Barriers to diagnosis and management of CNS infections in Indonesia

Concomitant cavernous sinus thrombosis and central serous chorioretinopathy in a patient with total ophthalmoplegia and monocular blindness: a case report

Cavernous sinus thrombosis (CST) is an unusual condition that can result in high mortality and morbidity rate if not treated immediately.

Case presentation

An Indonesian male, 47 years old, presented with total right ocular ophthalmoplegia followed by blindness, headache, ptosis, periorbital swelling, and hypoesthesia over the left V1 region. MRI of the brain showed suitable cavernous thickening until the right orbital apex, which in contrast showed enhancement suggestive of right Tolosa-Hunt syndrome. The patient was treated with a high dose of steroids, but the patient's complaints did not improve. The patient underwent digital subtraction angiography and found CST. The optical coherence tomography was found to be central serous chorioretinopathy. He was treated with an antibiotic, anticoagulant, and extraction of the right maxillary molar was performed to remove the source of the infection. After 3 weeks, visual acuity and optical coherence tomography examination were improved.

Discussion

A comprehensive examination, such as digital subtraction angiography, is essential to confirm CST diagnosis for the patient to obtain the right therapy. This report highlighted the value of the prompt diagnosis of CST through neuroimaging and the importance of proper therapy in patient management.

Conclusions

Early diagnosis, comprehensive examination, and proper treatment of CST will increase good prognosis.

Improving host-directed therapy for tuberculous meningitis by linking clinical and multi-omics data

There is a clear need to improve host-directed therapy for tuberculous meningitis (TBM), the most severe and deadly manifestation of tuberculosis. Corticosteroids represent the only host-directed therapy of proven benefit in TBM, yet their effect is modest, the mechanism by which they reduce mortality is unknown, and there is evidence for heterogeneity in their effect. Novel therapeutic approaches are therefore urgently needed. Cellular metabolism is critical for the function of immune cells; through unbiased metabolomics we recently found that high concentrations of cerebrospinal fluid (CSF) tryptophan are associated with increased mortality in Indonesian TBM patients, and that CSF tryptophan concentrations are under strong genetic regulation. Many questions remain. How exactly is tryptophan metabolism altered during TBM? How does it correlate with inflammation, immunopathology, and response to corticosteroids? How is tryptophan metabolism genetically regulated? What is the effect of HIV co-infection on tryptophan metabolism before and during TBM treatment? The ULTIMATE project addresses these questions by integrating data and specimens from large patient studies and clinical trials evaluating the effects of corticosteroids in Vietnam and Indonesia. Through its powerful and unbiased approach, ULTIMATE aims to identify which TBM patients benefit from corticosteroids and if novel therapeutic targets, such as the tryptophan pathway, could be targeted.

A case of an AIDS patient with Cryptococcus neoformans infection

Cryptococcosis is the most common fungal disease in HIV-infected persons. It is known as the AIDS-defining illness for 60-70% of HIV-infected patients. Before antiretroviral therapy (ARV) was discovered, fungal and other opportunistic infections were a major problem for people with advanced HIV/AIDS. Presented here is a case of a 43-year-old man who was newly diagnosed HIV, in which he was admitted due to shortness of breath and decreased consciousness. His clinical symptoms, physical examination, laboratory and radiologic findings indicated a Cryptococcus neoformans infection. The patient had received treatment using anti-fungal and ARV that showed a clinical improvement during observation.

Establishing the cascade of care for patients with tuberculous meningitis

Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.

Establishing the cascade of care for patients with tuberculous meningitis

Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.