The diagnostic utility of the "Thwaites' system" and "lancet consensus scoring system" in tuberculous vs. non-tuberculous subacute and chronic meningitis: multicenter analysis of 395 adult patients

Definition, diagnosis and classification of infection-related movement disorders: Consensus proposal

BACKGROUND

Infection-related movement disorders (IRMD) present a complex diagnostic challenge due to the broad phenotypic spectrum, the variety of possible infectious aetiologies, and the complicated underlying mechanisms. Yet, a comprehensive framework for classifying IRMD is lacking.

METHODS

An international consensus panel under the directives of the Movement Disorders Society Infection-Related Movement Disorders Study Group developed a comprehensive definition and a consensus classification system. Case scenarios were used for validation.

RESULTS

A definition for IRMD and a two-axis-based classification system consisting of six descriptors are proposed, intended as tools for researchers and clinicians. Collected information on clinical characteristics, investigational findings, the infectious organism and presumed pathogenesis facilitate the evaluation of diagnostic certainty.

CONCLUSION

The proposed framework will serve for optimised diagnostic algorithms, systematic aggregation of informative datasets across studies, and ultimately improved care and outcome of patients with IRMDs.

Role of MicroRNAs as post transcription regulators of matrix metalloproteinases and their association in tuberculous meningitis

Matrix metalloproteinases (MMPs) have a role in driving neuroinflammation in infectious as well as non-infectious diseases; however, recent reports have potentiated the role of microRNAs in regulating MMPs at post-transcriptional levels, leading to dysregulation of crucial MMP functions like tissue remodelling, blood brain barrier integrity, etc. In present study, microRNAs regulating MMPs (MMP2 and MMP3) were selected from database search followed by literature support. Expression of these microRNAs i.e., hsa-miR-495-3p, hsa-miR-132-3p and hsa-miR-21-5p was assessed by RT-PCR and the protein levels of MMPs were assessed by ELISA in the cerebrospinal fluid (CSF) of tuberculous meningitis (TBM) patients, healthy controls (HC) and non-infectious neuroinflammatory disease (NID) patients. The expression of hsa-miR-495-3p and hsa-miR-132-3p showed downregulation in TBM while hsa-miR-21-5p was overexpressed as compared to healthy controls. Moreover, MMP levels were found to be deranged with a significant increase in MMP3 levels in the TBM and NID patients compared to HC group. These observations highlight dysregulated microRNAs (hsa-miR-495-3p, hsa-miR-21-5p and hsa-miR-132-3p) levels might impair the levels of MMPs (MMP2 and MMP3) leading to neuroinflammation in TBM and NID population. These findings can further be applied to target these microRNAs for developing newer treatment modalities for better complication management.

A comparison of clinical features between neurobrucellosis and tuberculous meningitis

BACKGROUD

This study aims to compare the clinical manifestations, imaging findings, routine tests, biochemistry indicators and cerebrospinal fluid cytology between neurobrucellosis and tuberculous meningitis. The objective is to evaluate the similarities and differences of these two diseases and improve early diagnosis.

METHODS

A comprehensive evaluation was conducted by comparing clinical data, imaging results, routine tests findings, biochemistry indicators and cerebrospinal fluid cytology of patients admitted to the Department of Neurology, the Second Hospital of Hebei Medical University from 2019 to 2021. Statistical analysis was applied to identify significant differences and similarities between the two diseases.

RESULTS

Preliminary analysis demonstrated both diseases commonly present with symptoms such as fever, headache. However, there were no statistical differences between neurobrucellosis and tuberculous meningitis in early clinical data, imaging results, routine tests findings, biochemistry indicators. Further analysis indicates there is a statistically significantly difference in the lymphocyte ratio and neutrophil ratio in the cerebrospinal fluid between the two groups.

CONCLUSIONS

Neurobrucellosis and tuberculous meningitis share similarities in early clinical manifestations, imaging findings and initial cerebrospinal fluid parametes, making early-stage differentiation challenging. The ratio of lymphocytes and neutrophil in the cerebrospinal fluid and a detailed medical history investigation can provide clues for early clinical diagnosis. So the examination of CSF cytology might be a potential to distinguish these two diseases and become a powerful tool in the future.

Characteristics of Tuberculous Meningitis in HIV-Positive Patients from Northeast Romania

BACKGROUND AND OBJECTIVES

One of the most severe forms of extrapulmonary tuberculosis (EPTB) is tuberculous meningitis (TBM), which is linked to significant morbidity and high mortality. It is well recognized that human immunodeficiency virus (HIV)-positive people are more likely to develop EPTB, including TBM, especially if they have severe immunodeficiencies. We aim to highlight the profile and the characteristics of TBM in HIV-infected patients.

MATERIAL AND METHODS

We conducted a retrospective clinical study based on hospital medical records of patients diagnosed with HIV/AIDS (acquired immunodeficiency syndrome) and TBM in Northeast Romania, hospitalized at "St. Parascheva" Clinical Hospital of Infectious Diseases of Iasi from 1 January 2010 to 1 December 2022.

RESULTS

From a total number of 1692 patients on record in our center, 195 had a HIV-tuberculosis (TB) coinfection, and 19 cases were HIV-TBM coinfected. Six cases were newly HIV-diagnosed late presenters, and thirteen patients' names were already found in the center's records with deficient immunological viral status (median CD4 lymphocyte level 47/mm3). The average age in the study group was 27 years old. The clinical manifestations and cerebrospinal fluid (CSF) variables were typical in most cases, despite the severe immunodepression of the patients. The Thwaites scoring system correctly identified 89.5% of the patients. The median admission period was 18 days; the lethality rate was 31.6%, despite access to ART and anti-TB drugs, and was associated with a more severe immunosuppression. No rifampicin resistance was detected.

CONCLUSIONS

TBM appeared in a minority of our HIV cohort and affected severely immunodepressed patients; the clinical and CSF variables had a typical aspect in most cases, and the Thwaites scoring system performed well for this type of patient. The lethality rate was high and was correlated with a more severe immunodepression.

Tuberculostearic acid incorporated predictive model contributes to the clinical diagnosis of tuberculous meningitis

The conventional confirmation tests of tuberculous meningitis (TBM) are usually low in sensitivity, leading to high TBM mortality. Hence, sensitive methods for indicating the presence of bacilli are required. Tuberculostearic acid (TBSA), a constituent from Mycobacterium tuberculosis had been evaluated as a promising marker, but fails to demonstrate consistent results for definite TBM. This study retrospectively reviewed medical records of 113 TBM suspects, constructing a TBSA-combined scoring system based on multiple factors, which show sensitivity and specificity of 0.8148 and 0.8814, respectively, and the area under the receiver operating characteristic curve of 0.9010. Multivariate analyses revealed four co-predictive factors strongly associated with TBSA: extra-neural tuberculosis, basal meningeal enhancement, CSF glucose/Serum glucose <0.595, and coinfection in CNS (Total). The subsequent machine learning-based validation showed correspondent importance to factors in the TBSA model. This study demonstrates a simple scoring system to facilitate TBM prediction, yield reliable diagnoses and allow timely treatment initiation.

Assessing the impact of pregnancy and birth factors on the maternal and infant microbiota

Background: The microbiota acquired at birth is known to play an intimate role in later life health and disease and has been shown to be affected by the mode of birth. There has been recent interest in microbiota correction by maternal vaginal seeding in Cesarean section-born infants; however, the safety of this practice has been debated. The aim of this study was to assess how other factors, such as timing of sampling, maternal obesity, vaginal Group B Streptococcus colonization (GBS), and antibiotic exposure, affect the maternal and infant microbiota. Methods: Maternal vaginal and saliva samples were collected at three time periods: 35-37 weeks gestation (prenatal), within 24-36 hours after birth (birth), and at ~6 weeks postpartum. Infant saliva and stool samples were collected at ~6 weeks postpartum. 16S rRNA amplicon sequencing was utilized to assess the taxonomic and inferred functional compositions of the bacterial communities from both mothers and infants. Results: Samples from 36 mothers and 32 infants were obtained. Gestational age, breastfeeding, mode of birth, and gravidity were associated with taxonomic alterations in the infant samples, while obesity, antibiotic use, and GBS status were not. Maternal samples were predominantly affected by time, whereby significant alterations including increased microbial diversity were seen at birth and persisted to 6 weeks postpartum. Conclusion: This study provides information on the relationship between health and delivery factors and changes in vaginal and infant microbiota. These results may better direct clinicians and mothers in optimizing the infant microbiota towards health during infancy and later life.

Leukotriene A4 hydrolase (LTA4H rs17525495) gene polymorphisms and paradoxical reactions in extrapulmonary tuberculosis

Paradoxical reactions (PRs) are poorly studied complex immunological phenomena, among patients with tuberculosis (TB). When PRs involves critical structures like the central nervous system (CNS), immunomodulatory therapy is often required. Predictors for PRs in TB to pre-empt appropriate treatment strategies in high-risk groups are lacking. TT genotype of Leukotriene A4 hydrolase (LTA4H) promoter region rs17525495 polymorphisms are associated with exaggerated immune responses in Tuberculous meningitis (TBM), the most severe form of extrapulmonary tuberculosis (EPTB). The association of these polymorphisms with PRs is not known. We evaluated this plausibility among 113 patients with EPTB, at high risk of PRs. Majority [81 (71.7%)] had disseminated tuberculosis with prominent CNS [54 (47.8%)] and lymph node involvement [47 (41.6%)]. Human immunodeficiency Virus (HIV) co-infection was seen among 23 (20.3%) patients. PRs were noted in 38.9% patients, at a median duration of 3 months (IQR 2-4). LTA4H rs17525495 single nucleotide polymorphism (SNP) analysis showed 52 (46%) patients had CC, 43 (38.1%) had CT and 18 (15.9%) had TT genotypes. There was no statistically significant difference in occurrence [CC 38.5% vs CT 39.5% vs TT 38.7%] and time of onset [median (IQR)] of PRs across the genotypes [CC 3 (1-4.7), CT 3 (2-5), TT 2 (2-3)]. PRs was shown to be significantly linked with HIV co-infection (RR 0.6, 95% CI 0.29-1.28), culture positivity (RR 0.5, 95% CI 0.28-1.14), TB Lymphadenitis (RR 0.7, 95% CI 0.44-1.19) and CNS involvement RR 2.1, 95% CI 1.27-3.49) in the univariate analysis (p < 0.2). On multivariate analysis, CNS involvement alone was associated with PRs (aRR 3.8 (1.38-10.92); p < 0.01). PRs were associated with CNS involvement but not with LTA4H rs17525495 polymorphisms.

Clinical Management of Pathogen-Negative Tuberculous Meningitis in Adults: A Series Case Study

Tuberculosis remains a serious world public health problem. Tuberculous meningitis (TBM) is the one of most severe forms of extrapulmonary tuberculosis. However, the insensitivity and time-consuming requirement of culturing the pathogen Mycobacterium tuberculosis, the traditional "gold standard" diagnostic test for TBM, often delays timely diagnosis and treatment, resulting in high disability and mortality rates. In our series case study, we present five pathogen-negative TBM cases who received empirical anti-tuberculosis therapy with a good clinical outcome. We describe in detail the clinical symptoms, laboratory test results, and imaging findings of the five patients from symptom onset to dynamic follow-up. We then summarize the similarities of the clinical characteristics of the presented patients, as well as shared features in laboratory and imaging tests, and proceed to analyze the challenges in the timely diagnosis of TBM. Finally, we argue that monitoring of cerebrospinal fluid markers and imaging are critical for the diagnosis and treatment of TBM, and emphasize the importance of differential diagnosis in cases when tuberculous meningitis is highly suspected despite negative findings for that etiology.

Pelvic and central nervous system tuberculosis complicated by a paradoxical response manifesting as a spinal tuberculoma: a case report

Background

The post-partum period is a risk factor for tuberculosis (TB), possibly including the period after miscarriage as illustrated here. This case demonstrates how non-specific symptoms can hide widely disseminated TB.

Case presentation

A healthy 26-year-old female with a history of recent miscarriage presented to the emergency department with non-specific symptoms of headache, abdominal pain, and sub-acute fevers. She had immigrated to the United States from the Marshall Islands 9 years prior. Two months prior to presentation she had a miscarriage at 18 weeks of pregnancy. On admission, transvaginal ultrasound revealed retained products of conception and abdominal computed tomography revealed findings consistent with tubo-ovarian abscesses and peritonitis. The obstetrics and gynecology service performed dilation and curettage (D&C) to remove retained products of conception. Acid-fast bacilli cultures from cerebrospinal fluid as well as specimens from D&C and intra-abdominal abscesses subsequently all grew TB. She was diagnosed with TB meningitis, peritonitis, endometritis, and tubo-ovarian abscesses. Her treatment course was complicated by a paradoxical response resulting in a spinal tuberculoma causing lower extremity weakness. The tuberculoma was treated with surgical decompression as well as continuation of treatment with anti-tubercular chemotherapy and steroids.

Conclusion

Disseminated and extrapulmonary TB can present with non-specific symptoms. Recognition of risk factors for TB is critical for prompt diagnostic evaluation and treatment of this deadly disease. A paradoxical reaction needs to be taken into consideration when any new neurological symptoms occur during TB treatment.

Neurologic Complications of Tuberculosis

PURPOSE OF REVIEW

This article describes the current epidemiology, common clinical characteristics, and up-to-date evidence-based approaches to the diagnosis and management of the most common neurologic complications of tuberculosis (TB): tuberculous meningitis, intracranial tuberculoma, and spinal TB.

RECENT FINDINGS

Central nervous system (CNS) TB remains common and associated with significant mortality and neurologic sequelae worldwide. Human immunodeficiency virus (HIV) co-infection is strongly associated with both the development of and mortality due to CNS TB. Strongyloides co-infection is associated with reduced CNS inflammation and improved outcomes in the setting of tuberculous meningitis. Stroke remains a common complication of tuberculous meningitis, and emerging evidence suggests aspirin may be used in this context. Although a recent nucleic acid amplification test has demonstrated suboptimal sensitivity in the diagnosis of CNS TB, emerging diagnostic techniques include cell-free DNA, peripheral blood microRNA, metagenomic next-generation sequencing, and advanced imaging techniques, but these are not yet well validated. CNS TB is associated with high mortality even with current treatment regimens, although novel, promising strategies for treatment are under investigation, including a combination of IV isoniazid and ethambutol and high-dose rifampicin.

SUMMARY

TB can affect the nervous system in various ways and is associated with high mortality. Diagnosis remains challenging in endemic settings, with empiric treatment often initiated without a definitive diagnosis. Furthermore, optimal treatment regimens remain uncertain because current treatment for all forms of CNS TB is extrapolated from trials of tuberculous meningitis whereas the role of steroids in people with HIV and tuberculous meningitis remains controversial.