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Stadelman-Behar AM, Tiffin N, Ellis J, Creswell FV, Ssebambulidde K, Nuwagira E, Richards L, Lutje V, Hristea A, Jipa RE, Vidal JE, Azevedo RGS, Monteiro de Almeida S, Kussen GB, Nogueira K, Gualberto FAS, Metcalf T, Heemskerk AD, Dendane T, Khalid A, Ali Zeggwagh A, Bateman K, Siebert U, Rochau U, van Laarhoven A, van Crevel R, Ganiem AR, Dian S, Jarvis J, Donovan J, Nguyen Thuy Thuong T, Thwaites GE, Bahr NC, Meya DB, Boulware DR, Boyles TH. Diagnostic Prediction Model for Tuberculous Meningitis: An Individual Participant Data Meta-Analysis. Am J Trop Med Hyg 2024; 111:546-553. [PMID: 39013385 PMCID: PMC11376156 DOI: 10.4269/ajtmh.23-0789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/18/2024] [Indexed: 07/18/2024] Open
Abstract
No accurate and rapid diagnostic test exists for tuberculous meningitis (TBM), leading to delayed diagnosis. We leveraged data from multiple studies to improve the predictive performance of diagnostic models across different populations, settings, and subgroups to develop a new predictive tool for TBM diagnosis. We conducted a systematic review to analyze eligible datasets with individual-level participant data (IPD). We imputed missing data and explored three approaches: stepwise logistic regression, classification and regression tree (CART), and random forest regression. We evaluated performance using calibration plots and C-statistics via internal-external cross-validation. We included 3,761 individual participants from 14 studies and nine countries. A total of 1,240 (33%) participants had "definite" (30%) or "probable" (3%) TBM by case definition. Important predictive variables included cerebrospinal fluid (CSF) glucose, blood glucose, CSF white cell count, CSF differential, cryptococcal antigen, HIV status, and fever presence. Internal validation showed that performance varied considerably between IPD datasets with C-statistic values between 0.60 and 0.89. In external validation, CART performed the worst (C = 0.82), and logistic regression and random forest had the same accuracy (C = 0.91). We developed a mobile app for TBM clinical prediction that accounted for heterogeneity and improved diagnostic performance (https://tbmcalc.github.io/tbmcalc). Further external validation is needed.
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Affiliation(s)
| | - Nicki Tiffin
- South African National Bioinformatics Institute, University of the Western Cape, Cape Town, South Africa
- Wellcome CIDRI-Africa, University of Cape Town, Cape Town, South Africa
| | - Jayne Ellis
- MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Fiona V Creswell
- MRC/UVRI-LSHTM Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, East Sussex, United Kingdom
| | | | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lauren Richards
- Division of Infectious Diseases, Department of Internal Medicine, Helen Joseph Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Vittoria Lutje
- Cochrane Infectious Diseases Group, Liverpool, United Kingdom
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Raluca Elena Jipa
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - José E Vidal
- Departmento de Neurologia, Instituto de Infectologia Emílio, São Paulo, Brazil
- Divisão de Clínica de Moléstias Infecciosas e Parasitárias, Hospital das Clınicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica, Unidade 49, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Renata G S Azevedo
- Departmento de Infectologia, Instituto de Infectologia Emílio, São Paulo, Brazil
| | | | | | - Keite Nogueira
- Hospital de Clinicas, Universidade Federal do Paraná, Curitiba, Brazil
| | | | - Tatiana Metcalf
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Northern Pacific Fogarty Global Health Fellowship Program, National Institutes of Health, University of Washington, Seattle, Washington
| | - Anna Dorothee Heemskerk
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Tarek Dendane
- Medical Intensive Care Unit, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Abidi Khalid
- Medical Intensive Care Unit, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Amine Ali Zeggwagh
- Medical Intensive Care Unit, Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Kathleen Bateman
- Neurology Division, Department of Medicine Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Uwe Siebert
- Departments of Epidemiology and Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- UMIT TIROL-University for Health Sciences and Technology, Hall I.T., Tirol, Austria
| | - Ursula Rochau
- UMIT TIROL-University for Health Sciences and Technology, Hall I.T., Tirol, Austria
| | - Arjan van Laarhoven
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ahmad Rizal Ganiem
- Department of Neurology Hasan Sadikin Hospital and TB/HIV Research Center Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Sofiati Dian
- Department of Neurology Hasan Sadikin Hospital and TB/HIV Research Center Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Joseph Jarvis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Thuong Nguyen Thuy Thuong
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, Faculty of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Tom H Boyles
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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He H, Xu J, Peng Q, Li Y, Huang Y, Zhang YL, Li X. The application value of cerebrospinal fluid immunoglobulin in tuberculous meningitis. Microbiol Spectr 2024; 12:e0015724. [PMID: 38666897 PMCID: PMC11237685 DOI: 10.1128/spectrum.00157-24] [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: 01/17/2024] [Accepted: 03/17/2024] [Indexed: 06/06/2024] Open
Abstract
This article aims to study the value of cerebrospinal fluid (CSF) immunoglobulin in differential diagnosis, prediction, and prognosis of tuberculous meningitis (TBM). The clinical data of 65 patients with TBM in our hospital were collected, and 65 patients with cryptococcal meningitis (CM) were enrolled in 1:1 matching. Relevant data were collected for comparison. CSFs IgG [331.51 (164.85, 645.00) vs 129.00 (55.05, 251.00) ng/mL], IgM [22.38 (8.52, 40.18) vs 6.08 (2.19, 23.30) ng/mL], and IgA [64.11 (21.44, 115.48) vs 16.55 (4.76, 30.36) ng/mL] in the TBM group were higher than those in the CM group (P < 0.001). In the TBM group, after 24 weeks of treatment, the CSFs IgG, IgM, and IgA were significantly decreased, and the difference was statistically significant (P < 0.05). The predictive results of CSF immunoglobulin for TBM showed that IgG, IgM, and IgA all had some predictive value for TBM, and the combined predictive value of the three was the highest, with an area under the curve of 0.831 (95% CI: 0.774-0.881). Logistic regression analysis of CSF immunoglobulins and TBM prognosis showed that IgG [odds ratio (OR) = 4.796, 95% confidence interval (CI): 2.575-8.864], IgM (OR = 3.456, 95% CI: 2.757-5.754), and IgA (OR = 4.371, 95% CI: 2.731-5.856) were TBM risk factors for poor prognosis in patients. The levels of IgG, IgM, and IgA in CSF were positively correlated with the severity of cranial magnetic resonance imaging (MRI) in TBM patients (R2 = 0.542, F = 65.392, P < 0.05). CSFs IgG, IgM, and IgA can be used as a routine monitoring index for TBM patients, which has a certain reference value in differential diagnosis and efficacy evaluation. IMPORTANCE In clinical practice, physicians can determine the physical conditions of patients based on the levels of cerebrospinal fluids (CSFs) IgG, IgM, and IgA. Higher levels of CSFs IgG, IgM, and IgA suggest more possibility of tuberculous meningitis and worse prognosis and magnetic resonance imaging manifestations.
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Affiliation(s)
- Hua He
- Department of Infectious Disease, The Third People's Hospital of Kunming/Yunnan Clinical Medical Center for Infectious Diseases, Kunming, Yunnan, China
| | - Jun Xu
- Department of Infectious Disease, The Third People's Hospital of Kunming/Yunnan Clinical Medical Center for Infectious Diseases, Kunming, Yunnan, China
| | - Qin Peng
- Department of Infectious Disease, The Third People's Hospital of Kunming/Yunnan Clinical Medical Center for Infectious Diseases, Kunming, Yunnan, China
| | - Yang Li
- Department of Infectious Disease, The Third People's Hospital of Kunming/Yunnan Clinical Medical Center for Infectious Diseases, Kunming, Yunnan, China
| | - Ying Huang
- Department of Infectious Disease, The Third People's Hospital of Kunming/Yunnan Clinical Medical Center for Infectious Diseases, Kunming, Yunnan, China
| | - Yan-Ling Zhang
- Department of Infectious Disease, The Third People's Hospital of Kunming/Yunnan Clinical Medical Center for Infectious Diseases, Kunming, Yunnan, China
| | - Xiang Li
- Department of Radiology, The Third People's Hospital of Kunming/ Yunnan Clinical Medical Center for Infectious Diseases, Kunming, Yunnan, China
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Ssebambulidde K, Gakuru J, Ellis J, Cresswell FV, Bahr NC. Improving Technology to Diagnose Tuberculous Meningitis: Are We There Yet? Front Neurol 2022; 13:892224. [PMID: 35711276 PMCID: PMC9195574 DOI: 10.3389/fneur.2022.892224] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/22/2022] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of tuberculous meningitis (TBM) remains challenging due to a paucity of high-performance diagnostics. Even those that have reasonable sensitivity are not adequate to 'rule out' TBM. Therefore, a combination of clinical factors alongside microbiological, molecular, and radiological investigations are utilized, depending on availability. A low threshold for starting empiric therapy in the appropriate clinical scenario remains crucial for good outcomes in many cases. Herein, we review the current TBM diagnostics landscape with a focus on limitations frequently encountered, such as diagnostic test performance, cost, laboratory infrastructure, and clinical expertise. Though molecular technologies, particularly GeneXpert MTB/Rif Ultra, have been a step forward, diagnosis of TBM remains difficult. We also provide an overview of promising technologies, such as cerebrospinal fluid (CSF) lactate, a new lipoarabinomannan test (FujiLAM), metagenomic next-generation sequencing, and transcriptomics that may further improve our TBM diagnostic capacity and lead to better outcomes.
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Affiliation(s)
- Kenneth Ssebambulidde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fiona V. Cresswell
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global Health and Infection, Brighton and Sussex Medicine School, Brighton, United Kingdom
| | - Nathan C. Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, United States
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