Ocampo
- Fundación Instituto de Inmunología de Colombia (FIDIC), Carrera 50#26-20, 111321, Bogotá, Colombia.
- Universidad Distrital Francisco José de Caldas, Carrera 3#26A-40, 110311, Bogotá, Colombia.
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12
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Kong C, Xu D, Wang Y, Wang B, Wen J, Wang X, Zhan L, Sun Z, Jia X, Li M, Tang S, Hou D. Amplitude of low-frequency fluctuations in multiple-frequency bands in patients with intracranial tuberculosis: a prospective cross-sectional study. Quant Imaging Med Surg 2022; 12:4120-4134. [PMID: 35919063 PMCID: PMC9338357 DOI: 10.21037/qims-22-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/19/2022] [Indexed: 12/11/2022]
Abstract
Background Resting-state functional magnetic resonance imaging (rs-fMRI) is widely used to study brain functional alteration, but there have been no reports of research regarding the application of rs-fMRI in intracranial tuberculosis. The purpose of this prospective, cross-sectional study was to investigate spontaneous neural activity at different frequency bands in patients with intracranial tuberculosis using rs-fMRI with amplitude of low-frequency fluctuation (ALFF) and fractional ALFF (fALFF) methods. Methods The rs-fMRI data of 31 patients with intracranial tuberculosis and 30 gender-, age-, and education-matched healthy controls (HCs) were included. The ALFF and fALFF values in the conventional frequency band (0.01-0.08 Hz) and 2 sub-frequency bands (slow-4: 0.027-0.073 Hz; slow-5: 0.01-0.027 Hz) were calculated and compared between the groups. The resultant T-maps were corrected using the Gaussian random field (GRF) theory (voxel P<0.01, cluster P<0.05). Correlations between the ALFF and fALFF values and neurocognitive scores were assessed. Results Compared with the HCs, patients with intracranial tuberculosis showed decreased ALFF in the right paracentral lobule (T=-4.69) in the conventional frequency band, in the right supplementary motor area (T=-4.85) in the slow-4 band, and in the left supplementary motor area (T=-3.76) in the slow-5 band. Compared to the slow-5 band, the voxels with decreased ALFF were spatially more extensive in the slow-4 band. Compared with HCs, patients with intracranial tuberculosis showed decreased fALFF in the opercular parts of the right inferior frontal gyrus (T=-4.50) and the left inferior parietal lobe (T=-4.86) and increased fALFF in the left inferior cerebellum (T=5.84) in the conventional frequency band. In the slow-4 band, fALFF decreased in the opercular parts of the right inferior frontal gyrus (T=-5.29) and right precuneus (T=-4.34). In the slow-5 band, fALFF decreased in the left middle occipital gyrus (T=-4.65) and right middle frontal gyrus (T=-5.05). Conclusions Patients with intracranial tuberculosis showed abnormal intrinsic brain activity at different frequency bands, and ALFF abnormalities in different brain regions could be better detected in the slow-4 band. This preliminary study might provide new insights into understanding the pathophysiological mechanism in intracranial tuberculosis.
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Affiliation(s)
- Chengcheng Kong
- Translational Medicine Center, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Dong Xu
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Yichuan Wang
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Bing Wang
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Jianjie Wen
- School of Teacher Education, Zhejiang Normal University, Jinhua, China
| | - Xinguang Wang
- School of Information Science and Electronic Technology, Jiamusi University, Jiamusi, China
| | - Linlin Zhan
- Faculty of Western Languages, Heilongjiang University, Harbin, China
| | - Zhaogang Sun
- Translational Medicine Center, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Xize Jia
- School of Teacher Education, Zhejiang Normal University, Jinhua, China
- Key Laboratory of Intelligent Education Technology and Application of Zhejiang Province, Zhejiang Normal University, Jinhua, China
| | - Mengting Li
- School of Teacher Education, Zhejiang Normal University, Jinhua, China
- Key Laboratory of Intelligent Education Technology and Application of Zhejiang Province, Zhejiang Normal University, Jinhua, China
| | - Shenjie Tang
- Tuberculosis Clinical Medical Center, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Dailun Hou
- Department of Radiology, Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, China
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13
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Zhao BB, Tian C, Fu LJ, Zhang XB. Suprasellar cistern tuberculoma presenting as unilateral ocular motility disorder and ptosis: A case report. World J Clin Cases 2022; 10:4691-4697. [PMID: 35663056 PMCID: PMC9125296 DOI: 10.12998/wjcc.v10.i14.4691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/06/2022] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intracranial tuberculoma is a rare and serious type of tuberculosis, which mostly occurs in the frontoparietal and cerebellar hemispheres, with predominance in the gray-white matter junction area, while tuberculomas only in the cistern are extremely rare with only a few reported cases in the literature. We describe a unique case of isolated tuberculoma in the suprasellar cistern, with only right ocular motility disorder and upper eyelid ptosis.
CASE SUMMARY A 5-year-old boy without any medical history presented with right ocular motility disorder and upper eyelid ptosis one month ago. He had no history of fever, headache, vomiting, convulsions, or limb weakness. Neurological examination showed right third cranial nerve palsy with restrictions of eye movements and ptosis, pupil dilation and negative light reflex. Imaging suggested a space-occupying lesion in the suprasellar cistern with calcification and ring-enhancement. Moreover, no Mycobacterium tuberculosis was found in cerebrospinal fluid by polymerase chain reaction (PCR). The lesion was initially diagnosed as a tumor, while postoperative pathology combined with PCR indicated tuberculoma. The patient continued postoperative anti-tuberculosis treatment. At present, the patient's condition is stable and the symptoms are partially relieved compared with those before surgery.
CONCLUSION This case confirmed that isolated intracranial tuberculoma can occur in the suprasellar cistern. Therefore, for space-occupying lesions in the suprasellar cistern, tuberculoma should be included in the differential diagnosis even if there is no history or indication of tuberculosis infection.
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Affiliation(s)
- Bi-Bo Zhao
- Department of Radiology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Chao Tian
- Department of Radiology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Le-Jun Fu
- Department of Radiology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Xue-Bin Zhang
- Department of Pathology, Tianjin Huanhu Hospital, Tianjin 300350, China
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Ahmadpour E, Ebrahimzadeh A, Mortazavi-Moghaddam S, Pagheh A, Barac A. Tuberculous meningitis and miliary tuberculosis in Iran: A review. ASIAN PAC J TROP MED 2022. [DOI: 10.4103/1995-7645.343880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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